HEENT Flashcards

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Bates' HEENT with pictures
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A firm, nodular, hypertrophic mass of scar tissue extending beyond the area of injury. It may develop in any scarred area but is most common on the shoulders and upper chest. A keloid on a pierced earlobe may have troublesome cosmetic effects. Keloids are more common in darker-skinned people. Recurrence may follow treatment.

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Chondrodermatitis Helicis.
This chronic inflammatory lesion starts as a painful, tender papule on the helix or antihelix. Here the upper lesion is at a later stage of ulceration and crusting. Reddening may occur. Biopsy is needed to rule out carcinoma.

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A deposit of uric acid crystals characteristic of chronic tophaceous gout. It appears as hard nodules in the helix or antihelix and may discharge chalky white crystals through the skin. It also may appear near the joints, hands (p. 649), feet, and other areas. It usually develops after chronic sustained high blood levels of uric acid.

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Basal Cell Carcinoma.
This raised nodule shows the lustrous surface and telangiectatic vessels of basal cell carcinoma, a common slow-growing malignancy that rarely metastasizes. Growth and ulceration may occur. These are more frequent in fair-skinned people overexposed to sunlight.

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Cutaneous Cyst.
Formerly called a sebaceous cyst, a dome-shaped lump in the dermis forms a benign closed firm sac attached to the epidermis. A dark dot (blackhead) may be visible on its surface. Histologi- cally, it is usually either
(1) an epidermoid cyst, common on the face and neck, or (2) a pilar (trichilemmal) cyst, com- mon in the scalp. Both may become inflamed.

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Rheumatoid Nodules.
In chronic rheumatoid arthritis, look for small lumps on the helix or antihelix and additional nodules elsewhere on the hands, along the surface of the ulna distal to the elbow (p. 648),
and on the knees and heels. Ulceration may result from repeated injuries. Such nodules may antedate the arthritis.

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Normal Eardrum
This normal right eardrum (tympanic membrane) is pinkish gray. Note the malleus lying behind the upper part of the drum. Above the short process lies the pars flaccida. The remainder of the drum is the pars tensa. From the umbo, the bright cone of light fans anteriorly and downward. Posterior to the malleus, part of the incus is visible behind the drum. The small blood vessels along the handle of the malleus are normal.

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Perforation of the Drum
Perforations are holes in the eardrum that usually result from purulent infections of the middle ear. They are classified as central perforations, which do not extend to the margin of the drum, and marginal perforations, which do involve the margin.
The more common central perforation is illustrated here. A reddened ring of granulation tissue surrounds the perforation, indicating chronic infection. The eardrum itself is scarred, and no landmarks are visible. Discharge from the infected middle ear may drain out through such a perforation. A perforation often closes in the healing process, as in the next photo. The membrane covering the hole may be exceedingly thin and transparent.

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In the inferior portion of this left eardrum, there is a large, chalky white patch with irregular margins. It is typical of tympanosclerosis: a deposition of hyaline material within the layers of the tympanic membrane that sometimes follows a severe episode of otitis media. It does not usually impair hearing and is seldom clinically significant.
Other abnormalities in this eardrum include a healed perforation (the large oval area in the upper posterior drum) and signs of a retracted drum. A retracted drum is pulled medially, away from the examiner’s eye, and the malleolar folds are tightened into sharp outlines. The short process often protrudes sharply, and the handle of the malleus, pulled inward at the umbo, looks foreshortened and more horizontal.

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Serous Effusion
Serous effusions are usually caused by viral upper respiratory infections (otitis media with serous effusion) or by sudden changes in atmospheric pressure as from flying or diving (otitic barotrauma). The eustachian tube cannot equalize the air pressure in the middle ear with that of the outside air. Air is partly or completely absorbed from the middle ear into the bloodstream, and serous fluid accumulates there instead. Symptoms include fullness and popping sensations in the ear, mild conduction hearing loss, and perhaps some pain.
Amber fluid behind the eardrum is characteristic, as in this patient with otitic barotrauma. A fluid level, a line between air above and amber fluid below, can be seen on either side of the short process. Air bubbles (not always present) can be seen here within the amber fluid.

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Acute Otitis Media With Purulent Effusion
Acute otitis media with purulent effusion is caused by bacterial infection. Symptoms include earache, fever, and hearing loss. The eardrum reddens, loses its landmarks, and bulges laterally, toward the examiner’s eye.
Here the eardrum is bulging, and most landmarks are obscured. Redness is most obvious near the umbo, but dilated vessels can be seen in all segments of the drum. A diffuse redness of the entire drum often develops. Spontaneous rupture (perforation) of the drum may follow, with discharge of purulent material into the ear canal.
Hearing loss is of the conductive type. Acute purulent otitis media is much more common in children than in adults.

