Mouth, Throat, Nose, and Sinus Assessment

The mouth and throat make up the first part of the digestive system and are responsible for receiving food. Cranial nerves V"trigeminal", VII"facial", IX "glosopharyngeal", and IIX"hypoglossal" assist with some of the digestive functions. The nose and paranasal sinuses constitute the first part of the respiratory system and are responsible for receiving, filtering, warming, and moistening air to be transported to the lungs. Receptors of cranial nerve I "olfactory" are also located in the nose.

MouthThe roof of the oral cavity is formed by the anterior hard palate and the posterior hard palate. An extension of the soft palate is the uvula.

Contained within the mouth are the tongue, teeth, gums, and the opening of the salivary glands "parotid, submandibular, sublingual". The three pairs of salivary glands secrete saliva "watery, serous fluid contains salts, mucous, and salivary amylase" into the mouth. The parotid glands, located below, and in front of the ears, empty through Stensen's ducts, which are located inside the check across from the second upper molar.

The submandibular glands, located in the lower jaw, open under the tongue on either side of the frenulum through opening called Wharton's ducts. The sublingual glands, located under the tongue, open through several ducts located on the floor of the mouth.

Mouth and throat– Lips– Cheeks– Buccal mucosa– Hard palate– Soft palate– Tonsils– Oropharynx and nasopharynx– Uvula– Tongue – taste (CN VII)– Salivary glands– Parotid– Submandibular– Sublingual– Teeth– Crown– Neck– Root

Throat The throat "pharynx", located behind the mouth and nose, serves as a muscular passage for food

and air. The upper part is called the nasopharynx. Below it lays laryngopharynx.

The soft palate, anterior and posterior pillars, and uvula connect behind the tongue to form arches.

The lingual tonsils lie at the base of the tongue. Pharyngeal tonsils "adenoid" are found high in

the nasopharynx.

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External Nose and Mouth

NoseIt composed of bone and cartilage and is lined with mucous membrane. The nasal cavity is located.

External nose Internal nose Nasal cavity Paranasal Sinuses

– Frontal– Maxillary– Sphenoid– Ethmoid

Turbinates – Projections in nasal cavity that increase surface area– Superior, middle and inferior turbinates

Nasal mucosa Olfactory receptor cells (CN I)

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Functions of Nose

Identify odors (upper 1/3 of septum) CN I

Air passageway (obligate in newborns)

“Air conditioning”

– Humidify

– Warms/cools air

– Cleans and filters air of dust and bacteria

– Voice resonance

Common Chief Complaints

Nasal blockage or congestion

Halitosis – breath odor

– Fruity (acetone) – diabetic ketoacidosis

– Foul – URI, sinus, tonsil or mouth infection

– Ammonia – renal problems (uremia)

– Fecal – GI obstruction

Oral lesions

Ear, Nose & Throat Assessment: History ReviewPresent Problem

– dizziness or vertigo– earache– hearing loss– nasal discharge– snoring– nosebleed– dental problems– mouth lesions– sore throat

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– difficulty swallowing

Past Medial History– systemic diseases

– Ear- frequent problems in childhood

- surgery- labrynthitis- antibiotic use

– Nose- trauma- surgery- chronic nosebleeds

– Sinuses- chronic postnasal drip- repeated sinusitis- allergies

– Throat- frequent, documented strep infections- tonsillectomy- adenoidectomy

Assessment of the Nose

Inspection of internal nose

Otoscope with nasal speculum – avoid septum d/t increased sensitivity

Color & integrity of nasal mucosa

Septum deviation, perforation, bleeding (epistaxis)

New/old bleeding anywhere

Turbinates (color, exudate, swelling, polyps) Note the middle and inferior turbinates

Normal – dull red

Allergies – pale pink/gray, swollen (polyps & a clear, watery discharge are also common)

Acute rhionitis infection – bright red & swollen

Normal findings

– Located in midline of face

– No swelling, bleeding, lesions, or masses

– Both nostrils patent

– Septum midline

– Nasal mucosa is pink or dull red

Abnormal findings – Broken, misshapen, swollen nose– Occluded nasal passages– Septum is deviated– Nasal mucosa is red and swollen

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Nasal Polyp;

Smooth, pale gray nodule

Overgrowths of mucosa

Chronic allergic rhinitis

Mobile, nontender

Decrease/absence of smell

Assessment of the Sinuses

Inspection

Palpation, percussion & transillumination (very dark room)

Normal findings

– No evidence of swelling

– Resonance heard on direct percussion

– Will feel firm pressure with palpation, but no pain normally

– Healthy sinuses contain air and may light up symmetrically

Assessment of the Mouth

Inspection (use good light source)

– Lips (color, moisture, cracking, lesions) – smile for symmetry (CNVII)

– Tongue (color, surface fissures, moisture) – stick out for deviation (CN VII)

– Gums, buccal mucosa (check for pink color, bleeding, swelling)

– Teeth (#, molars, color, cavities, dental repair) 32 adult – 20 children (3rd molars may be missing – wisdom teeth)

– Hard palate & soft palate

– Floor of mouth (Wharton’s duct/Submandibular gland, Sublingual gland)

– Parotid gland (in cheek in front of ear) and Stensen’s duct (opposite 2nd molar)

– Tongue (Lingual frenulum, lingual veins)

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Palpate– Roof of mouth in infants– Lips, cheek, tongue, floor of mouth– Use gauze to hold tongue– Find Stensen’s duct (parotid salivary gland) opposite upper second molar– Check temporomandibular joint (TMJ) – depression in front of tragus felt with fingers

