头眼耳鼻喉课件

HEENTHEENT E. Solis MD, MPHE. Solis MD, MPH Learning ObjectivesLearning Objectives n n The student will be able to identify The student will be able to identify different components of the head, eyes, different components of the head, eyes, ears, nose, and throatears, nose, and throat n n The student will be able to identify The student will be able to identify anatomic landmarks of the head, eyes, anatomic landmarks of the head, eyes, ears, nose and throatears, nose and throat n n The student will be able to identify and The student will be able to identify and perform the proper techniques for a basic perform the proper techniques for a basic exam of the head, eyes, ear, nose and exam of the head, eyes, ear, nose and throatthroat n n The student will be able to describe and The student will be able to describe and record findings of the head, eyes, ears, record findings of the head, eyes, ears, nose and throat examinationnose and throat examination Learning ObjectivesLearning Objectives n n The student will be able to identify The student will be able to identify different disorders of the head, eyes, ears, different disorders of the head, eyes, ears, nose, and throatnose, and throat n n The student will be able to identify the The student will be able to identify the signs and symptoms of HEENT disorderssigns and symptoms of HEENT disorders Objective 1: Components of the Objective 1: Components of the HEENT ExamHEENT Exam n n HEADHEAD inspection: inspection: skull- size ,shape, symmetry, deformity skull- size ,shape, symmetry, deformity scalp- redness, scaling scalp- redness, scaling hair- quantity, distribution ,nits, lice hair- quantity, distribution ,nits, lice face symmetry, involuntary face symmetry, involuntary movements, skin lesions, color, movements, skin lesions, color, shape shape n n Palpation:Palpation: skull ( including temporal artery)- size skull ( including temporal artery)- size contour, lumps, deformities, contour, lumps, deformities, tenderness tenderness scalp- mobility, lesions scalp- mobility, lesions hair texture hair texture Temporomandibular joint pain, Temporomandibular joint pain, decreased ROM decreased ROM n n NeckNeck Lymph nodes- enlargement,mobility Lymph nodes- enlargement,mobility Trachea deviation Trachea deviation Thyroid gland- size, tenderness, mobility Thyroid gland- size, tenderness, mobility n n EYESEYES Inspection: Inspection: eyebrows- hair loss, scaling eyebrows- hair loss, scaling eyelids redness, swelling, lesions eyelids redness, swelling, lesions Conjunctiva paleness, inflammationConjunctiva paleness, inflammation Sclera icterus, inflammationSclera icterus, inflammation Cornea (anterior chamber) opacitiesCornea (anterior chamber) opacities Lens- opacitiesLens- opacities Pupils size ,shape, equality, reactionPupils size ,shape, equality, reaction n n Tests:Tests: -pupillary reactions -pupillary reactions direct and consensual direct and consensual -accommodation -accommodation -Extraocular movement -Extraocular movement Funduscopic ExaminationFunduscopic Examination - red orange reflex- red orange reflex - optic disc - optic disc - - blood vessels blood vessels - - Hemorrhages, exudatesHemorrhages, exudates Visual acuity Visual acuity - - Near VisionNear Vision - - Far VisionFar Vision - - Peripheral visionPeripheral vision n n EARSEARS Inspection: Inspection: Auricle (anterior smooth, soft, right lobe of the thyroid; smooth, soft, nontender, moves freely when patient nontender, moves freely when patient swallowsswallows Objective 5:Record abnormal Objective 5:Record abnormal FindingsFindings n n To be able to identify and record different To be able to identify and record different disorders of head ,neck, eyes, ears, nose disorders of head ,neck, eyes, ears, nose and throatand throat FaciesFacies n n Expression or appearance of the face and Expression or appearance of the face and features of the head and neck that whenfeatures of the head and neck that when considered together, are characteristics of considered together, are characteristics of a clinical condition or syndromea clinical condition or syndrome n n Acromegaly Acromegaly n n -large head -large head n n - forward projection of jaw - forward projection of jaw n n - protrusion of frontal bone - protrusion of frontal bone Cushing Syndrome