CH14 : Mouth, Pharynx & Voice

Bleeding or Swollen Gums

• Definition and common cause: bleeding gums, especially with brushing, are commonly due to gingivitis. Look for erythema and swelling of the interdental papillae.

• History questions:

  • Ask about local lesions and any tendency to bleed or bruise elsewhere.

  • Gingivitis features: erythema, swelling, interdental papillae changes.

• Related references in the source: Findings in the Gums and Teeth (Table 14-3, pp. 436–437).

Hoarseness

• Definition: a change in voice quality described as husky, rough, harsh, or lower pitched than usual.

• Causes spectrum:

  • Diseases of the larynx

  • Extralaryngeal lesions pressing on laryngeal nerves

• Key history to obtain:

  • Environmental allergies, acid reflux, smoking, alcohol use, inhalation of fumes/irritants

  • If patient talks a lot at work

• Acute hoarseness: consider voice overuse, acute viral laryngitis, neck trauma.

• If hoarseness lasts > $2\ weeks$ (persistent):

  • Refer for laryngoscopy

  • Consider: reflux, vocal cord nodules, hypothyroidism, head/neck cancers (including thyroid masses), neurologic disorders such as Parkinson disease, amyotrophic lateral sclerosis (ALS), or myasthenia gravis

• Red flags: prolonged tobacco or alcohol use, cough or hemoptysis, weight loss, unilateral throat pain

Malodorous Breath (Halitosis)

• Definition: unpleasant odor emitted from breath; many patients are not aware of it.

• Evaluation questions:

  • "Have you noticed any bad breath when you talk?"

  • "Has anyone mentioned that you have bad breath?"

  • Note: even healthy mouths have some malodor upon waking due to reduced salivation during sleep.

• Common oral causes:

  • Poor oral hygiene, tobacco smoking, plaque retention on teeth and appliances (retain ers, dentures), periodontal diseases (gingivitis, ulcers, periodontitis)

• Systemic/other causes:

  • Respiratory: sinusitis, tonsillitis, pharyngitis, foreign bodies, neoplasms, abscesses, bronchiectasis

  • Less common systemic: gastric acid reflux, hepatic cirrhosis, poorly controlled diabetes mellitus, fat maldigestion, metabolic disorders such as trimethylaminuria

Physical Examination: General Approach (Mouth & Pharynx)

• Requirements:

  • Appropriate lighting, thorough visual inspection, and palpation when indicated

  • If dentures are worn, remove them to inspect the underlying mucosa (offer a paper towel)

• Key structures to inspect and assess (mouth and pharynx):

  • Lips: color, moisture, lumps, ulcers, cracking, scaliness; observe for central cyanosis or pallor (anemia)

  • Oral mucosa: discoloration, ulcers, white patches, nodules

  • Gingiva: erythema, discoloration, ulceration, swelling

  • Gum margins and interdental papillae: swelling or ulceration

  • Teeth: missing, discolored, misshapen, or abnormally positioned; palpate for looseness

  • Roof (hard palate) and floor of mouth: erythema, discoloration, nodules, ulcerations, deformities; note torus palatinus (benign midline lump)

  • Tongue: inspect color and texture; palpate if indicated for lesions or thickening

  • Tongue tests: CN XII (hypoglossal) symmetry of tongue protrusion

  • Pharynx: inspect soft palate, anterior/posterior pillars, uvula, tonsils, pharynx for color, symmetry, exudate, swelling, ulceration, or tonsillar enlargement

  • Test CN X (vagus) symmetry via uvula position

Techniques of Examination (Mouth & Pharynx)

• Inspect lips:

  • Look at color and moisture; check for lumps, ulcers, cracking, scaliness

  • Note for central cyanosis or pallor (anemia)

  • Reference to abnormalities table (e.g., Table 14-1, Abnormalities of the Lips, pp. 430–431)

• Inspect oral mucosa:

  • Use good light and tongue blade; inspect for discoloration, ulcers, white patches, nodules

  • Aphthous ulcers are common

  • Denture stomatitis: bright red edematous mucosa beneath dentures; may have ulcers or papillary granulation tissue

• Gums and teeth:

  • Gums normally pink; brown patches can occur in dark-skinned individuals

  • Redness = gingivitis; black line may indicate lead poisoning

  • Interdental papillae swollen in gingivitis

  • Inspect teeth for missing/discolored/misshapen/abnormally positioned; palpate for looseness; check gums for tenderness

• Roof and floor of mouth; tongue:

  • Hard palate: look for erythema, discoloration, nodules, ulcerations, deformities; torus palatinus is a midline benign lump

  • Floor: inspect for white or reddened areas, nodules, ulcers

  • Test CN XII: ask patient to protrude tongue and observe symmetry

  • Tongue: inspect dorsum; sides and undersurface are common sites for cancer; risk factors include age > $50$, male sex, smoking, chewing tobacco, and heavy alcohol use; persistent nodules or ulcers (red or white) may be erythroplakia or leukoplakia and should be biopsied

  • Palpate the tongue for induration; grasp tip with gauze and pull toward the side to inspect lateral margins; repeat on the other side

• Pharynx and tonsils:

  • Visualize pharynx by asking patient to say “ah” or yawn; or depress the tongue blade to visualize the pharynx

  • CN X test: soft palate rise; symmetry of the uvula

  • CN X palsy: soft palate fails to rise; uvula deviates away from the lesion

  • Inspect soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx for color, symmetry, exudate, swelling, or tonsillar enlargement

  • Buccal tonsil crypts; note crypts and decidable white spots of normal exfoliating epithelium

  • Asymmetric tonsils with other symptoms may indicate pathology such as lymphoma

  • Streptococcal pharyngitis: tonsillar exudates with a beefy red uvula warrant rapid antigen testing or throat culture

Recording Your Findings (HEENT)

• Normal findings example (typical):

  • Head: normocephalic/atraumatic; hair, etc.

