Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4440_Библиотеки_им_академика_М_И_Перельмана.pdf
396
13 History andExamination ofMaxillofacial Trauma
• Nasal deformity—The deformities due
to trauma may range from depression
or deviation of one side of the nose to
depressed dorsum.
• Internal examination of the nose (anterior rhinoscopy) to know any septal
haematoma, deviation of septum and
bleeding.
(b) Palpation—Nasal dorsum and side of
nose should be palpated for;
• Tenderness—This may be due to either
soft tissue injury or bony injury.
• Crepitation at fracture site—
Crepitation at the trauma site is due to
abnormal movement of the fracture
segment, and it suggests fracture of
nasal bone with displacement.
• Abnormal movement of the fractured
segment—This suggests a displaced
fracture.
• Step deformity over dorsum on nose—
This is due to fracture.
• ARS—This is done to know fracture of
the septum, bleeding or watery
discharge.
3. Examination/signs of zygomaticomaxillary
complex
Signs of ZMC fractures
(a) Inspection: A patient with facial trauma
with suspicion of zygomatic fracture
should be inspected for;
• Inspection of the cheek area
– Subconjunctival and periorbital
oedema are always presents except
in case of the isolated fractured
zygomatic arch.
– Spectacle haematoma—It is a type
of periorbital haematoma.
– Ecchymosis/bruises of the cheek
and eyelids.
– Depression deformities—Malar
prominence attening, depressed
zygomatic arch (masseter muscle
may result in medial, inferior and
posterior rotation of the zygoma).
– Subcutaneous emphysema—This
is due to an orbital oor fracture.
• Oral cavity inspection
– Trismus (reduced jaw mobility)—It
may result from compression of the
zygomatic arch on the temporalis
muscle and coronoid process.
• Inspection of eye and orbit
– Diplopia—This is due to extraocular
muscle contusion or entrapment.
– Upward gaze diplopia is the most
common secondary entrapment of
the inferior rectus muscle and soft
tissue surrounding it.
– Enophthalmos or hypophthal-
mos: Disruption of the bony orbit
often results in expansion of the
orbital volume and herniation of
orbital contents.
– Proptosis—This is due to a decrease
in size of the orbit by medial displacement of the fractured segment.
– Anti mongoloid slant—Downward
displacement of the eye on the lateral side is due to fracture displacement of the lateral orbital rim and
lateral canthal ligament.
(b) Palpation
• Palpable periorbital step ladder deformity, bone gap, or abnormal movement—This is palpated by running the
index nger side by side over orbital
margins. On the inferior orbital margin, the lateral segment usually lies
below the medial segment.
• Tenderness—The sites of tenderness
indicate fracture site.
• Subcutaneous emphysema—This is
due to the fracture of the orbital oor
at the junction of the zygomaticomaxillary suture.
• Anaesthesia or paraesthesia of the
cheek, nose, upper lip and lower eyelid—This is due to the infraorbital
nerve injury that can be checked with a
gentle touch.
• Tenderness and depression along the
arch of the zygoma are felt in the fractured zygomatic arch.
13.2 Examination ofSpecic Area
397
• Comparison of forced duction tests on
each eye can help to identify the specic site of muscle entrapment. This
study is much easier to perform under
general anaesthesia. Evaluation of
unanaesthetised patients is often difcult because of poor patient
cooperation.
• Intraoral palpation may reveal swelling
or haematoma at the zygomaticomaxillary buttress.
4. Examination/signs of nasoethmoid
fracture-
(a) Inspection
• Height of dorsum of nose—There is
loss of height of dorsum.
• Soft tissue swelling, ecchymoses,
gross blood, laceration over nasoethmoid area, haematoma and ecchymosis indicate underlying fracture.
• Telecanthus—Increased intercanthal
distance is diagnostic for nasoethmoid
fracture.
• Mongoloid slant—This is a nding
present in NOE fracture in which
medial canthus is displaced
downward.
• Pig snout appearance—Nasal bridge
depression with elevation of tip of
nose.
• Narrowing of the horizontal palpebral
ssure.
• Periorbital and mid-face swelling and
bruising.
• Watery nasal discharge—It should
raise the possibility of a CSF leak.
This is indicative of a fracture to the
frontal bone or anterior skull base.
