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Examinations of Face and Head
https://t.me/med1917
Fig. 15.12: Cleft palate Type II a—bifid uvula.
Fig. 15.13: Cleft palate Type II b—bifid soft palate
(entire soft palate).
361
Congenital Short Frenum of Upper Lip
It is seen with a wide gap between the permanent incisor
teeth. Congenital fistulae of lower lip are two rare
blind pits one on either side of the midline containing
wide open mucus secreting glands.
Hydrocephalous
It is dilatation of ventricles due to blockage of flow
of cerebrospinal fluid (CSF).
Classification I
(a) Communicating type: Ventricles communicate
freely into the subarachnoid space. Here there is defective absorption of CSF following any inflammation,
subarachnoid haemorrhage or trauma. (b) Noncommu-
nicating type: Obstruction is in the ventricle or its
exit due to any tumours or any inflammatory process.
Classification II
Congenital: It is asociated with spina bifida/myelomeningocele. There is failure of formation of CSF
pathway . It is associated with Arnold-Chiari syndrome,
congenital stenosis of aqueduct of Sylvius. Clinical
features: Widening/separation of suture lines; bulged
tense fontanelle; engorged scalp veins; sun setting eye;
decreased cortical thickness; enlarged head. Acquired:
It may be unilateral or bilateral. It is due to chronic
meningitis, trauma, subarachnoid haemorrhage, brain
tumours, colloid cyst of 3rd ventricle, arachnoid cysts
(Fig. 15.15).
Fig. 15.14: Cleft palate Type II c—bifid soft palate entire
length with cleft of posterior hard palate (anterior palate
is normal).
Fig. 15.15: Hydrocephalous.
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SRB’s Clinical Surgery
Meningocele
Meningocele is protrusion of the meninges. It contains
clear fluid—CSF. It is brilliantly transilluminant. It
shows impulse on coughing or crying. Meningo-
encephalocele is protrusion of brain also along with
meninges. It is transilluminant. Encephalocele is
protrusion of brain. It is not transilluminant. There
may be neurological deficits, incontinence of urine
and faeces. These conditions are seen in midline –
root of the nose, occiput, anterior fontanelle region.
Often it is associated with spina bifida (Fig. 15.16).
Fig. 15.16: Encephalocele.
Preauricular Sinus
It is due to failure of fusion of anterior tubercles of
the auricle creating a sinus. Ear develops from six
tubercles. This sinus opens at the root of the helix
or on tragus. Sinus track runs downwards and ends
blindly. Often sinus opening gets sealed forming a
preauricular cyst which gets infected forming an
abscess. Sinus can get infected repeatedly discharging
pus through its opening. It is often multiple. Sinusogram
and study of discharge is needed. It often mimics cold
abscess or sebaceous cyst (Fig. 15.17).
Traumatic Problems of Face and Head
Head, faciomaxillary injuries are discussed in detail
in Chapters 11: Examination of Jaw and 29:
Examination of Intracranial Diseases.
Haematoma scalp is very common traumatic
swelling observed. It is common in 2nd layer –
connective tissue dense or 4th layer galea aponeurotica.
Haematoma in 2nd layer is localised, tender and tense
swelling. Haematoma in the 4th layer is often diffuse
and extensive. In front it may extend into the root
of nose and eyelids as galea aponeurosis is not attached
to any bone in front. Fracture of underlying skull bone
should be also thought of. Neurological deficits should
be assessed using Glasgow coma scale. Fracture in
the line of venous sinuses can be dangerous and life
threatening.
Subperiosteal haematoma also called as cephal-
haematoma. It is collection of blood under the
pericranium. It is common in newborn after forceps
delivery. It is comon in parietal region. It is localised,
smooth, soft, fluctuant swelling limited to the suture
lines of the particular bone. It gradually disappears
in few months (Figs 15.18 and 15.19).
Fig. 15.17: Preauricular sinus.
Fig. 15.18: Traumatic eyelid haematoma.
