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406
14 History andExamination ofSkin, andHair Disorders ofHead andNeck
(i) Consistency of lesions
• Soft
• doughy
• rm
(j) Colour of lesions
• Red
• Brown
• white-
• Blue
• Honey coloured—non-bullous
Impetigo
• Apple jelly coloured—lupus vulgaris
(k) Inspection
(l) Scalp skin
• The skin to be evaluated for appearance (oily or dry)
• Diffuse, patchy or perifollicular
erythema
• Diffuse, patchy or follicular anking
or scaling
• Follicular or non-follicular papule,
erosions, or pustule
• Excoriation
• Nits (Louse egg cases)
(m) Facial skin
• Acne vulgaris—There is either papule, red swollen breakout or pus-lled
cyst deep into skin.
• Drug-induced acne (acneiform eruption)—Papule and pustule, punctiform vesicle appear on centre.
• Phototoxic reaction—Rash or sunburn
like appearance.
• Lupus erythematous—Buttery rash,
which may be smooth, scaly over
bridge of nose and cheek. These
rashes are also called malar rash.
• Xeroderma pigmentosa—spider-like
blood vessel, oozing raw skin, scaling, blistering, patches of discoloured
skin.
• Aging—Skin thins and becomes less
elastic and more fragile, and fatty tissue just below the skin decreases.
Skin becomes drier, ne lines and
wrinkles appear, age spots, skin tags,
dull skin and uneven tone are more
common.
• Spider vein—Purplish skin swelling
or blood spot
• Hyperpigmentation—The excess melanin is deposited in the skin, creating
dark spots and patches that may be
tan, brown, grey-brown, grey, silver,
violet, blue or blue-black depending
on the colour of skin.
• Melasma—It is grey-brown patches
on the face in women.
(n) Neck skin
• Acanthosis nigricans—Dark discoloration in folds of neck
• Atopic dermatitis (eczema of neck)—
Itchy rashes, uid-lled blisters
4. Differential diagnosis skin disorders of
head and neck
Acute inammatory dermatoses: urti-
caria, acute eczema dermatitis and erythema multiforme
Chronic inammatory dermatoses: psoriasis and lichen planus
Infectious dermatoses: bacterial infections
(impetigo, cat-scratch disease, folliculitis),
fungal infections and viral infections (herpes simplex, chickenpox, herpes zoster)
Autoimmune diseases: systemic lupus
erythematosus, chronic cutaneous (discoid)
lupus erythematosus, scleroderma and
angioedema
Blistering (bullous) disorders: pemphigus, bullous pemphigoid and dermatitis
herpetiformis
Benign and premalignant epithelial
lesions and nevi: melanocytic nevus,
dysplastic nevus, actinic keratosis, seborrheic keratosis and keratoacanthoma
Malignant epidermal tumours: basal cell
carcinoma, squamous cell carcinoma and
malignant melanoma
Miscellaneous: Sturge-Weber syndrome,
Paederus dermatitis and melasma
14.1 History/Chief Complaints ofHair andSkin Disorders of Head andNeck
14.1.2 Common Skin Diseases
Signs of melanoma include:
A large brownish spot with darker speckles.
A mole that changes in colour, size or feel
or that bleeds.
A small lesion with an irregular border and
portions that appear red, pink, white, blue
or blue-black.
A painful lesion that itches or burns.
Dark lesions on your palms, soles, ngertips or toes, or on mucous membranes lining your mouth, nose, vagina or anus.
Melanoma warning signs
1. Asymmetry: If half the lesion does not
match the other half.
2. Border irregularity: the edges of the
lesion are ragged, notched or blurred.
3. Colour variegation: If pigmentation is not
uniform and may display shades of tan,
brown or black; white, reddish or blue
discoloration is of particular concern.
4. Diameter: A diameter greater than
6 mm is a characteristic, although
some melanomas may have smaller
diameters; any growth in a nevus warrants an evaluation.
5. Evolving: changes in the lesion over
time are a characteristic. This factor is
critical for nodular or amelanotic (nonpigmented) melanoma, which may not
exhibit the classic criteria above.
Kaposi sarcoma—it is presented as red or
purple patches on the skin or mucous
membranes.
