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346 PHYSICAL EXAMINATION

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Putting it all together – synthesise information

The nurse in this case would note the signicant features of the history, the presenting illness and the physical examination

UNIT 2

ndings, and refer to the medical ofcer. Important ndings in the consumer history and history of the

presenting illness include:

> Risk factors for cataract

• Age

• Tobacco use

• Recreational UV light exposure related to hobbies and

leisure activities

• Non-use of UV-light-ltering sunglasses when out of doors

> Symptoms and history of presenting illness indicating senile

cataract development

• Bilateral, progressive decrease in ability to see clearly both

at distance and near

• Glare, especially when driving at night

• Improved but not resolved with corrective lenses

• No pain or recent injury

• Unknown family history of eye diseases, including glaucoma,

retinal detachment and macular degeneration

> Signicant physical examination ndings include:

• decreased distance and near visual acuity

• normal visual elds

• normal pupils, no RAPD detected

• cloudy, pearly grey appearance of lens when examined

using torch; all other anterior segment structures normal

• blurred view of the optic disc and retina on ophthalmoscopy

indicating an opacity in the ocular media (in this case the lens).

Actions based on assessment ndings

The nurse should also provide additional consumer education for interventions that do not require a doctor’s order, such as:

1 use of safety devices such as UV-ltering sunglasses when sun

exposure is likely

2 advice and strategies to aid the cessation of smoking, advice

and referral to quit smoking services

3 developing an awareness of safety issues associated with

decreased visual acuity; for example, safety when driving and decreased depth perception. The nurse should be aware of the vision requirements for driving and be able to advise the consumer if they do not meet these requirements.

The nal step in the process is accurate documentation. The nurse must document ndings, referrals, interventions, advice and education given. The consumer would then be reassessed following denitive diagnosis and medical interventions for his ongoing health maintenance.

CHAPTER RESOURCES

REVIEW QUESTIONS

For answers to these questions, see Answer section at the end of the book.

1. Which of the following is the eye structure that is the round red

structure in the inner canthus and contains sebaceous glands?

a. Limbus b. Cornea c. Sclera d. Caruncle

2. What are some of the normal ageing changes that can be

observed during the eye examination? Select all that apply.

a. Drusen, or small white dots in the fundus b. Dry eyes c. Loss of peripheral vision d. Decreasing ability to focus on near objects e. Lagophthalmos f. Arcus senilis

3. A 40-year-old consumer tells you that he has noticed his right

eye is turning in towards his nose and this is not normal for him. What condition is this consumer describing?

a. Amblyopia b. Myopia c. Esotropia d. Hyperopia

4. Your patient has one pupil that is 1mm smaller than the other.

This nding is called:

a. Consensual response b. Anisocoria c. Accommodation d. Strabismus

5. Which non-eye specic medical history may be linked to eye

pathology? Select all that apply.

a. Renal disease b. Thyroid disease c. Long bone fractures d. Carpal tunnel syndrome e. Diabetes mellitus f. Surgical emphysema

6. The consumer’s bulbar conjunctiva has a bright red

appearance. What condition may have caused this clinical nding?

a. Ultraviolet light b. Warfarin therapy c. Osteogenesis imperfecta d. Cholecystitis

EYES 347

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7. Which of the following physical examination ndings is a

consumer likely to exhibit in glaucoma?

a. Steamy, cloudy cornea b. Conical protrusion of the centre of the cornea c. Greyish, well-circumscribed ulcerated area on the cornea d. Tree-like conguration on the cornea

8. A yellow sclera can be seen in which of the following

conditions in adults? Select all that apply.

a. Gallstones b. Hepatitis c. Sickle cell anaemia d. Osteogenesis imperfecta e. Pterygium f. Bacterial conjunctivitis

FURTHER RESOURCES

> Eyerobics – Natural eyesight improvement site: http://

eyerobics.com.au/eyesight.html

> Macular Degeneration New Zealand: http://www.mdnz.org.nz/ > Save our sight New Zealand: http://www.saveoursight.co.nz

9. Oculomotor nerve damage may be seen with which of the

following symptoms?

a. Fixed and dilated pupil on one side that does not react

to light and does not accommodate. Ptosis and lateral deviation of the eye is also present.

b. Fixed pinpoint pupil on one side. c. Pupils are bilaterally small and irregularly shaped. React

to accommodation but not to light.

d. One pupil is larger than the other, regularly shaped, reacting

to light and accommodation may be absent or sluggish.

