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1
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2
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- THE FACE
Observation of the faces, the expression, may give information
about the patient’s state of mind and physical health: mood or
hemoglobin, health or disease, malnutrition or endocrine state. Clues
are there to the system that is at fault.
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3
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- 1 Health
- Alert, bright-eyed, no pallor and normal skin turgor.
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4
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- 2 Disease (carcinoma of the pancreas)
- Apathetic and drowsy: loss of subcutaneous fat, sunken eyes and cheeks
with loss of skin turgor secondary to dehydration. The picture of
terminal illness.
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5
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- 3 Pallor
- This is not synonymous with anemia since a pale skin may be due to
depigmentation or vasoconstriction, apart from a fall in the hemoglobin
concentration. Pallor of the skin must be confirmed by looking at the
mucous membranes. Note: the color of the skin; a slight malar flush with
dilated superficial veins; a left sided corneal arcus; obesity - the
roundness of the face which is not due to steroid therapy, but could be;
the fact that the hair has been dyed (this is irrelevant but one should
learn to observe everything).
In fact this woman’s hemoglobin was 14g% and this underlines the
fallacy of using pallor as an index of anemia. (See 4).
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6
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- 4 Pallor of the conjunctivae
- Note the difference in color between the examiner’s nailbed and the
conjunctival mucous membrane - one can be misled since this woman’s
hemoglobin was 14g%. Confirmation should be sought by examination of
other mucous membranes and estimation of their degree of pallor.
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7
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- 5 Pallor (pernicious anemia)
- A woman of middle age. The lips and face are pale, the hair white, the
eyes blue. Note the pallor of the lower lid margin, the tattoo on the
left shoulder. This woman presents the classic clinical picture of the
faces of pernicious anemia.
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8
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- 6 Pallor (pernicious anemia)
- Facial pallor, blue eyes, grey hair. Bilateral corneal arcus.
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9
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- 7 anemia
- This thin, pale woman with a scarred abdomen had a gastrectomy which
produced her iron deficiency anemia. Note the wasting, the abdominal
scar and dilated veins which in her case are not significant. Dilated
veins should always be observed since they may indicate a venous block
in the deep circulation.
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10
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- 8 Megaloblastic anemia
- Megaloblastic anemia in the elderly, slight pallor, tinge of jaundice in
the eye, atrophy of the tongue and healed angular stomatitis.
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11
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- 9 Pallor (rectal bleeding)
- Pale lips and face. This man looks ill and apathetic. hemoglobin 6g%.
- Diagnosis: carcinoma of the rectum; long standing diarrhea secondary to
ulcerative colitis. Compare his faces and alertness with the preceding
plate where the hemoglobin was 5g% and with the pre and post transfusion
appearance of the mucous membrane on the inside of the lower lip (11
& 12).
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12
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- 10 Pallor of the conjunctivae in severe anemia
- The color of the mucous membrane and the conjunctival sac is an index of
the degree of anemia but it may be reassuringly red in severe anemia and
should be compared with the inside of the lower lip.
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13
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- 11 Pallor of the mucous membrane of the lower lip
- Same patient as 10, confirming the conjunctival impression of severe
anemia. Note the mild pyorrhea, gum recession and nicotine staining of
the teeth. This is a particularly reliable site to check for pallor and
estimate the hemoglobin by contrast with the examiners nailbed.
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14
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- 12 Normal mucosa of the lower lip
- The same patient, following transfusion of five pints of packed red
cells.
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15
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- 13 & 14 Facial plethora (polycythemia rubra vera)
- On the left the man has a red face compared with the normal on the
right. This facial plethora may be within normal limits or may be
secondary to an increase in the number of red cells.
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16
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- 15 Facial plethora
- Healthy open air worker. Secondary facial plethora, normal hemoglobin.
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17
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- 16 The anemic Negro
- In the Negro anemia may present as a greyness of a black skin and the
pallor is difficult to see. Hemoglobins of 5g% can be missed in active
farmers with hookworm, whose anemia has come on slowly and whose
symptoms are minimal. One must be familiar with the nuances of color
change.
Note the evidence of recent wasting in the folding of the skin.
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18
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- 17 A pale normal Negro
- A Negro whose pigmentation is not dense and therefore looks pale
compared with the previous picture. His conjunctivae are pink.
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19
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- 18 & 19 A dark, anemic Negro
- A Negro with dark pigmentation who has pallor of the conjunctivae and a
hemoglobin of 5g%. Compare this with his lower lip, where there is
obvious yellow pallor of the inside of the lower lip. This is a markedly
anemic Negro.
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20
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- 20 Pallor of the nailbeds contrasted with the normal
- hemoglobin: 6g%.
Examination of the hands should include comparison with your own
hand.
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21
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- 21 & 22 Koilonychia (spoon shaped)
- If you see pallor, look at the hands and nails. Koilonychia is
associated with iron deficiency anemia and hepatic disease. Classically,
Koilonychia is described as being able to take a drop of water in the
depression of the nailbed.
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22
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- 23 Malnutrition (child)
- Complete picture of early protein/calorie malnutrition. General misery,
wasting, edema, pallor of the skin, fineness and depigmentation of the
hair, puffiness of the face, and a protuberant belly.