Problems with Infective Lesions of
Face and Head
Cavernous Sinus Thrombosis
Infection from face and scalp may extend through
various routes to cavernous sinus causing its thrombosis. Routes are – along angular vein to ophthalmic
vein; along pterygoid plexus of veins which
Examinations of Face and Head
https://t.me/med1917
Fig. 15.19: Extensive soft tissue injury of face.
communicate deep facial vein to cavernous sinus across
foramen ovale and foramen lacerum. Patient develops
toxicity, proptosis, squint, ocular muscle paralysis
specifically lateral rectus which is supplied by abducent
nerve which is situated within the cavernous sinus.
Dangerous zone in the face is located in the area of
nose and upper lip as infection in this area is more
prone to develop cavernous sinus thrombosis. Any
boil, cellulitis, erysipelas, abscess in this zone can
cause this complication (Figs 15.20A and B).
Pott’s Puffy Tumour
Pott’s puf fy tumour is localised pitting oedema of the
scalp with adjacent cranial bone osteomyelitis. Acute
pain, localised swelling and tenderness with often
osteomyelitis of the underlying bone are the features.
It is common in frontal region. Acute frontal sinusitis
may be the initial pathology . Intracranial spread may
cause extradural abscess.
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A
B
Figs 15.20A and B: Dangerous area – triangular area
in the nose and upper lip.
Cancrum Oris
Cancrum oris is an infective gangrenous stomatitis
destructing gums, gingivae, cheek ; seen in debilitated
children after measles, kala azar, typhoid (Fig.
15.21).
Fig. 15.21: Cancrum oris extensively involving gingiva
and lower lip with plenty of maggots in it.
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Lupus Vulgaris
SRB’s Clinical Surgery
Lupus vulgaris is cutaneous tuberculosis extensively
involving face often, with destruction and ‘apple jelly’
like lesions.
Actinomycosis of Mandible
Actinomycosis of mandible can cause multiple sinuses
discharging sulphur granules in the lower jaw . Microscopy shows ‘Ray fungus’ nature of the bacteria
Actinomycosis israelii.
Benign Swellings of the Face and Head
Papilloma, lipoma, haemangioma, sebaceous cyst,
Cock’s peculiar tumour due to sebaceous cyst, dermoid
cyst, osteoma, cirsoid aneurysm, mucus cyst of lips
can occur (Figs 15.22 to 15.25).
Fig. 15.22: Dermoid ear.
Fig. 15.24: Multiple scalp swellings
(multiple sebaceous cysts) scalp.
Fig. 15.25: Sebaceous horn scalp.
Cirsoid Aneurysm
Cirsoid aneurysm is seen only in face in the forehead
affecting the superficial temporal artery, as dilated
interwoven artery and its branches. It feels like a ‘bag
of pulsating earthworms’ with thinned out overlying
skin with loss of hair ; often ulceration and severe
bleeding can occur. Intracranial extension is known
to occur into extradural space. X-ray skull shows bone
erosion.
Fig. 15.23: Eyelid swelling—upper eyelid.
Osteoma
Osteoma is common in skull bone which is compact
or ivory type and is sessile type. It affects the outer
table of the skull bone – frontal, parietal or occipital
bones. Painless bony hard nonmobile swelling in the
skull bone is the presentation. It does not turn into
malignancy.
Examinations of Face and Head
https://t.me/med1917
Paget’s Disease of Bone
Paget’s disease of bone causes progressive enlar gement
of the skull with thickened skull bones with systolic
bruit on auscultation due to vascularity.
Malignant Conditions of Face
and Head
Malignant conditions like basal cell carcinoma (rodent
ulcer), squamous cell carcinoma of lip or skin, malig-
nant melanoma, secondaries in skull, osteosarcoma,
can occur. Secondaries in skull can occur from primaries from thyroid, kidney, lungs, adrenals, breast, etc.
It is hard tender, multiple. It can be solitary also. Soft,
localised warm vascular pulsatile secondaries are seen
in secondaries from follicular carcinoma of thyroid.
Cylindroma
Cylindroma often called as turban tumour occurs in
the scalp involving entire scalp area as red lobulated
slow growing relentless rare tumour which is locally
malignant with alopecia in the affected area. It should
be differentiated from plexiform neurofibromatosis
and temporal arteritis.
Examination of Cranial Nerves
Cranial nerve palsies that commonly presents in head
and face is being discussed in this chapter.