CLINICAL SKILLS

The following Clinical Skill is relevant to this chapter and can be found in Tollefson & Hillman, Clinical Psychomotor Skills, 8th edition:

> 27 Healthcare teaching.

> Vision 2020 Australia: http://www.vision2020australia.org.au/ > Vision Australia: http://www.visionaustralia.org.au > Vision Initiative: http://www.visioninitiative.org.au

CHAPTER 10

REFERENCES

Australian Department of Health and Aged Care. (2023). Eye health and

vision. Retrieved 5 May 2023 from http://www.health.gov.au/internet/ main/publishing.nsf/Content/eye-health

Australian Institute of Health and Welfare (AIHW). (2021a). Eye health,

AIHW, Australian Government. Retrieved 5 December 2022 from https://www.aihw.gov.au/reports/eye-health/eye-health/contents/ about

Australian Institute of Health and Welfare (AIHW). (2021b). Indigenous eye

health measures 2021. Cat. no. IHW 242. Retrieved 5 December 2022 from https://www.aihw.gov.au/getmedia/efec3a5e-657e-412f-9e4ed6503c8b0cf6/aihw-ihw-242.pdf%C2%A0

Australian Institute of Health and Welfare (AIHW). (2022). Australia’s

health 2022 in brief. Australia’s health series no. 18. Cat. no. AUS 241. Canberra: AIHW, Australian Government.

Blind Low Vision New Zealand (NZ). (2022). Statistics and research: Cost

of vision loss in New Zealand. Retrieved 5 December 2022 from https:// blindlowvision.org.nz/news/cost-of-vision-loss-in-2021/

Centre for Eye Research Australia (CERA). (2022). Glaucoma. Retrieved

14 December 2022 from https://www.cera.org.au/conditions/glaucoma/

Chilibeck, C., Mathan, J. J., Ng, S. G., & McKelvie, J. (2020). Cataract

surgery in New Zealand: access to surgery, surgical intervention rates and visual acuity. New Zealand Medical Journal, 133(1524), 40–9. PMID: 33119569.

Glaucoma Australia. (2022). What is Glaucoma? Retrieved 12 December

2022 from https://glaucoma.org.au/what-is-glaucoma

Glaucoma Research Foundation. (2022). Glaucoma worldwide: A growing

concern. Retrieved 12 December 2022 from https://glaucoma.org/ glaucoma-worldwide-a-growing-concern/

Hoskin, A. (2020). Eye injuries: The hidden costs revealed, mivision The

Ophthalmic Journal. Retrieved 12 December 2022 from https://mivision. com.au/2020/04/eye-injuries-the-hidden-costs-revealed/

Kamińska, A., Pinkas, J., Wrześniewska-Wal, I., Ostrowski, J., &

Jankowski, M. (2023). Awareness of common eye diseases and their risk factors – a nationwide cross-sectional survey among adults in Poland.International Journal of Environmental Research and Public Health,20(4), 3594. https://doi.org/10.3390/ijerph20043594

Macular Degeneration New Zealand. (2020). Macular degeneration New

Zealand. Retrieved 5 December 2022 from https://www.mdnz.org.nz/

Macular Disease Foundation Australia. (n.d.(a)). Age-related macular

degeneration. Retrieved 12 December 2022 from https://www. mdfoundation.com.au/about-macular-disease/age-related-maculardegeneration/amd-overview/

Macular Disease Foundation Australia. (n.d.(b)). Diabetic retinopathy.