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23
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- 24 Malnutrition (adult), famine starvation
- Depigmentation of the hair, pale skin. The scars are of tribal cosmetic
significance. Yoruba, western region Nigeria.
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24
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- 25 Kwashiorkor (protein/calorie malnutrition)
- Note the edema, scaliness, depigmentation. (See 26).
- 26 Kwashiorkor
- As the skin peels an ooze of fluid appears and leads to further loss of
protein.
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25
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- 27 Malnutrition
- The tongue is smooth and shiny, has lost its normal furred papillae and
splitting of the corners of the mouth is noted. There is also a
characteristic scaling of the skin and depigmentation over the nose in a
patient with severe malnutrition.
- 28 Malnutrition
- A Nigerian with malabsorption following gastrectomy, pallor, wasting and
skin changes of protein deficiency: cracking of the skin and
pigmentation.
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26
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- 29 anemia, telangiectasia of the tongue
- This patient presented with anemia. Apart from slight pallor there were
no obvious physical signs, there are healed scars at the corners of the
mouth and two small telangiectases can be seen on the left cheek. When
the tongue was examined the telangiectases were easily seen.
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27
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- 30 & 31 Congenital telangiectasia
- The telangiectases may be seen on the face, around the angle of the jaw
and are well seen on the ear.
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28
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- 32 Telangiectasia
- This man, who has telangiectasia seen round the borders of the lips,
presented initially with hematemesis and over the course of years had a
gastrectomy followed by the malabsorption complications of gastrectomy
and developed tuberculosis. It was only when he shaved off his exuberant
moustache that the telangiectasia was noted.
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29
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- 33 Telangiectasia
- On the inside of the lower lip telangiectases may be more obvious.
Dilated capillaries are well seen and the capillary loop in the middle
is obvious.
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30
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- 34 Sickle cell anemia
- Note the pallor, the prominent forehead due to expansion of the bones of
the skull. A tint of jaundice can be seen in the conjunctivae. This
appearance may be seen in Mediterranean anemia and other
hemoglobinopathies where there is a hypertrophy of the bone marrow. The
scars on the cheeks are Yoruba tribal markings in the African.
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31
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- 35 Sickle cell anemia
- Dactylitis in a small child with bone infarction producing an acute,
tender swelling of the finger. Differential diagnosis between sepsis,
acute or chronic (tuberculosis), syphilis, sickle cell disease,
sarcoidosis.
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32
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- 36 The malar flush
- The redness of the cheeks may be seen in health. There is a clinical
association between this physical sign and mitral stenosis but it also
may be seen in polycythemia, in steroid therapy, and in outdoor workers.
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33
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- 37 Frank jaundice of the eyes
- Dehydration, emaciation, carcinoma of pancreas. Bilirubin 8mg%.
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34
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- 38 A tinge of jaundice
- Bilirubin 2mg%. The tinge compared with the normal lady on the right.
Best seen in the conjunctivae.
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35
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- 39 Jaundice
- The shininess of the nail due to the polishing effect of using the
fingers to scratch the back which itched. Patient was a 42-year-old man
with a stone in a common bile duct.
Note the polished nail tip is caused by scratching the skin.
Cosmetic polishing makes the whole nail shine. Pruritus maybe due to:
(1) parasitic infestations: scabies, pediculosis; (2) eczema; (3) liver
disease (even preceding jaundice); (4) drug reactions; (5) malignant
disease (lymphoma, leukaemia, carcinoma); (6) metabolic disease
(diabetes mellitus, uraemia); (7) old age.
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36
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- 40 Excoriations of the back secondary to scratching (primary biliary
cirrhosis)
- The excoriations all occur in those parts of the back within reach. This
physical sign may be seen before the development of other physical signs
of liver disease, and precede the jaundice.
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37
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- 41 Spider nevus on the nose
- Note the central vessel and the peripheral erythema. Pressure on the
central vessel produced blanching and release demonstrated the capillary
branches from the central arteriole. This condition of spider nevi is
usually seen above the nipples and may occur physiologically and
pathologically: (1) in pregnancy; (2) in normal women, increasing at the
time of period; (3) in high output states; (4) in liver disease. This
young girl developed a spider nevus during the first month of her
pregnancy and it increased in size to term and began to diminish in size
within hours of delivery of her baby.
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38
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- 42 Spider nevus
- A central feeding vessel can be seen, surrounded by a small zone of
erythema. This will blanch on pressure and will reappear from the centre
when the pressure is released.
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39
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- 43 Campbell de Morgan spots
- These are frequently seen, increasing in middle age and in the elderly.
Flat, slightly raised spots which do not blanch on pressure and have no
central arteriole and must not be confused with spider nevi. They are of
no significance.
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40
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- 44 Palmar erythema
- This is an increase in the erythema of the palms, usually localised on
the thenar and hypothenar eminences. It occurs in the healthy adult,
frequently in pregnancy, and in association with liver disease,
rheumatoid arthritis and thyrotoxicosis. In this picture one can also
see an early Dupuytren’s contracture developing in the palm. The palms
are warm and may even heve a burning quality. Areas of erythema are also
seen at the base of the fingers. The erythema blanches on pressure. This
patient suffered from cirrhosis of the liver and drank one and a half
bottles of whisky daily.