Cranial nerves are Olfactory; Optic; Oculomotor;
Trochlear; Trigeminal; Abducent; Facial; Auditory;
Glossopharyngeal; Vagus; Accessory; Hypoglossal
nerves. (Mnemonic—On Old Olympus T owering Tops
A Finn And German Picked Some Hops).
Olfactory
Sense of smell is tested with cloves, peppermint, etc.
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levator palpebrae superioris and muscle of accommodation. In oculomotor nerve palsy eye looks downwards
and outwards with ptosis (drooping of upper eyelid)
and fixed pupil. Superior rectus - to look up; medial
rectus – to converge; inferior rectus – to look down;
inferior oblique – to look up and out.
Trochlear
It supplies superior oblique muscle. When it gets
damaged turning eye downwards and outwards is
defective and patient looks inwards with diplopia below
the horizontal line.
Trigeminal
Sensory supply is to entire one side of the face by
three divisions – ophthalmic - upper ; maxillary –
middle ; mandibular – lower. Ophthalmic division also
supplies conjunctiva. Maxillary branch supplies
mucous membrane of nose, pharynx, roof of mouth,
soft palate and tonsil ; mandibular division to tongue,
lower teeth, mucous membrane of the mandible.
Sensations should be checked in this place.
Conjunctival reflex, palatal reflex will be altered. In
trigeminal neuralgia there is hyperaesthesia with touch
becoming pain. During the period of neuralgic attack
entire area is hyperaesthetic. Only certain trigger zones
of Patrick are hyperaesthetic in between attacks. Motor
supply to masseter, pterygoids and temporalis is from
mandibular branch. Clenching the teeth will confirm
the same. While opening the mouth widely jaw deviates
towards the affected side due to weakness of pterygoids.
Taste from anterior 2/3rd is through lingual nerve via
chorda tympani from geniculate ganglion. Sweet
(sugar), sour (acid), salt (salt) and bitter (quinine) tastes
are checked. Salt and sweet in the tip of the tongue
(through chorda tympani) ; sour is in lateral margin
of tongue through trigeminal nerve ; bitter is in posterior
tongue through glossopharyngeal nerve.
Optic
V isual acuity (ability to read), visual fields (peripheral
vision to be checked in one eye and compared to
examiner’s), Colour vision using charts.
Oculomotor
It supplies all extrinsic muscles of eyeball except
superior oblique (trochlear) , lateral rectus (abducent),
Abducent
Abducent nerve supplies the lateral rectus muscle of
the eye. Turning of eye outwards is defective in its paralysis and attempt to look sidewards will cause diplopia.
Facial
It supplies muscles of facial expression. It is motor
nerve. Supranuclear palsy causes lower facial palsy;
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SRB’s Clinical Surgery
infranuclear palsy causes entire facial nerve palsy.
Features includes—Eyelids cannot be closed; whistling
is defective; angle of the mouth deviates; wasting of
the muscles of the side; wrinkling of eye is defective;
inability to close the eyes properly (Fig. 15.26).
Fig. 15.26: Features of facial palsy.
Auditory
It supplies cochlea and semicircular canals. Weber’s
tuning fork test is used to rule out conductive deafness.
After placing the tuning fork on the forehead louder
sound is felt on the side of conductive deafness. Tuning
fork is placed on mastoid to get louder sound in
conductive deafness in Rinne’ s test. In sensory deafness
there is no change in sound appreciation. Assessing
the response to changes in temperature in the external
meatus – calorie test is used to check the sensitivity
of the vestibular apparatus.
Glossopharyngeal
It is sensory to posterior third of the tongue (and also
carries bitter taste checked by using quinine) and to
mucous membrane of pharynx. It is motor to middle
constrictor. Gag reflex can be elicited by stroking the
back of oropharynx.
Vagus
It is motor to soft palate, pharynx and larynx and
sensory to gut, heart and lungs. After opening the mouth
patient is asked to say ‘ Aahh’. Soft palate arches
upwards symmetrically. In paralysis of one side, it
will not arch symmetrically and uvula gets pulled
towards functioning (opposite) side. Change in voice,
inability to cough and vocal cord palsy in indirect
laryngoscopy are the other features.