Retrieved 12 December 2022 from https://www.mdfoundation.com. au/about-macular-disease/diabetic-eye-disease/about-diabeticretinopathy/

Mayo Clinic (2021). Cataracts. Retrieved 8 August 2022 from https://www.

mayoclinic.org/diseases-conditions/cataracts/symptoms-causes/ syc-20353790

Pagano, C. G. M., de Campos Moreira, T., Sganzerla, D., Matzenbacher, A.

M. F., Faria, A. G., Matturro, L., … Lutz de Araujo, A. (2021). Teaming-up nurses with ophthalmologists to expand the reach of eye care in a middle-income country: Validation of health data acquisition by nursing staff in a telemedicine strategy.PloS One,16(11), e0260594– e0260594. https://doi.org/10.1371/journal.pone.0260594

348 PHYSICAL EXAMINATION

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Razavi, H., Burrow, S., & Trzesinski, A. (2018). Review of eye health among

Aboriginal and Torres Strait Islander people. Australian Indigenous Health Bulletin, 18(4). Retrieved 12 December 2022 from https://

UNIT 2

healthbulletin.org.au/articles/review-of-eye-health-among-aboriginaland-torres-strait-islander-people/

Sturrock, B. (2018) Treating depression in people with vision impairment,

InPsych, 40(1), Australian Psychological Society. Retrieved 12 December 2022 from https://psychology.org.au/for-members/ publications/inpsych/2018/feb/treating-depression-in-people-withvision-impairm

Tolchard, B., & Stuhlmiller, C. M. (2018). Outcomes of an Australian Nursing

Student-led School Vision and Hearing Screening Programme. Child Care in Practice, 24(1), 43–52. https://doi.org/10.1080/13575279.2017.1 287058

Vision 2020. (2021). 2021–22 Pre-budget submission. Retrieved

12 December 2022 from https://www.vision2020australia.org.au/ resources/2021-22-pre-budget-submission/

Vision Australia. (2022). Age-related macular degeneration. Retrieved

12 December 2022 from https://www.visionaustralia.org/services/ eye-conditions/age-related-macular-degeneration

World Health Organization (WHO). (2022). Blindness and vision impairment.

Retrieved 5 December 2022 from https://www.who.int/news-room/ fact-sheets/detail/blindness-and-visual-impairment

Zhang, N., Wang, J., Li, Y., & Jiang, B. (2021). Prevalence of primary open

angle glaucoma in the last 20 years: a meta-analysis and systematic review. Scientic Reports, 11, 13762. https://doi.org/10.1038/s41598-02192971-w

CHAPTER

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EARS, NOSE, MOUTH AND THROAT

LEARNING OUTCOMES

By the end of this chapter you should be able to:

1 identify the structures of the ears, nose, mouth and throat 2 describe system-specic history and normal ndings in the physical examination of the

ears, nose, mouth and throat

3 describe common abnormalities with pathophysiology found in the physical examination of

the ears, nose, mouth and throat

4 identify health education opportunities for consumers with specic conditions 5 perform the physical examination of the ears, nose, mouth and throat 6 discuss the clinical reasoning in evaluating outcomes of health assessment and physical

examination including documentation requirements for recording information, health education given and relevant health referral.

349

BACKGROUND

Health assessment and physical examination of the ears, nose, sinuses, mouth and throat can be linked to assessment of the neurological, respiratory, endocrine, gastrointestinal, musculoskeletal and cardiovascular systems.

