Mouth, Throat, Nose, and Sinus

Assessment
The mouth and throat make up the first part of the digestive system and are responsible for
receiving food. Cranial nerves V"trigeminal", VII"facial", IX "glosopharyngeal", and
IIX"hypoglossal" assist with some of the digestive functions. The nose and paranasal sinuses
constitute the first part of the respiratory system and are responsible for receiving, filtering,
warming, and moistening air to be transported to the lungs.
Receptors of cranial nerve I "olfactory" are also located in the nose.

Mouth
The roof of the oral cavity is formed by the anterior hard palate and the posterior hard palate. An
extension of the soft palate is the uvula.
Contained within the mouth are the tongue, teeth, gums, and the opening of the salivary glands "parotid,
submandibular, sublingual". The three pairs of salivary glands secrete saliva "watery, serous fluid
contains salts, mucous, and salivary amylase" into the mouth. The parotid glands, located below, and in
front of the ears, empty through Stensen's ducts, which are located inside the check across from the
second upper molar.
The submandibular glands, located in the lower jaw, open under the tongue on either side of the
frenulum through opening called Wharton's ducts. The sublingual glands, located under the tongue, open
through several ducts located on the floor of the mouth.

 Mouth and throat

– Lips
– Cheeks
– Buccal mucosa
– Hard palate
– Soft palate
– Tonsils
– Oropharynx and nasopharynx
– Uvula
– Tongue – taste (CN VII)
– Salivary glands
– Parotid
– Submandibular
– Sublingual
– Teeth
– Crown
– Neck
– Root
Throat
 The throat "pharynx", located behind the mouth and nose, serves as a muscular passage for food
and air. The upper part is called the nasopharynx. Below it lays laryngopharynx.

 The soft palate, anterior and posterior pillars, and uvula connect behind the tongue to form
arches.

 The lingual tonsils lie at the base of the tongue. Pharyngeal tonsils "adenoid" are found high in
the nasopharynx.
 External Nose and Mouth

Nose
It composed of bone and cartilage and is lined with mucous membrane. The nasal cavity is located.

 External nose
 Internal nose
 Nasal cavity
 Paranasal Sinuses
– Frontal
– Maxillary
 – Sphenoid
– Ethmoid
 Turbinates
– Projections in nasal cavity that increase surface area
– Superior, middle and inferior turbinates
 Nasal mucosa
 Olfactory receptor cells (CN I)

Functions of Nose

 Identify odors (upper 1/3 of septum) CN I

 Air passageway (obligate in newborns)
 “Air conditioning”
– Humidify
– Warms/cools air
– Cleans and filters air of dust and bacteria
– Voice resonance

Common Chief Complaints

 Nasal blockage or congestion

 Halitosis – breath odor
– Fruity (acetone) – diabetic ketoacidosis
– Foul – URI, sinus, tonsil or mouth infection
– Ammonia – renal problems (uremia)
 – Fecal – GI obstruction
 Oral lesions

Ear, Nose & Throat Assessment: History Review

Present Problem

– dizziness or vertigo
– earache
– hearing loss
– nasal discharge
– snoring
– nosebleed
– dental problems
– mouth lesions
– sore throat
– difficulty swallowing

Past Medial History

– systemic diseases
– Ear
- frequent problems in childhood
- surgery
- labrynthitis
- antibiotic use

– Nose
- trauma
- surgery
- chronic nosebleeds

– Sinuses
- chronic postnasal drip
- repeated sinusitis
- allergies

– Throat
 - frequent, documented strep infections
- tonsillectomy
- adenoidectomy

Assessment of the Nose

 Inspection of internal nose
 Otoscope with nasal speculum – avoid septum d/t increased sensitivity
 Color & integrity of nasal mucosa
 Septum deviation, perforation, bleeding (epistaxis)
 New/old bleeding anywhere
 Turbinates (color, exudate, swelling, polyps) Note the middle and inferior turbinates
 Normal – dull red
 Allergies – pale pink/gray, swollen (polyps & a clear, watery discharge are also common)
 Acute rhionitis infection – bright red & swollen

 Normal findings
– Located in midline of face
– No swelling, bleeding, lesions, or masses
– Both nostrils patent
– Septum midline
– Nasal mucosa is pink or dull red

 Abnormal findings
– Broken, misshapen, swollen nose
– Occluded nasal passages
– Septum is deviated
– Nasal mucosa is red and swollen

Nasal Polyp;
 Smooth, pale gray nodule
 Overgrowths of mucosa
 Chronic allergic rhinitis
 Mobile, nontender
 Decrease/absence of smell
Assessment of the Sinuses
 Inspection
 Palpation, percussion & transillumination (very dark room)
 Normal findings
– No evidence of swelling
– Resonance heard on direct percussion
– Will feel firm pressure with palpation, but no pain normally
– Healthy sinuses contain air and may light up symmetrically

