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nose into two nasal cavities that join posteriorly in the postnasal
space. There are three turbinates on each side of the nose,
superior, middle and inferior, which warm and moisten nasal
airflow (Figs 9.13 and 9.14A).
One important function of the nose is olfaction. The olfactory
receptors are situated high in the nose in the olfactory cleft. Olfactory fibres from the nasal mucosa pass through the cribriform
plate to the olfactory bulb in the anterior cranial fossa.
The paranasal sinuses are air-filled spaces in the skull. There
are paired frontal, sphenoid, maxillary, and anterior and posterior
ethmoid sinuses. The anterior nasal sinuses (frontal, maxillary
and anterior ethmoid) drain into the middle meatus (between the
middle turbinate and lateral wall of the nose). The posterior
ethmoid and sphenoid sinuses drain into the sphenoethmoidal
recess (between the superior turbinate and nasal septum).
The history
Common presenting symptom s
Nasal obstruction
Ask about:
• unilateral or bilateral obstruction
• associated symptoms (bleeding, swelling, pain).
Unilateral nasal obstruction may be caused by anatomical
blockage, such as a deviated septum possibly secondary to
trauma. Bilateral obstruction can be due to rhinitis (allergic or
non-allergic) or chronic rhinosinusitis with or without polyps.
Nasal discharge
Ask about:
• unilateral or bilateral discharge (rhinorrhoea)
• purulent or clear nature
• anterior discharge or postnasal drip.
Clear, bilateral watery discharge suggests allergic or nonallergic rhinitis. Purulent discharge can point to acute bacterial
rhinosinusitis or chronic rhinosinusitis. A unilateral, purulent
discharge in a child raises the possibility of a foreign body in the
nose. Following a head injury, unilateral clear rhinorrhoea suggests a possible CSF leak secondary to an anterior skull-base
fracture.
Epistaxis (bleeding from inside the nose)
Ask about:
• unilateral or bilateral bleeding
• frequency and duration of episodes
• provoking factors such as trauma, sneezing, or blowing or
picking nose
• bleeding from the front or back of the nose.
The nasal septum has a very rich blood supply, particularly in
Little’s area (anterior septum), which is a common site for
bleeding. If bleeding is unilateral and associated with nasal
obstruction and pain, the possibility of sinonasal malignancy
should be considered. In adolescent males with unilateral nasal
obstruction and epistaxis, the rare diagnosis of juvenile angiofibroma should be excluded on nasendoscopy by an ear, nose
and throat specialist.
Sneezing
Ask about:
• associated itchy, red eyes
• whether symptoms occur all year round, only during certain
seasons, or during contact with allergens.
Sneezing is a protective sudden expulsive effort triggered by
local irritants in the nose and is most commonly due to allergy or
viral URTIs.
Disturbance of smell
Ask about:
• complete loss of smell (anosmia)
• reduced sense of smell (hyposmia)
• unpleasant smells (cacosmia)
• associated nasal symptoms such as obstruction and rhinor-
rhoea, which may suggest rhinitis or nasal polyps
• recent head injury
• recent URTI.
A sudden onset of anosmia can occur following a significant
head injury or viral URTI due to damage to the olfactory epithelium. Inflammation and swelling in the nasal mucosa as a result of
rhinitis, chronic rhinosinusitis or nasal polyps usually cause
hyposmia. Cacosmia is usually caused by infection in the nose or
sinuses, or occasionally by a foreign body in the nose. Phantosmia describes olfactory hallucinations, which may occur in
temporal lobe epilepsy.
Nasal and facial pain
Nasal pain is rare, except following trauma. Facial pain can be
caused by a number of problems but is often incorrectly attributed to sinusitis. The key to identifying the cause of facial pain is
an accurate history.
Ask about:
• quality of pain: for example, throbbing, aching, sharp, stab-
bing, tight-band
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• location of pain: unilateral or bilateral
• duration and frequency of pain
• associated nasal symptoms
• associated nausea, photophobia or aura (migraine)
• relieving and exacerbating factors.