Ear-related conditions include:

> infections (either bacterial or viral) such as otitis media (middle ear infection) and

otitis externa (‘tropical ear’ or ‘swimmer’s ear’). In Australia there are between 900000 and 2.4million cases per year of otitis media (Veivers et al., 2022), one of the leading causes of disease in Aboriginal and Torres Strait Islander children, and a signiﬁcant contributor to hearing loss (De Lacey, Dune & Macdonald,

2020). In 2018−19, 43% of Aboriginal and Torres Strait Islander children aged seven and older had measured hearing loss in one or both ears (AIHW, 2020a). Clinical presentation differs for this cohort, in that they are, on average, younger in age for ﬁrst infection, have a higher frequency of infection and experience infections of greater severity and persistence, compared with non-Indigenous children (Jervis-Bardy, Carney, Duguid & Leach, 2017). In New Zealand, approximately 60% of children have experienced at least one episode of acute otitis media by age four, and 27% of children aged 0 to 4 years are affected each year (BPAC, 2022). Research indicates Ma¯ori and Pasiﬁka children experience higher rates of middle ear infection and subsequent hearing loss than the broader New Zealand population (EMC, 2021).

> hearing loss, which may be due to disease processes such as Ménière’s disease,

age-related changes, drug-related conditions, acoustic neuroma and trauma. Hearing loss in children is signiﬁcantly correlated with ear disease and infection,

350 PHYSICAL EXAMINATION

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UNIT 2

which are especially prevalent among Aboriginal and Torres Strait Islander children. Self-reported ear and hearing problems in Aboriginal and Torres Strait Islander children were estimated to be over twice the rate for non-First Nations children in 2018−19; however, given that many cases go unreported, the true disparity is likely to be higher (AIHW, 2020a). Childhood hearing loss is due to preventable causes in 60% of cases (WHO, 2021), and can signiﬁcantly affect the achievement of developmental milestones, many of which are associated with the acquisition of language and cognitive function (Victorian Government, 2021).

> hearing disabilities, which include tinnitus and hyperacusis. In New Zealand,

15% of the population experiences tinnitus (Health Navigator New Zealand, 2021), while around one in three Australians experience tinnitus at some point in their lives (Tinnitus Australia, n.d.). Hyperacusis is a form of increased sensitivity for sound that causes a low tolerance for environmental noise. Common causes are exposure to loud noise and ageing (Better Health Vic, 2019). Nose and sinuses-related conditions are usually due to:

> infection (common cold, head cold and ﬂu) > allergy-related rhinitis, sinus-related infections (sinusitis) > trauma > nasal obstruction often due to nasal polyps.

Allergic rhinitis (hay fever) affects around 18% of the population (children and adults) in Australia and New Zealand (ASCIA, 2019). It is most prevalent in 25- to 54-year-olds (AIHW, 2020b).

Mouth-related conditions are categorised as:

> infections (for example: herpes, syphilis, thrush or candidiasis; and in children:

viruses such as coxsackie, which causes hand, foot and mouth disease,

and impetigo)

> oral cancers (with higher incidence of mouth and tongue cancer in smokers),

which account for approximately 2% of all cancers diagnosed in New Zealand

(Cancer Society NZ, 2018). In Australia there were 687 new diagnoses of mouth

cancer in 2021, up from 435 in 1994 (Cancer Council, 2021).

> loss of teeth, which affects nutrition, systemic health, self-image, quality of life

and the ability to socialise (Deutsch & Jay, 2021). In 2012, 52.2% of older adults

in New Zealand had lost all of their natural teeth and 74% of people living in

residential care and 87% of people living at home wore full upper and lower

dentures to replace their lost teeth (CBG Health Research, 2015). This suggests

a signiﬁcant proportion of this cohort were not wearing full dentures, which

can impact signiﬁcantly on nutritional intake and all aspects of health and

wellbeing. Untreated tooth decay, a precursor to tooth loss, in nursing home

residents with dementia is high, with 68% of residents in an Australian aged

care facility having coronal caries, and 77% having root caries (Deutsch & Jay,

2021). Preventative care such as tooth brushing with ﬂuoridated tooth paste was

a common protective measure; however prohibitive cost, lack of access, anxiety

and lack of perceived need were barriers to older adults receiving regular dental

health checks (Mohammed, 2019).

Throat-related conditions can be categorised into:

> diseases such as thyroid diseases, cancer > trauma > infection.

