Topic 12: Nose, Mouth, and Throat

nose

the first segment of the respiratory system that warms moistens, and filters the inhaled air; the sensory organ for smell

mouth

the first segment of the digestive system and an airway from the respiratory system

tongue

a mass of striated muscles arranged in a crosswise pattern so it can change shape and position provides functions of mastication, swallowing, teeth cleansing, and speech formation; sensory function is a taste

bifid uvula

occurs when the uvula splits completely or partially

cleft lip

torus palatinus

a normal, benign, body ridge running in the middle of the hard palate

leukoedema

a benign, milking, bluish-white opaque appearance of the buccal mucosa that occurs commonly in black people

dental caries

aka tooth decay is the MC chronic disease in kids and occurs when bacteria interact with carbs in juice, sweet drinks, or food producing acid that softens and demineralizes the tooth enamel; groups at high risk are rural residents, older adults, pregnant people, unhouse people, those with developmental disabilities, those who are institutionalized

significant because poor oral health is associated with coronary artery and peripheral vascular disease and metabolic syndrome

periodontal disease

affects the structures surrounding the tooth including the gingiva and alveolar bone and occurs due to pathogenic bacteria, persistent inflammation, poor oral hygiene, poor nutrition, and smoking; connected to obesity, DM, CVD, and other immune diseases

obstructive sleep apnea (OSA)

includes 10-second bouts of partial/complete upper airway collapse while sleeping, which reduces airflow causing hypopnea or apnea, waking the person up and/or decreases O2 saturation in the blood

increases the risk of CV and metabolic diseases

causes excessive daytime sleepiness, disturbed bed partners, impaired work performation

Tx: weight loss, exercise, PAP apparatus like a CPAP

1. discharge

   1. Do you have any discharge or a runny nose

   2. Is it continuous

   3. Is the discharge watery, purulent, mucoid, or bloody

2. frequent colds (upper resp infections)

   1. Any unusually frequent/severe colds

   2. how often do these occur

3. sinus pains

   1. Any sinus pain or sinusitis

   2. How do you treat it

   3. Do you have chronic postnasal drip

4. trauma

   1. Ever had any trauma or a blow to the nose

   2. Can you breathe through your nose

   3. Are one or both sides obstructed

5. epistaxis

   1. any nosebleeds, how often

   2. how much bleeding

   3. color of the blood, any clots

   4. from one or both nostrils

   5. aggravated by nose-picking or scaring

   6. how do you treat them

   7. are they difficult to stop

6. allergies

   1. Any allergies or hay fever

   2. what are you allergic to

      1. “seasonal” rhinitis if caused by pollen

      2. “perennial” if the allergen is dust

   3. How was this determined

   4. which type of environment makes it worse

   5. can you avoid exposure

   6. do you use inhalers, nasal spray, nose drops; how often, which time, how long have you used them

7. altered small

   1. any change in sense of smell

what are the subjective data questions a nurse should ask a client about their nose

1. sores and lesions

   1. noticed any sores or lesions in the mouth, tongue, or gums

   2. how long have you had them, have you ever had them before

   3. is it one or many

   4. does it seem to be associated with stress, season change, food

   5. have you treated the sore, any local medication

2. sore throat

   1. how frequently do you get them

   2. do you have a sore throat now

   3. when did it start

   4. is it associated with cough, fever, fatigue, decreased appetite, HA, postnasal drip, hoarseness

   5. is it worse when arising, what is the humidity in the room you sleep, any dust/smoke inhaled at work

   6. usually get a throat culture for the sore throats, any documented as streptococcal

   7. how has you teated this sore throat: medication, gargling; are these effective

   8. have you had your tonsils or adenoids removed

3. bleeding gums

   1. how long have you had them

4. toothache

   1. are your teeth sensitive to hot, cold

   2. have you lost any teeth

5. hoarseness

   1. any hoarseness or voice changes, for how long

   2. feel like having to clear your throat, or lump in your throat

   3. use your voice a lot at work, recreation

   4. is it associated with a cold, sore throat

6. dysphagia

   1. any difficulty swallowing liquids or solids, for how long

   2. does it feel like food sticks

   3. any pain

7. altered taste

   1. any changes in sense of taste

8. obstructive sleep apnea

   1. has anyone in your family told you that you snore

   2. are the snores loud, do they wake you up, do you stop breathing

   3. if so: do you feel tired or sleepy during the day, would you call yourself overweight, do you have high BP