The differential diagnosis of facial pain includes temporomandibular joint dysfunction, migraine, dental disease, chronic rhinosinusitis, trigeminal neuralgia (severe, sharp pain in a trigeminal
distribution), tension headache (band-like, tight pain) and cluster
headaches (unilateral nasal discharge, eye watering).
Nasal deformity
The most common cause of nasal deformity is trauma, resulting in
swelling, bruising and deviation of the nose. The swelling following
trauma will settle over a couple of weeks, but residual deviation may
remain if the nasal bones were fractured and displaced. It is
important to establish the impact of the nasal injury on function
(nasal breathing, sense of smell) and cosmetic appearance.
Nasal septal destruction or perforation can result in ‘saddle
deformity’ of the nasal bridge. Causes include granulomatosis
with polyangiitis, trauma, cocaine abuse, congenital syphilis and
iatrogenic factors (septal surgery, Fig. 9.14B).
The nose can appear widened in acromegaly or with
advanced nasal polyposis (see Fig. 9.14C). Rhinophyma can also
result from chronic acne rosacea of the nasal skin (Fig. 9.15).
Past medical history
Ask about:
• history of atopy
• asthma (around one-third of patients with allergic rhinitis have
asthma)
• prior nasal trauma or surgery
• history of bronchial infection (cystic fibrosis or ciliary disorders
may affect the nose and lower airways).
Inferior view of nose
Tip
Ala nasi
Anterior nares
Vestibule
Columella
Nasal septum
Pituitary
fossa
Lateral wall of nose
External nose
Fig. 9.13 The nose and paranasal sinuses.
Bridge
Ala nasi
Anterior nares
Tip
Columella
Cranial cavity
Frontal sinus
Sphenoid sinus
Bony portion of
nasal septum
Septal cartilage
Little’s area
Hard palate
Nasopharynx
Cranial cavity
Frontal sinus
Superior turbinate
Sphenoid sinus
Middle turbinate
Vestibule
Inferior turbinate
Hard palate
9
A
Fig. 9.14 Nasal abnormalities. A Turbinate hypertrophy. B Nasal septum perforation post-surgery. C Nasal polyps.
B
C
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Fig. 9.15 Rhinophyma as a complication of rosacea.
For patients with epistaxis, it is important to identify any history
of bleeding diathesis or hypertension.
Drug history
Ask about:
• use of anticoagulants, including warfarin, apixaban or
rivaroxaban
• use of antiplatelet drugs (aspirin, clopidogrel).
Intranasal cocaine use can cause septal perforation, epistaxis,
crusting and whistling.
Family history
A family history of atopy is relevant in rhinitis. In patients with
epistaxis, it is important to establish a family history of hereditary
haemorrhagic telangiectasia or inherited bleeding disorders.
Social history
Occupation is relevant because exposure to inhaled allergens,
occupational dusts and chemicals may exacerbate rhinitis.
Exposure to hardwood dust is associated with an increased risk
of sinonasal cancers. Atopic patients should be asked about
pets.
Heavy alcohol intake, leading to liver disease, can affect
coagulation and is relevant for epistaxis. Smoking impedes
mucociliary clearance and can contribute to nasal problems.
The physical examination
Examination sequence
• Assess the external appearance of the nose, noting swelling,
bruising, skin changes and deformity.
• Stand above the seated patient to assess any external
deviation.
• Ask the patient to look straight ahead. Elevate the tip of their
nose using your non-dominant thumb to align the nostrils
with the rest of the nasal cavity.
• Look into each nostril and assess the anterior nasal septum
(Fig. 9.16); note the mucosal covering, visible vessels in Little’s area, crusting, ulceration and septal perforation. In
trauma, a septal haematoma should be excluded.
• Using an otoscope with a large speculum in an adult, assess
the inferior turbinates. Note any hypertrophy and swelling of
the turbinate mucosa.
• You may see large polyps on anterior rhinoscopy. To distin-
guish between hypertrophied inferior turbinates and nasal
polyps, you can lightly touch the swelling with a cotton bud
(polyps lack sensation).
