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Examination of Oral Cavity
https://t.me/med1917
lymphadenopathy may be the first presentation.
Clinical features may be nasal, otogenic, ophthalmoneurogenic (involving most of the cranial nerves with
facial pain, squint, diplopia, exophthalmos, and
ophthalmoplegia), jugular foramen syndrome (cranial
nerves IX, X, XI spread), nodal spread and distant
spread to bones, lungs and liver . Unilateral serous otitis
media may be the only presentation.
Benign Tumours of the Tongue
Papilloma; fibroepithelial polyp; haemangioma and
lymphangioma; neurofibroma; lipoma; granular cell
myoblastoma are benign tumours of the tongue (Fig.
10.52).
251
Ulcers in Lichen Planus
Syphilitic ulcers: Extragenital chancre occurs in the
tongue as an ulcer which is painless, rubbery hard
with thick crust covering; ulcer leaves a fine superficial
scar while healing. Shotty discrete lymph nodes in
the neck are common – primary syphilis. In secondary
syphilis multiple shallow ulcers are found on the ventral
surface and lateral margins of the tongue; mucus
patches on the dorsum and tonsillar pillars;
Hutchinson’s condyloma (warts) are seen on the middle
of the dorsum of the tongue. In tertiary syphilis
gummatous ulcer is present on the midline of dorsum
of tongue which is punched out, deep and nontender.
Tuberculous ulcers: They are multiple undermined
ulcers seen at the margin, tip or dorsum of the tongue.
They are usually painful when located over the dorsum
of the tongue. Pulmonary tuberculosis or laryngeal
tuberculosis can occur.
Malignant ulcers are nothing but carcinomatous
ulcers.
Post pertussis ulcer occurs after whooping cough
infection over the frenulum on the ventral surface of
the tongue.
Chronic nonspecific ulcer occurs without any
specific aetiology which is not painful but often
indurated; occurs over anterior 2/3rd of the tongue;
mimics carcinoma of tongue.
Fig. 10.52: Papilloma of tongue – benign tumour. It can
be premalignant. It is firm, well localised swelling which may
bleed on touch. It needs excision.
Differential Diagnosis for Tongue Ulcers
Dental ulcers: Jagged tooth or denture causing
mechanical irritation of the margin or undersurface
of the tongue causing elongated, erythematous,
painful ulcer having slough at the floor surrounded
by hyperaemia.
Aphthous ulcers: They are usually single but can be
multiple, small painful ulcers in the tip/undersurface/
anterior part of the dorsum of the tongue having whitish
floor, yellow margin and hyperaemic zone around.
It is common in females; often familial. It can be
recurrent.
Stomatitis
It is a general term used for inflammation of the entire
lining of the mouth often including tongue.
Causes of stomatitis: Local causes: Sharp teeth, poor
fitting dentures, smoking, infections like Herpes virus,
candida, and Vincent’s angina, trauma either due to
mechanical, chemical, thermal or X-rays. General
causes: Haematological - Anaemia, agranulocytosis,
purpura, leukaemia; Vitamin deficiencies—Scurvy
(Vitamin C), sprue, coeliac disease, pellagra, pernicious anaemia, kwashiorkar; tuberculosis; advanced
carcinoma; drugs like phenobarbitone, phenytoin;
lead/mercury/bismuth poisoning; syphilis infection.
Infective stomatitis can occur either by opportunistic
(facultative) organisms like normal commensals (normally existing organisms causes infection when
patient’s defense mechanism is reduced) – streptococci,
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SRB’s Clinical Surgery
staphylococci, Vincent’ s or ganisms or by true pathogens.
Catarrhal stomatitis: It is associated with acute upper
respiratory tract infection and acute fevers. The entire
mucous membrane of the oral cavity; becomes
oedematous and red; small ulcers may coalesce to form
typical ulcerative stomatitis.
Aphthous stomatitis: It is formation of small painful
tender vesicles of unknown aetiology with hyperaemic
base which eventually breaks forming small white
circular deep painful ulcer. It is common in cheek,
lips, floor of the mouth, soft palate. It is common in
females. It heals in 2 weeks. Recurrent solitary aphthous
ulcers are also common.