Trauma and infection may also lead to loss of vocal ability.

Hearing loss or damage can quite radically affect a consumer’s life. This may be life-threatening due to the consumer’s inability to use hearing for safety responses. For example, mishearing health-related advice, especially regarding medication administration, affects people who also have poor eyesight. Although loss of sense of smell or taste may not be life-threatening, links have been made to distortions in these senses being caused not only by infection, injury and side effects ofdrugs,

EARS, NOSE, MOUTH AND THROAT 351

Antihelix

Antitragus

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butalso as a symptom of depression. Loss of quality of life is usually the most common complaint that loss or distortion of these senses has for consumers experiencing these conditions.

ANATOMY AND PHYSIOLOGY

Ear

The ear has three sections: the external, the middle and the inner ear.

The external ear, which is also called the auditory canal to the tympanic membrane. The auricle receives sound waves and funnels them through the auditory canal to produce vibrations on the tympanic membrane. The auricle is composed of cartilage and is ﬂared to catch sound waves and funnel them through to the middle ear. The helix is the rim of the auricle and the posterior portion of the auricle is also referred to as the lobule (

Pinna

Helix

auricle or pinna, extends through the

Figure 11.1).

Oriﬁce to external auditory canal

Tragus

CHAPTER 11

Lobule

FIGURE 11.1 External ear

The external auditory canal is an S-shaped tube approximately 2.5cm in length, with the outer third made up of cartilage and the remainder of bone covered by a thin layer of skin ( sweat glands that secrete a thick, wax-like substance called cerumen (ear wax), which can vary in consistency from dry and ﬂaky to wet and waxy. Cerumen ranges from a pale, honey colour in light-skinned individuals to dark brown or black in dark-skinned people. Colour and consistency may also change due to the presence of impurities and infections.

Figure 11.2). The canal is lined with tiny hairs and modiﬁed

Middle ear

The middle ear is composed of the tympanic membrane, the ossicles and the tympanic cavity. The cavity is an air-ﬁlled compartment that separates the middle ear from the internal ear. The tympanic membrane, which is circular or oval and is about 10–15mm in diameter, sits in an oblique position in the external canal so that it leans slightly forward. The rim of the tympanic membrane (also referred to as the ear drum) is called the annulus, the superior portion is the pars ﬂaccida, and the tighter, largest area of the drum is the pars tensa.

The ossicles are three tiny bones – the malleus (hammer), the incus (anvil) and the stapes (stirrup) – that play a crucial role in the transmission of sound. Vibrations set up in the tympanic membrane by sound waves reaching it through the external auditory canal are transmitted to the inner ear by rapid movement of the ossicles.

352 PHYSICAL EXAMINATION

External

Round window

Extremely

Moderate

Avoid prolonged or

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auditory canal

UNIT 2

Painful

loud

Very loud

Faint

Firearms, rock concert,

>140

personal music device, ﬁrecrackers

140

130

Jackhammer

120

Jet plane takeoff

Rock music

110

Lawn mower, motorcycle, chainsaw,

100

power boat

repeated exposure above this level.

Alarm clock

60–70 Busy trafﬁc

Shout

45–55 Loud voice

35–40 Conversation

25–30 Soft voice

0–15 Whisper

FIGURE 11.3 Decibel scale of frequently

heard sounds

Malleus

Stapes

Incus

and footplate

Semicircular canals

Ampulla

Vestibule

CN VIII

Cochlea

Oval window

Eustachian

Tympanic membrane

Tympanic

tube

cavity

Lobule

External ear

Middle ear

Inner ear

FIGURE 11.2 Cross section of the ear

The middle ear is connected to the nasopharynx by the auditory or eustachian

, which serves as a channel through which air pressure within the cavity can

tube

be equalised with air pressure outside to maintain normal hearing. Equalisation of pressure is aided by yawning or swallowing, which causes the opening of valve-like ﬂaps that cover the openings of the eustachian tubes.

