FACE - FACIES Neck- thyroid

Objectives:

To correlate specific changes of the face with a pathologic cond/disease To be able to identify the changes of the thyroid (insp, palpation, auscultation)

Structure:

Faces- changes Physical exam of thyroid

Face
Perhaps nothing is so eloquent and significant as the human face. Looking at one another is our most basic form of conversation, and wherever people meet in a primary or face-to-face relationship it is the face, which is generally the center of attention. It is the source of vocal communication, the expressor of emotions, and the revealer of personality traits. The face is the person him/herself.

(Macgregor, 1951)

Acromegaly

akros ="extremities" and megalos = large"

extremities enlargement Excess of growth hormone after puberty (epiphyseal plate closure) pituitary adenoma, ectopic secr. (pancreas, lung cancer)
enlargement of the hands, feet, nose, lips and ears, and a general thickening of the skin

ACROMEGALY

The nose is widened and thickened, The cheekbones are proeminent the forehead bulges Frontal bossing Teeth gapping macroglosia

Adenoid face

The mouth is constantly open- to breath altered mandibular and tongue position

Adenoid face= Long face syndrome

lean mid-face with high arched palate and dental crowding - in children with chronic nasal airway obstruction.

Down syndrome

= trisomy 21 Mental retardation+ facial changes+ others changes

Microcephaly and abnormal shape of the head. a flattened nose, protruding tongue, and upward slanting eyes. The inner corner of the eyes may have a rounded fold of skin= epicanthal fold

short hands, short fingers, a single crease in the palm. poss. cardiac malf., gastrointestinal abnormalities, increased freq. of leukemia

Myxedema

can be caused by permanent loss or atrophy of functional thyroid tissue (primary hypothyroidism), insufficient stimulation of a normal thyroid gland by as a result of hypothalamic or pituitary disease (secondary hypothyroidism, often accompanied by compensatory thyroid gland enlargement)

White full moon face Herzoghe sign= absence of hair in the ext part of the eyebrow non-pitting edema- pretibial Dry, cold skin Bradycardia Hypothermia coma

Cushing sdr.

prolonged exposure to elevated levels of either endogenous glucocorticoids (adrenocortical neoplasm -usually an adenoma and rarely a carcinoma) or exogenous glucocorticoids (therapy with cortizon)

Red moon face, facial plethora, supraclavicular fat pads, buffalo hump, truncal (abdominal) obesity, red-purple striae Hypertension Diabetes

SCLERODERMA

The American College of Rheumatology (ACR): systemic sclerosis require one major criterion or two minor criteria:

Major criterion: symmetric thickening, tightening, and induration of the skin of the fingers or may affect the entire extremity, face, neck, and trunk Minor criteria

Sclerodactyly includes the above major criterion limited to the fingers. Digital pitting scars or a loss of substance from the finger pad pulmonary fibrosis - a bilateral reticular pattern or honeycomb lung

Joints pain, muscle weakness Gastrointestinal manif.- motility Raynaud phenom. (Pallor, Cyanosis,Redness) Face:

Immobile- expressionless (icon, bird of prey) pinched nose Microstomia (small mouth)

Scleroderma en coup de sabre (cut of sword)- is confined to one side of the face (deep lesions); common: central nervous system involvement Limited scleroderma= morphea: mainly affects the hands, arms and face; common- pulmonary hypertension CREST form: calcinosis, Raynaud, esophageal dysmotility, sclerodactily, teleangiectsis

Lupus erythematosus
-

autoimmune disease with systemic involvement !!!

The revised criteria for SLE must include 4 of the following at any time during a patient's history (specificity 95% and sensitivity 75%):

Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis Renal disorder Neurologic disorder Hematologic disorder Immunologic disorder Antinuclear antibody

dermatomyositis

is an idiopathic inflammatory myopathy with characteristic skin changes Dermatomyositis is a disease that primarily affects the skin and the muscles but may affect other organ systems. The characteristic, and possibly pathognomonic, dermatomyositis are heliotrope rash and Gottron papules. other cutaneous features: malar erythema, poikiloderma (variegated telangiectasia, hyperpigmentation) in a photosensitive distribution, violaceous erythema on the extensor surfaces

The heliotrope rash consists of a violaceous-to-dusky erythematous rash with or without edema in a symmetrical distribution involving periorbital skin. Sometimes, this sign is subtle and may involve only a mild discoloration along the eyelid margin; its presence is highly suggestive of dermatomyositis ! The Gottron papules are found over bony prominences, particularly the metacarpophalangeal joints, the proximal interphalangeal joints, and/or the distal interphalangeal joints. Papules may also be found overlying the elbows, knees, and/or feet.
= slightly elevated violaceous papules and plaques. These lesions may resemble lesions of lupus erythematosus, psoriasis

Muscle disease manifests as a proximal symmetrical muscle weakness. Patients may have difficulty rising from a chair or squatting and raising themselves from this position. Often, the extensor muscles of the arms are more affected than the flexors. Muscle tenderness could be also found. Calcinosis of the skin or muscle may occur in 40% of children or adolescents

Calcinosis cutis is manifested by firm, yellow- or flesh-colored nodules, often over bony prominences; secondary infection may occur.