• Palpate the nasal bones to assess for bony or cartilaginous
deformity.
• In trauma, palpate the infraorbital ridges to exclude a step
deformity and to check infraorbital sensation. Eye movements
should be assessed to rule out restriction of movement
related to ‘orbital blowout’.
AB
Fig. 9.16 Nasal examination. A Elevation of the tip of the nose to give a clear view of the anterior nares. B Anterior rhinoscopy using an otoscope with a
large speculum.
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• Place a metal spatula under the nostrils and look for
condensation marks to assess airway patency.
• Palpate for cervical lymphadenopathy (p. 36).
• Note that rigid nasendoscopy and tests of olfaction are
confined to specialist clinics.
The mucosa of the inferior turbinate on anterior rhinoscopy is
pale, moist and hypertrophied in allergic rhinitis (see Fig. 9.14A).
In chronic rhinitis, the mucosa is swollen and red. Large polyps
may be seen on anterior rhinoscopy as pale yellow/grey swellings (see Fig. 9.14C).
A septal haematoma will app ear as a soft, red, fluctuant
swelling of the anterior septum. The septal cartilage receives
its blood supply from the overlying perichondrium; a septal
haematoma interrupts this supply and can result in cartilage
necrosis, septal perforation and ‘saddle deformity’.Itmust
therefore be identifi ed and referred for early drainage.
Facial swelling is not usually seen in chronic sinu siti s but ca n
occur with den tal abscesses and cancer of the maxillary
antrum.
Investigations
Initial investigations are summarised in Box 9.7 and Fig. 9.17.
9.7 Investigations in nasal disease
Investigation Indication/comment
Plain X-ray Not indicated for nasal bone fracture
Nasal endoscopy Inflammatory sinus disease, malignancy
Allergy tests Skin-prick tests for common inhaled allergens, specific immunoglobulin E blood test (RAST)
Computed tomography Inflammatory sinus disease, trauma and malignancy
Tests of olfaction Used in specialist clinics only
RAST, Radioallergosorbent test; UPSIT, University of Pennsylvania smell identification test.
Only required if associated facial fracture is suspected
Demonstrates extent of sinus disease, provides evidence of invasion into local structures and shows detailed bony anatomy,
enabling planning of endoscopic surgical procedures (see Fig. 9.17)
Include the UPSIT smell test and Sniffin’ Sticks
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A
Fig. 9.17 Computed tomograms of the paranasal sinuses. A Normal scan. B Right-sided chronic sinusitis.
B
A
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MOUTH, THROAT AND NECK
Anatomy and physiology
Mouth
The mouth extends from the lips anteriorly to the anterior tonsillar
pillar posteriorly and is divided into the vestibule; between the
buccal (cheek), mucosa and the teeth; and the oral cavity internal
to the teeth. The oral cavity contains the anterior two-thirds of the
tongue, the floor of the mouth, the hard palate and the inner
surfaces of the gums and teeth (Fig. 9.18). The tongue anteriorly
has filiform papillae containing taste buds, giving the tongue its
velvety texture. The circumvallate papillae are groups of taste
buds marking the boundary between the anterior two-thirds and
posterior third of the tongue.
Saliva is secret ed into the mouth from the parotid, submandibular and sublingual salivary glands (Fig. 9.19 ). The
parotid gland is situated anterior to the ear and has a superficial and deep lobe relative to the facial nerve that runs
through it. The parotid duct opens into the buccal mucosa
opposite the second upper molar. The submandibular gland
lies anterior and medial to the angle of the mandible and its
duct opens into the floor of the mouth next to the frenulum of
thetongue(seeFig. 9.18).
Throat
The pharynx is a shared upper aerodigestive channel that runs
from the anterior tonsillar pillar to the laryngeal inlet. The larynx
(‘voice box’) is responsible for phonation and has a protective
function to prevent aspiration. It consists of two external cartilages, the thyroid cartilage (Adam’s apple) and the cricoid
cartilage (prominence at the top of the trachea; see Fig. 10.1A).