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41
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- 45 White nails
- Although described in cirrhosis it is not diagnostic and is seen in a
variety of conditions. Best seen here in the third finger (normal
below). The whiteness of the nail due to opacification of the nailbed
diminishes as the tip is reached and a pink rim can be seen in the right
hand finger (ring finger). Note that the lunula cannot be seen compared
with the normal.
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42
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- Secondary to change in hemoglobin
- pallor
- changes in Hb concentration or
changes in Hb supply to
skin (vasoconstriction)
- plethora
- - cyanosis
peripheral -
vasoconstriction, stagnation
- central - shunts, anoxia, sulph
and methaemoglobinaemia
- carbon dioxide poisoning
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43
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- Hypopigmentation
albino
- vitiligo
- irradiation
- Hyperpigmentation
sunlight
racial
von Recklinghausen’s
disease
- melanosis
Hemochromatosis
thyrotoxicosis
ACTH administration
hypoadrenocorticalism
(Addison’s disease)
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44
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- Other pigments deposited in the skin
bilirubin
carotene
drugs: mepacrine
metals: lead, mercury, gold arsenic
- Miscellaneous
malnutrition
chloasma of pregnancy
- Surface applications
cosmetics and perfumes
silver nitrate - silver deposited
pot. permanganate - reacts with keratin, difficult to remove
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45
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46
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- 50 Hemochromatosis
- Chondrocalcinosis in Hemochromatosis, in the cartilage overlying the
metacarpo-phalangeal joints of the fingers. No evidence of
hyperparathyroidisrn, gout or pseudo gout, osteoarthritis, Wilson’s
disease, all of which may be associated with calcification in cartilage.
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47
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- 51 Melanosis in melanomatosis
- Secondary melanoma of the orbit. True pigmentation of a slate color,
both of the site of the secondary tumor
and strikingly of the skin. This slate grey pigmentation is a
darker color than the pigmentation of Hemochromatosis.
- 52 Melanosis (patient and control)
- Widespread secondary melanoma with liberated pigment staining the skin.
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48
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- 53 Melanoma in abdominal scar
- Note the grey pigment showing through in the upper and lower thirds of
the wound. This patient presented with a gland under the left arm and
gave a story of removal of a thumb nail several years earlier which may
have been the primary. The gland was removed, block dissection of the
axilla carried out and one year later he presented with intestinal
obstruction and at operation had secondaries throughout the small bowel,
some of them obstructing and about to perforate.
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49
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- 54 Caroteneaemia
- Yellow pigmentation due to carotene. This is caused by (1) excess
carotene intake - overeating mangoes, carrots (4kg a day!), pawpaw,
oranges: (2) Myxedema - high levels of carotene due to a defect of
enzymatic conversion to vitamin A; (3) an association with
hyperbetaIipoproteinaemia.
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50
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51
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- 59 Vitiligo
- An early patch on the neck which may gradually enlarge. The hair
pigmentation is unaffected. The depigmentation is due to damage to the
melanocyte secondary to inflammation which may be autoimmune in origin
and associated with other autoimmune disease, i.e. diabetes mellitus,
Addison’s disease (hypoadrenocorticalism), thyro-gastric disorders.
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52
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- 60 Pityriasis versicolor
- The flaking of the skin and apparent depigmentation after exposure to
sunlight may mimic vitiligo but the characteristic distribution of the
lesions in a peri-follicular manner distinguishes it. Once it becomes
widespread it loses this peri-follicular distribution and can be a
source of confusion to the inexperienced. Compare with 58.
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53
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- 61 Albinism
- One has a complete lack of melanin due to the absence of a single enzyme
concerned in tyrosine metabolism. Features are: (1) intolerance to
sunlight; (2) white skin and hair; (3) pink iris; (4) impaired vision;
(5) nystagmus.
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54
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- 62 Heterochromia of the iris
- A common failure of pigmentation of the eye, of no significance but
sometimes disconcerting to the examiner and may be mimicked by the
wearing of contact lenses!
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55
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- The classic faces of disease may superimpose themselves, overprinting
the individual’s own face. Even in their minor early forms recognised by
the trained eye and be the clue which can be grasped when the patient is
first seen.
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56
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57
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- 66 Hypothyroidism (infant cretin)
- The child is inactive and sluggish, pasty faced and constipated, the
face coarse, the hair sparse, the skin cold, the tongue is large and he
has a pot bellied abdomen, whereas the mongol is active, pink, the
bowels normal
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58
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- 67 Hypothyroidism (adult)
- Myxedema - appearance of the face in hypothyroidism is a summation of
many changes which is often recognised at first sight of the patient as
he walks into the room and if this association does not occur instantly
it may be missed, particularly if the abnormality is minor. The
apathetic look, pallor, thickness of the skin, dullness of the eye,
broadening and podginess of the face, the thin hair, loss of eyebrows;
coupled with the hoarse voice, slow speech and slow actions should
suggest the diagnosis. Note the incidental corneal arcus, loss of hair
on the temples, the fineness of the skin which is dry and the broadening
of the cheeks with this Myxedematous look.
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59
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- 68 Myxedema
- The podgy face, a characteristic of Myxedema, is well seen here. Apart
from this the thinness of the eyebrows is the only obvious abnormality
and the diagnosis is suggested by clinical awareness rather than any
specific point. Note the bilateral corneal arcus.
