PHYSICAL SIGNS OF THE HEAD AND NECK LIDIA IONESCU (ANDRIESCU) The IIIrd.Surgical Unit

1. PHYSICAL SIGNS OF THE HEAD AND NECKLIDIA IONESCU (ANDRIESCU)The IIIrd.Surgical Unit

2. Physical signs • Symptom- what the patient feels • Physical sign- what the doctor finds at clinical examination of the patient’s segments. • Symptom is subjective • Physical sign is objective • Clinical diagnosis = symptoms + signs • Final diagnosis= symptoms + signs + lab.tests + investigations.

3. SURFACE LANDMARKS OF THE HEAD • Nasion • External occipital protuberance • Vertex • Superior nuchal line • Mastoid process of the temporal bone • Zygomatic arch • Superficial temporal artery • Facial artery • Parotid duct

4. Surface landmarks

5. Sebaceous cysts • Swelling-cystic mass-cystic tumor-lump • Hairy parts of the body- scalp • The mouth of the seb. gland opens into the hair follicle • If blocked mouth, seb. gland becomes distended

6. Seb. Cyst • History- slow growing • Symptoms-a lump that gets scratched when the patient is combing the hair • Such scratches may get infected • If the cyst becomes infected it enlarges rapidly and becomes acutely painful

7. Seb. Cyst- examination-physical signs • Position-hairy parts of the body • Color- the skin overlying the cyst normal unless it is infected • Tenderness- not tender unless infected • Temperature-normal except when infected • Shape- spherical • Size- variable: mm-4-5 cm. • Surface- smooth • Edge-well defined • Composition- hard depending on the pressure in the cust “cheesy material”

8. Sebaceous cyst of the scalp

9. Sebaceous cyst

10. Surgical treatment- excision

11. Intact sebaceous cyst-specimen

12. Cut section- seb.cyst- “cheesy material”-sebum

13. Lipoma-case report • A 59-year-old woman was admitted with a 10 years' history of a painless swelling at the right thigh. The lesion became ulcerative over the past few months with mild pain. • She had no significant medical and surgical history. • Examination revealed normal vital signs, chest, heart, abdominal and rectal examinations.

14. Lipoma • On local examination, a large mass occupying the posterior aspect of the lower two thirds of the right thigh was confirmed. • There was an ulcerative lesion at the posteromedial aspect of the mass. • The right popliteal artery was difficult to palpate, but the posterior tibial and dorsalis pedis were normal. • There was no neuronal abnormality.

15. Lipoma- case report • Blood tests showed normal blood count, liver function, urea and electrolytes as well as ESR. She had a normal chest and abdominal X-ray. • The X-ray of the right thigh showed a soft tissue shadow and normal bone. • Surgical excision was performed and the findings were consistent with a giant lipoma. • The wound was closed easily as there was redundant skin because of the size of the mass. • The weight of the specimen was 3.2kg.

16. Lipoma- case report • The patient had an uneventful recovery and was discharged home with a very good condition. • Histology of the specimen reported benign lipoma.

17. Huge lipoma of the thigh

18. Ulcerated lipoma on the post-medial thigh

19. Specimen- 3.2 Kg.

20. Lipoma • This is the external surface of a lipoma, a benign tumor of adipocyte origin. •The bright yellow color is typical of fat. •Note the lobulated appearance. This is also typical of this lesion. •This particular tumor arose in the subcutaneous fat (note the small strip of skin denoted by the black arrows).

21. Case Report-lipoma • A 60 year old male presented in out patient clinic with history of progressively increasing swelling in right thigh, which he noticed 3½ years back. Swelling was otherwise asymptomatic except that he had to wear loose fitting trousers. • On examination, right thigh girth was grossly increased as compared to the left thigh.

22. Lipoma • There were erythema ab agni over the medial aspect of both thighs (as is usual in Kashmiri people because of Kangri – “the fire pot”). • The swelling was firm, non-tender and free from underlying structures.

23. Lipoma

24. CT scan of the right thigh was done which revealed a hypodense mass in the posterior compartment of the thigh beneath the hamstring muscles

25. Lipoma- case report • FNAC of the swelling revealed mature fat cells, suggestive of lipoma. • The patient was operated on under general anaesthesia, in prone position and the tumour was found beneath the hamstring muscles and was dissected out easily because of the pseudocapsule. • Wound was closed in layers, leaving a suction drain inside the cavity. Healing progressed uneventfully. • Histopathological examination revealed features consistent with lipoma. The tumour removed measured 21x17x14cm in size and weighed 2,95 Kg.

26. Specimen.Six months after surgery, the patient is symptom free and has no signs of recurrence

27. Lipoma • Lipoma is one of the commonest benign mesenchymal tumour in the body composed of mature adipose cells. • It is found in almost all the organs of the body where normally fat exists that is why it is also known as ubiquitous tumour or universal tumour. • Most of the lipomas present as small subcutaneous swellings without any specific symptom.

28. Lipoma • Giant lipomas, though rare, can present in thigh, shoulder or trunk. Clinical features of these giant lipomas are mainly because of their size which includes pain because of stretching of adjacent nerves,(restriction in movements of the part involved or social embarrassment because of mere size of the swelling). • Although definitive diagnosis of giant lipoma can be made only by histopathological examination, but once suspected, other investigations can provide additional information about the tumour.

