Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2853_Библиотеки_им_академика_М_И_Перельмана

Inspection. With the patient seated in a good cross-light, inspect the anterior triangles in the lower half of the neck. Have the patient swallow looking for a mass ascending in the midline or behind the sternocleidomastoid. With obe­sity or a short neck, have the patient swallow with the neck tilted back while supporting the occiput with clasped hands.

Palpation from behind. The examiner is behind the seated patient who low­ers their chin relaxing the neck muscles. The thumbs are placed behind the neck curling the ngers anteriorly so long and ring nger tips just touch over the upper tracheal rings (Fig. 7-27A). The patient holds water in the mouth swallowing when asked. Locate the thyroid and cricoid cartilages and tra­cheal rings. The lateral lobes are on either side of the trachea rising under the ngers during a swallow. Feel for tissue overlying the tracheal rings; it is likely a hyperplastic thyroid isthmus. Palpate systematically the lower poles of both lateral lobes. During the exam, shift the inclination of the patient’s head to relax the neck muscles, and have the patient swallow to test the ad­herence of palpated masses to the trachea. Palpate the anterior surface of each lateral lobe through the sternocleidomastoid with the patient’s head slightly inclined toward the side being examined to relax the muscles. Occasionally, the thyroid is more easily felt when the neck is dorsiexed.

Examining the Lymph Nodes: See Chapter 5, page 82.

Examining the Vascular System: See Chapter 8, page 287.

General Symptom

Face Pain. Facial pain is usually well localized, indicating the structure involved. Uncommonly, it is a difcult diagnostic problem.

Tinnitus. Ringing in the ears, tinnitus, is often sufciently distressing for a patient to seek care. Unilateral tinnitus may be the rst symptom of an acous­tic neuroma.

mine the symptom pattern (e.g., vertical or horizontal), precipitating activi­ties, visual axis where diplopia occurs, and head position or gaze giving relief. If the patient reports monocular diplopia or diplopia when one eye is covered, the cause is nearly always refractive. Binocular diplopia: see Chapter 14, page 653.

tal hernia; Painless Intrinsic Lesions: Achalasia, congenital stricture, stricture, scleroderma, dermatomyositis; Sjögren syndrome, amyloidosis, thyrotoxico­sis; Painless Extrinsic Lesions: Aortic aneurysm, aberrant right subclavian artery (page 252), vertebral spurs, enlarged left atrium.

Hoarseness. See page 232.

Salivary Gland Symptoms

Dry mouth—xerostomia. See page 255.

Neck Symptoms

tis; Salivary Glands: Mumps, suppurative parotitis; Neck Pain Increased by

Viral myalgia, muscle tension; Cervical Spine: Herniated intervertebral disk, spinal arthritis, meningitis, meningismus, craniovertebral junction abnormal­ities; Neck Pain Increased by Shoulder Movement—Superior Thoracic Aperture: Cervical rib, scalenus anticus syndrome, costoclavicular syndrome;

Fluctuant scalp mass—hematoma, abscess, fracture. Blood or pus accumu-

lating in the skin or subcutaneously form a discreet soft mass sliding readily over the skull. Blood or pus under an adult aponeurosis forms a boggy, uc­tuant mass covering the entire scalp. A uctuant mass bounded by the skull

suture lines indicates subperiosteal blood or pus or a depressed fracture. A subperiosteal hematoma usually has a soft plastic center and rm edges, feel­ing much like a depressed fracture.

Masseter muscle hypertrophy. Spontaneous hypertrophy of one or both masseter muscles produces facial swelling mimicking parotid gland swelling. If the entire mass hardens when the patient clenches his teeth, it is muscular.

Mastoid pain and tenderness—mastoiditis. See page 244.

Trismus. Trismus is tight jaw closure from spasm of the masticatory muscles.

Trismus, common with tetanus, has many other more common causes.

biconcave surface, it easily partially subluxes or completely dislocates. The

jaw won’t close after a yawn or receipt of an upward blow on the chin with the mouth wide open. The mandible protrudes, the lower teeth overriding the uppers. There is a depression or pit anterior to the tragus that is more obvious when bilateral. In unilateral dislocation, the pretragal depression occurs only on the affected side. No movement of the mandibular head is felt when palpating through the external acoustic meatus on the affected side.

ular. They may open discharging chalky contents.

and degeneration of cartilage especially of the pinna, nasal septum, laryn­geal cartilages, tracheal and bronchial rings; joint cartilages may be affected.

Ear discharge—otorrhea. Ear discharge has many causes, the type suggesting the diagnosis: Yellow Discharge: Melting cerumen; Serous Discharge: Eczema, early ruptured acute otitis media; Bloody Discharge: External canal trauma or longitudinal temporal bone fracture with TM and external canal laceration;

Foreign body. Children often place objects in their ears. A purulent discharge from the canal or an earache may be the rst indication.

Polyps. A bulbous, reddened, pedunculated mass arising from the canal wall or middle ear is associated with a foul purulent discharge. Moving it with forceps may reveal the origin.