Inner ear

The inner ear is a complex, closed, ﬂuid-ﬁlled system of interconnecting tubes called

labyrinth, which is essential for hearing and equilibrium. The labyrinth has

the bony and membranous portions. The bony labyrinth is composed of the cochlea, the semicircular canals and the vestibule. The

vestibule is located between the

cochlea and the semicircular canals and is important in both hearing and balance. The three semicircular canals located at right angles to each other provide balance and equilibrium for the body. The

cochlea is a snail-shaped structure made

up of three compartments ﬁlled with ﬂuid. As sound waves travel through the ear, they cause the ﬂuid to vibrate, stimulating the thousands of hearing-receptor cells of the organ of Corti. Nearby nerve ﬁbres transmit impulses along the cochlear branch of the vestibulocochlear nerve to the brain, allowing us to hear. The human ear is capable of hearing within a frequency range of 20 to 20000Hz, and a decibel range of 0 to 140. Figure 11.3 illustrates the decibel levels of various commonly heard sounds.

Nose

The nose consists of the external or outer nose and the nasal fossae, or internal nose (see Figure 11.4). The outer nose is made up of bone and cartilage and is divided internally into two nasal fossae by the nasal septum, and externally by the columella. Anterior openings into the nasal fossae are nostrils, or nares. Each fossa has a lateral extended ‘wing’ portion, the ala nasi, on the outside and a vestibule just inside the nostril. Superior, middle and inferior meatuses or grooves are

EARS, NOSE, MOUTH AND THROAT 353

Nasal septum

Superior turbinate

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Olfactory receptors

Frontal sinus

Sphenoid sinus

Superior meatus

Middle turbinate

Middle meatus

Inferior turbinate

Inferior meatus

Hard palate

Tongue

FIGURE 11.4 Lateral cross section of the nose

Nasal bone

Cartilage

Vestibule

Naris

Maxilla

located on the lateral walls of the nostrils just below the corresponding conchae, or

turbinates. The nasal turbinates are covered by mucous membranes and greatly

increase the surface area of mucous membrane in the nose because of their shape. Kiesselbach’s plexus is a vascular area on the nasal septum, and a common site of nosebleeds (also called epistaxis).

Air enters the anterior nares, passes through the vestibule, and enters the fossa. The vestibule contains nasal hairs and sebaceous glands. The fossae have both olfactory and respiratory functions. To protect the lungs from noxious agents, these structures of the nose clean, ﬁlter, humidify and control the temperature of inspired air. The mucous covering in the nose and sinuses traps ﬁne dust particles, and lysosomes kill most of the bacteria. The tiny hairs of the nose (cilia) transport the mucus and the particles to the pharynx to be swallowed.

The nasal mucosa is capable of adding large amounts of water to inspired air through evaporation from its surface. The rich vascular supply to the turbinates radiates heat to the incoming air as it passes through the nasal cavity.

CHAPTER 11

Sinuses

Air-ﬁlled cavities lined with mucous membranes are present in some of the cranial bones and are referred to as sinuses lighten the weight of the skull and add resonance to the quality of the voice. The frontal, maxillary, ethmoid and sphenoid paranasal sinuses open into the nose. Only the frontal and maxillary sinuses can be assessed in the physical examination.

Mouth and throat

The lips are sensory structures found at the opening of the mouth (see Figure 11.6). The labial tubercle is the small projected area in the midline of the upper lip. The area where the upper and lower lips meet is the labial commissure. The vermilion zone is the reddish or reddish-brown area of the lips, and the area where the lips meet the facial skin is called the vermilion border. The medial groove superior to the upper lip is called the philtrum. The cheeks form the lateral walls of the mouth and are lined with buccal mucosa. The posterior pharyngeal wall is at the back of the mouth.