Merkel cell carcinoma—It is presented as
rm, shiny nodules that occur on or just
beneath the skin and in hair follicles.
Merkel cell carcinoma is most often found
on the head, neck and trunk.
Sebaceous gland carcinoma—It usually
presented as hard, painless nodules that can
develop anywhere, but most occur on the
eyelid.
1. Erythema multiforme—It is a skin immune
2. Psoriasis—Psoriasis presented as well
3. Urticaria—It is dened as erythematous,
4. Acne—Acnes are one of the most wide-
ofHead andNeck
reaction triggered either by infection or medication. Its name combines the Latin “ery-
thema” (redness), “multi” (many) and
“forme” (shapes) and describes the main
symptom, which is a rash on the body where
each mark resembles a bullseye.
Erythema multiforme minor—On
examination, it appears bulging, rash-like
lesion that is red, pink, purple or brown. It is
usually circular, less than 3cm in size, and
similar to a bullseye in appearance. The outermost circle has a well-dened border,
while the centre may be a blister.
Erythema multiforme major—The rash
is still bullseye-shaped in major form, but it
might be a little bigger and the circles might
collide. These skin areas may be sore and
oozing, and the lesions are more likely to
blister and burst. The lesions may also produce mucus, depending on where they are
located. There will usually be mucus-lled
lesions in at least two body parts when erythema multiforme major is present. The
mouth is frequently one of these places.
demarcated, pink- to salmon-coloured plaque
covered by loosely adherent white silver
scale.
oedematous, and pruritic plaque are termed
wheals.
spread skin disorders, commonly involving
face, neck shoulder, chest and upper back.
The breakout on skin may present as redness,
blackhead, white head, pimple or deep painful cyst and nodule. Acne comes in many
forms or stages (Fig.14.1j).
Pustules are the common red pimples that
have pus at their tips.
Papules are the raised red bumps caused
by infected hair follicles.
Nodules are painful lumps that lie underneath the surface of the skin (Fig.14.1n).
407
408
14 History andExamination ofSkin, andHair Disorders ofHead andNeck
Cysts are the typically larger painful,
pus- lled infections that lie beneath the
skin.
5. Seborrheic dermatitis—Seborrheic derma-
titis in adults can develop anywhere and is
likely to are up and then go away over the
course of a lifetime. The aficted skin might
look oily, swollen and reddish. The skin’s
surface may also develop a white-to-yellow
crust.
6. Melanoma—Moles with asymmetrical
shapes, ragged edges, uneven colours, or
change in size, they should be checked for
melanoma.
7. Rosacea—Redness is most frequently linked
to the skin condition rosacea. Nevertheless,
there are four subtypes that also result in
additional symptoms:
Erythemato- telangiectatic rosacea—
Typical symptoms include ushing, redness,
and visible blood vessels.
Ocular rosacea—Swollen eyelids, red,
irritated eyes, and symptoms resembling a
stye can all be signs of ocular rosacea.
Papulopustular rosacea—It is characterized by redness, swelling and acne-like
breakouts.
8. Lupus vulgaris—Individual differences
exist in the complex disorder known as lupus.
Inammation and pain are caused by the disease’s attack on the immune system. Any
part of the body may be affected; skin symptoms include red spots or rings, rashes that
resemble sunburn on the cheeks and nose, or
round rashes that are painless and itchy.
Other symptoms like headaches, fever,
exhaustion, and swollen, stiff, or painful
joints may accompany these. Upon examination, the distinctive feature is a reddishbrown, well-dened irregular plaque. The
lesions are characterized by their softness
and friability, and their surface may be
hyperkeratotic or ulcerative. Scarring is a
noticeable symptom, whether or not cartilage
has been destroyed
9. Erysipelas—It is a painful, well-dened
shiny, erythematous oedematous plaques
which involves the central part of face.
10. Furuncle/furunculosis—It is deep seated
inammatory nodule develop in hair
follicle.
11. Impetigo (bullous/non-bullous)—A non-
bullous impetigo is characterized by honeycoloured crusted plaques while bullous
impetigo is characterized as bullae on normal
skin from vesicle.