The membrane between the two is called the cricothyroid
membrane; a cricothyroidotomy may be performed by an
experienced clinician at this site as an emergency procedure to
Parotid
gland
Sublingual
gland
Submandibular
gland
Fig. 9.19 The position of the major salivary glands.
obtain an airway. The sensory supply to the larynx is via the
superior and recurrent laryngeal branches of cranial nerve X
(vagus). The motor supply is mainly from the recurrent laryngeal
nerve, which loops round the aortic arch on the left side and the
subclavian artery on the right. Due to its longer pathway, the left
recurrent laryngeal nerve is exposed to greater risk of damage
during surgery to the neck or thorax, or from an upper lobe lung
lesion.
Teeth
In children the 20 deciduous teeth erupt by 3 years. There are
32 secondary teeth, erupting from ages 6 to 16 or later
(Fig. 9.20).
Hard palate
Uvula
Posterior
pharyngeal wall
Vallate papillae
Dorsum of tongue
Fig. 9.18 Anatomy of the mouth and throat. A Examination with the mouth open. B Examination with the tongue touching the roof of the mouth.
Soft palate
Posterior pillar
Tonsil
Anterior pillar
Undersurface
of tongue
Submandibular
duct
Opening of
submandibular
duct
B
Opening of
parotid duct
Buccal mucosa
Frenulum
Incisors
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Canine
Secondary dentition
The history • 209
II
I
Premolars
Molars
Primary dentition
Fig. 9.20 Primary and secondary dentition.
Neck
Anatomically, the neck is divided into anterior and posterior triangles (Fig. 9.21). The anterior triangle is bounded by the midline,
the anterior border of the sternocleidomastoid muscle and the
body of the mandible. The posterior triangle of the neck is
bounded by the posterior border of sternocleidomastoid, the
trapezius muscle, and the clavicle. The cervical lymph nodes
drain the head and neck (see Fig. 3.26). Examination of these
nodes is described on page 37 and shown in Fig. 3.27. Palpable
lymphadenopathy is most commonly due to URTI but may be
caused by atypical infection, inflammation, lymphoma or
Anterior
triangle
Fig. 9.21 Sites of swellings in the neck.
Posterior
triangle
III
VI
V
IV
I Submental and submandibular nodes
II Upper third sternocleidomastoid (SCM) muscle
III Middle third SCM (between hyoid and cricoid)
IV Lower third SCM (between cricoid and clavicle)
V Posterior to SCM (posterior triangle)
VI Midline from hyoid to manubrium
Fig. 9.22 Cervical lymph node levels.
metastatic malignancy. The neck can also be subdivided further
into different levels that are used to describe the location of
enlarged lymph nodes in the neck (Fig. 9.22).
The history
Common presenting symptom s
Sore mouth
Ask about:
• how long pain has been present and any progression
• trauma to the mouth
• mouth ulcers
• problems with teeth or gums
• associated bleeding.
Aphthous ulcers are small, painful, superficial ulcers on the
tongue, palate or buccal mucosa. They are common and usually
heal spontaneously within a few days. Oral ulcers can be caused
by trauma, vitamin or mineral deficiency, cancer, lichen planus or
inflammatory bowel disease.
A sore mouth can also be due to conditions of the gums,
including inflammation (gingivitis) or systemic conditions
(Box 9.8).
Infections, including candidiasis (caused by Candida albicans),
herpes simplex and herpes zoster, as well as dental sepsis, can
cause a painful mouth. Candidiasis may be secondary to poorly
fitted dentures, the use of inhaled glucocorticoids or immunodeficiency. Herpes zoster of the maxillary division of the
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9.8 The gums in systemic conditions
Condition Description
Phenytoin treatment Firm and hypertrophied
Scurvy Soft and haemorrhagic
Acute leukaemia Hypertrophied and haemorrhagic
Cyanotic congenital heart disease Spongy and haemorrhagic
trigeminal nerve (see Fig. 7.9B) can cause unilateral painful
vesicles on the palate.
