Nose, Mouth, and Nose, Mouth, and ThroatThroat

By Orest KornetskyBy Orest Kornetsky

Nose anatomyNose anatomy BridgeBridge is the superior part (nasal bone) is the superior part (nasal bone) Tip is the anterior part of nose (cartilage)Tip is the anterior part of nose (cartilage) Hair – Filter coarse matter from entering nasal cavityHair – Filter coarse matter from entering nasal cavity Ciliated mucous membrane filters dust and bacteria. The Ciliated mucous membrane filters dust and bacteria. The

rich blood supply warms and humidifies the airrich blood supply warms and humidifies the air Turbinates (conchae) increase the surface are of the nasal Turbinates (conchae) increase the surface are of the nasal

cavity so that more air is filtered, warmed, and humidifiedcavity so that more air is filtered, warmed, and humidified

Nose - Nose - SinusesSinuses

Frontal and

maxillary

Which sinuses can we examine?

Only the ethmoid and maxillary sinuses are

present at birth. Frontal develop between 7 and 8 years. Sphenoid

develop after puberty.

Mouth – A & PMouth – A & P Hard palate – made out of bone (whitish color)Hard palate – made out of bone (whitish color) Soft palate – made out of muscle (more pink in Soft palate – made out of muscle (more pink in

color)color) Uvula – hangs from middle of soft palateUvula – hangs from middle of soft palate Tongue – striated muscle assist with mastication Tongue – striated muscle assist with mastication

and swallowing. Papillae on dorsal surface of and swallowing. Papillae on dorsal surface of tongue hold neurons responsible for tastetongue hold neurons responsible for taste

Mouth – Mouth – Salivary GlandsSalivary Glands

Parotid glandParotid gland Located superior of Located superior of

mandibular anglemandibular angle Submandibular Submandibular

glandgland Lies beneath the Lies beneath the

mandiblemandible Sublingual glandSublingual gland

Lies posterior to Lies posterior to the tongue at the the tongue at the floor of the mouthfloor of the mouth

Function of the glands is to secrete saliva

Throat Throat (Pharynx) (Pharynx)

NasopharynxNasopharynx Located behind the nose, above Located behind the nose, above

the soft palatethe soft palate Contains adenoids (pharyngeal Contains adenoids (pharyngeal

tonsils)tonsils) Eustachian tube opens during Eustachian tube opens during

swallowing to equalize pressure swallowing to equalize pressure within the middle earwithin the middle ear

OropharynxOropharynx Located behind the mouth, Located behind the mouth,

below the nasopharynxbelow the nasopharynx Shared passageway for Shared passageway for

breathing and swallowingbreathing and swallowing Contains palatine tonsils, which Contains palatine tonsils, which

guard the body against guard the body against microorganismsmicroorganisms

LaryngopharynxLaryngopharynx Extends from base of tongue to Extends from base of tongue to

the esophagusthe esophagus Critical dividing point where Critical dividing point where

solids are separated from airsolids are separated from air Divides larynx from esophagusDivides larynx from esophagus

(adenoids)

Named according tolocation

Developmental Developmental Considerations – Infants Considerations – Infants

and Childrenand Children Children have 20 deciduous (temporary) teeth Children have 20 deciduous (temporary) teeth (compared to the adults’ 32). (compared to the adults’ 32).

Deciduous teeth are lost beginning at 6 years until Deciduous teeth are lost beginning at 6 years until about 12about 12

Developmental Developmental Considerations - AgingConsiderations - Aging

Nasal hair grow coarser and stiffer and may Nasal hair grow coarser and stiffer and may not filter air as well. Decreased sensation of not filter air as well. Decreased sensation of smell.smell.

Loss of taste due to soft tissue atrophyLoss of taste due to soft tissue atrophy Decrease in salivary secretionDecrease in salivary secretion Tooth surface is abraded. Gums begin to Tooth surface is abraded. Gums begin to

recede and erode.recede and erode. Poor oral hygiene may cause tooth loss, Poor oral hygiene may cause tooth loss,

which increase the difficulty of masticationwhich increase the difficulty of mastication Use of medications may have anticholinergic Use of medications may have anticholinergic

effects, which further decrease salivationeffects, which further decrease salivation

Health HistoryHealth History Nasal discharge? Nasal discharge?