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60
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- 69 & 70 Myxedema
- Lateral views of a man before and after treatment with Thyroxine.
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61
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62
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- 75 Apparent hypothyroidism
- Lateral view of woman with the facial suggestion of hypothyroidism and
loss of hair at the eyebrow, puffy face and apathy, until she spoke,
when she was bright and jolly. Her thyroid function studies were within
normal limits.
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63
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- 76 & 77 Borderline hypothyroidism
- This man had mild hypothyroidism coupled with depressive illness. He has
sparse eyebrows, a rounding of the face and presented with depression.
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64
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- 78 & 79 Thyrotoxicosis
- Before treatment (78). Note weight loss, tension, lid retraction more
marked on the left, sweatiness of the skin. After two weeks’ treatment
with Carbimazole (79) there is a diminution in lid retraction,
particularly in the left eye, and the tension appears to have gone out
of the face.
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65
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66
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- 84 Thyrotoxicosis
- Bilateral lid retraction.
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67
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- 85 & 86 Ophthalmic Graves’ Disease
- This man was euthyroid, but had thyroid auto antibodies and an elevated
thyrotrophic stimulating hormone level. He subsequently became
hypothyroid due to progressive Hashimoto’s thyroiditis and developed
progressive exophthalmoplegia: 86 was taken one year later.
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68
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- 87 & 88 Thyrotoxicosis (middle aged)
- This woman, 56 years, presented with recurrent attacks of explosive
diarrhea and weight loss. She was warm and sweaty with tremor of the
outstretched hands and had a curious brown pigmentation of the skin.
The same woman (88) after treatment with Carbimazole and
I131
showing weight gain, rounding of the face and loss of the tense
look.
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69
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70
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- 93 & 94 Malignant exophthalmos
- This man had a three month story of weight loss, irritability and
prominence of the eyes which had rapidly got worse so that the right eye
developed corneal ulceration (covered), the left eye shows the gross lid
retraction and exophthalmos. The cornea is already tending to dry
because the lids do not sweep it adequately. This can be seen from the
dryness of the light reflection on the cornea where the flash is
reflected. In the lateral view note the proptosis of the eyeball and
moist skin.
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71
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- 95 & 96 Malignant exophthalmos
- Thyrotoxicosis controlled with Carbimazole, the eyes had bilateral
tarsorrhaphies performed.
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72
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- 97 Obesity
- The roundness and fatness of the face in obesity must be differentiated
from the appearance of hyperadrenocorticalism (98).
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73
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- 98 & 99 Cushing's syndrome
- This young girl demonstrates all the facial features of
hyperadrenocorticalism - Cushing’s syndrome. She has a moon face with
erythema and acne. Compare this with the photograph taken six months
earlier, before the onset of her disease, which was due to a carcinoma
of the adrenal gland.
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74
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- 100 Cushing's syndrome, striae
- In association with the mooning of the face, striae may be seen on the
abdomen which characteristically are blue-pink in color. These can be
seen on this abdomen and on the upper thighs. This should be compared
with striae gravidarum which occur in pregnancy and are white.
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75
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- 101 Minor facial mooning
- The mooning of the face in Cushing's syndrome or following steroid
therapy can be minor, as in this young boy with Behçet’s syndrome (oral
and genital ulceration) treated with steroids and it is this degree of
early mooning of the face that should not be missed. The differential
diagnosis of this physical sign is mild obesity; in both striae may be
present but in the latter are usually pale and less livid.
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76
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- 102 Cushingoid faces
- The same child after nine months on high dose steroids for Behçet’s
syndrome with involvement of lung, heart, oral mucosa and scrotum. All
the features of Cushing’s syndrome are present.
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77
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- 103 & 104 Cushing's syndrome (anterior and lateral view)
- Cushing’s syndrome (secondary to steroid therapy) shows the deposition
of body fat producing the characteristic ‘orange on matchsticks’ shape.
Note the round, mooned face, malar flush, the striae over the abdomen
and back and comparative slimness of the legs and buttocks with
deposition of fat over the shoulders and upper back.
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78
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- 105 Adrenocortical insufficiency
- Addison’s disease. May be primary due to adrenal gland destruction or
secondary to pituitary/hypothalamic disease. Most cases of Addison’s
disease are either autoimmune or secondary to tuberculosis.
- Acute insufficiency presents in stress situations on top of the chronic
form
- the classical physical signs being characteristically: (1)
pigmentation of certain sites; (2) vitiligo -15% of idiopathic Addison’s
disease.
Note the increased pigmentation of the hands, the palmar creases,
the arms, face, shoulders and bra-strap area.
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79
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- 106 & 107 Addison’s disease
- In the European a characteristic pigmentation in the creases of the hand
and on the pressure points of the body occurs. Differentiate this from
the same appearance in the brown skinned races which is a racial
characteristic -107, the palm of an Arab complaining of lethargy and
suffering from depression, and which may be mimicked by henna on the
palms.
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80
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- 108 Addisonian pigmentation
- Pigmentation may occur in scars: here in the scar of an old varicose
vein operation. All scars should be examined, the ones affected are
those occurring after the onset of the condition.
- 109 Addison’s disease
- Note the pigmentation of the gums.