12. Warts—It is a most common mucocutaneous viral infection and caused by
human papillomavirus types 1, 2, 3, 4, 7. The
verruca vulgaris presents as rm papule with
rough and horny surface, liform wart presents like projection and plane wart as at
surface.
13. Herpes simplex—Facial lesions of herpes
simplex are usually caused by HSV1 and
present as either grouped vesicular lesions
(Herpes labialis) on the lip and face or painful vesicle with ulcerative erosion
(Herpes-gingivostomatitis).
14. Psoriasis—It is erythema-squamous relapsing dermatosis commonly involving scalp
skin presents as a small plaque with a loosely
adherent silvery scale. Facial psoriasis
involves eyebrows, upper forehead and
hairline.
15. Melasma—It is acquired hypermelanosis
exacerbated by sun exposure, pregnancy,
oral contraceptive commonly involves face,
cheek and chin (Fig.14.1a).
16. Veruca plana—It is a greyish yellow pap-
ules, which is slightly elevated or at and
present on face, shin and dorsal hand
(Fig.14.1b).
17. Nevus spilus—Usually present from birth,
nevus spilus is a relatively common lesion
that may be initially observed in infancy,
childhood or even later. It appears as a single,
at, brown, non-hairy patch of melanization
with tiny, dark brown to black macules scattered throughout (Fig.14.1c).
18. Milia—A small white bump (cyst) under the
surface of skin is a common presentation of
Milia (Fig.14.1d).
19. Adenoma sebacium (Facial angio-
broma)—Formerly called adenoma sebaceum, facial angiobromas manifest as a
14.1 History/Chief Complaints ofHair andSkin Disorders of Head andNeck
409
reddish-brown papular rash that is characteristically distributed in a ‘buttery’ pattern
across the face. A pathognomonic hallmark
of tuberous sclerosis, this rash is extremely
sensitive and affects more than 85% of
patients (Fig.14.1e).
20. Macrocomedones—They are facial closed
comedones, larger than 2–3mm in diameter
(Fig.14.1f).
21. Lichen planus—These are at-topped, vio-
laceous papules that are typically itchy. a
system of tiny white lines known as Wickham
striae. May be observed on the papules’ surface. Atrophic, annular, hypertrophic, linear,
zosteriform erosive, oral, actinic, follicular,
erythematous and bullous forms are among
the clinical variations (Fig.14.1g).
22. Melanocytic nevus—It is benign located
either under the skin (subdermal) or a pigmented growth on the skin, formed mostly
of a type of cell known as a melanocyte.
Commonly known as mole also
(Fig.14.1h).
23. Solar elastosis—It is a skin disorder pre-
sented as yellow and thickened skin caused
by abnormal elastic tissue accumulation. It is
due to chronic sun damage on ageing skin
also known as actinic elastosis and elastosis
senilis (Fig.14.1i).
24. Acne
25. Acne scarring—The scarring is caused by
all types of acne, more commonly by nodular
and cystic type (Fig.14.1k).
26. Dermatosis papulosa nigra (DPN)—It is a
benign epidermal growth, which develops on
face and neck in adolescent. It is presented as
hyperpigmented or skin-coloured papule in
people with Fitzpatrick type III and type IV
skin and in Asian descent (Fig.14.1l).
27. Molluscum contagiosum—It is a common
skin viral infection presented as round, rm,
painless swelling in children (Fig.14.1m).
28. Tinea faciei—It is a supercial dermato-
phytes infection limited to the glabrous skin
of face (Fig.14.1o).
29. Xanthelsma—It is a sign of hypercholesteremia and diabetes presented as yellow discolouration of swelling on medial corner of eye
due to cholesterol deposition (Fig.14.1p).