Monilial stomatitis (Oral thrush): Infection of
gastrointestinal tract by Candida albicans is common
in children, debilitated patients, immunosuppressed
individuals like HIV patients, patients on cancer
chemotherapy or antibiotic therapy. Initially small red
patches appear on the mucosa of cheek and tongue
which turns curdy white due to desquamated
oedematous epithelium with contaminated fungus.
These lesions are painful with excessive salivation.
Associated thrush in the pharynx, oesophagus is
common causing dysphagia also.
Fig. 10.53: Cancrum oris involving gingiva and lower
lip extensively with plenty of maggots in it.
Angular stomatitis (Cheilosis, Perleche): They are
inflamed red brown fissures at the corners of the mouth
probably due to dribbling of saliva at the corners;
common in edentulous; Perleche is common in children
who rub or lick the corners of their mouth (Perleche
means lick in French). Condition does not extend to
adjacent mucous membrane and heals without scarring
(Fig. 10.54).
Ulcerative stomatitis (Vincent’ s angina): It is caused
by anaerobic gram negative Borrelia vincentii (spirochaete) and Fusiformis fusiformis bacteria (rod shaped)
initially causing severe gingivitis later Vincent’s
stomatitis. Swollen inflamed, painful, peppered gums
with small ulcers covering yellow slough is typical.
Later similar lesions appear in cheek, tonsils, fauces.
Features are gum bleeding, foetor oris, ill look, toxicity,
fever, loss of appetite, enlarged tender neck nodes.
Cancrum oris (Noma) (Fig. 10.53): It is an infective
gangrene as a result of severe form of V incent’s acute
ulcerative stomatitis and gingivitis seen in children
who are malnourished and often in patients with
measles and leukaemia; begins in lips, cheek, soft
tissues, bone, skin with extensive tissue destruction,
ischaemic necrosis; toxaemia, anorexia, pyrexia;
excessive salivation, fetid odour; a rare condition
nowadays but carries high mortality.
Fig. 10.54: Severe infection of lip (Cheilitis), angle of
mouth. Patient is also having severe stomatitis.
Examination of Oral Cavity
https://t.me/med1917
Syphilitic Lesions of Oral Cavity
Syphilis is rare nowadays. Primary syphilis shows
Hunterian chancre in the lip and tongue. It is similar
to that occur in genitalia. Flat pink painless initially
macule becomes hemispherical papule with breakage
of superficial mucosa causing ulcer with thick crust
and rubbery base; a fine superficial scar is formed
when ulcer heals; neck lymph nodes may be enlarged.
Rhagades are radiating cracks developing in secondary
syphilis which extends to mucous membrane which
on healing leaves a fine scar. Gray white pearl coloured
mucous patches develop on the inner side of lips,
cheeks and pillars of tonsils, often reaching upto
2 cm size; with desquamated oedematous epithelium
as white patch. It is contagious and often presents as
sore throat. Linear ulcers are seen in faucial pillars
covered with transparent glistening mucus or white
boggy epithelium looking like ‘snail track’ ulcers.
253
Fig. 10.55: Tongue tie: Typical look (for detail refer Page
No. 231) (Courtesy Dr Sathish, MCh, Plastic Surgeon,
Mangalore).
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SRB’s Clinical Surgery
Examination
11
There are two jaws—upper and lower. Upper jaw is
formed by maxilla and lower jaw by mandible.