• Saddle-nose deformity—Flattened
nose with widened nasal dorsum.
• Thorough eye examination—The eye
should be examined for subconjunctival haemorrhage, visual acuity, pupillary responses, circumorbital oedema
and extraocular motion, which is
crucial.
• Periorbital swelling—It may indicate
associated LeFort II or III fractures.
• Rounded canthi (‘cow’s eye’)—It is
another common sign of a dislocated
fracture.
(b) Palpation
• The presence of mobile bony segments, step ladder and crepitus suggest
a fracture.
• Epistaxis—This may be due to a rupture of the anterior ethmoidal artery.
• Forehead paraesthesia—This is due
to supraorbital and supratrochlear
nerve involvement.
• Intercanthal distance—It refers to
the distance between the medial canthus of the eyes. The increased distance is called telecanthus.
• Interpupillary distance—It should be
approximately double the intercanthal
distance.
• Interpupillary and intercanthal dis-
tance ratio—The intercanthal distance should be compared to the
interpupillary distance. Normally, the
intercanthal distance is half of the
interpupillary distance. If the intercanthal distance exceeds one-half the
interpupillary distance, traumatic telecanthus must be considered.
• Eyelid traction test—This is to
check the integrity of the MCT
(medial canthal ligament). In this
test, the examiner grasps the lower
lid and pulls laterally while palpating the nasal root. A lack or reduction of tension with lateral pull
suggests NOE fracture with MCT
displacement.
• Bow string test—The eyelid is to be
grabbed between the thumb and
index nger or skin of the medial
canthal area to be held with a forcep
and pulled laterally while the MCT
area is palpated to detect movement
of fracture segments. A lack of resistance or movement of the underlying
bone is indicative of a fracture
(Fig.13.7f, q).
398
13 History andExamination ofMaxillofacial Trauma
• Subcutaneous emphysema—
Subcutaneous emphysema due to air
from the ethmoid cells inltrating the
soft tissues.
• Forced duction test—This simple test
is done to test the function of the extraocular muscle (EOM) that can be used
to differentiate between EOM weakness (i.e. paresis) and restriction (e.g.
entrapment, enlargement, inltration,
or brosis of muscle). The eyeball is
rst anaesthetized by instilling 2%
xylocaine, bulbar sclera/conjunctiva is
held with plane forceps and moved in
all directions to know any restriction
of movements (Fig.13.10).
• Ruled out associated injuries:
– Nasolacrimal duct disruption and
subsequent frontal mucocele
formation.
– Orbital injuries and exophthalmos
due to reduced intra-orbital
volume.
– Cerebrospinal uid rhinorrhoea due
to fracture through the cribriform
plate and lateral lamella.
– Epiphora secondary to nasolacri-
mal duct injury.
5. Examination/signs of maxillary (Le Fort or
mid-face) fracture (Table 13.6)-
(a) Inspection:
(b) Palpation (Table13.7):
6. Examination/signs of mandibular fracture
(a) Inspection
• Extra oral inspection—Face should be
inspected for:
– Swelling over Temporomandibular
(TM) joint—This is suggestive of
fracture and displacement of the
condylar and sub- condylar
fracture.
S
S
M
M
I
I
M
M
I
I
L
L
S
S
L
L
M
M
M
M
Fig. 13.10 Procedure to do forced duction test (lateral,
medial, inferior and superior movement of the eyeball)
S
S
L
L
I
I
S
S
L
L
I
I
Table 13.6 Signs of Le Fort fractures on inspection
Lefort-1 Lefort-2 Lefort-3
Anterior open bite Malocclusion
Ecchymosis of the maxillary buccal
sulcus and palate.
Guérin’s sign—It is dened by
ecchymosis in the area of greater
palatine vessels
Dish-face deformity
B/L conjunctival ecchymosis
Subconjunctival haemorrhage
Swelling
Chemosis
B/L periorbital oedema and
ecchymosis (raccoon eyes)
Anterior open bite (malocclusion)
Molar gagging
Mid-palatal split
Buccal ecchymosis
Bilateral periorbital oedema and
ecchymosis (raccoon eyes)
Telecanthus
Elongation of face Anterior open
bite
Molar gagging
Mid-palatal split
Flattening of the face and Dish-face
deformity—depressed nasal bridge
Orbital hooding—Increase skin on
upper eyelid
Enophthalmos
Battle’s sign—It is dened as
ecchymosis over the mastoid region.
