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Leprosy - case definition and examination

leprosy examination in detail

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Leprosy - case definition and examination

  1. 1. LEPROSY – case definition and clinical examination - Dr. Shivi Nijhawan
  2. 2. LEPROSY At the seventh meeting of the WHO expert committee on Leprosy in 1997, A case of leprosy was defined as an indivisual who has not completed the course of treatment and has one or more of the three cardinal signs :-  Hypopigmented or erythematous skin lesions with definite loss /impairment of sensations.  Involvement of the peripheral nerves as demonstrated by definite thickening with sensory impairment.  Skin smear positive for AFB
  3. 3. CLASSIFICATION  Leprosy can present with predominantly neural symptoms or mainly with cutaneous involvement.  In ancient India it had been called ‘Vat Rakta’ denoting the neural component of the disease .  ‘Arun kushta’ for cutaneous form of leprosy  First international classification –MANILA(1931) by Leonard Wood Memorial, categorized the disease into cutaneous, neural and mixed type.  MADRID classification (1953)- maculoanaesthetic macules , lepromatous macules and intermediate macules.  In the following years , many similar clasifications came up, where the term cutaneous was replaced by lepromatous that repesented a widespread involvement of skin , and the term neural got replaced by tuberculoid representing raised lesions with neural deficit.
  4. 4.  Lepromatous and tuberculoid were regarded as polar forms.  A widespread discontentment among leprologists about maculoanaesthetic lesions and pure neuritic cases.  Indian leprologists regarded these two as separate entities  INDIAN classification,1953 (Indian Association of Leprologists) proposed by Dharmendra and Chatterjee , similar to the Madrid classification. Accepted in 1955.  RIDLEY AND JOPLING classification (1962) – spectral classification for research purposes. Since then globally accepted.  1982, WHO classification- Paucibacillary (PB) and Multibacillary (MB)
  5. 5. MADRID CLASSIFICATION  International Leprosy Congress held at Madrid in 1953 .  Two types –Lepromatous (L)and Tuberculoid (T)  Two groups- indeterminate (I) and borderline or Dimorphous
  6. 6. NEW IAL CLASSIFICATION  5 Group classification
  7. 7. RIDLEY JOPLING CLASSICATION • William Jopling together with D.S. Ridley proposed this classification. • Referred as the immunological classification. • Based on bacteriological, immunological, histopathological and clinical features. • Spectral and polar concept of leprosy. • Two polar forms –Tuberculoid and Lepromatous –stable • Immunologically unstable-Borderline group- BT,BB and BL
  8. 8.  BB –most unstable form  These forms transform into each other by uprading or downgrading reactions.  Clinical , histopathological , bacteriological and immunological features show slow continous change from one pole to another  ADVANTAGES- 1. Leprsoy is a disease of a wide range of clinical presentations , course , prognosis and complications. This classification helps to categorize different types of leprosy based on correlationship of various parameters Widely used for research purposes. 2. Strengthens the spectral and polar concept of leprosy. 3. Gives an idea about the prognosis.
  9. 9.  DRAWBACKS – No specific place for indeterminate and pure neuritic leprosy in the spectrum.
  10. 10. WHO CLASSIFICATION for Leprosy control  Used for treatment purposes.  Segregation into two groups for treatment purposes - the less bacillated patients could be treated with with lesser number of drugs for shorter period , more bacillated patients treated with more number of drugs for longer period.  Paucibacillary(PB) and Multibacillary leprosy(MB).  In 1988, based on whether the skin slit smears demonstrated bacilli or not. Paucibacillary (no AFB in split skin smear), multibacillary(AFB present in any skin lesion).  In 1998, based on the number of skin lesions. 1. Paucibacillary single lesion leprosy(SLPB) 2. Paucibacillary leprosy (2-5 lesions) 3. Multibacillary leprosy >6 lesions and also any split skin smear positive
  11. 11.  Presently in India , number of nerves involved is also taken into consideration while categorizing the patients into paucibacillary and multibacillary types as per the NLEP (National leprosy Eradication programme ) of Government of India.
  13. 13. TUBERCULOID LEPROSY(TT)  Benign and stable  Number – 1 to 3 lesions.  Morphology- well defined erythematous plaques with raised and clear cut edges sloping inwards. Lesions may be flat in the center with a raised well defined margin(annular)  Surface – dry ,hairless, anesthetic and usually scaly.  Nerve involvement occurs as a result of extension from or through cutaneous nerve branches. Patchy and asymmetric.  Peripheral Nerve - sensory loss  Autonomic nerve -dry surface and loss of sweating. Rough skin .  A solitary peripheral nerve trunk may be thickened in the vicinity of a TT lesion (feeding nerve)  No AFB found on slit skin smear.  Lepromin test strongly +ve .