Mandible is the largest, and strongest bone of the
face. It has got horse shaped body with two rami
projecting upwards from its posterior ends. Outer
surface of body contains symphysis menti, mental
protuberance, mental foramen, oblique line, incisive
fossa. Inner surface contains mylohyoid line, submandibular fossa (below), sublingual fossa (above), genial
tubercles. Upper alveolar border bears sockets for
teeth. Quadrilateral ramus has got medial and lateral
surfaces, anterior, posterior , upper and lower borders
and coronoid and condyloid processes. Medial surface
of ramus contains mandibular foramen above the centre
of the ramus near the occlusal surface of teeth (transmits
inferior alveolar nerve and vessels across mandibular
canal to mental foramen on the outer surface); lingula
(bony projection of mandibular foramen gives attachment to sphenomandibular ligament); mylohyoid
groove (medial pterygoid is inserted below and medial
to this groove). Lateral surface of ramus is flat
(attachment of the masseter muscle). Upper border of
ramus forms curved mandibular notch; lower border
containing angle of mandible is the continuation of the
base of mandible; posterior border of ramus is thick;
anterior is thin. Anterior projection is called as coronoid
process (temporalis is inserted on its apex and medial
surface); posterior projection is called as condyloid
process. Condyloid process is strong with expanded
upward head which articulates with temporal bone to
form temporomandibular joint. Anterior part of neck
of condyloid process has got pterygoid fovea for the
insertion of lateral pterygoid muscle. Oblique line on
the outer surface of the body gives origin to buccinator;
mylohyoid line on the inner surface of body gives origin
to mylohyoid and superior constrictor muscles; upper
of Jaw
genial tubercle gives origin to genioglossus and lower
to geniohyoid; digastric fossa gives origin to anterior
belly of digastric muscle. Investing layer of deep fascia
and platysma is attached to lower border (base) of the
mandible. Masseteric vessels and nerve passes through
mandibular notch; mental foramen transmits mental
vessels and nerve; inferior vessels and nerve passes
through the mandibular canal; mylohyoid vessels and
nerve are related to mylohyoid groove; lingual nerve
is related on the medial surface; auriculotemporal nerve
is related to medial side of the neck of the mandible.
Mandible is the second bone to ossify in the body after
clavicle. Ossification centre (only one centre) appears
in 6th week of intrauterine life, one on each side near
mental foramen. Entire body ossifies from membrane
except only one near incisor teeth; ramus above the
mandibular foramen ossifies from cartilage. Site at
canine socket is weak and is the commonest site of
fracture which may involve inferior alveolar nerve
causing neuralgic pain and loss of sensation over the
distribution of mental nerve (Fig. 11.1).
Maxilla is the 2nd largest bone of the face. Two
maxillae form upper jaw . Each maxilla has got body ,
4 processes – frontal, zygomatic, alveolar and palatine.
Body is pyramidal in shape with base medially at nasal
surface; apex laterally at zygomatic process. Body has
got 4 surfaces – anterior/facial; posterior/infratemporal; superior/orbital and medial/nasal. Anterior facial
surface gives attachments to many muscles of facial
expression. Infraorbital foramen transmitting the
infraorbital vessels and nerve is above the canine fossa.
Posterior surface forms the anterior wall of infratemporal fossa. Maxillary tuberosity gives origin to
superficial head of medial pterygoid muscle. Anterior
wall of the pterygopalatine fossa is above the tuberosity
– grooved by maxillary nerve. Superior surface is
Examination of Jaw
https://t.me/med1917
Fig. 11.1: Anatomy of mandible showing attachments and relations.
255
orbital surface forming floor of the orbit. It is related
to lacrimal crest, inferior orbital fissure, nasolacrimal
canal (contains nasolacrimal duct), infraorbital groove,
inferior oblique muscle. Medial nasal surface forms the
lateral wall of the nose. Posterosuperiorly maxillary
sinus opening, and maxillary hiatus is present. Below
inferior meatus of nose is present. Behind hiatus, there
is greater palatine canal containing greater palatine
vessels, anterior, middle and posterior palatine nerves.
In the alveolar process canine socket is deepest; molar
sockets are widest with each having 3 minor sockets.
Palatine process is thick horizontal medial projection
forming roof of the mouth and floor of the nasal cavity.
Two palatine processes, one on each side forms the
anterior 3/4th of the bony palate which articulates with
the horizontal plate of palatine bone. Greater palatine
vessels and anterior palatine nerves are present
posteromedially. Maxilla articulates laterally with 1
bone – zygomatic; superiorly with 3 bones – nasal,
frontal, ethmoidal; medially with 5 bones – ethmoid,
inferior nasal concha, vomer, palatine and opposite
maxilla. Maxillary sinus is the pyramidal shaped cavity
inside the body of maxilla with base medially and apex
towards zygomatic process. Its roof is floor of the orbit.
Its floor is alveolar process of maxilla. It is 3.7 × 3.7
× 2.5 cm in size. Maxillary sinus is first sinus to develop.
