leprosy - case definition and examination

LEPROSY – case definition and clinical examination - Dr. Shivi Nijhawan

LEPROSYAt 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

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.

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)

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

NEW IAL CLASSIFICATION 5 Group classification

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

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.

DRAWBACKS – No specific place for indeterminate and pure neuritic leprosy in the spectrum.

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

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.

LEPROSY TYPES

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 .

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 .

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.

Skin smears show moderate number of AFB’s.

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.

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.

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.

b)Infiltrated LL Areas of marked infiltration Advanced stage of macular LL, easily visible

infiltration

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.

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.

Testicular atrophy Prone to type 2 reactions. Cause of Death – due to secondary infections

(pneumonia and TB) , amyloidosis and renal failure.

LEONINE FACIES

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.

Children with histopathologically proven indeterminate leprosy revealing hypopigmented, scaly macule over left cheek

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

CLINICAL EXAMINATION

1. GENERAL PHYSICAL EXAMINATION2. CUTANEOUS AND MUCOSAL

INVOLVEMENT3. OCULAR INVOLVEMENT4. PALPATION OF PERIPHERAL NERVES

AND TESTING FOR SENSORY IMPAIRMENT

5. EXAMINATION OF MUSCULOSKELETAL SYSTEM

6. EXAMINATION OF EXTERNAL GENITALIA7. OTHER SYSTEMIC EXAMINATION

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.

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,

Documentation of indivisual skin lesions should be done on a printed proforma.

Allows proper follow up of the patients.

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/bulla2. 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 hair6. Lesional tenderness

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-LL2. Well defined, succulent, hemispherical glistening nodules –

histoid leprosy3. 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

Testing sensations Lesional skin should be tested for1. 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.

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.

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)

Icthyosis – widespread dryness indicates lack of sweat and sebum secretion (autonomic neuropathy)

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 –LL4. Uvula- intact/partial or complete destruction, uvular

movements normal or restricted(fibrosis) Nasal mucosa1. Nasal examination done with artificial light and nasal

speculum2. 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.

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 fissure4. Photophobia, redness and watering of eyes. Take the opinion of an opthalmologist in

suspected cases of eye involvement.

Eyebrows and eyelashes Eyelids Pteregium Redness Cornea Pupil Visual acquity

Grading of occular manifestations in leprosy Grade 0,1 and 2.

NERVE INVOLVEMENT

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.

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.

PALPATION OF PERIPHERAL NERVES Before palpating nerves , we must know

the surface anatomy of these peripheral nerves .

SURFACE ANATOMY OF NERVES

Radial nerve palpation

Ulnar nerve

Radial cutaneous nerve

Median nerve

Lateral popliteal nerve

Sural nerve

Posterior Tibial nerve

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

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.

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.

Sensory distribution of nerve trunks in hands .

Sensory testing sites of hands

Sensory distribution in feet

Sensory testing of feet

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)

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

MUSCLES AND NERVES OF UPPER EXTREMITIES

Muscles Nerve supply Test Interpretation Disability

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

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)

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.

2. FDS and radial half of FDP -Pointing index

3. APB- Pen test

4.OPPONENS POLLICIS

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

Muscles Nerve supply Test Interpretation Disability

1.FCU: Flexion at Wrist – deviates hand to Radial Side

2.INTEROSSEI

DORSAL (ABDUCTION OF FINGERS)

EGAWA TEST - Pt is asked to abduct fingers against Examiner’s resistance; individually tested ; Palm facing downwards

PALMAR

CARD TEST - With palm facing upwards, patient is asked to hold card between 2 fingers tightly against the pull exerted by Examiner

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.

MUSCLES AND NERVES OF LOWER EXTREMITIES

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

TIBIAL NERVE –posterior compartment of legs & soles

Medial plantar nerve Lateral plantar nerve

FDBFHB1ST LumbricalAbductor hallucis (LAFF)

FDMAbductor hallucis

3 lumbricalsAbDM

In the legs, supplies soleus,

gastrocnemius& plantaris

muscles.

Muscles Nerve supply Test Interpretation Disability

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

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

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.

Trigeminal nerve Opthalmic (purely sensory) Maxillary(“ “) Mandibular (sensory and motor)Sensory supply- one half of the faceMotor supply: temporalis tensor tympani masseter tensor veli palitini lateral /medial pteregoids

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.

Absence of corneal reflex – lesions of Vth

Or VII th CN, and loss of connection btw these nerves.

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.

Facial nerve Peripheral branches – facial expressions

Muscles of facial expressions

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 .

4. Platysma Ask pt to show the teeth with mouth

open Prominence of platysma

5. Loss of nasolabial fold6. Deviation of angle of mouth to normal side – drooling of saliva 7. Labial dsyarthria – slurring of speech

External genitalia examination In males, testes palpated to see for – 1. Size and consistency2. Testicular sensation 3. Tenderness