Spinal Accessory
Wasting of sternomastoid and trapezius is obvious.
When chin is pushed towards opposite side against
resistance weakness can be appreciated; shrugging of
the shoulder against resistance when checked from
behind is defective.
Hypoglossal
It is motor to tongue. When it is paralysed, wasting
of tongue is seen on the same side; tongue deviates
towards same side while protruding out.
Examination of Breast
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Examination of
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16
Pain and/or lump in the breast are the common
complaints for which patient consults a surgeon or
gynaecologist or breast clinic.
History
Chief Complaints
• Swelling in the right/left breast/both breasts; its
time duration.
• Pain in the breast with duration; ulceration in the
breast with duration.
• Discharge from nipple.
• Swelling in the breast/axilla/neck.
History of Present Illness
Swelling: History of duration of swelling, its progression whether slowly increasing in size or rapidly
increasing has to be asked for. Swellings of short
duration are most probably due to carcinoma. But most
often, once the swelling is noticed the patient immediately consults a doctor for opinion and so duration
may not be clearly obtained. Condition like fibroadenoma and fibroadenosis has got long duration of
history. Duration in carcinoma is usually only few
weeks. History of swelling in the opposite breast is
also important. In 2% of cases, breast carcinomas are
bilateral; and so also fibrocystadenosis which
commonly has bilateral presentation.
Pain: Pain in the breast is often termed as mastalgia.
It is common in fibrocystadenosis and acute mastitis.
There will be associated fever in mastitis. Carcinoma
breast is initially painless but eventually becomes
painful following infiltration or development of tumour
necrosis or skin ulceration/fungation. Pain in fibroadenosis is more prior to menstruation (cyclical), and may
Breast
disappear during pregnancy and after menopause.
Duration of pain, type, timing, site and relation to
menstruation has to be noted. Referred pain from
muscle and skeletal system (ribs) can also develop
in the breast. Periductal mastitis/duct ectasia can cause
pain. Patient with breast abscess will show severe
excruciating pain in the breast.
Nipple discharge: Duration of discharge, its type
whether it is of serous/purulent/bloody/serosanguinous/milky/greenish type has to be asked for and noted.
Bloody discharge is often seen in duct papilloma,
carcinoma. Serous and greenish discharge is seen in
fibroadenosis.
History of changes in nipple: Like retraction
(depression), deviation, destruction, displacement,
discolouration, duplication and discharge is noted.
Recent history of changes signifies carcinoma. Often
retraction may be congenital, since birth.
History of alteration in size and asymmetry of the
breasts should be asked for with duration.
History of trauma: Trauma may cause haematoma in
the breast and breast abscess. Direct or indirect trauma
often can cause traumatic fat necrosis after few
weeks. Here trauma may be forgotten or may not be
noticed by the patient and swelling developed due
to traumatic fat necrosis is painless, nonprogressive
and nonregressive.
History related to swelling in the axilla/neck and their
details like duration, progress, pain, ulceration, etc.
is noted.
History related to respiratory pr oblems has to be asked
like chest pain/breathlessness/cough/haemoptysis—
signifies the secondaries in lung from carcinoma breast.
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SRB’s Clinical Surgery
History of abdominal pain, loss of appetite, decreased
weight, jaundice, and abdominal distension should be
asked for which signifies liver secondaries.
History related to bone secondaries—like bone pain,
low back pain, altered sensation like sense of position
and vibration, lower limb weakness, features of paraplegia, loss of control over urination and defecation
is asked for.
History of convulsions, loss of consciousness, vomiting, limb weakness, headache, visual disturbances,
behavioral changes (psychological changes) and
localisation changes may seen whenever there is brain
metastases.
Past History
Past history of any surgeries of breast (recurrence can
occur after excision of fibroadenoma, conservative
breast surgery may cause recurrent carcinoma breast)
or drug therapies like for fibroadenosis. Abscess may
recur in congenital retraction of nipple; tuberculosis
of breast can show recurrence; fibroadenosis may
present repeatedly with long gaps of asymptomatic
period.
