Nose, Mouth & ThroatNose, Mouth & Throat

N1037N1037

Nose A & PNose A & P

•Review structure and function of Review structure and function of External nose, nasal fossa, internal External nose, nasal fossa, internal nose (p 377) nose (p 377)

Nose A & PNose A & P

Nasal CavityNasal Cavity Extends over the roof of the mouthExtends over the roof of the mouth Lined with coarse nasal hairsLined with coarse nasal hairs Mucous blanket filters out dust and Mucous blanket filters out dust and

bacteriabacteria Divided by the Divided by the septumseptum 3 parallel bony projections: 3 parallel bony projections: superior, superior,

middle and inferior turbinates.middle and inferior turbinates. Olfactory receptors lie at the roof of the Olfactory receptors lie at the roof of the

nasal cavitynasal cavity

Nose – Sinuses Nose – Sinuses

4 pairs of Sinuses: 4 pairs of Sinuses: air-filled within the air-filled within the cranium, serve as resonators for sound cranium, serve as resonators for sound production, lighten the weight of skull production, lighten the weight of skull bone, provide mucous and drain into the bone, provide mucous and drain into the nasal cavity.nasal cavity.

Ethmoid:Ethmoid: between the orbits (smaller and between the orbits (smaller and deeper)deeper)

SphenoidSphenoid: deep within the skull in the : deep within the skull in the sphenoid bone (post. to nasal cavity). sphenoid bone (post. to nasal cavity).

These are non-palpableThese are non-palpable

Nose - Sinuses Nose - Sinuses These are These are Palpable Palpable

1.1. Frontal:Frontal: in frontal bone, above in frontal bone, above and medial to the orbits.and medial to the orbits.

2.2. Maxillary:Maxillary: in the maxilla in the maxilla (cheekbone) along the side walls (cheekbone) along the side walls of the nasal cavity.of the nasal cavity.

Mouth Mouth Structure and FunctionStructure and Function

Exterior and InteriorExterior and Interior

Exterior structuresExterior structures

Head-Salivary GlandsHead-Salivary Glands 3 pairs of Salivary glands3 pairs of Salivary glands: :

– parotid, submandibular and sublingual parotid, submandibular and sublingual

ParotidParotid: : ant. and below the ear in cheeks, normally ant. and below the ear in cheeks, normally not not palpable, palpable, secret amylase-rich fluid through Stensen’s Ducts secret amylase-rich fluid through Stensen’s Ducts located near upper 2located near upper 2ndnd molars molars

SubmandibularSubmandibular: : beneath the mandible, size of beneath the mandible, size of walnuts, opens at either side of the tongue frenulumwalnuts, opens at either side of the tongue frenulum

SublingualSublingual: : lie in the floor of the mouth, has many lie in the floor of the mouth, has many small openings along the sublingual fold under the tongue.*small openings along the sublingual fold under the tongue.*

ThroatThroat

Structure and FunctionStructure and Function

Throat (Pharynx)Throat (Pharynx)

Area behind the mouth and the noseArea behind the mouth and the nose

OropharynxOropharynx

TonsilsTonsils: : mass of lymphoid tissue, deep cryptsmass of lymphoid tissue, deep crypts

NasopharynxNasopharynx: : above and continuous with above and continuous with oropharynx, oropharynx,

behind the nasal cavitybehind the nasal cavity Pharyngeal tonsils (adenoids) and Pharyngeal tonsils (adenoids) and

eustachian tube openings hereeustachian tube openings here

Nose Mouth & ThroatNose Mouth & Throat

Health History - Subjective Health History - Subjective DataData

Nose Mouth & ThroatNose Mouth & ThroatHealth HxHealth Hx

NoseNose DischargeDischarge Frequent colds (Upper Resp Infection)Frequent colds (Upper Resp Infection) Sinus painSinus pain Trauma (cause a deviated septum)Trauma (cause a deviated septum) Epistaxis (nosebleeds)Epistaxis (nosebleeds) AllergiesAllergies Altered smellAltered smell

Nose Mouth & ThroatNose Mouth & ThroatHealth HxHealth Hx

Mouth & ThroatMouth & Throat Sores or lesionsSores or lesions Sore throatSore throat Bleeding gumsBleeding gums ToothachesToothaches HoarsenessHoarseness DysphagiaDysphagia Altered tasteAltered taste Smoking, alcohol consumptionSmoking, alcohol consumption Self-care behaviours (dental care, Self-care behaviours (dental care,

dentures or appliances dentures or appliances

Nose Mouth & ThroatNose Mouth & Throat

Objective DataObjective Data

Preparation and Preparation and Equipment NeededEquipment Needed

Nose, Mouth & ThroatNose, Mouth & Throat

Preparation Preparation

o Client sitting up Client sitting up straightstraight

o Head at your eye Head at your eye levellevel

o Remove denturesRemove dentures

Equipment Equipment

Otoscope (nasal Otoscope (nasal speculum with speculum with light)light)