(rhinorrhea) – Cold, (rhinorrhea) – Cold, allergies, sinus allergies, sinus infection, traumainfection, trauma

Frequent colds? – Frequent colds? – immunosuppressionimmunosuppression

Epistaxis Epistaxis (nosebleeds)? – may (nosebleeds)? – may occur with trauma, occur with trauma, irritantsirritants

Allergies?Allergies? Sores or lesions in Sores or lesions in

mouth or oral cavity? mouth or oral cavity? – may be malignant– may be malignant

Sore throat? – Sore throat? – Determine if bacterial or Determine if bacterial or viral cause. Strep viral cause. Strep throat may lead to throat may lead to rheumatic fever. Are rheumatic fever. Are tonsils still in place?tonsils still in place?

Bleeding gums or Bleeding gums or toothache? – may toothache? – may indicate poor oral indicate poor oral hygienehygiene

Any voice changes?Any voice changes? Dysphagia (difficulty Dysphagia (difficulty

swallowing)? – may be swallowing)? – may be caused by GERD, caused by GERD, pharyngitis, neurologic pharyngitis, neurologic diseases, cancer.diseases, cancer.

Assessing the Assessing the NoseNose External noseExternal nose

Normal – nose is symmetric, midline, Normal – nose is symmetric, midline, proportionalproportional

Test for obstruction of by blocking Test for obstruction of by blocking each nare and asking the person to each nare and asking the person to inhale with the open nare.inhale with the open nare.

Nasal cavityNasal cavity Insert otoscope into the nasal Insert otoscope into the nasal

vestibule, lifting the tip of the nosevestibule, lifting the tip of the nose Normal – nasal mucosa pink, smooth, Normal – nasal mucosa pink, smooth,

and moistand moist Abnormal – note any bleeding, Abnormal – note any bleeding,

swelling, redness, discharge, foreign swelling, redness, discharge, foreign bodybody

Rhinitis – mucosa swollen, red, and Rhinitis – mucosa swollen, red, and often includes discharge (watery, often includes discharge (watery, thick, purulent, green) in upper resp thick, purulent, green) in upper resp infectioninfection

Observe for deviated septum, which Observe for deviated septum, which is only significant if airflow is is only significant if airflow is obstructedobstructed

Observe turbinates for polyps Observe turbinates for polyps (benign growths) – smooth, gray, (benign growths) – smooth, gray, avascular, mobile, nontenderavascular, mobile, nontender

Assessing the SinusesAssessing the Sinuses PalpationPalpation

Using thumbs, Using thumbs, palpate the frontal palpate the frontal and maxillary sinusesand maxillary sinuses

Tenderness in persons Tenderness in persons with sinusitis or with sinusitis or allergiesallergies

TransilluminationTransillumination Using a pen light in a Using a pen light in a

darkened room, darkened room, place light under the place light under the superior orbital superior orbital ridge, inferior to the ridge, inferior to the frontal sinusesfrontal sinuses

Clear sinuses should Clear sinuses should transilluminatetransilluminate

Assessing the LipsAssessing the Lips

Black people normally have bluish Black people normally have bluish lipslips

What do bluish lips signify in light What do bluish lips signify in light skinned people?skinned people?

Hypoxemia or hypothermiaHypoxemia or hypothermia Pallor on lips?Pallor on lips?

Anemia, shockAnemia, shock Cherry red lips?Cherry red lips?