Sore throat
Ask about:
• unilateral or bilateral pain
• otalgia (earache)
• difficulty opening the mouth (trismus, due to spasm of the jaw
muscles)
• associated fever, malaise, anorexia, neck swelling
• associated red flag symptoms (dysphagia, odynophagia,
hoarseness, weight loss).
Throat pain can radiate to the ear because of the dual
innervation of the pharynx and external auditory meatus via the
vagus nerve (referred pain). The most common cause of sore
throat is pharyngitis (inflammation of the pharynx) and is
usually viral. Acute tonsillitis may be viral or caused by streptococcal bacterial infection (Fig. 9.23A) and cannot be distinguished clinically.
Infectious mononucleosis caused by Epstein–Barr virus (EBV)
(glandular fever) results in tonsil erythema and swelling, a white
pseudomembrane covering the tonsil, palatal petechiae (see
Fig. 9.23B), cervical lymphadenopathy and sometimes hep-
atosplenomegaly. A peritonsillar abscess (quinsy) can lead to
unilateral throat pain, trismus, drooling of saliva, soft-palate
swelling, deviation of the uvula to the opposite side (see
Fig. 9.23C) and ‘hot-potato voice’ (as though you were trying to
speak with a hot potato in your mouth).
It is important to establish whether there are any ‘red flag’
symptoms associated with sore throat. Progressive dysphagia or
hoarseness associated with weight loss should raise suspicion of
malignancy. A mass or ulcer on the tonsil associated with throat
pain may be a tonsil squamous cancer. Human papillomavirusrelated oropharyngeal cancer is now the most common primary head and neck malignancy in young, sexually active
non-smokers.
Globus pharyngeus is a sensation of something in the throat in
the context of a normal clinical examination. Patients classically
describe the feeling of a lump in the throat, usually in the midline,
which fluctuates from day to day and eases when swallowing.
Anxiety, habitual throat clearing and acid reflux are thought to be
contributory factors.
A
B
C
Fig. 9.23 Sore throat. A Acute tonsillitis. The presence of pus strongly
suggests a bacterial (streptococcal) aetiology.
palatal petechiae.
of ENT Diagnosis. 3rd edn. London: Mosby–Wolfe; 1995.
C A left peritonsillar abscess. (A) From Bull TR. Color Atlas
B Glandular fever showing
Stridor
Stridor is a high-pitched noise produced by turbulent airflow
through a narrowed, partially obstructed upper airway and can
indicate laryngeal or tracheobronchial (p. 88) obstruction. It most
commonly occurs on inspiration but may also be expiratory or
biphasic. The level of obstruction determines the type of stridor.
Inspiratory stridor suggests narrowing at the level of the vocal
cords, biphasic stridor suggests subglottic/tracheal obstruction,
and stridor on expiration suggests tracheobronchial obstruction.
Common causes of stridor include infection/inflammation,
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trauma, foreign bodies (particularly in children) and tumours.
Stridor should always be urgently evaluated.
Ask about:
• sudden or gradual onset
• associated fever
• associated hoarseness.
Stertor differs from stridor. It is a low-pitched snoring or
gasping sound audible during inspiration and is due to
obstruction at the level of the nasopharynx or oropharynx. This
can result from enlarged inflamed tonsils, peritonsillar abscess or
tongue swelling (trauma, anaphylaxis).
Dysphonia
Ask about:
• how long dysphonia (hoarseness) has been present
• whether it is persistent or intermittent
• progression
• voice quality (croaky, breathy, weak)
• associated stridor, dysphagia, otalgia or weight loss.
If hoarseness has been present continuously for more than
3 weeks, urgent laryngoscopy is indicated to exclude laryngeal
cancer. If voice quality is breathy and associated with a weak
(bovine) cough (p. 87), a recurrent laryngeal nerve palsy due to
lung or oesophageal cancer should be considered. Recurrent
laryngeal nerve palsy may also be iatrogenic (thyroid surgery) or
secondary to trauma or neurological conditions (Box 9.9).
Dysphagia
The approach to dysphagia is described on page 110.
Neck lump
Neck lumps are common; they may be reported by patients or
found incidentally on physical examination. While many lumps
are benign, there may be a more serious underlying diagnosis
(Box 9.10).
