The face and eyes

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The face may provide important diagnostic information (Fig. 2.34). Some facial appearances are characteristic of specific diseases (Table 2,11). The eyes are discussed in Chapter 7.

The ears

Normal ears vary widely in size, shape and form. There are some genetic deformities. For example, in Down's syndrome the auricles are usually small and the lobule may be rudimentary or absent. The helix of the ear is a recognised site of gouty tophi - white chalky nodules consisting of sodium biuratc crystals deposited in the cartilage (Fig. 2.35). Local trauma to the car may cause haemorrhage. When frequent, partial organisation can lead to permanent deformity and the features of "cauliflower ear".

Acute otitis media usually causes earache, which may be

Tophi Tofus Ear
Fig. 2.32 Temporal arteritis showing an enlarged palpable artery.
Palpable Artery Temporal Arteritis
Fig. 2.33 78-year-old lady with 'buzzing noises in head due to right carotid-cavernous fistula. Periorbital oedema and severe chemosis are present and a bruit was heard over Ihe right forehead and eyelid.

severe, but in infants it may present as an acute febrile illness without local pain and auroscopy is indicated in all such children and any patient with headache or a hearing difficulty.

The normal drum as seen through the auriscope, appears pearly grey, with the handle of the malleus visible and lying almost vertically near the centre of the tympanic membrane.

TABLE 2.11 Examples of facial appearance characteristic of specific diseases

Endocrine

Tophi Tofus Ear

Fig. 2.35 Gouty tophus of the ear (Reproduced by perm Isslon of J. Gibson.)

TABLE 2.11 Examples of facial appearance characteristic of specific diseases

Endocrine

Genetic Renal

Cardiovascular

Infective

Neuromuscular

Hyperthyroidism Hypothyroidism Cushing's syndrome Down's syndrome Nephrotic syndrome Superior vena caval obstruction Risussardonicus in tetany Myasthenia gravis VII nerve palsy

Fig. 2.35 Gouty tophus of the ear (Reproduced by perm Isslon of J. Gibson.)

Wax commonly obscures the view and may need to be removed. Hard wax may need to be softened by die application of a few drops of olive oil or an appropriate preparation for 2 or 3 days before removal. Syringing should be undertaken by an expert if there is a history of middle ear disease or in the presence of perforation. Foreign bodies in the external meatus are not uncommon in children.

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