  • Eyes: visual acuity 20/20 bilaterally; sclera white; conjunctiva pink; pupils 4 mm to 2 mm, equal, reactive

  • Ears: hearing good to whispered voice; tympanic membranes with good cone of light; Weber midline; AC > BC

  • Nose: nasal mucosa pink; septum midline; no sinus tenderness

  • Throat/Mouth: oral mucosa pink; dentition good; tongue midline; tonsils absent bilaterally; pharynx without exudates or erythema

  • Neck: trachea midline; thyroid isthmus palpable; lobes not felt; lymph nodes absent

• Abnormal findings example:

  • Dysfunctional CN X: soft palate not rising; uvula deviation; exudates in pharynx; enlarged tonsils; tender nodes

  • Normal vs abnormal regional variations should be noted (e.g., asymmetric tonsils, exudates, erythema) per clinical context

Normal vs Abnormal Findings: Quick Reference

• Normal HEENT mouth/pharynx findings:

  • Oral mucosa pink; dentition good; tongue midline; tonsils absent; pharynx without exudates or erythema

• Abnormal findings to recognize and pursue:

  • Dental caries, erythematous pharynx, enlarged tonsils, tender submandibular/anterior cervical nodes

  • Findings suggest pharyngitis or mild tonsillitis

Practice MCQs: Mouth, Pharynx & Voice — Exam-Style Questions

Q1. During an oral exam, you inspect the gingiva. Which of the following is a normal finding?

• A. Bright red swollen interdental papillae

• B. Gingiva pink in color without swelling

• C. Black line along the gum margins

• D. Ulceration at gum margins
  Correct Answer: B
  Explanation: Normal gums are pink, firm, and without swelling or ulceration. A indicates gingivitis; C suggests lead poisoning; D indicates pathology or trauma.

Q2. You inspect the tongue and ask the patient to protrude it. The tongue deviates to the right. What does this suggest?

• A. Normal variation

• B. Right hypoglossal nerve (CN XII) lesion

• C. Left hypoglossal nerve (CN XII) lesion

• D. Right vagus nerve (CN X) lesion
  Correct Answer: B
  Explanation: In CN XII palsy, the tongue deviates toward the side of the lesion. A is not accurate; Left CN XII would deviate left; CN X palsy affects the palate/uvula not the tongue.

Q3. When testing CN X (vagus), you ask the patient to say “ah.” Which of the following is a normal finding?

• A. Uvula deviates to the left

• B. Soft palate rises symmetrically in midline

• C. Palate fails to rise

• D. Uvula deviates away from the lesion
  Correct Answer: B
  Explanation: A normal vagus exam shows symmetric elevation of the soft palate; uvula remains midline. A and D indicate CN X palsy; C is abnormal.

Q4. During inspection of the oral mucosa, you see a white patch on the lateral tongue that cannot be scraped off. Which action is most appropriate?

• A. Reassure patient this is benign

• B. Biopsy to rule out squamous cell carcinoma

• C. Prescribe antifungal treatment

• D. Advise increased hydration
  Correct Answer: B
  Explanation: A non-scrapable white patch (leukoplakia/erythroplakia) may be premalignant; biopsy is indicated. Scrapable patches are often candidal and may respond to antifungals.

Q5. A 60-year-old smoker has a persistent, indurated ulcer on the side of the tongue. Which of the following is most likely?

• A. Aphthous ulcer

• B. Squamous cell carcinoma

• C. Torus palatinus

• D. Denture stomatitis
  Correct Answer: B
  Explanation: An indurated, persistent ulcer on the lateral tongue in an older smoker is highly suspicious for squamous cell carcinoma; aphthous ulcers heal; torus palatinus is a benign midline palatal bony growth; denture stomatitis involves mucosa under dentures.

Q6. You inspect under a patient’s dentures and find bright red, swollen mucosa with papillary granulation tissue. What is this consistent with?

• A. Normal mucosa under dentures

• B. Denture stomatitis

• C. Gingivitis

• D. Oral leukoplakia
  Correct Answer: B
  Explanation: Denture stomatitis presents as erythematous, swollen mucosa beneath dentures; papillary granulation tissue may be present. Normal mucosa is pink; gingivitis affects gums; leukoplakia appears as white patches.

Q7. During pharyngeal exam, you observe tonsils with white exudates and a beefy red uvula. What is the most likely diagnosis?

• A. Viral pharyngitis

• B. Streptococcal pharyngitis

• C. Tonsillar lymphoma

• D. Allergic rhinitis
  Correct Answer: B
  Explanation: Tonsillar exudates with a beefy red uvula strongly suggests streptococcal pharyngitis; confirm with rapid strep test or culture. Viral pharyngitis usually lacks exudates; lymphoma often presents with asymmetry; allergic rhinitis affects nasal mucosa.

Q8. Halitosis is most commonly caused by:

• A. Respiratory tract infections such as sinusitis or tonsillitis

• B. Cirrhosis (fetor hepaticus)

• C. Poorly controlled diabetes mellitus

• D. Inborn metabolic error (trimethylaminuria)
  Correct Answer: A
  Explanation: The most common causes of halitosis are oral and respiratory etiologies (plaque, gingivitis, dentures, sinusitis, tonsillitis, pharyngitis, bronchiectasis). Systemic causes exist but are less common.

Would you like me to add more questions or adjust the focus (e.g., more emphasis on CN X/XII testing, denture examinations, or pharyngeal exudates) for your exam prep?