9. smoking

   1. do you smoke, pipe or cigarettes, smokeless tobacco

   2. how many packs per day, for how many years

10. alcohol consumption

    1. when was your last drink

    2. how much do you usually drink

11. dental care patterns

    1. what is your daily dental care

    2. how often do you use a toothbrush and floss

    3. when was your last dental exam

    4. do dental problems affect which foods you eat

12. dentures or appliances

    1. do you wear braces, bridge, or head gear

    2. do you wear dentures, all the time, for how long, how do they fit

    3. do you have any sores/irritation on the palate or gums

what are the subjective data questions a nurse should ask a client about their mouth and throat

rhinorrhea

discharge of thin, watery, or thick mucus fluid from the nasal passages that occurs with colds, allergies, sinus infections, and trauma

dysphagia

occurs with pharyngitis, GERD, stroke, neuromuscular diseases, esophageal cancer

1. any dryness in the mouth, any medications

   1. xerostomia (dry mouth) is a side effect of many drugs

2. have you lost any teeth, can you chew all types of food

3. are you able to care for your own teeth or dentures

4. have you noticed a change in your sense of taste or smell

what are additional subjective questions a nurse should ask the aging adult about the nose, mouth, and throat

polyps

benign growths that accompany chronic allergy and are smooth, grapelike, yellow or gray, avascular, mobile and nontender

circumoral pallor

in light-skinned people, this occurs with shock and anemia, cyanosis with hypoxemia and chilling, cherry red lips with CO poisoning, acidosis from aspirin poisoning, or ketoacidosis

cheilitis (perleche)

cracking at the corners

• The nose appears more prominent of the face from a loss of subcutaneous fat

• mouth and lips fold in, giving a purse-string appearance

• teeth look slightly yellowed, although the color is uniform, as a result of worn enamel

• The surface of the incisors may show vertical cracks from a lifetime of exposure to extreme temps

• teeth may look longer as the gum margins recede

• The surface of teeth looks worn down or abraded, old dental work deteriorates

• teeth loosen with bone resorption and many move with palpation

• tongue looks smoother as a result of papillary atrophy

• buccal mucosa is thinned and may look shinier, as though it were “varnished”

what are common changes in the older adult that occur in the nose, mouth, and throat

choanal atresia

congenital bony septum between the nasal cavity and the pharynx that when B/L is an airwar emergency in newborns

epistaxis

nosebleed; causes are trauma, intranasal drugs, inflammation, infection, blood disorders, HTN, HF, and local tumor

sinusitis

aucte inflamed infected sinus areas following URI that can be viral or bacterial; major signs are mucopurulent drainage, nasal obstruction, facial pain or pressure, fever, chills, malaise, maxillary sinusitis has dull, throbbing pain in cheek and teeth and pain when palpation when bending over; frontal sinusitis has pain above supraorbital ridge

seasonal allergic rhinitis

aka hay fever; an abnormal immune response from repeated exposure to antigens with rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing; common allergens are dust mites, animal dander, mold, pollen; leads to disordered sleep, OSA, sinusitis, avoidance of outdoor activities, and poor work performance

acute rhinitis (nonallergic)

nose abnormality that presents with clear, watery, discharge, rhinorrhea, which later becomes purulent with sneezing, nasal itching, stimulation of cough reflex, and inflamed mucosa which causes nasal obstruction

perforated septum

a hole in the septum, usually in the cartilaginous part, caused by snorting cocaine or meth, chronic infection, trauma from continual picking of crusts, or nasal surgery

nasal polyps

benign overgrowths that look smooth, grapelike, gray or yellow, often appearing with chronic asthma, occupational dust exposure, or genetic factor; S/S are absence of smell, disturbed sleep, postnasal drip, and a valve that moves a the person breathes

furuncle

a small boil located in the skin or mucous membrane that appears red and swollen and is quite painful; avoid any manipulation or trauma that may spread the infection

cleft lipe

common congenital deformities and occur with strong family history, maternal use of Dilantin, alcohol, and certain drugs, maternal diabetes; early treatment preserves the functions of speech and language formation and deglutition (swallowing)

Herpes Simplex 1 (HSV-1)

common cold sores; groups of clear vesicles with a surrounding indurated erythematous base that involve pustules, which rupture, weep, crust, and heal in 4-10 days; highly contagious and spread by direct contact, recurrent infections triggered by sunlight, fever, colds, and allergy

angular cheilitis

aka stomatitis and perleche; erythema, scaling, shallow, and painful fissures at the corners of the mouth occur with excess salivation and candida infection; seen in edentulous people and those with poorly fitted dentures, causing folding in of corners of mouth, which creates a warm, moist environment favoring growth of yeast

carcinoma

initial lesion is round and indurated, it becomes crusted and ulcerated wit an elevated border; most occur between the outer and middle thirds of the lip

retention “cyst” (Mucocele)

a round, well-defined translucent nodule that may be very small or up to 1-2 cm; a pocket of mucus that forms when a duct of a minor salivary gland ruptures

baby bottle tooth decay

destruction of numerous deciduous teeth may occur in children who take a bottle past the first year because liquid pools around the upper front teeth and acids break down tooth enamel and destroy its protein

tooth avulsion

a traumatic injury may dislodge a primary (deciduous) or a permanent tooth from its alveolar socket; trauma is often the result of falls or sports collision