CO poisoning, acidosisCO poisoning, acidosis Angular cheilitis (inflammation of Angular cheilitis (inflammation of

lips)lips) Painful fissures at corners of mouth Painful fissures at corners of mouth

caused by caused by CandidaCandida infection infection Herpes simplex virusHerpes simplex virus

Mostly HSV-1 virus, possibly HSV-2Mostly HSV-1 virus, possibly HSV-2 Vesicles or pustules, highly contagiousVesicles or pustules, highly contagious

CarcinomaCarcinoma Mostly crusted or ulcerated Mostly crusted or ulcerated

Assessing TeethAssessing Teeth Teeth normally look white, Teeth normally look white,

straight, and free of decay. straight, and free of decay. In the back, the upper In the back, the upper molars should directly rest molars should directly rest on the lower molars. In the on the lower molars. In the front, upper incisors should front, upper incisors should overlap lower incisorsoverlap lower incisors Yellowing as result of tobacco Yellowing as result of tobacco

useuse Malocclusion – misalignment Malocclusion – misalignment

of upper and lower teethof upper and lower teeth Dental carries – tooth decay Dental carries – tooth decay

as result of acids produced by as result of acids produced by bacteria “eating” bacteria “eating” carbohydrates and sugars, carbohydrates and sugars, destroying enamel.destroying enamel.

Assessing GumsAssessing Gums Normally the gums look pink, Normally the gums look pink,

with well defined margins with well defined margins between teeth and gumsbetween teeth and gums Gingival hyperplasia – Gingival hyperplasia –

enlargement of gums. Possible enlargement of gums. Possible SA of Dilantin SA of Dilantin

GingivitisGingivitis – redness, swelling, – redness, swelling, or bleeding of gum margins or bleeding of gum margins caused by anaerobic bacteria caused by anaerobic bacteria as a result of poor dental as a result of poor dental hygiene or vitamin C deficiency hygiene or vitamin C deficiency . If disease is untreated and . If disease is untreated and spreads to bone, the result is spreads to bone, the result is periodontitisperiodontitis (absorption of (absorption of bone)bone)

Assessing the TongueAssessing the Tongue Normally the tongue is pink with a Normally the tongue is pink with a

roughened dorsal surface and roughened dorsal surface and moist underneathmoist underneath

Inspect tongue by holding it with Inspect tongue by holding it with cotton gauze pad and moving to cotton gauze pad and moving to each sideeach side

Tongue Tongue AbnormalitiesAbnormalities

Enlarged tongue Enlarged tongue (macroglossia)(macroglossia)

occurs in Down occurs in Down syndrome, acromegaly, syndrome, acromegaly, cretinism, myxedemacretinism, myxedema

Fissured tongueFissured tongue congenital, benign. congenital, benign.

Mild form may be Mild form may be caused by dehydrationcaused by dehydration

CandidiasisCandidiasis White, cheesy, patch on White, cheesy, patch on

buccal mucosa or buccal mucosa or tonguetongue

Occurs after use of Occurs after use of antibiotics, steroids, antibiotics, steroids, and immunosuppression and immunosuppression (AIDS)(AIDS)

Tongue Tongue AbnormalitiesAbnormalities Atrophic Glossitis (glossy Atrophic Glossitis (glossy

tongue)tongue) surface of tongue is smooth and surface of tongue is smooth and

shiny, burning. Occurs with shiny, burning. Occurs with pernicious anemia (vit B 12 pernicious anemia (vit B 12 deficiency), folic acid deficiency, deficiency), folic acid deficiency, and iron deficiency anemiaand iron deficiency anemia

Black hairy tongueBlack hairy tongue fungal infection usually due to fungal infection usually due to

prolonged antibiotic useprolonged antibiotic use CarcinomaCarcinoma

common underneath the tonguecommon underneath the tongue

Assessing the Assessing the Buccal Buccal MucosaMucosa

Normal mucosa looks Normal mucosa looks pink, smooth, and moistpink, smooth, and moist

Inspect by using light Inspect by using light and a tongue bladeand a tongue blade

Note presence of Note presence of Stensen’s ducts Stensen’s ducts (openings of parotid (openings of parotid gland) which are gland) which are inflamed and red with inflamed and red with mumpsmumps Koplik’s spots – prodromal Koplik’s spots – prodromal

sign of measlessign of measles Also notice breath. Also notice breath.