CSF rhinorrhoea
CSF otorrhea Hemotympanum
13.2 Examination ofSpecic Area
Table 13.7 Signs of Le Fort fracture on palpation
Le Fort 1 (oating palate) Le Fort 2(oating maxilla) Le Fort 3 (oating face)
Mobile upper jaw but Impacted type
of fractures may be almost
immobile.
Characteristic grate on movement of
segment.
Percussion of upper teeth results in
cracked pot sound
Tele canthus
Step ladder deformity if nasal septal
fracture present.
Tenderness and paraesthesia in
infraorbital region.
Dull sound on percussion
Disarticulation of the pyramidshaped facial skeleton from the
remainder of the skull but zygoma
remains attached to the cranium.
Maxilla and nose are mobile as one
segment
Tenderness
Altered pupillary level
The whole face is separated from
head and become mobile on
palpation.
Altered sensation over frontal area
399
– Bleeding from the ear—This is a
sign of condylar fracture with frac-
ture of the tympanic plate.
– Trismus (reduced mouth opening)
– Respiratory distress
– Elongated face
– Associated injury
• Intraoral inspection
– Malocclusion
– Deviation of mouth
– Gagging of teeth
– Tenderness over site of fracture
– Increased pain with movement and
compression of the adjacent mandibular segments.
– Intraoral lacerations, intraoral
bleeding, loosened teeth, fractured
teeth and drooling—Indicate fractured mandible.
– Sublingual haematoma indicates
potential fractures along the lingual
cortex.
(b) Palpation
• Extraoral palpation should be done to
evaluate the mandibular contours.
Palpable step-off in the area of the
ramus, lateral border, inferior border,
in the occlusal plane or inferior border and of the mandible is the most
common sign of fracture of the
mandible.
• Bi-digital palpation is done to evaluate
the movement of the fractured
segment.
• Crepitus and tenderness are present on
manipulation of the fractured
segment.
• Deviation and restriction of movement
of jaw in case of sub-condylar
fracture.
• Decreased sensation of the lower lip—
This often resulted from a stretch of
the inferior alveolar nerve at the fracture site.
(c) Differential diagnosis of fracture man-
dible (Table 13.8):
400
Table 13.8 Differential diagnosis of mandibular fractures
Signs Type of fracture/diagnosis
Swelling over TM joint
Bleeding from ear
Reduced height of ramus
Gagging of the teeth on the fractured side means teeth on fractured side meet
earlier than the non-fractured side.
Deviation of the mandible toward the fractured side when the mouth is open.
Superior displacement of the condyle through the roof of the glenoid fossa into
the middle cranial fossa and posterior condylar displacement to EAC are rare.
Bilateral condylar fractures combined with a symphyseal fracture are sometimes
termed a guardsman’s fracture. The name comes from this injury occurring in
soldiers who faint on parade grounds and strike the oor with their chin
Lateral crossbite, limited mandibular movement and swelling in the zygomatic
arch area
Malocclusion, tenderness over the angle of the mandible, abnormal movement
and crepitation
Restricted mouth opening, anterior open bite, tenderness around the angle,
crepitus and step off at the fracture site
Laceration of the gingiva, malocclusion, paraesthesia over the lower lip, step
ladder defect in occlusion, ecchymosis on the oor of the mouth, mobile
fracture segment, change in facial contour (attened appearance of the lateral
aspect of the face), and elongated face
Bilateral body or para symphysis fractures are sometimes termed “ail
mandible” and can cause involuntary posterior movement of the tongue with
subsequent obstruction of the upper airway
13 History andExamination ofMaxillofacial Trauma
Unilateral or bilateral condyle
Coronoid fracture
Fracture of angle of mandible
Fracture of ramus of the
mandible
Fracture of the body of the
mandible
Fracture of symphysis
Traumatic optic neuropathy: Traumatic
optic neuropathy may result from direct
injury to the nerve either by a penetrating object like fractured bone fragments
impinging on the nerve or other injury
like vibrational transmission of forces to
the optic nerve from the craniofacial
skeleton, shearing force at the optic foramen, nerve compression from extrinsic
(haematoma) or intrinsic (haematoma or
oedema) sources. A high suspicion of
traumatic neuropathy arises when any
patient presents with periorbital trauma,
lacerations, or contusions (at the occiput,
glabella, or over the lateral superior
orbital rim) altered visual acuity, diminished visual eld, abnormal pupillary
response, change in bright light or red
colour perception, and it may or may not
be associated with facial fractures.