Menstrual History, Obstetric History and
Family History
This is important in breast diseases as breast carcinoma
can be familial. Family history of carcinoma of breast
(in mother, grandmother, aunt, cousins, and 1st and
2nd degree relatives), ovarian tumour or other tumours
has to be noted. Often multiple tumours can occur.
History of age of menarche and menopause, menstrual
cycles, marital status, number of pregnancies, breastfeeding, last child birth and usage of contraceptives/
postmenopausal HRT are very important. Fibroadenosis and carcinoma are more common in unmarried
individuals.
Personal History and Treatment History
History of smoking, alcohol intake, dietary habits (high
fat diet) is noted. History of any drug intake at present
is important.
General Examination
Like for any other long case, patient should be examined for pallor, jaundice, oedema feet and clubbing.
Pulse and blood pressure should be checked.
Local Examination of Breasts
Usually normal breast should be examined first. Proper
exposure of both breasts from neck to waist should
be done. While examining the breasts adequate privacy;
and presence of a female nurse is a must. Initially
examination is carried out with the patient sitting in
45° semi-recumbent position (lying flat makes breasts
flatten and fall sideways; upright sitting position makes
breasts pendulous and bulky). Later examination is
done in lying down (recumbent) position as lump is
better felt against chest wall for additional information.
During inspection, the clinician should stand in front
and later on the side of the patient. Commonly used
position is sitting posture as it is easier to examine
nipples, lump and axillary nodes; and patient also will
Breast is examined in different positions to elicit different
clinical features.
• Sitting position with arms by the side
• 4 5° semi-recumbent position is very much convenient
• Sitting position with leaning forward
• Sitting position with arms over the waist
• Sitting position with arms rising above the shoulderto see fixity to chest wall and changes in nipple
• Lying down position for self-examination
Inspection
For proper inspection, both breasts should be exposed
properly including axillae. Inspection is done in sitting
position with the arms by the side of the body.
Inspection is also done with the arms raised above the
shoulder touching the head (with arms touching the
ears) so that nipple levels, lump, dimples are seen well.
Inspection is also done with the arms on the hips
pressing and relaxing so that skin dimpling, nipple
movements and changes become more prominent.
Examination/inspection done in bending forward
position helps to see whether breast falls forward or not;
and also to see nipple retraction or failure of nipple to
fall away. Carcinoma fixed to chest wall will not fall
forward while bending forward (Figs 16.1A to 16.3).
Examination of Breast
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A
A
369
B
C
Figs 16.1A to C: Examination of breast is done in
sitting position with arms beside.
B
C
Figs 16.2A to C: Examination with both arms raised
above the shoulder and leaning forward.
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Fig. 16.3: Examination in 45°
semi-recumbent position.
SRB’s Clinical Surgery
Inspect both breasts—note the size, shape and
symmetry. Asymmetry can be seen in breast lumps.
Inspect both breasts while leaning forward to see
whether both breasts fall forward or not. In carcinoma,
if the breast lump gets fixed to underlying chest wall,
it will not fall forward. Both breasts should be inspected
while the arms are raised upwards to see whether breast
is/breasts are adherent to chest wall (Fig. 16.4).
of nipple, discharge/ulceration in the nipple,
discolouration, duplication, cracks/fissures. Many of
these changes occur in carcinoma. Fissuring and cracks
can occur in breastfeeding mothers Nipple retraction
of recent onset may be due to infiltration of lactiferous
duct by carcinoma. Often congenital retraction may
be present; so duration of nipple retraction is very
important. Retraction of nipple can occur in duct
ectasia/periductal mastitis also. Nipple retraction is
circumferential in carcinoma; slit like in periductal
mastitis. Vertical distance from the clavicle and horizontal distance from the midline should be measured
and compared to opposite side. Nipple may be drawn
towards the lump in the affected breast. Nipple
elevation may become prominent by raising the arm
above the head; which may be due to inflammatory
pathology (Figs 16.5A and B). In fibroadenoma nipple
Inspection of nipple – Look for symmetry/asymmetry ,
pushed up/down, displacement, retraction, size/shape
Fig. 16.4: Lump in the breast left sided. Obvious lump
is visible in the upper quadrant.
A
B
Figs 16.5A and B: Nipple deviation and retraction
should be looked for in breast lumps.
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