14.1.2.1 Common Disorders ofHair
(Table14.3)
Table 14.3 Common hair disorders
Name of disease Description
Bubble hair deformities It is damage to hair shaft resulting in patches of short weak and brittle
hair that feels rough
Hair cast These are remnants of the inner root sheath
Hirsutism It is described as the presence of excessive hair on body where usually absent
Hypertrichosis It is described as ingrowth or curl of hair back into body. This is common
in who have coarse or curly hair
Monilethrix (beaded hair) It is autosomal dominant hair disorder that results in short, fragile, broken hair
that looks beaded. Hairline form M shape with family history of baldness
Premature greying of hair It is termed as greying of hair before 25years of age
Pattern hair loss (androgenic alopecia) It can be male-pattern or female-pattern alopecia. It is genetic disorder
Trichorrhexis invaginate It is a hair shaft abnormality that may occur either in normal hair with
other hair shaft deformities
Trichotillomania It is also known as hair-pulling disorder or compulsive hair pulling
characterized by urge to pull own hair
Piedra It is fungal infection characterized by nodule on shaft of hair
Alopecia Areata (Patchy hair loss) It is an immune disorder characterized by sudden hair loss in small spots
around the scalp or face
Traction Alopecia This is due to constant pulling by tightly braided hairstyle, weaves,
barrettes or due to compulsive pulling disorder
Telogen efuvium It is temporary hair loss triggered by stress
Anogen efuvium It is a sudden loss of hair from the follicle in the anagen phase due to
chemotherapy and radiation therapy
410
14 History andExamination ofSkin, andHair Disorders ofHead andNeck
14.2 Clinical Images ofCommon
Head andNeck Skin Diseases
a b c
d e f
g h
i
Fig. 14.1 Common skin disorders of head and neck
(courtesy Dr. Neeraj Srivastava). (a) Melasma, (b) Verruca
plana, (c) Nevus spilus, (d) Milia, (e) Adenoma sebaceum, (f) macrocomedones, (g) Lichen planus, (h)
j
Melanocytic nevus, (i) Solar elsatosis, (j) Acne, (k) Acne
scarring, (l) Dermatosis papulose nigra, (m) Mulluscum
contagiosum, (n) Nodulo cystic acne, (o) Tinea faciei, (p)
Xanthelsma
k
14.2 Clinical Images ofCommon Head andNeck Skin Diseases
411
m
n
p
q
o
Fig. 14.1 (continued)
History andExamination
ofStructural andFunctional
Deformities oftheFace (Facial
Plastic Surgery, Orthodontic
Orofacial-Myofunctional Disorders
ANDTemporomandibular Joint
Disorders)
15
15.1 Facial Aesthetic, Structural and Functional Deformities
1. History and presentation of facial struc-
tural, aesthetic deformities and orofacial,
temporomandibular joint dysfunction
(a) Chief complaints/symptoms of facial
structural and aesthetic deformities.
• Deformity:
– Nose/nasal deformities—It is
dened as a deformity of the bony
structure and/or soft tissue as well
as the shape of the nose that results
in difculty breathing, impaired
sense of smell and altered shape of
the nose-like saddle nose, loss of
part of the nose, deviated nose,
crooked nose, etc. It is either congenital or acquired, presented with
nasal obstruction; loss of part of the
nose; duplication of part of nose;
absence or decrease in sense of
smell; and abnormal shape, size
and position.
– Whole face/facial deformities—
(discussed in Chap. 16)
– Jaw/jaw (orthognathic or maxillo-
facial) deformities—It is dened as
an abnormal form like disgurement or loss of the natural arrangement of jaw. Humans have two
jaws, an upper and a lower jaw. Jaw
deformities are disgurements of
one or both jaws. Jaw deformities
can present with difculty in speaking, chewing, swallowing and
breathing. These conditions also
may cause undue stress on the tem-
poromandibular joint (TMJ) and
facial muscles, affecting the longterm health of gums and teeth. Jaw
deformities also may cause pain,
degeneration, jaw clicking and the
appearance of face and facial aesthetic problems like underbite or
overbite, Gummy smile, long-face
syndrome and toothless smile.
– Dentofacial deformities—
Signicant deviation from the typical proportions of the
maxillomandibular complex that
also have an adverse effect on the
relationships between the teeth
within each arch and the arches
with each other (i.e. occlusion) are
referred to as dentofacial deformities. Asymmetries, undergrowth
(hypoplasia) and overgrowth
(hyperplasia) are dentofacial abnormalities of the maxilla, mandible
and chin. The chin, maxilla and
mandible are positioned abnormally, which compromises the
facial aesthetics. Patients may
© 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_15
413
414
15 History and Examination of Structural and Functional Deformities of the Face…
appear to have an excessively large
or small upper or lower jaw or chin,
which can show up as a malocclusion (class I, II, III) in the dentition.