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81
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- 110 & 111 Addison’s disease
- Intra oral mucosal pigmentation in Addison’s disease in a European, and
similar pigmentation in an Arab on high dose tetracosactrin (synthetic
ACTH).
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82
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83
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84
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- 120 Acromegaly
- The lax skin secondary to soft tissue overgrowth on the forehead. One of
the main problems was an increase in sweating which is associated with
the increased growth hormone secretion.
- 121 Acromegaly
- The increased growth of the lower jaw takes the teeth forwards and they
do not close in the bite correctly. This picture also shows the red line
of gingivitis and pyorrhea coupled with deposits of tartar which have
become stained over the teeth. The hirsute upper lip is also seen.
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85
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- 122 Acromegaly
- With an increase in growth of the lower jaw the teeth become splayed and
begin to separate.
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86
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- 123 Acromegaly
- The tongue may also hypertrophy, producing the appearance of
macroglossia. Macroglossia must be distinguished from the large tongue
which may occur in amyloid disease.
- 124 Acrornegaly
- The normal large spatulate male hand above looks delicate beside the
fingers of the acromegalic female. Note increase of soft tissues and
broadening of the fingers
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87
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- 125 Acromegaly (female)
- The hands show the spade-like palm. Wasting of the thenar eminence is
particularly obvious on the right hand, due to a carpal tunnel syndrome
with median nerve compression.
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88
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- 126 Acromegaly (male)
- The soft tissue overgrowth is marked - on the left is the patient’s
brother, one year younger.
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89
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- 127 Acromegalic feet
- Note the increase in soft tissues and bony overgrowth causing the feet
to increase in size and also to become broad and spade-like.
Radiologically there is an increase in the cortical thickness with
tufting of the terminal phalanx. All these signs are due to growth
hormone excess. Lactation had also continued for five years and the
lactating nipple with very high prolactin levels is seen in 612.
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90
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91
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- 132 & 133 Paget’s disease
- The increase in the size of the skull leads to prominence of the
forehead.
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92
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- 134 Paget’s disease, x-ray
- The x-ray appearance demonstrates the increase in thickness of the
vault.
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93
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- 135 Paget’s disease, bowing
- A single bone may be involved. The thickened but soft bone bends: it may
be warmer than the other due to increased vascularity. Bowing may occur
in (1) Paget’s disease; (2) Rickets- in 1 and 2 the soft bone bends; (3)
Yaws, 691; (4) Congenital syphilis - in 3 and 4 the bowing is more
apparent than real as the long axis is unchanged.
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94
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- 136 Sickle cell anemia
- The increase in the size of the skull due to thickening of the vault in
Paget’s disease should be compared to the similar thickening due to an
increase in the medullary space which occurs in hemoglobinopathies. The
similarity is obvious, the age group is different.
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95
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- 137 & 138 Paralysis agitans (the shaking palsy)
- The cardinal features are tremor, rigidity, and akinesia. A fixed flat
expression devoid of emotion despite changes in circumstance, due to the
immobility of the facial muscles. Note the sweaty, flushed look, from
constant muscular activity. Patient 138 also dribbles excessively and
finds swallowing requires effort. Because he tends to hold his head
downwards in order to look at the camera he has to lift the eyes upwards
- this is not the picture of an oculogyric crisis.
Oculogyric crisis, fixed upward deviation of the eyes, occurs in
Parkinson’s disease - post-encephalitic, phenothiazine overdosage,
hysteria and hypoparathyroidism.
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96
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- 139 Parkinson’s disease
- Stooped posture. The centre of gravity nearly outside the stable base,
leading to a festinant gait - small steps always hurrying to keep the
centre over the feet. Note abducted right shoulder and flexed elbows.
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97
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- 140-141 Myotonia
- Muscle tone may be increased in:
(1) extrapyramidal disorders, the tone is plastic in character
with or without a ’cog wheel’ component associated with tremor. The
facial immobility of Parkinson’s disease is due to the increase in
muscle tone fixing the face.
(2) upper motor neuron defect - spasticity - clasp knife in
character.
(3) myotonia -the muscle, once stimulated, remains contracted for
varying periods of time and occurs in (a) Dystrophia myotonica; (b) Myotonica
congenita (no dystrophy); (c) Paramyotonica congenita (increased with
cold) (141). Myotonia may be spontaneous with voluntary effort (142) or
demonstrated by percussion (140). This accounts for the delay in letting
go on gripping something, particularly noted when shaking hands with the
patient.
In this picture the triceps is tapped with a patellar hammer and
a contraction of the muscle takes place which can be seen as an
indentation running down from the shoulder. This persisted for three
seconds, long enough to put the patellar down, pick up the camera and
take the picture!
The physical sign is brought out by cold surroundings, since the
stiffness is always worse at a low temperature. In this particular
patient he was perfectly well in the warm summer where he lived but
noted the stiffness in the winter, and his children could not swim in
the sea during the winter because they became very stiff.
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98
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99
|
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100
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101
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- 149-154 Facial palsy, Bell’s palsy
- In repose it may appear that there is no abnormality present (149,150). On
closer appearance the face on the side of the palsy may have fewer
lines, appear more youthful, and have less expression especially if the
palsy is of long standing (151, forehead right).