29. Lipoma • The characteristics of benign lipoms on ultrasonography, CT and MRI have been well established and even Tc99 DTPA scan have been used to confirm the diagnosis.

30. Lipoma • Surgery is the treatment of choice of these giant swellings due to their tendency to recur and their potential hazard of malignant transformation, other option for treatment of these giant swelling is liposuction. • The dissection of these lipomas is usually easy because of continuous pressure on the surrounding tissue, a well defined pseudocapsule is formed. • Dead space created because of dissection of the giant lipomas is usually drained with the help of a suction drain to avoid collection. • As already mentioned, these tumours have tendency to recur and can have malignant transformation, therefore, should be followed meticulously.

31. Lipoma

32. Hemangioma • Benign skin lesion consisting of dense, usually elevated masses of dilated blood vessel. • Benign neoplasm characterized by blood vascular channels. • A cavernous hemangioma consists of large vascular spaces. • A capillary hemangioma consists of many small blood vessels. A collection of dilated small vessels, 3 types: • strawberry nevus, • port-wine stains, • spider nevus

33. Cavernous hemangioma

34. Hemangioma • Congenital benign tumour made of blood vessels in the skin. • Capillary hemangioma , an abnormal mass of capillaries on the head, neck, or face, is pink to dark bluish-red and even with the skin. Size and shape vary. It becomes less noticeable or disappears with age. • Immature hemangioma (hemangioma simplex, strawberry mark), a reddish nub of dilated small blood vessels, enlarges in the first six months and may become ulcerated but usually recedes after the first year. • Cavernous hemangioma, a rare, red-blue, raised mass of larger blood vessels, can occur in skin or in mucous membranes, the brain, or the viscera. Fully developed at birth, it is rarely malignant. Hemangiomas can often be removed by cosmetic surgery.

35. Strawberry nevus • Intradermal, subdermal collection of dilated blood vessels • Congenital lesion- present at birth • Looks like a strawberry • Often regress spontaneously in months/years after birth • Rubbed or knocked they may ulcerate and bleed

36. Strawberry nevus

37. Physical examination • Position- any part of the body- head/neck> • Color- bright or dark red • Shape- protrude from the skin surface • Size- usually- 1-2 cm. • Surface-irregular • Consistence- soft, compressible not pulsatile • Relations- confined to the skin, freely mobile over the deep tissues

38. Port-wine stain-extensive intradermal hemangioma, mostly venous

40. Cavernous hemangioma on the tongue

41. This angiogram (an X-ray taken after dye has been injected into the blood stream) shows a mass of blood vessels (hemangioma) in the liver.

42. Meningocele • Meningocele (MM):Protrusion of the membranes that cover the spine and part of the spinal cord through a bone defect in the vertebral column. • MM is due to failure of closure during embryonic life of bottom end of the neural tube. • The term spina bifida refers specifically to the bony defect in the vertebral column through which the meningeal membrane and cord may protrude (spina bifida cystica) or may not protrude so that the defect remains hidden, covered by skin (spina bifida occulta). • The risk of MM (and all neural tube defects) can be decreased by the mother eating ample folic acid during pregnancy.

43. A birth defect involving an abnormal opening in the spinal bones (vertebrae) is called spina bifida. The spinal vertebrae have not formed and joined normally, leaving an opening

44. A defect which also includes a small, moist sac (cyst) protruding through the spinal defect, containing a portion of the spinal cord membrane (meninges), spinal fluid, and a portion of spinal cord and nerves is called a meningocele, myelomeningocele, or meningomyelocele

45. Surgical treatment is needed to repair the defect and is usually done within 12 to 24 hours after birth to prevent infection, swelling, and further damage.While the baby is deep asleep and pain-free (using general anesthesia), an incision is made in the sac and some of the excess fluid is drained off. The spinal cord is covered with the membranes (meninges) and the skin is closed over the protruding meninges, spinal cord, and nerves.

46. The long-term result depends on the condition of the spinal cord and nerves. Outcomes range from normal development to paralysis (paraplegia).Infants may require about 2 weeks in the hospital after surgery.

47. Physical signs in head injuryExamination of a case of recent head injury • The patient is unconscious • Examine the scalp for a wound or local bruising or hematoma • Examine the nostrils and ears for evidence of blood diluted with CSF • Compare the size of the pupils and test their reaction to light • Make a general survey of the body for other injuries • Search for paralysis • Palpate and percuss the hypogastrium for evidence of an overfull bladder • Temperature, pulse rate, RR-charted every half-hour

48. Head injury • Radiographs of the skull should be taken at the first opportunity compatible with safety • Brain injury is more likely in the presence of a skull fracture BUT skull fracture of itself does not indicate brain injury

49. COMA • Coma is a state of absolute unconsciousness in which the patient does not respond to any stimulus • Reflexes are absent, including the corneal and swallowing reflexes. • Semi-coma- the patient responds only to painful stimuli and reflexes are present

50. Head injuryThe patient is conscious or semi-conscious • Patient with skull fracture – hospital admission • Close observation: PR, BP, RR, pupil size and reaction/ every ½ h. • Signs of neurological deterioration: • Falling pulse rate • Reduced respiratory rate • Falling GCS • Dilatation of pupils • Loss of light reaction or developing asymmetry of pupils