Cushing Syndrome n n - thin erythematous skin - thin erythematous skin n n - hirsutism - hirsutism n n - rounded or moon - rounded or moon n n shaped face shaped face Mxyedema Mxyedema n n - dull, puffy, yellowed - dull, puffy, yellowed n n skin skin n n - coarse sparse hair - coarse sparse hair n n - temporal loss of - temporal loss of n n eyebrows eyebrows n n - periorbital edema - periorbital edema n n - prominent tongue - prominent tongue Hyperthyroid Facies Hyperthyroid Facies n n - fine moist skin - fine moist skin n n - fine hair - fine hair n n - prominent eyes - prominent eyes n n - lid retraction - lid retraction n n - startled expression - startled expression n n (R) Facial Palsy (R) Facial Palsy n n - assymmetry of one side of - assymmetry of one side of n n the face the face n n - eyelid not closing completely - eyelid not closing completely n n - loss of nasolabial fold - loss of nasolabial fold n n - drooping lower eyelid and - drooping lower eyelid and n n corner of the mouth corner of the mouth SIGNSSIGNS n n Hydrocephalus Scars Head tumorHydrocephalus Scars Head tumor n n Alopecia Alopecia areataareata SYMPTOMSSYMPTOMS HEADACHE HEADACHE nHEADACHE - refers to pain perceived more than momentarily in the cranial vault , orbits and the nape. Pain elsewhere in the face is not included nMechanisms of Headache 1. infection meningitis, encephalitis 2. arterial dilatation Malignant Hypertension 3. hemorrhage intracebral , subdural and SAH 4.Expanding mass lesion brain tumor 5. Trauma head trauma , inc. ICP 6. Tissue Ischemia hypoxia, hypoglycemia n n Muscle contraction headache Muscle contraction headache n n Muscle Contraction Headache: TensionMuscle Contraction Headache: Tension Headache Headache - Mild or moderate discomfort, a heavy feeling, a - Mild or moderate discomfort, a heavy feeling, a sense of pressure, tight band, steady rather sense of pressure, tight band, steady rather than throbbingthan throbbing - related to emotional tension - related to emotional tension - not intensified by coughing - not intensified by coughing - improved by shaking the head, massage, mild - improved by shaking the head, massage, mild analgesics, application of hot packsanalgesics, application of hot packs n n Migraine HeadacheMigraine Headache n n Classic MigraineClassic Migraine 4 phases 4 phases 1. 1. ProdromeProdrome- an attack is often triggered - an attack is often triggered by period of anxiety, tension, by period of anxiety, tension, bright light, loud noise, bright light, loud noise, skipped meals, foods and skipped meals, foods and beverages, strong odors and beverages, strong odors and change in sleep patterns change in sleep patterns 2. Aura visual disturbances2. Aura visual disturbances 3. Headache3. Headache - frequently present on awakening - frequently present on awakening -severe throbbing, boring, aching -severe throbbing, boring, aching headache over 1 hr. headache over 1 hr. - does not disrupt sleep - does not disrupt sleep - increased in the reclining position, shaking - increased in the reclining position, shaking the head, coughing or straining at stool the head, coughing or straining at stool - - Associated symptoms are N/V, Associated symptoms are N/V, photophobia, annoyance for odors, photophobia, annoyance for odors, maybe normal or cold limbs and pale skin maybe normal or cold limbs and pale skin 4. Recovery4. Recovery n n Cluster HeadacheCluster Headache n n Cluster headache : Histamine headacheCluster headache : Histamine headache or Histamine Cephalgia or Histamine Cephalgia - due to dilatation of branches of the - due to dilatation of branches of the internal carotid artery internal carotid artery - 5-6x more common in men - 5-6x more common in men - onset is typically 3 - onset is typically 3rd rd- 4 - 4th th decade of life decade of life - commonly episodic and begins w/o - commonly episodic and begins w/o aura aura - - Unilateral , severe ,boring, and throbbing Unilateral , severe ,boring, and throbbing headache that recurs consistently on the headache that recurs consistently on the same side lasting an average of 40 minsame side lasting an average of 40 min - - Associated symptoms are flushing, Associated symptoms are flushing, rhinorrhea, conjunctivitis, lacrimation, rhinorrhea, conjunctivitis, lacrimation, temporal