Ask about:
• sudden or gradual onset
• progression
• associated pain
• associated hoarseness or dysphagia
• fever or other systemic symptoms (weight loss, night sweats).
Sudden, painful, unilateral salivary gland swelling (sialadenopathy) is due to a stone obstructing the duct (sialolithiasis).
Other causes of enlarged salivary glands are mumps (usually
bilateral), sarcoidosis, human immunodeficiency virus-related
cysts, bacterial infection (suppurative parotitis; Fig. 9.24) and
cancer. The clinical features of important neck lumps are summarised in Box 9.10.
9.9 Causes and features of dysphonia
Causes Features
Neonate
Congenital abnormality Laryngomalacia most frequent cause
Neurological disorder Examples include vocal cord palsy
Child
Infection:
Croup
(laryngotracheobronchitis)
Laryngitis Bacterial or viral
Voice abuse (screamer’s
nodules)
Adult
Infection:
Upper respiratory tract
infection
Laryngitis
Trauma Mechanical or chemical
Lung cancer Vocal cord paralysis, breathy voice
Vocal cord nodules (singer’s
nodules)
Neurological disorder Weak, wet or dysarthric voice
Cancer of the larynx Rough voice, constant, progressive,
Functional cause
More common in preterm neonates
Associated stridor due to immature
larynx folding in on inspiration
Unilateral causing weak, breathy cry
Bilateral may cause stridor and
airway obstruction
Barking cough, stridor, hoarse voice
History of voice abuse
Associated features of upper
respiratory tract infection
injuryCigarette smoking
Gastro-oesophageal reflux disease
(reflux laryngitis)
Prolonged vocal strainRough voice
Reduced vocal range
Vocal fatigue
often affects smokersAssociated with
dysphagia, odynophagia, otalgia
Past medical history
It is important to establish whether there are any previous dental
problems or systemic disease – particularly those affecting the
gastrointestinal tract – as the mouth is part of this. Neurological
conditions may affect swallowing and cause drooling or dry
mouth with secondary infection. Previous head and neck surgery
and trauma should be noted.
Any prior intubations or admissions to intensive care should be
recorded, as repeated or prolonged intubation can result in
subglottic stenosis and stridor.
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9.10 Causes and features of neck lumps
Location in neck Diagnosis Clinical features
Midline Thyroglossal cyst Smooth, round, cystic lump that moves when patient sticks out tongue
Lateral
Anterior triangle Thyroid lobe swellings:
Posterior triangle Lymph nodes:
Supraclavicular fossa Supraclavicular lymphadenopathy Left supraclavicular (Virchow’s) node may suggest gastric malignancy
Submental lymph nodes Associated infection of lower lip, floor of mouth, tip of tongue or cheek skin
Thyroid isthmus swelling Lump moves on swallowing
Dermoid cyst Small, non-tender, mobile subcutaneous lump
Simple, physiological goitre
Multinodular goitre
Solitary nodule
Thyroid tumours: benign (adenoma) and
malignant (papillary, follicular, medullary,
anaplastic)
Submandibular gland swelling:
Infection, stones, autoimmune disease
Benign or malignant tumours
Parotid gland swelling:
Mumps, parotitis, stones, autoimmune
disease
Parotid gland mass:
Benign
Malignant tumours
Branchial cyst Smooth, non-tender, fluctuant mass. Not translucent. Slowly enlarging, may
Lymph nodes:
Malignant: lymphoma, metastatic cancer Large, hard, fixed, matted, painless mass suggests malignancy
Infection: bacterial infection of head and
neck, viral infection (e.g., infectious
mononucleosis), human
immunodeficiency virus, tuberculosis
Malignant
Benign
Carotid body tumour Firm, rubbery, pulsatile neck mass fixed vertically due to attachment to bifurcation
Carotid artery aneurysm Rare, present as pulsatile neck mass
Cystic hygroma Soft, fluctuant, compressible and transilluminable mass, usually seen in children
Cervical rib Hard, bony mass
Lump moves with swallowing but not on tongue protrusion
Swelling below the angle of the mandible. Can be felt bimanually. Involvement of
more than one gland suggests a systemic condition. A lump within the gland
suggests a tumour. Uniform enlargement with pain suggests infection or stones
Swelling in the preauricular area or just below the ear
Hard, fixed mass with facial nerve weakness suggests a malignant tumour of the
parotid gland
increase after upper respiratory tract infection
Lymph nodes can be reactive to infection and are usually smooth, firm, mobile and
tender
See p. 34
of common carotid. A bruit may be present
Drug history
Many drugs, including tricyclic antidepressants and anticholinergics, cause a dry mouth. Multiple repeated courses of antibiotics increase the risk of oral candidiasis, as do any prolonged
illness.