  14. 14. BORDERLINE TUBERCULOID(BT)  3 to 10 skin lesions  Lesions similar to TT , but there is evidence of the disease not being contained. Small extension of the lesion at one edge(pseudopodium) or there may be satellite lesions. Lesions have less defined margins and the border may fade into the normal skin.  Loss of sensations, dryness ,scaling ,erythema or hypopigmentation less conspicuous than that in TT .
  15. 15. BORDERLINE BORDERLINE(BB)  Most unstable. BB state is short lived and rapidly shifts to other poles, more often to BL.  Mostly downregulates towards lepromatous pole if untreated.  Presence of dimorphous type of lesions .  Multiple skin lesions with a tendency to symmetry. Lesions are of all shapes and sizes including papules, plaques, circinate lesions or rarely even nodules.  Characerstic skin lesions are the annular lesions where the inner edge is well demarcated and the outer edge is ill defined and slopes towards normal skin. ‘Punched out’ appearance (inverted saucer shape).  Clinically , normal looking skin;within such plaques gives a “swizz cheese” appearance.  Face may show inflitration with occasional nodules over ears and chin.
  16. 16.  Skin smears show moderate number of AFB’s.
  17. 17. BORDERLINE LEPROMATOUS(BL)  Numerous skin lesions (>30)  Ill –defined showing tendency to bilateral symmetry.  Infiltrated macules with copper hue, round or oval about 2-3cm in diameter. With disease progression , papules, nodules and plaques may develop, with sloping margins which merge into the normal skin.  Infiltration takes place within the itinial macules, creating a plaque like appearance on face and ears. Surface of lesions shiny.  Nerve trunks get damaged (not so symmetrically)  Eyebrows involvement absent or partial.  Systemic symptoms of involvement of oral cavity or eyes, testes appear later  More prone to develop type 2 reactions (erythema nodosum leprosum).  Many AFB’s seen on sss.  Lepromin test negative.
  18. 18. LEPROMATOUS LEPROSY(LL)  Multiplication and universal spread of M.leprae  Early lesions –innumerable small infiltrated, shiny, erythematous macules, with indistinct edges, widely disseminated and distributed symmetrically.  Insidious onset and steady progression  LL with with infiltrated lesions presents as 3 distinct forms- diffuse, infiltrated and nodular forms.  AFB positive in sss.  Lepromin reaction negative.
  19. 19. a) Diffuse LL  True subtype of LL  Results from gradual coalescing of various numerous vague macules of macular LL.  Slight infiltration which is better appreciated by touch rather than sight.  Thickness of skin due to diffuse infiltration. Thickness most marked over the face especially forehead, earlobes, eyebrows, nose and malar surfaces. Ear lobes are shiny and thickened (buddha ears)  Thinning or loss of eyebrows.
  20. 20. b)Infiltrated LL  Areas of marked infiltration  Advanced stage of macular LL, easily visible infiltration
  21. 21. c)Nodular LL  Result of progressive deterioration of macular, diffuse or infiltrative forms of LL.  Disease advances and the nodules appear on buttocks, face ,extremeties specially the elbows, fingers, over the joints and genitals.  Infiltrated plaques accentuate the skin folds producing the classical leonine facies.  Gradual appearance of sensory and autonomic nerve damage. Clinical signs of nerve damage appears until the disease is well advanced. Peripheral anesthesia is extensive due to systemic dissemination of lepra bacilli. Sensory fibres damaged first.  Peripheral nerves first become firm, hard and then fibrosed at the places where nerve trunks are close to cooler skin surface(radial groove,behind medial epicondyle of ulna, neck of fibula)  Anhidrosis with compensatory hyperhidrosis of the face ,trunk and axillae.  Symmetrical sensory loss-over the extensors of forearms, legs, hands and feet-typical glove and stocking anesthesia.