artery dilatation on the affected temporal artery dilatation on the affected side, sweating of the skinside, sweating of the skin Other causes of headache: Other causes of headache: n n Hypertensive headacheHypertensive headache n n Brain tumorBrain tumor n n Hemorrhage Hemorrhage -intracereberal hemorrhage -intracereberal hemorrhage -subarachnoid hemorrhage -subarachnoid hemorrhage n n Bacterial meningitisBacterial meningitis n n Lumbar puncture headacheLumbar puncture headache nHypertensive headache - due to segmental dilatation of branches of external carotid artery - headache occurs in half of patients with accelerated HPN without encepalopathy - Headache often occipital, no aura - Diastolic pressure must exceed 120 mm hg to cause headache nBrain tumor -Benign and malignant intracranial neoplasms compress and place traction on surrounding structures -Headache maybe the first symptom, the onset is recent, a recent change in the customary headache pattern has occured -An apparent migraine aura persists after the headache subsides -Headache starts by abrupt change in position, exertion and inc. in recumbent position -May interfere with sleep nSubarachnoid hemorrhage -Results fr. rupture of a saccular anuerysm of the circle of willis, preceeded often by a leakage -Excruciating generalized headache, followed by nuchal rigidity, then coma, often death nMeningitis -Headache , fever and signs of meningeal irritation ( nuchal rigidity) -Headache intensified by sudden movement of the head NECKNECK n n Stiff neck:Stiff neck: 1) 1) TorticollisTorticollis ( wryneck) ( wryneck) - the congenital type is due to - the congenital type is due to hematomahematoma or partial rupture of the muscle at or partial rupture of the muscle at birthbirth resulting in unilateral muscle resulting in unilateral muscle shorteningshortening 2) Idiopathic 2) Idiopathic fibromyalgiafibromyalgia 3) inflammatory/immune 3) inflammatory/immune osteomyelitisosteomyelitis 4) Infectious 4) Infectious pharyngitispharyngitis, meningitis, meningitis 5) Metabolic - Tetanus5) Metabolic - Tetanus 6) Mechanical /trauma- fracture, 6) Mechanical /trauma- fracture, dislocationdislocation 7) 7) NeoplasticNeoplastic thyroid cancer, lymphoma thyroid cancer, lymphoma 8) 8) NeurologicNeurologic parkinsonsparkinsons disease disease 9) Psychosocial malingering 9) Psychosocial malingering n n Nongoitrous cervical massesNongoitrous cervical masses Midline cervical mass Midline cervical mass - - Thyroglossal cystsThyroglossal cysts - - Suprahyoid cystsSuprahyoid cysts - - Subhyoid cystsSubhyoid cysts - - Pyramidal lobe of thyroidPyramidal lobe of thyroid - - Thyroid cartilage cystsThyroid cartilage cysts - - Cricoid cartilage cystsCricoid cartilage cysts Lateral cervical cystLateral cervical cyst - - Branchial cystBranchial cyst - - HygromaHygroma - - Carotid body tumorCarotid body tumor - - Cavernous hemangiomaCavernous hemangioma - - Branchial fistula Branchial fistula - - Zenkers diverticulum ( pharyngeal pouch)Zenkers diverticulum ( pharyngeal pouch) ThyroidThyroid n n Thyroid enlargement ( GOITER)Thyroid enlargement ( GOITER) - results from: - results from: a) hyperplasia of the thyroid tissue a) hyperplasia of the thyroid tissue b) infection b) infection c) c) neoplasticneoplastic growth ( primary thyroid cancer, growth ( primary thyroid cancer, metastaticmetastatic growth, lymphoma) growth, lymphoma) d) infiltration with foreign substances ( d) infiltration with foreign substances ( amyloidamyloid) ) - - - patient complains of fullness of mass in - patient complains of fullness of mass in the neck , pressure symptomsthe neck , pressure symptoms - Determine the size of the component of - Determine the size of the component of the gland, extension the gland within the the gland, extension the gland within the neck or into the neck or into the retrosternalretrosternal space, space, fixation to surrounding structuresfixation to surrounding structures -characterize the enlarge thyroid as -characterize the enlarge thyroid as diffuse, focal, nodular, or smoothdiffuse, focal, nodular, or smooth - tenderness- tenderness -make an assessment of the state of thyroid -make an assessment of the state of thyroid function: Hypothyroid, Hyperthyroid, function: Hypothyroid, Hyperthyroid, euthyroideuthyroid - - Clinical