Decide whether the palsy is unilateral or bilateral, upper motor
neuron or lower motor neuron lesion at fault and if a lower motor neuron
lesion, the site. The biggest catch is bilateral facial palsy (153). Ask
the patient to smile (154). The commonest causes are acute infective
polyneuritis, sarcoidosis, bilateral Bell’s palsy.
The face is observed for symmetry, blinking, and examined by
asking the
patient to bare the teeth, close the eyes and then to screw up the
eyes. Power is tested by trying to open them with the finger.
This young man has a mild right sided lower neuron lesion of the
facial nerve (149). Asking him to screw up the eyes and show the teeth (152)
results in an upheaval of movement of the face, pulling it to the normal
side, often producing a momentary confusion in the inexperienced
examiner’s mind that it is the left side of the face that is at fault.
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102
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103
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- 159 & 160 Upper motor neuron lesion facial weakness of the tongue
- When asked to put out the tongue mild asymmetry is noted with slight
deviation to the right side due to a right sided weakness of the tongue.
Best seen in the close-up view - 160.
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104
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- 161 Unilateral lower motor neuron palsy
- If the lesion is in the lower motor neuron there is total weakness of
the face (161,
‘raise your eyebrows’). The lesion is of the nucleus or more commonly
the nerve.
Localise by:
(1) Herpes vesicles in the ear (162). The Ramsay Hunt syndrome
due to
involvement of the geniculate ganglion with the herpes virus.
(2) Any associated deafness, due to nerve involvement, points to
a lesion in the cerebello pontine angle or in the brainstem. Conductive
deafness may be unrelated or may indicate a lesion at the base of the
skull such as a nasopharyngeal carcinoma.
(3) Loss of sensation of the 5th nerve points to a lesion of the
brain stem or cerebello pontine angle.
(4) Loss of taste sensation on the anterior two-thirds of the
tongue indicates a disturbance between the brain stem and the chorda
tympani.
Other causes are: idiopathic or in association with diabetes mellitus;
infections, tetanus and polio may present with facial palsy. Bilateral
palsy (153,154) occurs in sarcoidosis and acute infective polyneuritis
and must be differentiated from myaesthenic weakness responding to
edrophonium, and myopathic facial weakness (257).
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105
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- 162 Herpes vesicles in the ear
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106
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- 163 Acoustic neuroma
- Note: (1) tarsorrhaphy on the right (no corneal sensation); (2) lower
motor neuron facial palsy on right; (3) he was deaf in the right ear for
many years.
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107
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108
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- 168 Tabes dorsalis
- The face in tabes. Note the loss of expression and the bilateral ptosis.
Bilateral pterygia are present.
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109
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- 169 Tetanus
- This adult cut her foot and developed tetanus. The tension of the
sternomastoids can be seen. Immediately after this picture was taken a
door slammed and she developed a tetanic spasm with the classic risus
sardonicus (171).
- 170 Tetanus
- This woman presented with stiffness. Note the tense sternomastoids as
she sat waiting for consultation.
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110
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111
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- 172 Neonatal tetanus with risus sardonicus
- This form is usually related to cord sepsis and the practice of applying
earth and cow dung to the cut umbilical cord. (See 636).
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112
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- 173 Lepromatous leprosy
- The classical thickened skin on the ear and nose. The leonine appearance
produced by thickening of the brows, note the loss of the eyebrows. The
ear lobes present the appearance of a lepromatous infiltrate, the
lesions being soft and succulent in appearance. They may be full of
lepra bacilli and contrast with the well defined, clear cut margin of
the tuberculoid type of leprosy. Between lepromatous leprosy and
tuberculoid leprosy there is a continuously varying spectrum of disease.
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113
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- 174 Lepromatous leprosy
- The hypopigmented macules seen on this man’s face are an occasional
accompaniment of lepromatous leprosy when they occur early and are
multiple, as opposed to tuberculoid leprosy in which they tend to be
sparse.
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114
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- 175 & 176 Leprornatous leprosy
- These are examples of the skin lesions in lepromatous leprosy, with
macule formation in the skin, lepromatous erythematous papules and
associated raised and patchy areas of depigmentation.
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115
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- 177 Tuberculoid leprosy
- Flat plaques of depigmentation, sometimes anaesthetic, may be the only
skin change present. This is known as a macular-tuberculoid lesion
compared with the lesion on the arm (179) which is a minor-tuberculoid
with the one on the leg a major tuberculoid example of macular
anaesthetic leprosy.
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116
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- 178 Tuberculoid leprosy
- The unnamed cutaneous nerves may be thickened and felt. The shininess is
due to liquid paraffin spread on the skin in order to produce a light
reflex and show up the bulge of the nerve running diagonally just above
the ring finger extensor tendon.
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117
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- 179 Tuberculoid leprosy
- Benign, stable, presenting with skin lesions, associated with nerve
involvement, often extending through cutaneous nerves. Plaques with red
raised edges on the inside of the knee and forearm were insensitive to
pinprick. The plaques spread slowly and were associated with some
thickening of the peripheral nerves. The lepromin test was positive. The
patient had been diagnosed as an example of sarcoid of the skin. The
erythematous early lesion on the upper arm and the transition to the
plaque can be seen in the lower lesion on the arm with a fully developed
plaque on the leg.