A gummy smile, mentalis strain,
underbite, overbite, poor neckchin- throat morphology, sagging
skin, submental redundancy, lip
incompetence, lack of malar projection, scleral show, ptotic nasal
tip, everted lower lip, thin upper lip
and other facial aesthetic are problems with which a patient can present to the doctor.
Mandibular deformities—
Mandibular defects can result in
severe functional and aesthetic
limitations in terms of swallowing, voice function and extraoral
lining.
Maxillary deformities—some of
the maxillary deformities are
maxillary hypoplasia, maxillary
retrusion and hemifacial
microsomia.
Mandibulomaxillary deformity—These deformities cause
occlusal, functional and aesthetic problems to patients.
Structural classication of
dentofacial asymmetries
(Table15.1)
– Lip deformities (discussed in Chap.
16):
– Chin deformities (chin dysmor-
phism)—An essential element of
facial harmony is a chin that is aes-
thetically pleasing. There are seven
categories of chin deformities (dysmorphism) (Table 15.2). Different
types of treatment are required for
different types of deformities.
Classes I, III and IV need an osteotomy of the chin; class II chin
deformity can be corrected with
augmentation; classes V and VI are
beneted from soft tissue correction; and class VII deformity can be
treated with a maxillary osteotomy.
• Site of deformities—The deformity
can involve the whole face, nose, lip,
chin, forehead, or combination of
these sites.
• Side of deformities—The face has two
left and right. The deformity can
involve one side or both sides.
• Time of onset
– Acquired—It develops later in life
either due to trauma or disease.
– Congenital—This is present since
birth.
• Associated symptoms—Other deformities and trauma.
(b) Orofacial-myofunctional disorders—
Orofacial-myofunctional disorders
describe issues with speech, restricted airways, dental malocclusion, irregular chewing and swallowing patterns and aberrant
resting posture of the orofacial muscles.
Both adults and children can be affected
with Oromyofacial disorders (OMD).
OMD in children—Tongue thrust is a
prevalent form of OMD in infants and is
often referred to as swallowing with an
Table 15.1 Classication of dentofacial asymmetries
Skeletal asymmetry Soft tissue asymmetry Functional asymmetry
Unilateral condylar hyperplasia
Unilateral condylar ankylosis
Fracture and trauma
Hemifacial atrophy
Postural scoliosis
Congenital hemifacial hypertrophy
Hemimandibular hypertrohy
Dish face deformity—Lengthening of
middle third of the face
Congenital muscular torticolis
Cleft Lip
Cleft palate
Muscly dysfunction
Moon face—B/L circumorbital
ecchymosis, gross oedema
Malocclusion (anterior/
lateral)
15.1 Facial Aesthetic, Structural and Functional Deformities
Table 15.2 Chin deformities
Denition Presenting symptoms
Class I—Macrogenia It is a condition where the chin prominence, height,
width and projection are excessively large in
comparison to the rest of the facial skeleton
Class II—Microgenia It is a condition with too small prominence, height,
width and projection of the chin in comparison to
the face
Class III It is a combination of macrogenia on one side and
microgenia on the other side
Class IV Asymmetric deformity Short, normal and long
Class V Soft tissue ptosis (“witch’s chin”)
Class VI—Pseudomacrogenia Normal skeletal symphysis menti with excess soft
tissue covering
Class VII—Pseudomicrogenia It is deformity with long-face producing clockwise
rotation of the normal mandible
A big chin in relation to
face
Small chin in relation to
face
One side big another
side is small chin
anterior facial height
415
anterior tongue posture. Non-nutritive
sucking behaviours such as thumb sucking, clenching and bruxing that resulted
in aberrant dentition and oral cavity
development are also referred to as OMD.
OMD in adult and geriatric populations—OMDs in adults and geriatrics are
due to various neurological impairments,
oral hygiene, altered functioning of mus-
cles due to ageing and systemic diseases.
• Chief complaints/symptoms of OMD
– Open mouth and habitual mouth
breathing and habitual lip apart in
resting position.
– Persistence of drooling and poor
oral control after age 2years.
– Bruxism/teeth grinding—This is a
medical condition in which a person grinds or gnashes his/her teeth.
