Examination of head and neck Flashcards
What are the 4 systematic steps in principal examination
- Inspection = visual examination of the area
- Palpation = feeling the area of examination
- Percussion = tapping around the area
- Auscultation = listening to area with stethoscope
How does Cushing’s syndrome present on the face
- Moon face
- Plethora = redness
- Hirsutism = excessive facial hair
- Acne
How does Cushing’s syndrome present else where on the body
- Red striae on abdomen
- Weight gain; buffalo hump
- Ammenorhoea
- Personality change
- Hypertention
- Osteoperosis
- Diabetes due to increased gluconeogenesis
What are the causes of Cushing’s syndrome
- Cushing’s disease
- Ectopic ACTH secreting tumours (small cell lung cancer and bronchus carcinoma)
- Adrenal tumour causing cortisol production
- Excess cortisol exposure e.g. prednisolone
What is the dental relevance of Cushing’s syndrome
- Candidiasis (if DM)
- If on bisphosphonates risk of osteonecrosis of the jaw
- Need steroid cover for dental surgeries
What is the difference between Cushing’s disease and Cushing’s syndrome
Disease = due to pituitary tumour causing XS ACTH
Syndrome = due to exogenous steroids, small cell lung cancer, adrenal tumours
How does hypothyroidism present on the face
- Coarse mottled skin
- Peaches and cream complexion
- Peri-orbital oedema
- Loss of eyebrows
- Dull, listless appearance
How does hypothyroidism present elsewhere on the body
- Tiredness
- Poor appetite, weight gain and constipation
- Cold intolerance
- Hairloss
- Infertility
- Heavy irregular periods
- Depression
- Bradycardia
- Myxoedema facies
What causes hypothyroidism
- Dietary iodine deficiency (needed for thyroxine production)
- Thyroidectomy
- Pituitary gland disorder thus no TSH production
- Hashimoto’s thyroiditis = autoimmune
- Drugs e.g. amiodarone, lithium
What is the dental relevance of hypothyroidism
- Delayed dental eruption
- Glossitis
- Dysgeusia
- Delayed wound healing
- Compromised periodontal health due to delayed bone formation
What is myxoedema coma
Lethal deterioration of the patients mental status when the body’s compensatory responses to hypothyroidism are overwhelmed by a precipitating factor such as drug or infection (this means they cannot be put under GA)
How does acromegaly present on the face
- Frontal bossing
- Prominent supraorbital ridge
- Brow furrow
- Enlarged nose
- Prognathism (bulging of lower jaw)
How does acromegaly present else where on the body
- XS hair growth (hirsutism) and sweating
- Spade-like hands and feet
- Carpel tunnel (where medial nerve is trapped)
- Loss of temporal vision (bitemporal heminopea)
What causes acromegaly
Fast growth causing gigantism as a result of an anterior pituitary tumour
What is the dental relevance of acromegaly
- Macroglossia
- Spacing of teeth
- Malocclusion
- Anterior open bite
- Hypercementosis of root
- Enlarged prognatic mandible
What can acromegaly cause
CVS - hypertension, cardiomyopathy, coronary artery disease
Metabolic - DM type II, impotence, amenorrhea
Osteoarthritis
Why do patients with acromegaly have bitemporal hemianopia
Because the anterior pituitary tumour can enlarge to compress the optic chiasm meaning the nasal half of fibres are disrupted causing loss of vision in temporal region (decussation)
How does downs syndrome present on the face
- Dysmorphic round face
- Eyes that slant upwards
- Epicanthic folds (upper eyelid skin fold covering inner eye)
- Brushfield spots (white spots in iris arranged circularly)
- Small nose with a flattened bridge
- Protruding tongue
- Small low set ears
- Flat occiput (back of head)
How does downs syndrome present else where on the body
- Small head and short neck
- Broad and short hands with single palmar crease
- Hyperflexible joints
What is the cause of downs syndrome
Trisomy of chromosome 21
- there is a random error is cell division causing an extra chromosome
What is the dental relevance of downs syndrome
- Delayed eruption
- Small teeth causing spacing or
- Crowding due to small upper jaw
- Unstable neck due to atlantoaxial subluxation which can compress spinal chord (take care extending neck)
- Increased periodontal disease risk
- Macroglossia
- Anterior open bite
What complications can downs syndrome cause
- Congenital heart disease; predisposed to IE
- Learning difficulty and developmental delay
- Increased risk of leukaemia and infections
- Intestinal problems
- Hyperthyroidism
- Hearing and visual problems
- Risk of Alzheimer’s
How does Bell’s palsy present on the face
- Unilateral facial weakness
- Inability to furrow brow
- Droopy eyelid (ptosis) cannot close eye
- Loss of nasolabial fold
- Drooping corner of the mouth; cannot smile or pucker
- Abnormal contraction of the platysma muscle
- Facial numbness
- Changes in salivation
- Alterations of taste sensation (afferent fibres of taste receptors)
How does Bell’s palsy present else where on the body
Patients are sensitive to sound and light
Hyperacusis or ear pain due to involvement of somatic afferent fibres of the external auditory canal and pinna
What causes Bell’s palsy
It is caused by lower motor neurone lesion of the facial nerve which can occur due to; herpes, EBV/CBV or be autoimmune
There is inflammation and swelling of the facial nerve near the stylomastoid canal which can cause compression and ischaemia or demyelination of the nerve
What is the dental relevance of Bell’s palsy
- Hard to clean teeth on affected side
- Food accumulation so risk of tooth decay and gum disease
- Xerostomia so increased caries risk
- Dentures don’t fit well due to poor cheek tone
What is the difference between the symptoms experienced from upper and lower motor neurone lesions
UMN lesions spare the upper face so unilaterally affects lower half of face