classification is based whether thyroid Clinical classification is based whether thyroid is diffuse or nodularis diffuse or nodular - - Level of functional thyroid state: Level of functional thyroid state: a) toxic goiter a) toxic goiter b) nontoxic goiter ( b) nontoxic goiter ( euthyroideuthyroid or hypothyroid) or hypothyroid) n n RetrosternalRetrosternal Goiter ( Goiter ( substernalsubsternal, , intrathoracicintrathoracic , or submerged goiter) , or submerged goiter) - when the lower border of a goiter cant - when the lower border of a goiter cant be palpatedbe palpated - Goiter may rise only with inc. - Goiter may rise only with inc. intrathoracicintrathoracic pressure like coughing. This pressure like coughing. This is also called plunging is also called plunging goiter. goiter. n2 physical signs of retrosternal goiter nTracheal displacement nVenous engorgement in the neck n n Diffuse toxic goiter ( Graves Disease)Diffuse toxic goiter ( Graves Disease) -autoimmune disease char. by goiter, -autoimmune disease char. by goiter, exophthalmosexophthalmos, , pretibialpretibial edema, edema, hyperthyroidismhyperthyroidism n n Thyroid syndromesThyroid syndromes - excess or deficit of thyroid hormones - excess or deficit of thyroid hormones alter the physical structure of the body to alter the physical structure of the body to produce physical signsproduce physical signs - examine your patient to determine the - examine your patient to determine the size of the TG, to assess thyroid function, size of the TG, to assess thyroid function, to judge the likehood of cancerto judge the likehood of cancer n n Thyroid syndromesThyroid syndromes a) Hyperthyroidism a) Hyperthyroidism - overproduction of the thyroid - overproduction of the thyroid hormone or excessive thyroid hormone or excessive thyroid medication medication - often with generalized muscle weakness, - often with generalized muscle weakness, energetic, irritable, tachycardic, tremor energetic, irritable, tachycardic, tremor frequent defecation, wt. loss , inc appetite frequent defecation, wt. loss , inc appetite b) Hypothyroidismb) Hypothyroidism -due to iodine deficiency, deficit of TH, -due to iodine deficiency, deficit of TH, excessive dose of thiouracil drugs, excessive dose of thiouracil drugs, lithium, thiocyanates, paraaminosalicylic lithium, thiocyanates, paraaminosalicylic acid, phenylbutazone acid, phenylbutazone - slow metabolism, fatigue, loss of energy, - slow metabolism, fatigue, loss of energy, wt gain, constipation, coldnesswt gain, constipation, coldness Lymph NodesLymph Nodes n n Determine if the lymph node is localized Determine if the lymph node is localized to the neck or generalized in other parts to the neck or generalized in other parts of the bodyof the body n n Acute cervical lymphadenopathyAcute cervical lymphadenopathy 1) Localized lymphadenitis1) Localized lymphadenitis - common infections of the scalp, face, - common infections of the scalp, face, mouth, teeth, pharynx or ear mouth, teeth, pharynx or ear nSubmental lymph nodes - primary lesions from the lower lip, anterior tongue, floor of the mouth nPosterior cervical lymph nodes and occipital - primary lesions from the posterior 2/3 of the scalp and nasopharynx nAnterior cervical lymph nodes - primary lesions from anterior 2/3 of the scalp, face including maxillary sinus, oral cavity ( tongue, tonsils, larynx) 2) Generalized lymphadenitis2) Generalized lymphadenitis - syphilis - syphilis - rubella - rubella - IM - IM - HIV - HIV - Generalized - Generalized FurunculosisFurunculosis n n Chronic localized cervical Chronic localized cervical lymphadenopathylymphadenopathy a) TB a) TB b) Hodgkin disease b) Hodgkin disease c) c) actinomycosisactinomycosis d) Virchow node ( sentinel node)d) Virchow node ( sentinel node) -enlargement of a single lymph node -enlargement of a single lymph node usually in the left usually in the left supraclavicularsupraclavicular group group - it may be the result of either abdominal - it may be the result of either abdominal or thoracic malignancyor thoracic malignancy Thank YouThank You n n Definitions of Parts Shown AboveDefinitions of Parts Shown Above n n Helix - The in-curve rim of the external earHelix - The in-curve rim of the external ear n n Antihelix - A landmark of the outer earAntihelix - A lan