paranasal sinuses (see Figure 11.5). These air-ﬁlled

354 PHYSICAL EXAMINATION

Frontal sinus

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UNIT 2

Ethmoid sinus

Maxillary sinus

FIGURE 11.5 Location of the sinuses (sphenoid sinuses are directly behind ethmoid sinuses)

Ala Nasi

Nares

Labial

tubercle

Labial

commissure

Vermilion

border

FIGURE 11.6 Landmarks of the area around the mouth

Labiomental

groove

Columella

Nasolabial

groove

Philtrum

Vermilion

zone

The roof of the mouth consists of the hard palate anteriorly and the soft palate

posteriorly (see Figure 11.7). The linear raphe is a linear ridge in the middle of the hard palate that is formed by two palatine bones and part of the superior maxillary bone. The mucous membrane on either side of the linear raphe is thick, pale and corrugated, while the posterior mucous membrane is thin, a deeper pink, and smooth.

Situated in the ﬂoor of the mouth, the tongue is a muscular organ connected

to the hyoid bone posteriorly and to the ﬂoor of the mouth anteriorly by the

fraenulum. The tongue assists with mastication, swallowing, speech, and

mechanical cleansing of the teeth.

The mucous membrane covering the upper surface of the tongue has numerous

projections called papillae, which assist in handling food and contain taste buds. Four qualities of taste are found in taste buds distributed over the surface of the tongue. The sulcus terminalis is the midline depression that separates the anterior two-thirds of the tongue from the posterior one-third.

EARS, NOSE, MOUTH AND THROAT 355

Opening of Stensen's duct

Lower lip

Posterior pharynx

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Upper lip

Fraenulum of upper lip

Hard palate

Linear raphe

Soft palate

Posterior pillar

Uvula Anterior pillar

Palatine tonsil Dorsum of tongue Papillae

Floor of mouth

Buccal surface of teeth

Fraenulum of tongue

Opening of Wharton's duct

Gingiva

CHAPTER 11

Gingival recess

Fraenulum of lower lip

FIGURE 11.7 Structures of the mouth

Two of the three pairs of salivary glands open into the mouth on the ventral

surface of the tongue. Submaxillary glands secrete ﬂuid through

Wharton’s ducts,

located on both sides of the fraenulum. Sublingual glands open into the ﬂoor of the mouth posteriorly to Wharton’s ducts. The larger parotid glands are located in the cheeks and secrete their amylase-rich ﬂuid through Stensen’s ducts, located just opposite the upper second molars.

The salivary glands produce 1000 to 1500mL of saliva per day to assist with digestion of food and maintenance of oral hygiene. Saliva prevents dental caries and bacterial damage of healthy oral tissue by washing away bacteria and destroying it with antibodies and proteolytic enzymes.

Gums, or gingivae, appear pink or coral in light-skinned individuals and brown with a darker melanotic line along the edges in dark-skinned individuals. Gums hold the teeth in place.

Adults have 32 permanent teeth: four incisors, two canines, four premolars and six molars in each half of the mouth (

Figure 11.8). The teeth are well designed for chewing.

Incisors provide strong cutting action, and molars provide strong grinding action.

The soft palate is suspended from the posterior border of the hard palate and extends downwards as folds, the palatine arches or pillars forming an incomplete septum between the mouth and the nasopharynx. The uvula is a ﬁnger-like projection of tissue that hangs down from the centre of the soft palate. Two palatine tonsils (primarily lymphoid tissue) are connected to the palatine arches; they vary greatly in size from one individual to another. Lymphoid tissue in the tonsils plays a role in the control of infection.

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30.08.202647 Мб0Книга_2653_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202647 Мб0Книга_2654_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202647 Мб0Книга_2655_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202647 Мб0Книга_2656_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202646 Мб0Книга_2657_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202646 Мб0Книга_2658_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202645 Мб0Книга_2660_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202644 Мб0Книга_2662_Библиотеки_им_академика_М_И_Перельмана.pdf
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30.08.202643 Мб0Книга_2664_Библиотеки_им_академика_М_И_Перельмана.pdf