Tongue bladeTongue blade Cotton gauze pad Cotton gauze pad

(4x4)(4x4) glovesgloves

Nose, Mouth & ThroatNose, Mouth & Throat

Objective DataObjective Data

Inspection and PalpationInspection and Palpation

Assessment of NoseAssessment of Nose

External InspectionExternal Inspection SymmetricSymmetric MidlineMidline Proportionate to other facial featuresProportionate to other facial features Deformity, asymmetryDeformity, asymmetry InflammationInflammation Skin lesionsSkin lesions

Assessment of NoseAssessment of Nose Inspect and palpate external nose Inspect and palpate external nose

– Inspect external nose for symmetry– Palpate external nose noting any tenderness - may Palpate external nose noting any tenderness - may

indicate inflammationindicate inflammation

PatencyPatency– Occlude one nostril at a time with a finger and ask pt to Occlude one nostril at a time with a finger and ask pt to

breath in & out through the nose.breath in & out through the nose.

Internal InspectionInternal Inspection – Extend pt’s head, place non dominant hand on pts head Extend pt’s head, place non dominant hand on pts head

and use thumb to lift the tip of the nose , insert nasal and use thumb to lift the tip of the nose , insert nasal speculum or otoscope and inspect nasal septum, speculum or otoscope and inspect nasal septum, turbinates turbinates

Nasal Cavity – InspectionNasal Cavity – Inspection(short, wide tipped speculum to otoscope)(short, wide tipped speculum to otoscope)

N- N- nasal mucosa should be pink or dull red colour, smooth, nasal mucosa should be pink or dull red colour, smooth, moist surface with small amount of clear watery discharge.moist surface with small amount of clear watery discharge.

Nasal septum: *deviations, perforations or bleeding Nasal septum: *deviations, perforations or bleeding (airflow must not be obstructed)(airflow must not be obstructed)

Note *polyps, (benign growths that sometimes accompany Note *polyps, (benign growths that sometimes accompany chronic allergy)chronic allergy)

Note swelling, *discharge (watery, copious to thick, Note swelling, *discharge (watery, copious to thick, purulent, green-yellow)purulent, green-yellow)

Bleeding or foreign bodyBleeding or foreign body

Assessment of SinusesAssessment of Sinuses

Inspection Inspection – Observe patients face for any swelling Observe patients face for any swelling

around nose and eyesaround nose and eyes

– N= no evidence of swelling N= no evidence of swelling

Sinuses – PalpationSinuses – Palpation

Client feels pressure but no painClient feels pressure but no pain

Press frontal sinuses (below eyebrows)Press frontal sinuses (below eyebrows) Press maxillary sinuses ( below Press maxillary sinuses ( below

cheekbones)cheekbones)

Chronic allergies and acute infections Chronic allergies and acute infections (sinusitus) = tenderness to sinuses(sinusitus) = tenderness to sinuses

Perscussion of SinusesPerscussion of Sinuses

Gently percuss frontal and maxillary Gently percuss frontal and maxillary sinuses using direct percussion techniquesinuses using direct percussion technique

N = elicits a resonant sound indicating air N = elicits a resonant sound indicating air filled cavityfilled cavity

– If a dull sound is heard = fluid in cavityIf a dull sound is heard = fluid in cavity– note any signs of tenderness or pain which note any signs of tenderness or pain which

may indicate sinusitis due to infection, allergies may indicate sinusitis due to infection, allergies

Transillumination of the SinusesTransillumination of the Sinuses Turn lights off in roomTurn lights off in room Place strong light under bony ridge of upper Place strong light under bony ridge of upper

orbitsorbits Observe red glowObserve red glow

Place strong light under each eye just above the Place strong light under each eye just above the infraorbital ridgeinfraorbital ridge

Ask pt to open mouthAsk pt to open mouth Observe red glow on hard palateObserve red glow on hard palate

N= glow on each side is equal indicating air filled N= glow on each side is equal indicating air filled frontal and maxillary sinusesfrontal and maxillary sinuses

Mouth InspectionMouth Inspection

BreathBreath Should smell freshShould smell fresh

LipsLips Observe colour, Observe colour,

moisture, swelling moisture, swelling cracking or lesionscracking or lesions

Inner surface Inner surface pinkish-red.pinkish-red.