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Bullous Myringitis
Bullous myringitis is a viral infection characterized by painful hemorrhagic vesicles that appear on the tympanic membrane, the ear canal, or both. Symptoms include earache, blood-tinged discharge from the ear, and hearing loss of the conductive type.
In this right ear, at least two large vesicles (bullae) are discernible on the drum. The drum is reddened, and its landmarks are obscured.
Several different viruses may cause this condition, including mycoplasma.


Pathophysiology of Conductive Loss

External or middle ear disorder impairs sound conduction to inner ear. Causes include foreign body, otitis media, perforated eardrum, and otosclerosis of ossicles.


Pathophysiology of Sensorineural Loss

Inner ear disorder involves cochlear nerve and neuronal impulse transmission to the brain. Causes include loud noise exposure, inner ear infections, trauma, tremors, congenital and familial disorders, and aging.


Differences in usual age of onset between Conductive Loss and Sensorineural Loss

Conductive - Childhood and young adulthood, up to age 40

Sensorineural - Middle or later years

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Damage on Ear Canal and Drum and Effects
of Conductive Loss

Ear canal and drum- Abnormality usually visible, except in otosclerosis

-Little effect on sound
-Hearing seems to improve in noisy environment -Voice becomes soft because inner ear and cochlear nerve are intact

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Damage on Ear Canal and Drum and Effects
of Sensorineural Loss

Problem not visible in ear canal and drum.

-Higher registers are lost, so sound may be distorted.
-Hearing worsens in noisy environment
-Voice may be loud because hearing is difficult.


What does the Weber Test show in conductive loss?
(in unilateral hearing loss)

-Tuning fork at vertex
-Sound lateralizes to impaired ear—room noise not well heard, so detection of vibrations improves.


What does the Weber Test show in sensorineural loss?
(in unilateral hearing loss)

-Tuning fork at vertex
-Sound lateralizes to good ear—inner ear or cochlear nerve damage impairs transmission to affected ear.


What does the Rinne Test show in conductive loss?

-Tuning fork at external auditory meatus then on mastoid bone
-Bone conduction longer than or equal to air conduction (BC ≥ AC). While air conduction through the external or middle ear is impaired, vibrations through bone bypass the problem to reach the cochlea.


What does the Rinne Test show in sensorineural loss?

-Tuning fork at external auditory meatus then on mastoid bone
-Air conduction longer than bone conduction (AC > BC). The inner ear or cochlear nerve is less able to transmit impulses regardless of how the vibrations reach the cochlea. The normal pattern prevails.

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Angular Cheilitis

Angular cheilitis starts with softening of the skin at the angles of the mouth, followed by fissuring. It may be due to nutritional deficiency or, more commonly, to overclosure of the mouth, as in people with no teeth or with ill-fitting dentures. Saliva wets and macerates the infolded skin, often leading to secondary infection with Candida, as seen here.

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Actinic Cheilitis

Actinic cheilitis results from excessive exposure to sunlight and affects primarily the lower lip. Fair-skinned men who work outdoors are most often affected. The lip loses its normal redness and may become scaly, somewhat thickened, and slightly everted. Because solar damage also predisposes to carcinoma of the lip, be alert to this possibility.

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Herpes Simplex (Cold Sore, Fever Blister)

The herpes simplex virus (HSV) produces recurrent and painful vesicular eruptions of the lips and surrounding skin. A small cluster of vesicles first develops. As these break, yellow-brown crusts form, and healing ensues within 10 to 14 days. Both of these stages are visible here.

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Angioedema is a diffuse, nonpitting, tense swelling of the dermis and subcutaneous tissue. It develops rapidly, and typically disappears over subsequent hours or days. Although usually allergic in nature and sometimes associated with hives, angioedema does not itch.

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Hereditary Hemorrhagic Telangiectasia

Multiple small red spots on the lips strongly suggest hereditary hemorrhagic telangiectasia. Spots may also be visible on the face and hands and in the mouth. The spots are dilated capillaries and may bleed when traumatized. Affected people often have nosebleeds and gastrointestinal bleeding.

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Peutz-Jeghers Syndrome

When pigmented spots on the lips are more prominent than freckling of the surrounding skin, suspect this syndrome. Pigment in the buccal mucosa helps to confirm the diagnosis. Pigmented spots may also be found on the face and hands. Multiple intestinal polyps are often associated.

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Chancre of Syphilis

This lesion of primary syphilis may appear on the lip rather than on the genitalia. It is a firm, buttonlike lesion that ulcerates and may become crusted. A chancre may resemble a carcinoma or a crusted cold sore. Because it is infectious, use gloves to feel any suspicious lesion.

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Carcinoma of the Lip

Like actinic cheilitis, carcinoma usually affects the lower lip. It may appear as a scaly plaque, as an ulcer with or without a crust, or as a nodular lesion, illustrated here. Fair skin and prolonged exposure to the sun are common risk factors.