LMN lesion (Bell’s palsy) affects the face unilaterally
What are the causes of bilateral parotid gland swellings
- Diabetes
- Alcoholic liver disease
- Sjogren’s syndrome
- Infections like mumps
What are the causes of unilateral parotid gland swellings
- Parotitis = painful bacterial infection
- Salivary calculus
- Parotid tumour
What is peri-orbital erythema
Redness and swelling around the eye; this could be due to an adverse drug reaction, local infection (periorbital cellulitis) or an allergy
What can peri-orbital bruising indicate
If it is not a result of trauma/soft tissue injury it can indicate life threatening conditions such as cancer
What is a meibomian cyst
Lump or swelling on the eyelid due to blockage of a tarsal gland
What is a stye
A staph infection of the hair follicle affecting the eyelid; this is self healing but can be aided with hot water compresses and antibiotics if infected
What is xanthalessma
Yellow fatty deposits commonly on the medial aspect of eyelids due to hyperlipidaemia, diabetes and hyperthyroidism
What is eyelid retraction characteristic of
Graves disease; autoimmune attack on thyroid causing hyperthyroidism
What is exopthalmos
Bulging out of the eye
What does a red sclera indicate
conjunctivitis
What does a yellow sclera indicate
jaundice
What does a blue sclera indicate
osteogenesis imperfects where there is thinning of the sclera which means the veins show through causing a blue appearance
What can changes in the conjunctiva indivate
Pale/pink is characteristic of anaemia and dryness could indicate Sjogren’s
How does basal cell carcinoma present on the face
Pink localised skin cancer with raised and rolled edges and telangactasia, and this can crust and bleed - this is slow growing but if left untreated it can form a rodent ulcer which will require skin grafting
What are the causes of jaundice
- Pre-hepatic = haemolytic anaemia
- Hepatic = dysfunction causing hepatitis, drugs, alcohol, tumours in the liver
- Post-hepatic = bile duct issue e.g. gallstones so bile cannot drain, or a pancreatic tumour obstructing the biliary tree
What are the common causes of bilateral exopthalmous
- Grave’s disease
- Metastatic neuroblastoma
- Lymphoma/leukemia
- Cavernous sinus thrombosis
What are the common causes of unilateral exophthalmos
- Eye trauma/infection (bleeding behind eye or orbital cellulitis)
- Optic nerve tumour
- Meningioma
- Haemangioma
What is stomatitis caused by
Infection, iron deficiency, chemotherapy, contact dermatitis
What GIT disease could be the cause of ulcers in the mouth
Crohn’s disease (not ulcerative colitis) because Crohn’s affects from the mouth to anus
What can gingival hypertrophy be caused by
- Ca2+ channel blockers
- Phenytoin (anti-epileptic)
- Cyclosphorin (immunosuppressive)
What is lichen planus on the tongue a result of
Chronic inflammatory condition which is premalignant for squamous cell carcinoma and appears as white lacy patters on the tongue or oral mucosa
What is geographic tongue
When there is inflammation on the top and sides of the tongue
What is angular chelitis
Inflammatory condition affecting corners of the mouth
What can abnormal pigmentation on the lips and around oral cavity be caused by
- Addison’s disease; not enough cortisol
- Peutz-Jeghers syndrome; genetic condition where there is benign colonic polyps (hamartomas) which can bleed and cause GI blood loss
What is oral candidiases
Fungal infection by Candida albicans which is related to diabetes, HIV and patients that are immunosuppressed
What can cause atrophic glossitis
- B12 deficiency
- Iron deficiency anaemia
- Folate deficiency
What can cause macroglossia
- Acromegaly
- Amyloidosis
- Hyperthyroidism
Describe the anatomical locations of the two triangles of the neck
Anterior = below digastric, infant of sternomastoid Posterior = behind sternomastoid, infront of trapezius, above clavicle
Describe how a neck lump should be assessed
Site, size, shape, surface (smooth or nodular)
Texture, consistency, temperature, tenderness
Motility and surrounding tissues and fluctuance
Overlying skin changes, pulsatilitu, lymph drainage
What are fluctuant neck lumps
These are fluid filled and can be assessed by
- holding the lump by its sides and applying pressure to the centre of the mass
- if it is fluid filled then it will budge outwards
What does transillumination of neck lumps indicate
That it is fluid filled e.g. cystic hygroma
What is a vascular bruit
This is an audible vascular sound associated with turbulent blood flow and can indicate goitre or carotid body tumour when found in neck lumps and is heard in Grave’s disease
How does goitre present
It is an enlargement of the thyroid gland and appears as a diffuse central neck swelling which will move up on swallowing and not move upon tongue protrusion
What type of neck swelling will move up on tongue protrusion
Thyroglossal cycst
Outline how the thyroid gland is palpated
- Move behind the patient and identify cricoid cartilage with fingers of both hands
- Move downwards 2/3 tracheal rings while palpating for the isthmus
- Move laterally away from the midline while palpating for the lobes of the thyroid
What does retrosternal dullness upon percussion below neck indicate
Large goitre extending inferiorly
What is the only neck swelling that is pulsatile
Carotid body tumours
What is a laryngocoele
Congenital anomalous air sac communicating with the cavity of the larynx showing as an anterior neck swelling
List anterior triangle neck swellings
- Lymphadenopathy
- Thyroid swelling
- Parotid tumour
- Branchial cyst
- Dermoid cyst
Rare; carotid body tumour, laryngocoele
List midline neck swellings
- Lymphadenopathy
- Thyroid swelling
- Thyroglossal cyst
List posterior triangle neck swellings
- Lymphadenopathy
- Cystic hygroma
- Cervical rib