Social and family history
Risk factors for head and neck squamous cancer include alcohol
and smoking. Oral cancer is more common in those who
experience orogenital contact and in those who chew tobacco or
betel nuts. Any history of head and neck cancer in the family
should be established.
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Fig. 9.24 Pus discharging from the parotid duct.
The physical examination
Mouth and throat
Examination sequence
• Listen to the patient’s voice (rough, breathy, wet, muffled,
nasal escape).
• Use a head light to leave both of your hands free to use
instruments.
Inspection
• Ask the patient to remove any dentures.
• Look at their lips. Ask them to half-open their mouth and
inspect the mucosa of the vestibule, buccal surfaces and
buccogingival sulci for discoloration, inflammation or ulceration, then at bite closure. Inspect the parotid duct opening
opposite the second upper molar for any pus or inflammation.
• Ask the patient to open their mouth fully and put the tip of
their tongue behind their upper teeth. Check the mucosa of
the floor of the mouth and the submandibular duct openings.
• Ask them to stick their tongue straight out, noting any devi-
ation to either side (XII nerve dysfunction), mucosal change,
ulceration, masses or fasciculation.
• Ask them to deviate their tongue to one side. Retract the
opposite buccal mucosa with a tongue depressor to view the
lateral border of the tongue. Repeat on the other side.
• Inspect the hard palate (Fig. 9.25) and note any cleft,
abnormal arched palate or telangiectasia.
• Inspect the oropharynx. Ask the patient to say ‘Aaah’ and use
a tongue depressor to improve visualisation.
• Assess the soft palate for any cleft, bifid uvula, swelling or
lesions.
• Inspect the tonsils, noting size, symmetry, colour and any pus
or membrane.
• Touch the posterior pharyngeal wall gently with the tongue
depressor to stimulate the gag reflex. Check for symmetrical
movement of the soft palate.
Palpation
• If any lesion is seen in the mouth or salivary glands, palpate it
(wearing gloves) with one hand outside on the patient’s cheek
Fig. 9.25 Torus palatinus. This benign asymptomatic central palatal bony
mass is more common in Asian populations. From Scully C. Oral and
Maxillofacial Medicine. 2nd edn. Edinburgh: Churchill Livingstone; 2008.
or jaw and a finger of your other hand inside the mouth
(bimanual palpation).
• Feel the lesion and identify its characteristics (p. 36).
• If the base of the tongue or the tonsils are asymmetrical,
palpate it using a gloved finger.
• If the parotid gland is enlarged or abnormal on inspection,
examine the facial nerve and check if the deep lobe (tonsil
area) is displaced medially.
• Palpate the parotid and submandibular duct, feeling for
stones.
• Palpate the cervical lymph nodes (p. 36).
Cracking of the lips can be the result of cold exposure
(‘chapped lips’), riboflavin deficiency, chronic atrophic candidiasis or iron deficiency (Fig. 9.26). Squamous and basal cell
cancers occur on the lips and are associated with smoking and
sun exposure.
The normal tongue appearance includes areas of smooth
mucosa (‘geographic tongue’) or, conversely, excessive furring.
A smooth red tongue with diffuse papillary atrophy occurs in iron
or vitamin B
neurological disease, painful mouth or a tight frenulum.
Fig. 9.26 Angular stomatitis.
deficiency. Tongue protrusion may be limited by
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