External and Internal Assessment of the Nose and Mouth: Comprehensive Study Guide

External and Internal Assessment of the Nose

External Assessment * Placement and Alignment: Observe if the nose is sitting midline to the face. Look for any large deviations that may indicate a previous injury, such as a broken nose. * Skin Integrity: The nose is a common site for skin cancer due to decades of sun exposure. Inspect the surface specifically for lesions or abnormalities.
Internal Assessment * Examination Technique: In clinical practice, a speculum may be used, but a penlight is often sufficient for basic assessments. The focus is on the area just inside the nostrils. * The Turbinates: * The turbinates are three vascular, "pillowy" areas located up and back inside the nasal cavity. * Function: Their primary job is to warm and moisturize inhaled air before it reaches the lungs. The lungs are sensitive to cold, dry air. * Congestion: When the turbinates swell due to a cold or allergies, they cause nasal congestion, making it difficult to breathe. * The Adenoids: These are located behind the oral cavity, up behind the mouth, similar in function to the tonsils.

Nosebleeds and Vascularity

Epistaxis: The medical term for a nosebleed.
Kisselbach Complex: * An anterior area of the nose that is highly vascular. * Approximately $80\,\%$ of all nosebleeds originate from this site.
Anterior vs. Posterior Nosebleeds: * Anterior Nosebleeds: These occur in the front of the nose and typically drip outward. They can often be managed with pressure or even a tampon to absorb blood. * Posterior Nosebleeds: These are more serious and difficult to assess. The patient may swallow or gag on the blood, making it impossible to monitor the exact volume of blood loss by external observation alone.

Assessment of the Sinuses

The Four Sets of Sinuses: * Frontal Sinuses: Located on the forehead; these are palpable. * Maxillary Sinuses: Located on the cheekbones; these are palpable. * Ethmoid Sinuses: Located deep on the inside of the eyes; these are non-palpable. * Sphenoid Sinuses: Located way back behind the eyes; these are non-palpable.
Clinical Assessment: * Only the frontal and maxillary sinuses are assessed via physical exam. The ethmoid and sphenoid sinuses require an X-ray or CAT scan for visualization. * Technique: Palpate the sinuses by pressing on the frontal and maxillary areas (named after the bones of the skull). Do not percuss (tap) on the face. * Findings: Sinuses are documented as either "tender" or "non-tender." Swelling and infection in these areas put pressure on the eyeballs because the eye is surrounded by sinuses on three sides.

Anatomy and Assessment of the Mouth

Lips: An essential indicator of several physiological states: * Hydration: Dry or cracked lips suggest dehydration. * Oxygenation/Perfusion: Look for cyanosis (purple/blue) or pallor (pale). * Nutrition: Sores or lesions (like cheilitis) can indicate nutritional deficiencies. * Ethnicity: Lip color should be appropriate for the patient's ethnicity.
Teeth and Gums (Gingiva): * Oral Hygiene: Assessed as "good" or "poor." * Gingiva: Should be pink and moist, though they may be tan in darker-skinned individuals. Inspect for bleeding, lesions, or inflammation (gingivitis).
Internal Structures (North, South, East, West): * North (Hard and Soft Palates): The hard palate is forward; the soft palate is further back. Both should be pink and moist. When a patient says "Ah," the soft palate should rise (controlled by the Vagus nerve). * East and West (Buccal/Oral Mucosa): The inside of the cheeks. Should be pink and moist without lesions, pallor, or cyanosis. Dryness here indicates at least moderate-to-severe dehydration. * South (The Tongue): Should be pink, moist, and sit midline. Roughness is normal.
The Uvula: Should be sitting midline. Its movement is important for neurological assessment.
Salivary Glands: Sublingual salivary glands sit under the tongue.
Clinical Note on Oral Cancer: Oral cancer frequently occurs in the "oral gutter" (the area under and at the sides of the tongue). Toxins like smoke, tobacco, and alcohol tend to settle here.