Maxilla ossifies from membrane from 3 centres. One
for maxilla proper is above the canine fossa during 6th
week of intrauterine life. T wo for premaxilla – one just
above the incisive fossa at 6th week; another paraseptal
is at 10th week.
T emporomandibular joint is a condylar synovial
joint. Upper temporal articular surface articulates with
lower head of the mandible. Joint is covered with
fibrocartilage with an intra-articular disc inside dividing the joint into upper and lower parts. Fibrous
capsule, lateral temporomandibular ligament, stylomandibular ligament and sphenomandibular ligaments
are the supports. Sphenomandibular ligament is related
to lateral pterygoid, auriculotemporal nerve, maxillary
artery, chorda tympani and pharynx. Laterally joint
is related to parotid and temporal branches of facial
nerve; medially tympanic plate, internal carotid artery,
sphenomandibular ligament and related structures;
below maxillary vessels; behind parotid, external
auditory meatus, superficial temporal vessels, auriculotemporal nerve.
Movements: Depression (mouth opening) is by lateral
pterygoid mainly (gravity muscle) supported by
digastric, geniohyoid and mylohyoid; elevation is by
masseter, temporalis and medial pterygoid (antigravity
muscles); protrusion/protraction by both lateral and
medial pterygoids; retraction by posterior fibres of
temporalis. Lateral/side-to-side movement is by same
side lateral pterygoid and opposite side medial
pterygoid.
History taking begins with:
Name:
Age:
Occupation:
Address:
History
History of present illness: History of trauma and
method of injury should be asked for. Blood stained
saliva after trauma suggests compound fracture
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especially in mandible as mucoperiosteum is adherent.
Pain, swelling in the floor of the mouth (haematoma),
difficulty in speech and swallowing, difficulty in
moving the jaws are the other history to be asked.
History of swelling, its duration, progression of
swelling; History of pain, its nature, severity,
progression; History of nasal block, nasal discharge,
epistaxis; History of visual disturbances (diplopia,
eyeball protrusion); History of swelling in the oral
cavity; History of headache over the sinuses are other
matters to be asked for. Referred pain in the ear can
occur though auriculotemporal nerve. Maxillary sinus
tumours can present with swelling, nasal problems,
visual disturbances, headache. History of ulcer,
swelling in the alveolus, palate or gums should be
asked. History of epiphora suggests blockage of
nasolacrimal duct causing constant overflow of tears.
History of bleeding gums, purulent nasal discharge
suggests maxillary antral sepsis (empyema); history
of caries teeth, persistent severe neuralgic pain are
also important. Tumour may invade especially
maxillary division of trigeminal nerve causing severe
pain. History of swelling in the neck suggests cervical
lymph node enlargement suggesting neoplastic or
inflammatory pathology. Its duration, progress,
presence of pain should be asked.
SRB’s Clinical Surgery
lips should be everted to examine jaw properly. Nasal
cavity should be inspected properly using nasal
speculum. Any swelling, deviation of septum, blockage
should be observed. Nasal discharge may be evident.
Inner surface of the mandible and inferior/palatine
surface of the maxilla is inspected by opening the mouth
widely (using proper light source). Teeth (missing,
caries) should be numbered and labeled; ulcers;
swelling from inner surface of the bone should be
inspected. When swelling is present, its size, shape,
extent should be observed. Nasopharynx should be
examined. Epulis (swelling arising from gums), odontomes may be evident. Contour of the alveolus; alignment of teeth; trismus should be observed. Ears should
be inspected using a speculum (Figs 11.2A to 11.3).
Past history: Earlier history of similar complaints;
treatment of sinus pathology, surgeries done earlier
for similar condition; response to treatment should
be asked.
Personal history: Alcohol intake, smoking, tobacco
chewing history are important points to be noted.
General Examination
Anaemia, clubbing, pulse, cyanosis, lymphadenopathy,
blood pressure should be checked.
Local Examination of Jaw
Inspection
Inspection of outer surface of the maxilla, and mandible
is done for swelling, ulcer, skin oedema; discharging
sinus (due to dental infection or osteomyelitis of the
bone or due to malignancy or due to previous radiotherapy or due to recurrent tumour), upper and lower
Fig. 11.2A
Examination of Jaw
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Fig. 11.2B
Figs 11.2A and B: Inspect the oral cavity and palate
carefully. Use a spatula and light source.