Joint swelling - the small joints of the hands are most frequently involved. The arthritis associated with dermatomyositis is not erosive or deforming. Patients with pulmonary disease may have abnormal breath sounds (crackles from interstitial fibrosis or pneumonitis). Patients with an associated malignancy may have physical findings relevant to location.

Basedow Graves - exophtalmus

Tetanos: lockjaw, risus sardonicus

Parkinson disease

degeneration of dopaminergic neurons in the nigrostriatal system. Immobile face

leukemia

Corvisart face- cardiac failure

Mitral stenosis

diabetes

Other changes

- xantelasma

The eye

Nystagmus: involuntary oscillation of the eyes

Horizontal, vertical, rotatory Abnormality of vestibular system and its connections Jerk nystagmus: peripheral or central etiology
A slow phase and then a fast corrective phase (the direction of the fast phase shows the direction of nystagmus) Periph: unilat. nystagmus away from the affected side Centr: bidirectional nystagmus

Examination of vision
Often: cranial nerves II and VII (and their central connections) Inspection Visual acuity and field Ocular alignment Pupillary exam Colour vision ophtalmoscopy

Abnormal findings

Ptosis (droopy eyelid)

Claude Bernard Horner syndrome: ptosis, miosis, anhidrosis) compresssion of sympathetic nerv. system Other causes: myasthenia gravis, myopathy

Periorbital edema:

Allergy Thyroid disease Nephrotic syndrome (renal edema)

Associated with edema of conjunctiva= chemosis

Cornea= the transparent window of the eye

Peripheral deposition of lipids= arcus senilis (gerontoxon) Copper deposition= Kayser Fleisher ring (Wilson disease)

Visual acuity, field- specialist Ocular alignment:

Normally parallel in all positions except convergence When not: a squint A paralytic squint causes diplopia= the images are maximally separated and squint greatest in the direction of action of the paretic muscle Central supression causes amblyopia= lazy eye

Pupillary abnorm. - The exam: shape, symmetry - Anisocoria= asymmetry - Dilatation= midriasis - The opposite- miosis

The nose

rhinophyma

The ears

Deafness/ hearing loss:

Conductive: due to a process disrupting conduction from the outer to the inner ear Sensorineural: due to cochlear or neurological damage with impaired speech Mixed

Weber test: the base of the vibrating tuning fork on the top of the patient.s head- he will hear the noise in the middle or equally in both ears

Conductive: he will hear loudest in the ear affected (outside sounds are not interfering with it) Sensorineural: loudest in the unaffected ear

Rinne test: the base is placed on the mastoid process till he cannot hear anymore; then place quickly close to the external auditory meatus on the same side and ask if he can hear it now

If yes= no conduction pblm (air cond. is better then bone conduction)

Deformities of the ear

Congenital
Microtia, anotia Markedly protruding ears- bat ears Small auricles, absent lobule- Down syndrome

Gouty tophi- deposits of crystals

Symptoms:

Tinnitus: subjective sensation of sound without auditory stimulus Vertigo= feeling of the movement of the surroundings

Travel sickness, vestibular disorders

THYROID
The thyroid: two symmetrical lobes joined by a central isthmus that normally covers the second and third tracheal rings

It may extend into the superior mediastinum, or be entirely retrosternal or located higher in the neck A goitre = the enlargement of the thyroid gland

1. Inspect the neck from the front and profile Ask the patient to sit with the neck muscles relaxed and stand behind the patient. Look for a thyroid swelling while the patient swallows. The thyroid moves upwards on swallowing (it is enveloped in the pretracheal fascia attached to the cricoid cartilage) 2.Palpation: place your hands gently on the front of the patient's neck with your index fingers touching the skin Ask the patient to swallow. 3.Auscultation: listen with the diaphragm of your stethoscope for a thyroid bruit.

Note the size, surface-regular/irregular, consistency, mobility, sensibility, bruit of goitre

Abnormal findings:

Surface- irregular: multinodular goitre Mobility

Immobile: invasive thyroid cancer, very large goitres A hard consistency cancer (large, firm lymph nodes near a goitre also suggest thyroid cancer). Fluctuation: compressing the swelling on one side and seeing and feeling if a bulge is created on the opposite side.

Consistency.

Thyroid bruit: abnormally high blood flow hyperthyroidism.

Goitre does NOT mean necessary hyperthyroidism !!!

Graves Disease (Basedow Graves)

Autoimmune disease (antibodies against TSH receptor) Goiter + hyperthyroidism + exophtalmus (protuberance of one or both eyes) + non pitting edema

Hashimoto thyroiditis

Autoimmune dis.

(autoantibodies against thyroid peroxidase, thyroglobulin and TSH receptors)

Hypothyroidism- usually

weight gain, depression, mania, sensitivity to cold, fatigue, panic attacks, bradycardia

Take home messages

Changes of the face may suggest a specific pathology Thyroid enlargement does not mean necessarily hyperthyroidim Thyroid- inspection, palpation and auscultation