  22. 22.  Nail changes- growth may be disturbed late in the disease course.Nail plates become lustureless, ridged and curved  Hands and feet – swollen digits tending to taper towards the tips (fusiform swelling)  Digits may shorten due to resorption of phalanges.  When significant anesthesia has developed, the hands and feet are liable to trauma and pressure necrosis of soft tissue , leading to ulceration and seconday infection with clinical signs of cellulitis & osteomyelitis.  Involvement of upper respiratory tract mucosa -80 percent of LL cases in form of a stuffy or blocked nose followed by epistaxis.  Anosmia , crusting or bleeding.  Nasal septal perforation –destruction of bony part-saddle nose deformity  Oral mucosa- nodules and plaques over tongue and palate.  Larynx – hoarseness of voice and stridor  Eye – corneal anesthesia due to bacillary infiltration of cornel nerves, lagopthalmos, uveitis, corneal opacity, perforation and blindness.
  23. 23.  Testicular atrophy  Prone to type 2 reactions.  Cause of Death – due to secondary infections (pneumonia and TB) , amyloidosis and renal failure.
  25. 25. INDETERMINATE LEPROSY  Medium to large hypopigmented patches which are faintly visible,often on the external aspect of the thigh, face, extensor aspect of limbs.  Vague edges  Some loss of tactile and thermal sensations  Commonly misdiagnosed as P. alba  Excellent prognosis  Lepromin reaction is variable  AFB mostly not detectable.  Diagnosis can only be confirmed with a biopsy- typical perineurovascular infiltrate.
  26. 26. Children with histopathologically proven indeterminate leprosy revealing hypopigmented, scaly macule over left cheek
  27. 27. PURE NEURITIC LEPROSY  Area of sensory loss in the absence of any skin patch along the distribution of an involved nerve trunk with or without motor deficit.  Neuritic manifestations- tingling,heaviness, numbness, peresis, hypotonia, atrophy,claw hand and toes, wrist drop and foot drop, neuropathic ulcers, bone resorption.  Most frequently in India and Nepal  Accounts for 5-10 percent
  30. 30. GENERAL PHYSICAL EXAMINATION  Thorough physical exmination should be performed.  Pallor, edema and lymphadenopathy may be a part of lepromatous disease.  If a patient on dapsone therapy shows profound pallor of sudden onset ,evidence of hemolysis should be looked for.  Pulse and blood pressure of all patients should be recorded at presentation and followed up.  Hypertension in leprosy patients may result from chronic renal impairment due to type 2 reactions.  Bilateral pedal edema also involving the dorsa of hands is seen in lepromatous patients.  Generalized edema may result from autonomic neuropathy affecting the small blood vessels or due to acute glomerulonephritis associated with type 2 reactions.  Widespread tender lyphadenopathy – type 2 reaction  Fever, arthralgia and prostration in leprosy patients, possiblty of type 1 or 2 reactions.
  31. 31. CUTANEOUS EXAMINATION  In adequate daylight, following proper exposure and ensuring the privacy of the patient.  Widespread infiltration , shiny skin, sparse body hair, prominent follicular openings and mild thickening appreciatble by gentle pinching of the skin, is suggestive of LL.  Infilterated face with thick skin folds and nodularity (leonine facies), depressed nose, enlarged ear lobules(buddha ears) sparse beard and moustache indicate advanced LL.  Unilateral gynecomastia in males-impairment of testicularfunction in LL  An overall brownish pigmentation involving skin, conjunctiva and oral mucosa may indicate treatment with clofazimine,
  32. 32.  Documentation of indivisual skin lesions should be done on a printed proforma.  Allows proper follow up of the patients.