257
Palpation
Palpation is done initially over the outer surface then
inside by wearing a glove. T enderness, swelling, fracture site (in mandible there is loss of continuity of
lower border and crepitus) should be examined.
Surface, consistency, tenderness, mobility, fixity
should be ascertained while examining a swelling.
Orbital margins of the maxilla should be palpated
carefully on both sides for bone erosion, discontinuity,
and swelling. Patient is asked to blow through one
nostril while closing the other nostril. Free easier
blowing means there is no nasal blockage. Only tenderness in the maxillary antrum suggests sepsis in the
antrum. Area adjacent to loose teeth should be palpated.
Entire elveolar margin of both upper and lower jaw
should be palpated. Body, angle and lower part of
the ramus of the mandible should be palpated from
outside and inside. Bidigital palpation is done by
placing one finger inside the mouth and fingers of
other hand is placed outside to feel tenderness,
irregularity, discrepancies, swelling, and thickening.
It should be done on both sides for comparison (Figs
11.4A to 11.8B).
Fig. 11.3: Inspect alveolus by properly
retracting the lips.
Movements of the Temporomandibular Joint
Joint can be felt by placing little finger in the external
auditory canal with pulp facing forward and asking
the patient to open and close the mouth (Figs 11.9A
to C). Condylar movements cannot be felt in dislocated
TM joint. Dislocation can be unilateral or bilateral.
Partially opened jaw with deviation towards opposite
side and hollowness behind the dislocated condyle
can be felt. In bilateral dislocation mouth is opened
and fixed (prognathous deformity). In normal opening
of the jaw the distance is 2.5 cm between upper and
lower incisor teeth. Joint movement is also checked
by placing fingers over the joint just below and in
front of the tragus. Crepitus due to osteoarthritis; click
due to loose bodies can also be felt. Ankylosis of TM
joint causes restricted mouth opening. Osteoarthritis,
fibrosis of soft tissues around are the causes. It is often
difficult to differentiate it from trismus. Trismus is
due to muscular spasm (masseter and pterygoids) by
inflammation (dental abscess, acute parotitis, partially
erupted 3rd molar/wisdom tooth, pharyngeal,
peritonsillar abscess); Risus sardonicus of tetanus; oral
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A
SRB’s Clinical Surgery
A
B
C
Figs 11.4A to C: Eliciting the tenderness in maxilla
and also checking the nasal blockage.
B
Figs 11.5A and B: Palpating inferior orbital
margin for tenderness or disruption.
malignancy infiltrating the soft tissues beneath also
causes restricted jaw opening. Clicking of jaw also
occurs due to displacement of articular cartilage of
the TM joint which is common in females. When the
mouth is opened widely like in yawning the jaw gets
suddenly locked with a snap in the ear; and patient
cannot close the mouth later. Later each time mouth
opening causes a click.
Sensation over the mental area, infraorbital region
and other areas of trigeminal nerve should be checked
when needed (Figs 11.10A and B).
Cervical lymph nodes should be palpated for
significant enlargement (Fig. 11.11).
Examination of Jaw
https://t.me/med1917
A
Fig. 11.7: Bidigital palpation of
jaw (mandible) is important.
259
B
C
Figs 11.6A to C: Palpating the alveolar margins
of the jaw and lower margin of the mandible.
A
B
Figs 11.8A and B: Transillumination of maxilla is done by
two methods. One is by illuminating the torch over the external
surface of the maxilla in a dark room. Another is by placing
the tip of illuminating torch into the mouth and mouth is
closed in a dark room to see whether maxilla is
transilluminating (normal) or not (pus or tumour).
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A
SRB’s Clinical Surgery
A
B
C
Figs 11.9A to C: Temporomandibular joint movements
should be checked both by placing little finger inside and
from outside the ear.
B
Figs 11.10A and B: Sensation should be checked using
cotton over the mentum in lower jaw; over the infraorbital
region in upper jaw.
Fig. 11.11: Cervical lymph nodes should be palpated
in jaw tumours.
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