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118
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- 180 Tuberculoid leprosy, thickening of the greater auricular nerve
- This and figure 713, a perforating ulcer, are all from the same patient.
The nerves should all be palpated for thickening: particularly
the greater auricular where it crosses the sternomastoid muscle, the ulnar nerve at the elbow,
and the lateral peroneal around the fibula. The cardinal sign is one of
anaesthesia. The sense of touch may be preserved but temperature and
pain sensation lost.
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119
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- 181 Tuberculoid leprosy
- The thickened greater auricular nerve in the neck comes out from behind the
posterior border of the sternomastoid and passes to the postauricular
region. It must not be confused with a dilated
external jugular venous system. Other causes of thickened
nerves are: congenital - hypertrophic interstitial neuritis,
neurofibromatosis; traumatic - repeated trauma to the nerve where it is
exposed, e.g. at the elbow; inflammatory infiltrations - leprosy,
sarcoid, amyloidosis; neoplastic - reticulosis.
Do not forget that in the thin and wasted person normal nerves
may be palpable and may appear thickened. (1) greater occipital, (2)
lesser occipital, (3) third occipital, (4) greater auricular, (5) nerves
to levator scapulae, (6) accessory nerve, (7) medial supra clavicular
nerve, (8) anterior cutaneous nerve of the neck, (9) cervical branch of
facial.
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120
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- Distribution of rashes on the face can sometimes allow a spot diagnosis.
There are three kinds of Lupus - all unrelated: (a) lupus erythematosus,
autoimmune; (b) lupus vulgaris, tuberculous; (c) lupus pernio, sarcoid
granuloma.
- Lupus erythematosus (LE)
A varying picture whose common factor is an increase of rash over
areas catching the sun - the forehead, the malar bone and bridge of the
nose.
(1) The classic butterfly rash, with or without plugging of
pores, distribution related to light exposure. It has some similarities
in distribution to rosacea but without pustule formation.
(2) A generalized erythema often increased over the face with
edema of the skin analogous to a severe sunburn. Seen in acute systemic
LE.
(3) A macular/papular rash greater on exposed areas seen in acute
systemic LE.
(4) Red plaques active and spreading at the edge with central
scarring and telangiectasia, with a predilection for the face, nasal
bridge, ear and scalp. On hair-bearing skin, scarring may lead to
alopecia. Seen in chronic discoid LE.
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121
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- 182 Lupus erythematosus . . . erythematous patches. . . arranged in
tolerable symmetry. . the batswing or butterfly is very fairly attained
. . One of the earliest illustrations of LE taken from Jonathan
Hutchinsons Archives of Surgery 1890: the redness over the cheeks and
forehead spares the shaded hollows of the eyes (compare with 183).
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122
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- 183 Systemic lupus erythematosus
- He presented with arthralgia and edema, the batswing erythema is
tolerably well attained, some forehead rash is present and there is
plugging of the pores over the cheek. Slight mooning of the face is
present (not yet on steroids).
- 184 Lupus erythematosus
- The classic bat or butterfly wing: note the peripheral scaling. Compare
this with rosacea (185).
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123
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- 185 Rosacea
- The distribution is across the cheeks and nose, associated with
erythema, telangiectasia, and pustule formation which is not seen in
lupus erythematosus, and often associated with facial flushing,
increased by alcohol.
- 186 Lupus erythematosus
- Marked erythema in the V of the dress: macular/papular on the face.
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124
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- 187 Lupus erythematosus
- Acute systemic illness, macular papular rash over the body increased on
the arms, chest and face - sparing the area covered by short sleeves.
- 188 Lupus erythematosus
- Acute small joint arthralgia with pain and swelling of the proximal
interphalangeal joints, part of the clinical presentation of the patient
in 187.
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125
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- 189 & 190 Lupus erythematosus
- There is slight facial edema and erythema which blanches when the eyes
are screwed up.
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126
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- 191 Disseminated lupus erythematosus
- This young girl has the erythema of butterfly distribution across the
face. A nephritic faces of edema - slit eyes - and the erythematous rash
over the trunk, are sufficiently typical of lupus erythematosus to
suggest the diagnosis. The facial edema is typical of the so called
‘nephritic’ faces.
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127
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- 192 Chronic discoid lupus erythematosus and TB gland
- An area of scarring is seen over the bridge of the nose with
depigmentation in the scar. There is no continuation of the rash over
the malar areas and this example is confined to the bridge of the nose.
Active red plaques are present in the scalp.
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128
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- 193 Chronic discoid lupus erythematosus
- In the scalp active red plaques can be seen. The central scarring on
healing leads to alopecia.
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129
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- 194 & 195 Chronic discoid lupus and TB gland in the neck
- This woman exhibits two types of lupus. The scarring around the ear is
healed Discoid LE while the reddening of the skin with the production of
a sinus discharging pus seen in the supra clavicular area is typical of
tuberculous lymphadenitis.
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130
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- 196 Active lupus vulgaris (tuberculosis of the skin)
- Exuberant hypertrophic ulceration spreading over the nose and malar
areas.
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131
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- 197 & 198 Active lupus vulgaris
- A less exuberant form which, when covered with a glass slide, exhibits
the typical apple jelly appearance. This may progress to the situation
shown in 199 with scarring and the destruction of cartilage.