Teeth, Buccal mucosa & Teeth, Buccal mucosa & GumsGums

White, straight, evenly White, straight, evenly spaced, clean and free of spaced, clean and free of debris or decaydebris or decay

Note absent, loose, Note absent, loose, abnormally positionedabnormally positioned

Gums are pink with Gums are pink with margins tight and well margins tight and well defined.defined.

Note swelling, Note swelling, retractions, spongy or retractions, spongy or bleeding gingivae.bleeding gingivae.

Mouth – Inspection Mouth – Inspection

TongueTongue Pink and even, Pink and even,

roughenedroughened White coating may be White coating may be

presentpresent Ventral suface Ventral suface

smooth, shows veinssmooth, shows veins Saliva presentSaliva present Note *induration on Note *induration on

palpationpalpation

Mucous membranesMucous membranes Pink, smooth and moistPink, smooth and moist

Palate – hard (anterior) Palate – hard (anterior) and soft (posterior)and soft (posterior)

Anterior:Anterior: white with white with irregular transverse irregular transverse rugaerugae

Posterior:Posterior: pink, smooth pink, smooth and movableand movable

““Say ahhh,”: soft Say ahhh,”: soft palate and uvula rise palate and uvula rise (may be split in two)(may be split in two)

Mouth - PalpationMouth - Palpation Don glovesDon gloves LIPS = Pull pts lower lip with thumb and index finger LIPS = Pull pts lower lip with thumb and index finger N= lips should be flaccid and without lesionsN= lips should be flaccid and without lesions

Tongue = ask pt to stick out tongue (CNXII)Tongue = ask pt to stick out tongue (CNXII)– Move tongue from side to side, and up and downMove tongue from side to side, and up and down– Press tongue against cheek on each sidePress tongue against cheek on each side– Using gauze and gloves hold tongue and inspect Using gauze and gloves hold tongue and inspect

ventral surface for Whartons’ ducts, frenulum, color, ventral surface for Whartons’ ducts, frenulum, color, hydration, lesions, inflammation and vasculaturehydration, lesions, inflammation and vasculature

N= tongue is midline, dorsum is pink, moist with taste N= tongue is midline, dorsum is pink, moist with taste buds (rough) and without lesions. Tongue strength buds (rough) and without lesions. Tongue strength is equal. Ventral surface has visible vasculature. is equal. Ventral surface has visible vasculature. Lateral aspect is pink, moist and free of lesionsLateral aspect is pink, moist and free of lesions

Salivary and Parotid GlandSalivary and Parotid GlandIInspect and palpatenspect and palpate

Note for enlargement of salivary Note for enlargement of salivary gland as the client moves their head gland as the client moves their head back and forthback and forth

Note swollen parotid gland with head Note swollen parotid gland with head extended ( below the angle of the extended ( below the angle of the jaw)jaw)

Throat - InspectionThroat - Inspection Ask pt to stick tongue out Ask pt to stick tongue out Place tongue depressor on middle third of Place tongue depressor on middle third of

tonguetongue Shine light at back of pt throatShine light at back of pt throat Ask pt to say “ah” & observe uvulaAsk pt to say “ah” & observe uvula Observe tonsillar pillars Observe tonsillar pillars Touch posterior third of tongue & observe Touch posterior third of tongue & observe

for gag reflexfor gag reflexN= soft palate, uvula is midline and rises N= soft palate, uvula is midline and rises

symmetrically (CN IX & X), gag reflex is symmetrically (CN IX & X), gag reflex is present, tonsils are not enlargedpresent, tonsils are not enlarged

Throat - InspectionThroat - Inspection

TonsilsTonsils

pink, peppered pink, peppered with indentations with indentations or crypts.or crypts.

No exudate No exudate presentpresent

GradedGraded

Tonsil - GradeTonsil - Grade

1+ visible1+ visible

2+ halfway pillars/uvula2+ halfway pillars/uvula

3+ touching uvula3+ touching uvula

4+ touching each other 4+ touching each other

Developmental ConsiderationsDevelopmental ConsiderationsInfant and childrenInfant and children Drool before they swallowDrool before they swallow Milia on noseMilia on nose No nasal flaring presentNo nasal flaring present Note # of teeth 20 temporary (by 2 ½)Note # of teeth 20 temporary (by 2 ½) Lost between 6 and 12 Lost between 6 and 12

PregnantPregnant GingivitisGingivitis Stuffiness and epistaxisStuffiness and epistaxis

Aging AdultAging Adult Mouth and lips fold inMouth and lips fold in Changes to appearance of teeth, gums recedeChanges to appearance of teeth, gums recede Mucosa is shinier, thinner, less vascularMucosa is shinier, thinner, less vascular Tongue is smoother (atrophy)Tongue is smoother (atrophy) Sense of smell diminishesSense of smell diminishes