  33. 33. Examination of indivisual skin lesions  Total number of lesions- single, 1-5, >5(multiple) or numerable. Fewer the number, lower the bacillary load.  Distribution – trunk, extremities, face; protected sites like, scalp, axillae, groin, perineum, genitalia, palms and soles, genitalia or buttocks. Asymmetric or bilaterally symmetrical ?  Shape- regular(round/oval), irregular/bizarre,annular  Size  Morphology :- 1. Patch/plaque,papule/nodule/vesicle/bulla 2. Color (hypo/hyperpigmented, skin-colored, erythematous, coppery) 3. Surface (no change, dry/scaly/smooth and shiny/edematous or ulcerated) 4. Border(well defined, raised/flat,sloping,punched out) 5. Presence, absence or sparseness of hair 6. Lesional tenderness
  34. 34.  An ill-defined, hypopigmented, flat lesion without surface changes may be an intermediate leprosy patch.  Thick ,elevated margin of a lesion suggestive of TT or BT. A feeding nerve to the lesion can be detected by gentle rolling of a finger along the borders in TT or BT.  Annular lesions- inner and outer margins –better defined inner margin and outer margin sloping into normal skin giving a punched out appearance (inverted saucer shaped) suggestive of a BB lesion.  Presence of pseudopodia and satellite lesions along the margins of large lesion are suggestive of a BT lesion.  Nodules 1. Persistent, asymptomatic, erythematous, coppery normal skin colored nodules, firm on palpation-LL 2. Well defined, succulent, hemispherical glistening nodules –histoid leprosy 3. Recurent, erythematous, evanescent, tender nodules on the skin over face, arms and thighs, healng with postinflammatory hyperpigmentaion –ENL  Ulcerated lesions, Sudden onset of lesional erythema, edema and tenderness suggests reactions
  35. 35. Testing sensations  Lesional skin should be tested for 1. Temperature(hold/cold water in test tubes) 2. Touch (wisp of cotton wool) 3. Pain(pin-prick)  while testing the sensation, the examiner should proceed from uninvolved to involved skin.  All sensations shuld be tested gently ,only once at one site, for a short while, not pressing the test object too hard or brushing it on patient’s skin.  The patient may not be able to point the exact location of the application of stimulus(misreference), which may be an early sign of hypoesthesia. Permissible limits of mis- refernce on hands are 1cm, on face 2cm and on back it is upto 7cm.  Testing with Semmes-Weinstein monofilaments helps in detecting early hypoesthesia.
  36. 36.  Distal extremeties should be examined for ‘gloves and stockings’ hypoesthesia in LL.  WHO recommended sensory testing sites on palms and soles(10 on each side) for disability grading . *Hands – ulnar nerve :distal pulp and proximal phalynx of little finger and hypothenar eminence. median nerve:distal pulp of thumb and index fingers and thenar eminence *Feet – big toe, metatarsal heads( 1st,5th), mid- lateral border of foot.
  37. 37.  Trophic changes: asymptomatic, deep, non-healing fissures on heels and toes may be observed in people who walk bare foot and agricultural/manual workers suffering from leprosy.  Multiple, spontaneous and asymptomatic blisters on hands and feet are indicative of anesthetic hands and feet. Callosities may be present on both palms and soles.  Vulnerable pressure points on palms, soles and bony prominences like lateral malleoli, heel of the hand(pisiform bone) and point of elbow should be inspected for trophic ulcers.  Trophic ulcers should be examined carefully for evidence of secondary infections( pus discharge, foul smell and slough)
  38. 38.  Icthyosis – widespread dryness indicates lack of sweat and sebum secretion (autonomic neuropathy)
  39. 39. MUCOSAL EXAMINATION  Lips and oral mucosa : 1. Diffuse engalrgement of lips may be a part of infilteration in LL or type 1 reaction involving a BT lesion overlying lips and surrounding areas. 2. Nodular infiltration of lip, tongue, palate and uvula may be seen in patients of LL. 3. Fissuring of tongue –LL 4. Uvula- intact/partial or complete destruction, uvular movements normal or restricted(fibrosis)  Nasal mucosa 1. Nasal examination done with artificial light and nasal speculum 2. Mouth breathing, foul smell indicates nasal crusting. 3. Removal of crusts facilitates better visualization of mucosa. 4. Nasal mucosa is insensitive, pale, thickened and irregular with destrction of inferior turbinates.
  40. 40. OCCULAR EXAMINATION  Patient’s face should be inspected closely for : 1. Any skin lesion involving the peri-ocular area. 2. Frequency of blinking, blink interval (normally 6 per minute) is indicative of preserved corneal sensation 3. Width of palpepral fissure 4. Photophobia, redness and watering of eyes.  Take the opinion of an opthalmologist in suspected cases of eye involvement.
  41. 41.  Eyebrows and eyelashes  Eyelids  Pteregium  Redness  Cornea  Pupil  Visual acquity
  42. 42. Grading of occular manifestations in leprosy Grade 0,1 and 2.
  44. 44.  Schwann cells play a host to M.leprae.  Not all nerves get affected in leprosy.  Only the peripheral nerves bear the brunt of damage , that too limited to certain segments of the nerve.  Sites of predilection of nerve damage -where the nerves are most superficial, without the cover of muscle mass and hence cooler.  Localisation of M.leprae in the segments having low temperature.  At these sites, nerves pass through tough fibro osseous tunnels. Any inflammation here presses upon the nerve supply of the fibres to result in ischemia and damage. Local inflammation results in nerve thickening.  Sudden increase in inflammation and inflammatory edema in nerve gives rise to pain or nerve tenderness  Therefore, thickening of nerves with or without tenderness on palpation –very important.