Tonsil Grading and Characteristics

Function: Tonsils function like external lymph nodes, filtering drainage at the back of the throat.
Grading Scale ( $1+$ to $4+$ ): * $1+$ : Tonsils are visible as small bumps. * $2+$ : Tonsils are halfway to the uvula ( $50\,\%$ of the space). * $3+$ : Tonsils reach the uvula or take up $75\,\%$ of the space. * $4+$ : "Kissing tonsils"; the tonsils are touching each other.
Hypertrophy vs. Infection: * Swollen tonsils (hypertrophy) can occur due to allergies without being infected. * Streptococcal Tonsillitis: Indicated by redness and white exudate (patches) on the tonsils. * Tonsil Stones: Food and bacteria trapped in tonsillar crypts (holes). These are not necessarily infections.

Developmental and Lifespan Considerations

Older Adults: * Decreased saliva production (Risk factor for dental problems, Sjogren's disease). * Increased risk of being edentulous (lacking teeth) or having ill-fitting dentures. * Angular Cheilitis: Cracks at the corners of the mouth (nutritional or fungal cause). * Smooth Tongue: The tongue may become smooth or glossy with age. * Scrotal Tongue: A benign condition where the tongue surface appears fissured (resembling a scrotal sac).
Pediatrics: * Dental visits should begin when the first teeth appear or around ages $2$ to $3$ . * Baby Bottle Tooth Decay: Caused by prolonged exposure to sugary liquids in bottles. * Congenital Defects: * Cleft Lip: Affects only the lip. * Cleft Palate: The lip, gums, and hard palate are open, exposing the nasal cavity. This requires special feeding devices because babies cannot form a seal for suction.

Obstructive Sleep Apnea (OSA)

Pathophysiology: When lying down, the tongue moves posterior and the throat collapses, blocking the airway. This causes snoring and periods of apnea.
Health Risks: Years of untreated OSA deprive the heart and brain of oxygen, leading to heart attacks and strokes.
Treatments: * CPAP (Continuous Positive Airway Pressure): High-pressure air keeps the airway open. * Inspire: A newer "tongue pacemaker" implanted to contract the tongue away from the airway.

Urgent ENT Issues and Symptoms

Aspiration: Impaired swallowing (from stroke or TBI) blocks the airway ("A" in ABCs). Speech therapy performs "swallow studies" and may prescribe thickened liquids (nectar thick, honey thick, or pudding thick) to prevent aspiration pneumonia.
Anosmia: Sudden, complete loss of smell. Potential causes include COVID-19 or brain tumors blocking the olfactory nerve (Cranial Nerve $1$ ).
Hoarseness: If hoarseness lasts for several weeks or months, it requires investigation for growths, vocal cord issues, or infections.
Common Terminology: * Halitosis: Bad breath. Causes include poor hygiene, tonsil stones, strep throat (distinct odor), respiratory issues, smoking, and GERD (acid reflux). * Pharyngitis: Inflammation of the pharynx (back of the throat). * Laryngitis: Inflammation of the larynx (voice box). * Dysphagia: Difficulty swallowing. * Thrush: Oral yeast infection ( $Candida\,albicans$ ), often caused by antibiotics killing healthy bacteria.

Questions & Discussion

Q: Are we checking the nonpalpable sinuses in our checkup? * A: No, just the frontal and maxillary sinuses.
Q: What is the medical word for nosebleed? * A: Epistaxis.
Q: What about an extra bone in the hard palate? * A: This is likely a Torus, which is a benign genetic variation. If it has always been there and is normal for the patient, it is not a concern.
Q: How is a root canal performed? * A: The pulp of the tooth (containing nerves) is removed, the area is cauterized, and then filled with tooth cement.
Q: How do you perform a strep test? * A: You must brush the tonsils, not just the back of the throat. If the patient gags, the procedure was likely performed correctly.