Testing for red colour desaturation in
the setting of orbital trauma is a
sensitive indicator of optic nerve
injury. This test is performed by
showing the patient a bright red object
and having them assess the hue and
colour intensity with one eye at a time.
The colour should appear the same
with each eye.
Retrobulbar haematoma: It is presented
as severe pain, progressive loss of vision,
dilated and xed pupil, exophthalmos, ptosis, subconjunctival haemorrhage and
swelling of the eyelid.
13.2 Examination ofSpecic Area
401
Carotid cavernous stulas: Carotid cav-
ernous stulas are abnormal communicating blood ow from the internal
carotid arterial system to the cavernous
sinus venous system. It is classied etiologically as traumatic or spontaneous,
hemodynamically as high ow or low
ow and morphologically as direct or
indirect (dural). The classication system described by Barrow and colleagues includes Type A stula and
Types B, C and D stulas. Type A stulas are high ow, direct shunts between
the internal carotid artery and the surrounding cavernous sinus, complication
of head trauma, and represent 70–90%
of all carotid-cavernous stulas.
Conversely, Type B, C and D are lowow, indirect dural shunts that are
thought to be congenital or spontaneous
arteriovenous connections mostly seen
in an older female with H/O hypertension, diabetes and atherosclerosis, and
rarely due to trauma. The diagnosis
should not be delayed because permanent visual loss may progressively
develop if IOP is not reduced, and cranial nerve palsies may become
permanent.
Carotid cavernous sinus stula often
presents with a triad of pulsating exophthalmos, conjunctival chemosis, and
orbital bruit, dramatically few days or
weeks after head injury. The ocular
manifestations reect the underlying
pathophysiology of overload and retrograde lling of the venous system.
Arterial blood ows anteriorly into the
superior or inferior ophthalmic veins,
and arterial and venous stasis causes
increased episcleral venous pressure
along with decreased arterial blood ow
to the cranial nerves within the cavern-
ous sinus. This situation leads to the
hallmarks of carotid-cavernous stula,
including arterialization of the conjunctival vessels, conjunctival chemosis and
the classic fundus ndings of ipsilateral
optic disc swelling, dilated retinal veins
and intraretinal haemorrhages.
Proptosis: Proptosis is often among the
earliest ndings that develop due to congestion of orbital tissues, either acutely
or progressively within a few days after
trauma.
Pulsating exophthalmos: Pulsatile
exophthalmos is present in most
patients with direct carotid-cavernous
stula. This develops due to increased
IOP from increased episcleral venous
pressure and orbital congestion develops in up to half of the patients with
untreated direct carotid-cavernous
stula.
Diplopia: Diplopia is usually present in the
direct carotid-cavernous stula.
Mechanisms of diplopia include the initial trauma, mechanical restriction of the
extraocular muscles, cranial nerve ischaemia from the stula, and direct compression of the cranial nerves by dilated
petrosal venous sinuses. The sixth cranial nerve is most commonly affected
due to its free- oating location within
the cavernous sinus.
Visual loss: The direct carotid-cavernous
sinus stula presents with loss of vision
in up to 90% of patients. The loss of
vision may be either immediate of
delayed. This is the major cause of morbidity in those whose stulas are not
complicated by intracranial bleeding.
The threat of irreversible secondary
visual loss with carotid cavernous stula
usually arises from the increased IOP
that can be severe enough to damage the
(continued)
402
13 History andExamination ofMaxillofacial Trauma
optic nerve or retina. Other causes of
secondary delayed visual loss in carotid
cavernous stula include exposure keratopathy (secondary to proptosis), venous
stasis retinopathy, central retinal vein
occlusion, serous choroidal detachment,
and anterior or posterior ischaemic optic
neuropathy.