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Large Normal Tonsils

Normal tonsils may be large without being infected, especially in children. They may protrude medially beyond the pillars and even to the midline. Here they touch the sides of the uvula and obscure the pharynx. Their color is pink. The white marks are light reflections, not exudate.

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Exudative Tonsillitis

This red throat has a white exudate on the tonsils. This, together with fever and enlarged cervical nodes, increases the probability of group A streptococcal infection or infectious mononucleosis. Anterior cervical lymph nodes are usually enlarged in the former, posterior nodes in the latter.

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These two photos show reddened throats without exudate.
-redness and vascularity of the pillars and uvula are mild to moderate.

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These two photos show reddened throats without exudate.
-redness is diffuse and intense. Each patient would probably complain of a sore throat, or at least a scratchy one. Possible causes include several kinds of viruses and bacteria. If the patient has no fever, exudate, or enlargement of cervical lymph nodes, the chances of infection by either of two common causes—group A streptococci and Epstein-Barr virus (infectious mononucleosis)—are very small.

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Diphtheria (an acute infection caused by Corynebacterium diphtheriae) is now rare but still important. Prompt diagnosis may lead to life-saving treatment. The throat is dull red, and a gray exudate (pseudomembrane) is present on the uvula, pharynx, and tongue. The airway may become obstructed.

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Thrush on the Palate (Candidiasis)

Thrush is a yeast infection due to Candida. Shown here on the palate, it may appear elsewhere in the mouth (see p. 279). Thick, white plaques are somewhat adherent to the underlying mucosa. Predisposing factors include (1) prolonged treatment with antibiotics or corticosteroids and (2) AIDS.

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Kaposi’s Sarcoma in AIDS

The deep purple color of these lesions, although not necessarily present, strongly suggests Kaposi’s sarcoma. The lesions may be raised or flat. Among people with AIDS, the palate, as illustrated here, is a common site for this tumor.

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Torus Palatinus

A torus palatinus is a midline bony growth in the hard palate that is fairly common in adults. Its size and lobulation vary. Although alarming at first glance, it is harmless. In this example, an upper denture has been fitted around the torus.

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Fordyce Spots (Fordyce Granules)

Fordyce spots are normal sebaceous glands that appear as small yellowish spots in the buccal mucosa or on the lips. A worried person who has suddenly noticed them may be reassured. Here they are seen best anterior to the tongue and lower jaw. These spots are usually not so numerous.

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Koplik’s Spots

Koplik’s spots are an early sign of measles (rubeola). Search for small white specks that resemble grains of salt on a red background. They usually appear on the buccal mucosa near the first and second molars. In this photo, look also in the upper third of the mucosa. The rash of measles appears within
a day.

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Petechiae are small red spots that result when blood escapes from capillaries into the tissues. Petechiae in the buccal mucosa, as shown, are often caused by accidentally biting the cheek. Oral petechiae may be due to infection or decreased platelets, as well as to trauma.

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A thickened white patch (leukoplakia) may occur anywhere in the oral mucosa. The extensive example shown on this buccal mucosa resulted from frequent chewing of tobacco, a local irritant. This kind of irritation may lead to cancer.

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Marginal Gingivitis

Marginal gingivitis is common among teenagers and young adults. The gingival margins are reddened and swollen, and the interdental papillae are blunted, swollen, and red. Brushing the teeth often makes the gums bleed. Plaque—the soft white film of salivary salts, protein, and bacteria that covers the teeth and leads to gingivitis—is not readily visible.

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Acute Necrotizing Ulcerative Gingivitis

This uncommon form of gingivitis occurs suddenly in adolescents and young adults and is accompanied by fever, malaise, and enlarged lymph nodes. Ulcers develop in the interdental papillae. Then the destructive (necrotizing) process spreads along the gum margins, where a grayish pseudomembrane develops. The red, painful gums bleed easily; the breath is foul.

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Gingival Hyperplasia

Gums enlarged by hyperplasia are swollen into heaped-up masses that may even cover the teeth. The redness of inflammation may coexist, as in this example. Causes include dilantin therapy (as in this case), puberty, pregnancy, and leukemia.

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Pregnancy Tumor (Epulis, Pyogenic Granuloma)

Gingival enlargement may be localized, forming a tumorlike mass that usually originates in an interdental papilla. It is red and soft and usually bleeds easily. The estimated incidence of this lesion in pregnancy is about 1%. Note the accompanying gingivitis in this example.

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Attrition of Teeth; Recession of Gums

In many elderly people, the chewing surfaces of the teeth have been worn down by repetitive use so that the yellow-brown dentin becomes exposed—a process called attrition. Note also the recession of the gums, which has exposed the roots of the teeth, giving a “long in the tooth” appearance.