epulis

a benign nontender, fibrous nodule of the gum seen emerging between the teeth; overgrowth of vascular granulation tissue

gingival hyperplasia

painless enlargement of the gums, sometimes overreaching the teeth that occurs with puberty, pregnancy, and leukemia and with long use of phenytoin

gingivitis

gum margins are red and swollen and bleed easily, inflammation is usually caused by poor dental hygiene or vit c deficiency or due to changing hormonal balance

meth mouth

illicit meth abuse leads to extensive dental caries, gingivitis, tooth cracking, and edentulism; causes vasoconstriction, decreased saliva, and increased urge to consume sugars and starches and give up oral hygiene

aphthous ulcers

a common “canker sore” that is a vesicle at first and then a small, round, punched-out ulcer with a white base surrounded by a red halo that is quiyte painful and lasts for 1-2 weeks; cause is unknown but associated with stress, fatigue, and food allergy

Koplik spots

small blue-white spots with irregular red halo scattered over mucosa opposite the molar that is an early and pathognomic sign of measles

leukoplakia

chalky white, thick, raised patch with well defined borders; painless and firmly attached, does not scrape off; occurs on lateral edges of tongue and is caused by chronic irritation of smoking and alcohol use; lesions are precancerous

candidiasis or monilial infection

a white, cheesy, curd-like patch on the buccal mucosa and tongue that scrapes off leaving a raw, red surface that bleeds easily; called thrush in newborns and occurs after antibiotic and corticosteroid use and in immunosuppressed people

Herpes Simplex 1 (HSV-1)

HSV-1 infection on the hard palate

ankyloglossia

a congenital tongue defect in which a short lingual frenulum, that fixies the tongue tip to the floor of the mouth and gums limits mobility and affecting speech specifically the pronunciation of a, d, and n if the tongue tip cannot be elevated to the alveolar ridge

geographic tongue (migratory glossitis)

pattern of normal coating interspersed with bright red, shiny, circular bald areas caused by atrophy of the filiform papillae with raised pearly borders; pattern resembles a map and changes with time; not significant and cause is unknown

smooth, glossy tongue (atrophic glossitis)

tongue surface is slick and shiny, the mucosa thins and looks red from decreased papillae and is accompanied by dryness of tongue and burning; occurs with Vit B12 deficiency (pernicious anemia), folic acid deficiency, and iron deficiency anemia

black hairy tongue

tongue abnormality in which elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue causes the appearance of black-brown/yellow hair on the tongue; occurs after use of antibiotics and with heavy smoking

carcinoma

an ulcer with rolled edges, indurated; occurs particularly at sides, base, and under the tongue and grows insidiously and may go unnoticed for months, can have associated leukoplakiafi

fissured or scrotal tongue

tongue abnormality in which deep furrows divide the papillae into small irregular rows

enlarged tongue (Macroglossia)

the tongue is enlarged and may protrude from the mouth; not painful by may impair speech development; occurs with down syndrome, cretinism, myxedema, and acronmegaly

Bifid uvula

the uvula looks partly severed and may indicate a submucous cleft palate, which feels like a notch at the junction of the hard and soft palate; affects speech development because it prevents necessary air trapping

oral Kaposi sarcoma

bruiselike, dark red/violet, confluent macule, usually on the hard palate, may be on soft or gingival margin; oral lesions may be among earliest lesions to develop with AIDS

peritonsillar abscess

untreated acute streptococcal pharyngitis may cause suppurative complications, peritonsillar abscess, or suppurative thrombophlebitis

acute tonsillitis and pharyngitis

bright red throat, swollen tonsils, white or yellow exudate on tonsils and pharynx, swollen and enlargedvuvual, tender anterior cervical and tonsillar nodes that is accompanied by a severe sore throat, painful swallowing, fever > 101 of sudden onset

cleft palate

a congenital defect due to the failure of fusion of the maxillary processes

Nose

1. Inspect external nose for symmetry, any deformity, or lesions

2. Palpation—Test patency of each nostril

3. Inspect with nasal speculum:

   1. Color and integrity of nasal mucosa

   2. Septum—Note any deviation, perforation, or bleeding

   3. Turbinates—Note color, any exudate, swelling, or polyps

4. Palpate the sinus areas—Note any tenderness

   Mouth and Throat

5. Inspect with penlight:

   1. Lips, teeth and gums, tongue, buccal mucosa—Note color; whether structures are intact; any lesions

   2. Palate and uvula—Note integrity and mobility as a person phonates

   3. Grade tonsils

   4. Pharyngeal wall—Note color, any exudate, or lesions

6. Palpation:

   1. When indicated in adults, bimanual palpation of mouth

   2. In the neonate, palpate for integrity of palate and to assess sucking reflex

what is a summary checklist when assessing the nose, mouth, and throat