The CT and MRI with contrast show
distended superior and inferior orbital
veins with diffuse enlargement of extraocular muscles.
Optic pathway trauma: It consists of
damage to the optic chiasm or the retrochiasmal visual pathways which is common in
head trauma. The damage to optic chiasma
is secondary to intracanalicular optic nerve
segment damage and may result from indirect or penetrating injury. Visual eld testing demonstrating bitemporal hemianopia,
in combination with brain MRI, is usually
diagnostic. However, knowledge of optimal management is minimal and treatment
consists of corticosteroids or observation.
History andExamination ofSkin,
andHair Disorders ofHead
andNeck
14
14.1 History/Chief Complaints
ofHair andSkin Disorders of
Head andNeck
1. History/symptoms of disorders of hair
(a) Chief complaints/common symptoms/
presenting complaints of hair loss or hair
disorders—The chief complaints range
from minimum loss of hair to complete
baldness. The disorders of hair present
with
• Gradual thinning of hair on top of
head. This is the most common type of
hair loss, affecting people. In men,
receding hairline is the most common
presentation and women have a broadening of the part in their hair. The
receding hairline is also becoming a
common hair loss pattern in older
women (frontal brosing alopecia).
• Circular or patchy bald spots. Loss
of hair in circular or patchy bald spots
on the scalp, beard or eyebrows is also
presenting symptoms in some patients.
There may be a history of itching
before loss of hair.
• Sudden loosening of hair. A handful
of hair fall during taking bath and
combing is often due to physical or
emotional shock but it is temporary.
• Full-body hair loss. The loss of whole
body hearing loss is often due to some
conditions and medical treatments,
such as cancer chemotherapy.
• Patches of scaling that spread over
the scalp. This ringworm infection
causes broken hair, redness, swelling
and, at times, oozing.
• Other problems are greying of hair,
dandruff, dry hair, zzy hair, split
ends, dull hair.
(b) Duration of symptoms—It may be acute
(stress, poor diet, child birth, medical
condition, chemotherapy) or chronic
(hereditary hair loss, alopecia areata, hormonal, scalp infection).
(c) Associated symptoms/history of
• H/o Hormonal changes and medical
conditions—Patient should be
enquired about conditions that can
cause permanent or temporary hair
loss, for example, pregnancy, childbirth, menopause and thyroid problems and other medical conditions
include alopecia areata (causes patchy
hair loss), scalp infections such as
ringworm and a hair-pulling disorder
called trichotillomania.
• H/o-Medications and supplements—
Patient should be asked about taking
certain drugs, such as those used for
cancer, arthritis, depression, heart
problems, gout and high blood pressure, which can result in hair loss.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck
Surgery, https://doi.org/10.1007/978-981-96-1765-4_14
403
404
14 History andExamination ofSkin, andHair Disorders ofHead andNeck
• H/o-Radiation therapy to the head—
Radiotherapy to head can cause permanent hair loss.
• H/o-A very stressful event—The H/O
stressful event, emotion shock can
result in hair loss but temporary.
• H/o-Hairstyles and treatments—
Patient should be enquired about H/O
excessive hairstyling or hairstyles that
pull your hair tight, such as pigtails or
cornrows. This type of alopecia is
called traction alopecia. A H/O hot-oil
hair treatment can cause scarring and
result in permanent hair loss.
(d) Family history (heredity). This is the
most common cause of hair loss that happens with aging. This condition is called
androgenic alopecia, male-pattern baldness and female-pattern baldness. It usually occurs gradually and in predictable
patterns such as receding hairline and
bald spots in men and thinning hair along
the crown of the scalp in women.
2. History/presentation of of skin diseases of
head and neck
(a) Chief complaints/presenting symptoms
• Raised swelling (red or white)
• A painful and itchy rash
• Rough and scaly skin
• Peeling skin
• Ulcers over skin
• Open sores
• Dry, cracked skin
• Discoloured patches of skin
• Scar on skin
(b) Associated H/O—Precancerous lesions
(Actinic keratosis), personal H/O skin
cancer HIV, taking immunosuppressive
drugs.