Fruity odor might Fruity odor might indicate ketoacidosis.indicate ketoacidosis.

Assessing the PalateAssessing the Palate The anterior hard palate is normally filled The anterior hard palate is normally filled

with irregular transverse rugaewith irregular transverse rugae Might appear yellow with jaundice in whites and Might appear yellow with jaundice in whites and

yellow-brown in blacksyellow-brown in blacks The posterior soft palate is pinker, smooth, The posterior soft palate is pinker, smooth,

and upward movable. Contains the uvulaand upward movable. Contains the uvula To check for CN X (vagus nerve) reflex, ask person To check for CN X (vagus nerve) reflex, ask person

to open mouth and say “ahhhh.” Uvula should to open mouth and say “ahhhh.” Uvula should move up.move up.

Palate AbnormalitiesPalate Abnormalities

Cleft palateCleft palate is a congenital defect where is a congenital defect where the maxillary process fails to fuse. This the maxillary process fails to fuse. This causes a gap in the hard palate and causes a gap in the hard palate and possibly the upper lip. Surgery required.possibly the upper lip. Surgery required.

Assessing the Assessing the TonsilsTonsils

Normal are pink at the Normal are pink at the sides of mouth, barely sides of mouth, barely visiblevisible

Inspect by depressing the Inspect by depressing the tongue blade on the tongue blade on the tonguetongue

During an upper During an upper respiratory infection, the respiratory infection, the tonsils become bright red, tonsils become bright red, swollen, and might contain swollen, and might contain exudate and/or white spotsexudate and/or white spots 1+ tonsils visible1+ tonsils visible 2+ tonsils inflamed2+ tonsils inflamed 3+ tonsils touching uvula3+ tonsils touching uvula 4+ tonsils touching each 4+ tonsils touching each

otherother

Question 1Question 1

A 70-year-old woman complains of A 70-year-old woman complains of dry mouth. The most frequent dry mouth. The most frequent cause of this problem is:cause of this problem is:

1.1. The aging processThe aging process

2.2. Related to medications she may be Related to medications she may be takingtaking

3.3. The use of denturesThe use of dentures

4.4. Related to a diminished sense of smellRelated to a diminished sense of smell

Question 2Question 2

Because of history of headache, the Because of history of headache, the examiner uses transillumination to examiner uses transillumination to assess for an inflamed sinus. The assess for an inflamed sinus. The findings in a healthy individual would findings in a healthy individual would be:be:

1.1. A diffuse red glowA diffuse red glow

2.2. No transilluminationNo transillumination

3.3. Findings vary with ethnicity of the personFindings vary with ethnicity of the person

4.4. Light visible in the nares through a Light visible in the nares through a speculumspeculum

Question 3Question 3 The nurse observes blackish lesions on The nurse observes blackish lesions on

the top of the tongue of an adult client. the top of the tongue of an adult client. The client indicates that his tongue is The client indicates that his tongue is painful. Which question by the nurse painful. Which question by the nurse would be helpful in explaining this would be helpful in explaining this finding?finding?

1.1. ““Have you been taking antibiotics lately?”Have you been taking antibiotics lately?”2.2. ““Have you injured your tongue?”Have you injured your tongue?”3.3. ““Have you been diagnosed with a mouth Have you been diagnosed with a mouth

cancer before?”cancer before?”4.4. ““When was the last time you brushed your When was the last time you brushed your

teeth?”teeth?”

Question 4Question 4

Which of the following statements Which of the following statements made by a 72-year-old client is made by a 72-year-old client is considered a normal process or considered a normal process or aging?aging?

1.1. ““My tongue feels swollen.”My tongue feels swollen.”

2.2. ““My tonsils are large and sore.”My tonsils are large and sore.”

3.3. ““I have white and black spots under my I have white and black spots under my tongue.”tongue.”

4.4. ““Food does not taste the same as it used Food does not taste the same as it used to.”to.”