  45. 45.  Done with the pulp of fingers and not tip of digits .  Both sides to be compared. While palpating the nerve , following points are noted: 1. Enlarged or not ? 2. Is the nerve compressible? Lack of compressibility indicates a fibrosed nerve . 3. Unilateral /bilateral? (asymmetric nerve enlargement – borderline) 4. Extent of nerve palpable in its course. 5. Regularity –smooth or regular. If swelling present – its extent, nature-uniform, sausage shaped or beaded, whether the swelling is solid or fluctuant. 6. Nerve tenderness – indicative of neuritis.
  46. 46. PALPATION OF PERIPHERAL NERVES  Before palpating nerves , we must know the surface anatomy of these peripheral nerves .
  48. 48. Radial nerve palpation
  49. 49. Ulnar nerve
  50. 50. Radial cutaneous nerve
  51. 51. Median nerve
  52. 52. Lateral popliteal nerve
  53. 53. Sural nerve
  54. 54. Posterior Tibial nerve
  55. 55. Sensory testing  Semmes–Weinstein monofilaments (SWM) to measure light- pressure thresholds  Standard clinical sensory tests employing cotton wool,(tactile), pinpricks(pain), and tubes containing hot and cold water(thermal).  Semmes-weinstein (SW) monofilaments – nylon monofilaments made of polyhexamethylene dodecanediamine (nylon 612). Set of 6 monofilaments depending on the force they produce.  Green -0.05 gm- normal sensation  Blue- 0.2 gm- diminished light touch  Purple- 2gm- diminished protective sensation  Red- 4gm- loss of protective sensation for hands  Orange-10gm - “ “ “ “ for feet  Light red- 300gm- deep pressure
  56. 56.  Applied perpendicularly with mild pressure until there is a bent-c curve .  Start with the finest touch (green) and built up to orange.  Reference values to which normal indivisuals to respond are: 0.05gm (green) for face ,0.2gm (blue) for hand and 2gm (purple) for the foot.
  57. 57. Temperature testing  2 Test tubes  Cold sensation- containing water around 5 to 10 °C  Hot sensation- water around 37 to 47°C  Alterations in thermosensation - warm hypoaesthesia, or cold hypoaesthesia.
  58. 58. Sensory distribution of nerve trunks in hands .
  59. 59. Sensory testing sites of hands
  60. 60. Sensory distribution in feet
  61. 61. Sensory testing of feet
  62. 62. MOTOR SYSTEM EXAMINATION  Inspection of patient as a whole , then detailed examination 1. Face(signs of facial pasly, leonine facies etc) 2. Upper extremities (obvious deformities like claw hand, wrist drop, wasting of muscles, shortening of digits etc) 3. Lower extremeties ( abnormal gait- “high stepping gait”, foot drop, claw toes, collapsed arches, shortening of toes,wasting of muscles etc)
  63. 63. VOLUNTARY MUSCLE TESTING(VMT)  Assessment of functions of muscles of forearms, hands, legs and feet (strength or power)  6 grades( medical research council scale):  Grade 5- normal power (with full resistance)  Grade 4- muscle contraction against slight resistance but power subnormal  Grade 3- movement possible without resistance  Grade 2- active movement when gravity is eliminated  Grade 1- flicker of movement  Grade 0- no movement
  65. 65. Muscles Nerve supply Test Interpretation Disability
  66. 66. RADIAL NERVE  The radial nerve (and its deep branch) provides motor innervation to the muscles in theposterior compartment of the arm and forearm, which are mostly extensors.  radial nerve proper  triceps  anconeus  ECRL  ECRB  brachioradialis  PIN  ED  supinator  EDM  ECU  APL  EPL  EPB  EI
  67. 67. MEDIAN NERVE  Motor branches  Arm -Pronator Teres  Forearm -Supf Flexors –muscles of superficial compartment- Pronator Teres / FCR / PL / FDS) ; Ant Interosseus N -deep compartment-FDP / FPL / Pronator Quadratus  Hand - Thenar Eminence / Lateral Lumbricals (02)
  68. 68. 1. FPL : Flexion of the Terminal Phalanx of 1 digit ; Pt asked to flex terminal phalanx of thumb while base is steadied by the examiner.