Unconsciously clenching their
teeth while sleeping and
occasionally while awake are common symptoms of bruxism.
– Misaligned teeth/malocclusion of
the teeth—Misaligned teeth is a
condition when teeth are unable to
t comfortably in the mouth; they
crowd one another or leave no room
for new teeth to develop.
– Sleep apnoea—It is a sleep disorder
in which the patient has many epi-
sodes of apnoea and hypopnea with
cessation of breathing, presented
with daytime sleepiness, snoring,
fatigue and other symptoms.
– Facial discomfort—Patients may
have facial pain and headaches due
to problems in the jaw and muscular dysfunctions.
– Speech problems—OMD can pre-
set with inability to speak uently
or pronounce words correctly.
– Mouth breathing—This is due to
persistent bilateral nasal
obstruction.
– Tongue thrusting—Habitual thrust-
ing means when the tongue often
protrudes forward between the
upper and lower teeth during speaking or eating. Normally, the tongue
tip should press against the gum
over the back of the upper front
teeth; therefore, this is incorrect.
– Associated symptoms and history
H/O Upper airway obstruction,
H/o Digit sucking
Consequence of tongue
thrust—The consequences are
lisping (e.g. saying “thun” for
sun), speaking noises that are
not articulated precisely, open
bite, open mouth position,
416
15 History and Examination of Structural and Functional Deformities of the Face…
abnormal tooth and dental arch
eruption, abnormal facial muscular tone, extended mealtimes
brought on by poor swallowing
and chewing techniques, food or
liquid spillage from the front of
the mouth, adverse effects on
appearance and decreased
self-esteem.
Chronic middle ear infections,
sinusitis, allergic rhinitis, upper
airway infections and sleep disturbances (e.g. snoring) take
place.
Open mouth posture: The transition from
nasal to oral breathing occurs. Furthermore,
mouth breathing is frequently linked to a
reduction in the amount of oxygen that
enters the lungs. Because the improper
strain of these muscle groups on the facial
bones causes gradual deformation and misalignment, mouth breathing can have a particularly negative effect on the developing
face. An open mouth posture, in which the
lower jaw is kept open and the upper lip is
lifted, is eventually produced. The sooner
these changes occur in life, the more signicant the changes are in face growth. To
enable a larger volume of air intake, the
tongue, which is typically tucked under the
roof of the mouth, lowers to the oor of the
mouth and protrudes. As a result, an open
mouth position can lead to malocclusions
and swallowing problems. Other causes of
open mouth posture are the weakness of lip
muscles, whole body lack of tone or hypotonia and chronic allergies of the respiratory tract.
Tongue thrusting: The habitual resting or
thrusting of the tongue forward and/or sideways against or between the teeth when
eating, chewing, resting, or speaking is
known as tongue thrusting, and it is a form
of orofacial- myofunctional dysfunction.
Open bites result from abnormal swallowing behaviours that force the upper teeth
forward and away from the upper alveolar
processes. The following factors lead to
tongue thrusting in children: immature oral
behaviour, narrow dental arch, chronic
upper respiratory tract infections, diastema
(gap between teeth), muscle weakness,
malocclusion, irregular sucking habits,
open mouth posture due to structural abnormalities of genetic origin, macroglossia
(enlarged tongue), ankyloglossia (tongue
tie), specic types of articial nipples used
to feed infants, allergies or nasal congestion and large tonsils and adenoids.
(c) Chief complaints/symptoms of temporo-
mandibular joint dysfunction
• Chronic masticatory muscle discomfort is usually unilateral present with
dull pain which is excerbated by chewing, radiate to jaw and ear. The pain
become worse day by day.
• Complaint of locking jaw while opening mouth.
• Ear popping or clicking, typically
caused by articular disc displacement.
• Headache and/or neck ache—There
may be headaches in some cases without localized pain in the temporomandibular joint.
• Bite—Unusual and uncomfortable
bites.
• Bruxism and teeth clenching.
• Timing of symptoms—how long
symptoms are present.
• Associated symptoms/history
– Neck pain, dizziness, headaches,
migraines, or other neurological
symptoms
– Signicant history (previous frac-
tures or trauma, dental history,
bruxism, etc.). History of jaw and/