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132
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- 199 & 200 Inactive lupus vulgaris
- In the healed stage scarring and destruction of cartilage, typically of
the nose and the ear, occur. This lady had the ‘new treatment with the
Finsen lamp (ultraviolet) in the early 20th century when the first lamp
came to The London Hospital and to England.
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133
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134
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- 204 Congenital syphilis (saddle nose)
- Depression of the nasal bridge due to retarded growth of the septum and
nasal bones due to persistent rhinitis in infancy. Compare with
deformity in Wegener’s granuloma when the nasal bones are involved with
depression of the cartilage.
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135
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- 205 Lupus pernio, sarcoidosis
- This man shows red raised plaques on the right cheek and just below the
nose. He has a facial palsy secondary to sarcoid - note the loss of
small skin creases around the eye, the slight droop of the right side of
the mouth and the normal skin creases on the other side.
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136
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137
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- 209 Facial edema
- The facial appearance is basically the same whether due to sodium and water retention in
acute glomerulonephritis,
hypoalbuminaemia in protein malnutrition or local exudation in angioneurotic
edema, urticaria, allergy to insect stings and drugs, etc.
- This woman presented with difficulty in climbing stairs and lightning
pains. The WR was positive and the plantars extensor - she was treated
with 14 days penicillin and steroids - at the end of the course and the
cessation of steroids gross urticaria developed due to penicillin
allergy originally suppressed by steroids. This subsided. The lightning
pains remained and over the next six months the legs became weaker and
the paraplegia more prominent - a myelogram, originally withheld, was
performed and demonstrated a dorsal meningioma. Double diagnosis: neuro-syphilis
and a spinal meningioma and not syphilitic arachnoiditis.
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138
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- 210 Dermal wheals
- The whealing produced after nettle stings and the exaggerated triple
response of dermographism all produce transient dermal edema.
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139
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- 211 Dermographism
- This girl had recurrent attacks of urticaria with facial swelling -the
initial blanching, flare and developing wheal are all shown.
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140
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- 212 Acne vulgaris
- Excess secretion of sebum and follicular inflammation - a problem of
adolescence - the seborrhoea gives rise to a greasy skin and comedones
(blackheads).
- 213 Cystic acne vulgaris
- The cysts contain pus - note blackheads and follicular inflammation.
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141
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- 214 Sturge-Weber syndrome
- Epilepsy and a capillary nevus in the ophthalmic division of the
trigeminal nerve: there is an associated ipsilateral capillary
haemangioma of the meninges often with cortical atrophy and
calcification underlying it (which may be seen on plain x-ray).
- One complication of the Sturge-Weber syndrome is epilepsy. In this case
he was on Phenytoin which aggravated his acne.
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142
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143
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- 215 & 216 The female hairline
- Note that it goes straight across without the recession at the temples -
this woman also demonstrated bilateral parotid enlargement due to
sarcoidosis.
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144
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- 217 & 218 Recession, male and female
- The typical male temporal recession. This man also has a cautery mark on
the forehead done in childhood in the Middle East. The frontal recession
seen typically in the male differs in its form from the widow’s peak
hair recession in females, seen here in this woman who also has a well
marked chloasma.
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145
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- 219 Widow’s peak, male
- A similar appearance may be seen in the male with
a widow’s peak phenomenon, a female hair line and Klinefelter’s
syndrome, the chromosomes being XXY.
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146
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- 220 Recession and psoriasis
- The normal male temporal recession of hair in a man with psoriasis of
the scalp.
- 221 Recession in progress
- This temporal recession progresses with a gradual loss of hair over the
frontal area as in this man who also demonstrates the increase in the
size of the skull secondary to Paget's disease (osteitis deformans).
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147
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- 222 Complete top recession
- The typical frontal baldness of the male may progress until hair over
the top of the head is completely lost whilst a normal growth continues
at the sides and back.
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148
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149
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150
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151
|
- 229 Scleroderma
- The shiny, tight skin of the hands and the atrophic nails with disorder
of nail growth are typical of systemic sclerosis. There is patchy
telangiectasia of the face.
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152
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- 230 & 231 Scleroderma
- These hands show the shiny skin and should be compared with the previous
slide. Here the changes are minor with slight firmness and shininess.
The change is best appreciated by touch.
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153
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- 232 Scleroderma
- In this early case note the shiny inelastic quality of the skin
under the chin and the numerous telangiectases.
- 233 Scleroderma
- As the disease progresses and the skin becomes tighter the
face loses its normal wrinkles and expression. Many
telangiectases.
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154
|
- 234 & 235 Local scleroderma (en bande)
- Atrophy of subcutaneous tissue beneath the tethered and thickened skin (234).
Note the patchy pigmentation over the upper arm. This variety of
scleroderma is not associated with systemic manifestations.
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155
|
- 236 Malar flush
- The erythema across the cheekbones is by tradition associated with tight
mitral stenosis. However you can see this in fit people of all walks of
life whether they live in the open air or not. It is probably one of the
traditional associations of medicine without foundation in fact.
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156
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- 237 The febrile patient
- This man is ill. He is hot, sweating, the eyes are slightly sunken and
the face is apathetic. He has a lobar pneumonia, temperature 104oF
(40oC).
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157
|
- 238 Fever and herpes simplex
- Herpes febrialis - this woman h
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Notes