(c) Past history/o—Sun burn, excessive sun
exposure, living at high altitude, moles,
change in enviornment
(d) Family H/o skin cancer
(e) Subjective information
When condition started
Part of body where the condition starts
rst
At which speed it is growing
Anything which triggers the lesion
What treatment has been taken
Any H/O pain, nausea, vomiting
14.1.1 Examination ofPatient
withSkin or Hair Disorder
ofHead andNeck
3. Examination of hair
(a) Inspection
• Hair density—It depends on the
number of hair and its density. The
diameter of hair ranges between 57
and 90 μm in Europeans and can be
120 μm in Asians. The number of
hairs in a person varies with age, from
1100 follicles/cm2 in children to
600 follicles/cm2 in a 25-year-old
adult, and just 300follicles/cm2 in an
adult aged between 30 and 50years.
Hair loss is thus also physiological,
with hair becoming less dense as people age.
• Hair colour—The natural hair colour
can be black, brown, blonde, red and
white.
• Excessive hair—hypertrichosis or
hirsutism
• Pattern of loss—thinning or bald-
ness may be generalized or localized (Table14.1)
(b) Palpation
• Hair pull test—Hold a lock of hair
and look whether it can be extracted
with a rm pull or not. The telogen
hair (hair in resting phase, rounded
bulb at the end) can be extracted but
anagen hair in growing phase is hair
with elongated or tapered end if positive for pull test consider pathologic.
• Fold signs or Jaquet’s sign—This
consists of folding an area of the scalp
between the two thumbs. In a positive
test, if several folds are formed easily,
the test is positive and indicates an
absence of hair bres in some, many
or all of the follicles. The negative test
14.1 History/Chief Complaints ofHair andSkin Disorders of Head andNeck
Table 14.1 Difference between localized and generalized baldness
Localized Generalized
Round/oval patch
Moth-eaten or linear bald patches
Short hair
Pull test may be positive or negative
Scarring/cicatricial (no follicle) or
Non-scarring alopecia (follicle present)
Tufted folliculitis
Table 14.2 Various types of skin lesions of head and neck with description and differential diagnosis
Lesions Description Diagnosis
Macule It is at, circumscribed area of the
Patch
Papule It is a circumscribed elevation of
Plaque It is a, circumscribed elevation of
Weal It is a transient, smooth, slightly
Vesicle (blister) It is a<0.5cm, circumscribed,
Bulla (blister)
Pustule Visible collection of pus Staphylococcal folliculitis
Abscess Localised collection of pus in a
Erythema Redness, blanching on skin Erythema nodosum
Purpura Redness, non-blanching, secondary
Telangiectasis Dilated capillaries visible on the
altered skin colour of <0.5cm
It is a≥0.5cm, at, circumscribed
area of altered skin colour
skin of <0.5cm
skin of ≥0.5cm
raised lesion, with a pale centre and
a pink margin
uid-containing elevation
It is a≥0.5cm, circumscribed,
uid-containing elevation
cavity
to collections of red blood cells on
skin
skin surface
Alopecia at vertex
Frontal recession
Hair shaft is thin
Pull test is positive
Vitiligo (small)
Vitiligo (large)
Molluscum contagiosum
Psoriasis
Urticaria
Acute eczema
Burn, friction
Bacterial infection
Vasculitis, platelet or clotting defect
Side-effect of topical steroids
405
indicates the presence of miniaturized
hair (AGA), or the absence of follicles
(scarring alopecia).
• Sabouraud’s sign—The Sabouraud’s
sign is used to measure the resistance
of the hair to traction. It is elicited
after removing a group of hairs for
trichogram using a rubber-sheathed
Kocher forceps then increasing traction is applied to the hair while it is
still held between the blades of the
forceps. Other way to perform this test
is by holding a tuft of hairs rmly
between two ngers of one hand and
pulling with increasing force on the
free ends of the hairs with the other
hand. Positive results are when hair
breaks easily, mainly seen in patients
with alterations of the hair shaft or
hair damaged by external aggression.
(c) Examination of head and neck skin
(d) General inspection of head and neck
(e) Various types of skin lesion (Table14.2)
(f) Shape of lesions—The lesions can be
annular, iris, arciform, linear, etc.
(g) Arrangement of lesions—Isolated
multiple, scattered or grouped
(h) Distribution of lesions—Isolated,
grouped, scattered, localized or
generalized