(slight pop can be normal; crepitus and masses are abnormal)

Normal findings– Pink, moist lips– Tongue midline, adequate movement– No lesions– Tongue, gums, buccal mucosa are pink, moist, smooth– No bleeding– Smooth, white teeth, no dental caries

Abnormal findings– Lesions, growths– Dry, cracked lips– Vesicles or blisters– Red, tender, inflamed tongue, gums, buccal mucosa– Thrush– Coating on tongue– Bleeding gums

Thrush – Candidiasis Scrapes off easily Leaves red, raw surface that may bleed Can occur after antibiotics, corticosteroids, and with immunosupression

Gum Hyperplasia

Painless enlargement Occurs with puberty, pregnancy, leukemia, and extensive use of phenytoin (Dilantin)

Gingivitis Gum margins red, swollen, bleed easily Gums will recede and produce purulent drainage with chronicity Poor dental hygiene, vitamin C deficiency More common in pregnancy & puberty

Inspection of the Throat Gag reflex (CN IX & X) Posterior pharynx and oropharynx Presence of swelling, exudate or lesions. Note color. Inspect tonsils Grade tonsils (+1 – +4)

Normal findings Soft palate and uvula rise when patient says, “ahhh” (CN IX & X) Uvula is midline No swelling, exudate, or lesions Gag reflex is present (CN IX & X)

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Abnormal findings Posterior pharynx is red with white patches Tonsils and uvula are red and swollen Hoarse voice Grayish membrane covering tonsils, uvula, soft palate

Tonsil Exudate Streptococcal pharyngitis and acute tonsillitis Bright red pharynx with red, swollen tonsils, pillar and uvula Patches of white/yellow exudate

Family History– hearing problems/loss– Meniere’s disease– allergies– hereditary renal disease

Personal & Social History– employment…hazards– nutrition– oral care pattern– tobacco use– alcohol use– intranasal cocaine use– OTC nasal spray use

Infants and Children– prenatal history– prematurity– infection

- meningitis/encephalitis- recurrent otitis media

– congenital defects– playing with small objects– behaviors indicating hearing loss– dental care

Pregnant Women– weeks gestation/postpartum– symptoms before pregnancy– pattern of dental care

Older Adults– hearing loss– physical disability– deterioration of teeth– dry mouth– medications – salivation

NOSE & NASOPHARYNX

Warm/humidify/moisten air and resonate sound

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Floor is hard and soft palate

Roof is sphenoid and frontal bone

Mucous membrane caries debris

Turbinates increase surface area

Sinuses

- maxillary and frontal accessible to exam

- ethmoid and sphenoid behind frontal

- mucous and cilia move mucous

Check patency of nares

Percuss and palpate sinuses

Observe mucosa color and discharge

allergy = white mucosa with clear discharge

virus = red mucosa with colorful discharge

?CSF = unilateral clear discharge

foreign body = unilateral colorful discharge

Assess polyps or ulcer

MOUTH & OROPHARYNX

Passage of food/fluid, emit air & speech, initiate digestion & identify taste

Gingivae cover neck and roots of teeth

Teeth - 32 permanent (4 incisors, 2 canines, 4 premolars and 6 molars)

Oropharynx separated from mouth by tonsilar pillars

Assess lips, buccal mucosa, teeth and gums

Observe occlusion of clenched teeth (CN VIII)

Inspect tongue color, texture, ulcerations and note movement (CN XII)

Assess soft palate and rise of posterior curtain with “ahh” (CN IX/X)

Inspect posterior pharynx noting tonsillar pillars

Lips- cyanosis = hypoxia- pallor = poor perfusion- vesicles = HSV

Oral lesions- Candida = white patches on red base

Pharynx - viral vs bacterial pharyngitis- Peritonsillar abcess = deviated uvula

Pediatric Variations

Essential to determine nasal patency of newborn (choanal atresia) Bilaterally will need immediate intervention d/t obligate nose breathing

Only the maxillary and ethmoid sinuses are present at birth (easier to transilluminate)

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Tonsils vary widely in size during childhood

3 month old begins salivation (drooling)

Teeth/tooth may be present at birth, most infants start between 6-10 months, will lose teeth between 6-12 yrs

Gerontological Variations

Nose may appear more prominent d/t loss of SQ fat in face.

Diminished sense of smell and taste (decreased # of olfactory nerve fibers in nose and papilla on tongue)

Periodontal disease

Gum lines recede

Oral alterations due to disease or side effects of medications

Tooth loss

Teeth will darken with age d/t exposed dentin

Lifestyle and Health Practices

Predisposing factors for oral cancer : Cigarette smoking Excessive use of alcohol Age over 40 Male gender Genetic predisposing Vitamin A deficiency

Grinding the teeth is a sign of stress or slight malocclusionProper brushing, flossing, and oral hygiene can prevent dental caries and gum diseasesCleaning the tongue is a way to prevent bad breath resulting from bacteria that accumulates on the posterior tongueElderly and some disabled clients may have difficult caring properly for teeth or dentures because of poor vision or impaired extremities

Collecting Objective Data

- Examination of the mouth and throat can help the nurse detect abnormalities of the lips, gums, teeth, oral mucosa, tonsils, and uvula.

- It allows for early detection of oral cancer

- Examination top detect oral problems, septum defects, patency of the nose and nasopharynx.

- Early detection of impaired oral mucous membrane s or poor dental hygiene conditions may require a change in client's diet. Early detection of septum deviation help the nurse determines which nostrils to use to insert a NGT or suction tube.

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