  69. 69. 2. FDS and radial half of FDP -Pointing index
  70. 70. 3. APB- Pen test
  72. 72. ULNAR NERVE  MUSCULAR : FCU / FDP(medial)  DEEP TERMINAL BRANCH : Abductor Digiti Minimi / Flexor Digiti Minimi / Opponens Digiti Minimi (HYPOTHENAR EMINENCE)  Medial Lumbricals (3 / 4) ; Palmar / Dorsal Interossei (04 + 04) ; Adductor Pollicis
  73. 73. Muscles Nerve supply Test Interpretation Disability
  74. 74. 1.FCU: Flexion at Wrist – deviates hand to Radial Side
  75. 75. 2.INTEROSSEI  DORSAL (ABDUCTION OF FINGERS) EGAWA TEST - Pt is asked to abduct fingers against Examiner’s resistance; individually tested ; Palm facing downwards
  76. 76.  PALMAR CARD TEST - With palm facing upwards, patient is asked to hold card between 2 fingers tightly against the pull exerted by Examiner
  77. 77. 3. 1st Palmar Interossei + Adductor Pollicis – BOOK TEST Pt is asked to hold a book between extended thumb and fingers with both hands against pulll by the Examiner ; FROMENT’S SIGN + when pt pinches grasp by flexing thumb, using FPL.
  79. 79.  Common peroneal nerve (L4,5, S1,2)  Saphenous nerve , cutaneous branch of femoral nerve  Superficial peroneal nerve  Deep peroneal nerve  Sural nerve , formed from branches of tibial and common peroneal nerve  Tibial nerve , branch of sciatic nerve  Medial plantar nerve  Lateral plantar nerve
  80. 80. TIBIAL NERVE –posterior compartment of legs & soles Medial plantar nerve Lateral plantar nerve FDB FHB 1ST Lumbrical Abductor hallucis (LAFF) FDM Abductor hallucis 3 lumbricals AbDM In the legs, supplies soleus, gastrocnemius & plantaris muscles.
  81. 81. Muscles Nerve supply Test Interpretation Disability
  82. 82. COMMON PERONEAL NERVE- lateral and anterior compartment Superficial peroneal Deep peroneal • Anterior compartment of leg • Tibialis anterior • EHL • EDL • Dorsiflexion & extension of toes • Lateral compartment of leg • Peroneus longus • Peroneus brevis • Eversion and plantar flexion
  83. 83. CRANIAL NERVES  12 cranial nerves  But in leprosy , only involvement of :  olfactory nerve  peripheral branches of trigeminal nerve (supratrochlear, supraorbital)  Peripheral branches of facial nerve (zygomaticotemporal, buccal, mandibular, cervical)  Most common facial>olfactory>trigeminal
  84. 84. Olfactory nerve  Tested by having bottles containing characteristic substances such as peppermint, coffee or lavender and asking the patient to identify each in turn. If you do not have such tools available, ask the patient to close his/her eyes and then hold a bar of soap under the patient's nose for them to smell.
  85. 85. Trigeminal nerve  Opthalmic (purely sensory)  Maxillary(“ “)  Mandibular (sensory and motor) Sensory supply- one half of the face Motor supply: temporalis tensor tympani masseter tensor veli palitini lateral /medial pteregoids
  86. 86. Sensory part - 1. One half of the face 2. Corneal reflex - • Touch the cornea with cotton wisp from lateral aspect. • Affarent – opthalmic division of trigeminal nerve • Efferent – branch of facial nerve supplying orbicularis oculi.
  87. 87.  Absence of corneal reflex – lesions of Vth  Or VII th CN, and loss of connection btw these nerves.
  88. 88. Motor part-  Testing of temporalis and masseter – Ask the patient to clench the teeth, and palpate the muscles above and below zygomatic arch. Compare the strength of both sides.  Lateral pterygoids – lateral movement of jaw against resistance.
  89. 89. Facial nerve  Peripheral branches – facial expressions
  90. 90. Muscles of facial expressions
  91. 91. Testing the muscles of facial expressions 1. Frontal belly of occipitofrontalis  Ask the patient to look upwards.  Wrinkling of forehead 2. Orbicularis oculi  ask patient to closes his eyes tightly.  Unable to do so , in case of palsy. 3. Buccinator  ask patient to blow the cheek .
  92. 92. 4. Platysma  Ask pt to show the teeth with mouth open  Prominence of platysma 5. Loss of nasolabial fold 6. Deviation of angle of mouth to normal side – drooling of saliva 7. Labial dsyarthria – slurring of speech
  93. 93. External genitalia examination  In males, testes palpated to see for – 1. Size and consistency 2. Testicular sensation 3. Tenderness