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Erosion of Teeth

Teeth may be eroded by chemical action. Note here the erosion of the enamel from the lingual surfaces of the upper incisors, exposing the yellow- brown dentin. This results from recurrent regurgitation of stomach contents, as in bulimia.

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Abrasion of Teeth With Notching

The biting surface of the teeth may become abraded or notched by recurrent trauma, such as holding nails or opening bobby pins between the teeth. Unlike Hutchinson’s teeth, the sides of these teeth show normal contours; size and spacing of the teeth are unaffected.

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Hutchinson’s Teeth

Hutchinson’s teeth are smaller and more widely spaced than normal and are notched on their biting surfaces. The sides of the teeth taper toward the biting edges. The upper central incisors of the permanent (not the deciduous) teeth are most often affected. These teeth are a sign of congenital syphilis.

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Geographic Tongue.

In this benign condition, the dor- sum shows scattered smooth red areas denuded of papillae. Together with the normal rough and coated areas, they give a maplike pattern that changes over time.

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Hairy Tongue.

Note the “hairy” yellowish to brown or black elongated papillae on the tongue’s dorsum. This benign condition may follow antibiotic therapy; it also may occur spontaneously.

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Fissured Tongue.

Fissures appear with increasing age, sometimes termed scrotal tongue. Food debris may accumulate in the crevices and become irritating, but a fissured tongue is benign.

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Smooth Tongue (Atrophic Glossitis).
A smooth and often sore tongue that has lost its papillae suggests a deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron, or treatment with chemotherapy.

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Note the thick white coating from Candida infection. The raw red surface is where the coat was scraped off. Infection may also occur without the white coating. It is seen in immunosuppressed conditions.

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Hairy Leukoplakia.
These whitish raised areas with a feath- ery or corrugated pattern most often affect the sides of the tongue. Unlike candidiasis, these areas cannot be scraped off. They are seen with HIV and AIDS.

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Varicose Veins.
Small purplish or blue-black round swellings appear under the tongue with age. These dilatations of the lingual veins have no clinical significance.

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Aphthous Ulcer (Canker Sore).
A painful, round or oval ulcer that is white or yellowish gray and surrounded by a halo of reddened mucosa. It may be single or multiple. It heals in 7–10 days, but may recur.

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Mucous Patch of Syphilis.
This painless lesion in the secondary stage of syphilis is highly infectious. It is slightly raised, oval, and covered by a grayish membrane. It may be multiple and occur elsewhere in the mouth.

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With this persisting painless white patch in the oral mucosa, the undersurface of the tongue appears painted white. Patches of any size raise the possibility of malignancy and require a biopsy.

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Tori Mandibulares.
Rounded bony growths on the inner surfaces of the mandible are typically bilateral, asymptomatic, and harmless.

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Carcinoma, Floor of the Mouth.
This ulcerated lesion is in a common location for carcinoma. Medially, note the reddened area of mucosa, called erythroplakia, suggesting possible malignancy.

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Diffuse Enlargement.

Includes the isthmus and lateral lobes; there are no discretely palpable nodules. Causes include Graves’ disease, Hashimoto’s thyroiditis, and endemic goiter.

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Single Nodule.
May be a cyst, a benign tumor, or one nodule within a multinodular gland. It raises the question of malignancy. Risk factors are prior irradiation, hardness, rapid growth, fixation to surrounding tissues, enlarged cervical nodes, and occurrence in males.

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Multinodular Goiter.
An enlarged thyroid gland with two or more nodules suggests a metabolic rather than a neo- plastic process. Positive family history and continuing nod- ular enlargement are additional risk factors for malignancy.


Symptoms of hyperthyroidism

Weight loss despite increased appetite
Excessive sweating and heat intolerance Palpitations
Frequent bowel movements
Muscular weakness of the proximal type and tremor


Symptoms of hypothyroidism

Fatigue, lethargy
Modest weight gain with anorexia
Dry, coarse skin and cold intolerance
Swelling of face, hands, and legs
Weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing


Signs of hyperthyroidism

Warm, smooth, moist skin
With Graves’ disease, eye signs such as stare, lid lag, and exophthalmos
Increased systolic and decreased diastolic blood pressures
Tachycardia or atrial fibrillation
Hyperdynamic cardiac pulsations with an accentuated S1
Tremor and proximal muscle weakness


Signs of hyopthyroidism

Dry, coarse, cool skin, sometimes yellowish from carotene, with nonpitting edema and loss of hair Periorbital puffiness
Decreased systolic and increased diastolic blood pressures
Bradycardia and, in late stages, hypothermia Intensity of heart sounds sometimes decreased
Impaired memory, mixed hearing loss, somnolence, peripheral neuropathy, carpal tunnel syndrome