Assessment of the Mouth

 Inspection (use good light source)
– Lips (color, moisture, cracking, lesions) – smile for symmetry (CNVII)
– Tongue (color, surface fissures, moisture) – stick out for deviation (CN VII)
– Gums, buccal mucosa (check for pink color, bleeding, swelling)
– Teeth (#, molars, color, cavities, dental repair) 32 adult – 20 children (3rd molars may be
missing – wisdom teeth)
– Hard palate & soft palate
– Floor of mouth (Wharton’s duct/Submandibular gland, Sublingual gland)
– Parotid gland (in cheek in front of ear) and Stensen’s duct (opposite 2nd molar)
 – Tongue (Lingual frenulum, lingual veins)

 Palpate
– Roof of mouth in infants
– Lips, cheek, tongue, floor of mouth
– Use gauze to hold tongue
– Find Stensen’s duct (parotid salivary gland) opposite upper second molar
– Check temporomandibular joint (TMJ) – depression in front of tragus felt with fingers
(slight pop can be normal; crepitus and masses are abnormal)

 Normal findings
– Pink, moist lips
– Tongue midline, adequate movement
– No lesions
– Tongue, gums, buccal mucosa are pink, moist, smooth
– No bleeding
– Smooth, white teeth, no dental caries

 Abnormal findings
– Lesions, growths
– Dry, cracked lips
– Vesicles or blisters
– Red, tender, inflamed tongue, gums, buccal mucosa
– Thrush
– Coating on tongue
– Bleeding gums

Thrush – Candidiasis
 Scrapes off easily
 Leaves red, raw surface that may bleed
 Can occur after antibiotics, corticosteroids, and with immunosuppression

Gum Hyperplasia

 Painless enlargement
 Occurs with puberty, pregnancy, leukemia, and extensive use of phenytoin (Dilantin)

Gingivitis
 Gum margins red, swollen, bleed easily
 Gums will recede and produce purulent drainage with chronicity
 Poor dental hygiene, vitamin C deficiency
 More common in pregnancy & puberty
 Inspection of the Throat

 Gag reflex (CN IX & X)

 Posterior pharynx and oropharynx
 Presence of swelling, exudate or lesions. Note color.
 Inspect tonsils
 Grade tonsils (+1 – +4)

 Normal findings
 Soft palate and uvula rise when patient says, “ahhh” (CN IX & X)
 Uvula is midline
 No swelling, exudate, or lesions
 Gag reflex is present (CN IX & X)

 Abnormal findings
 Posterior pharynx is red with white patches
 Tonsils and uvula are red and swollen
 Hoarse voice
 Grayish membrane covering tonsils, uvula, soft palate

Tonsil Exudate
 Streptococcal pharyngitis and acute tonsillitis
 Bright red pharynx with red, swollen tonsils, pillar and uvula
 Patches of white/yellow exudate

Family History

– hearing problems/loss
– Meniere’s disease
– allergies
– hereditary renal disease

Personal & Social History

– employment…hazards
– nutrition
– oral care pattern
– tobacco use
– alcohol use
– intranasal cocaine use
– OTC nasal spray use

Infants and Children

 – prenatal history
– prematurity
– infection
- Meningitis/encephalitis
- Recurrent otitis media

– congenital defects
– playing with small objects
– behaviors indicating hearing loss
– dental care
Pregnant Women

– weeks gestation/postpartum
– symptoms before pregnancy
– pattern of dental care

Older Adults

– hearing loss
– physical disability
– deterioration of teeth
– dry mouth
– medications
– salivation

NOSE & NASOPHARYNX

 Warm/humidify/moisten air and resonate sound

 Floor is hard and soft palate
 Roof is sphenoid and frontal bone
 Mucous membrane caries debris
 Turbinates increase surface area
 Sinuses
- maxillary and frontal accessible to exam
- ethmoid and sphenoid behind frontal
- mucous and cilia move mucous
 Check patency of nares
 Percuss and palpate sinuses
 Observe mucosa color and discharge
 allergy = white mucosa with clear discharge
 virus = red mucosa with colorful discharge
  ?CSF = unilateral clear discharge
 foreign body = unilateral colorful discharge
 Assess polyps or ulcer

MOUTH & OROPHARYNX

 Passage of food/fluid, emit air & speech, initiate digestion & identify taste
 Gingivae cover neck and roots of teeth
 Teeth - 32 permanent (4 incisors, 2 canines, 4 premolars and 6 molars)
 Oropharynx separated from mouth by tonsilar pillars
 Assess lips, buccal mucosa, teeth and gums
 Observe occlusion of clenched teeth (CN VIII)
 Inspect tongue color, texture, ulcerations and note movement (CN XII)
 Assess soft palate and rise of posterior curtain with “ahh” (CN IX/X)
 Inspect posterior pharynx noting tonsillar pillars
 Lips
- cyanosis = hypoxia
- pallor = poor perfusion
- vesicles = HSV
 Oral lesions
- Candida = white patches on red base
 Pharynx
- viral vs bacterial pharyngitis
- Per tonsillar abcess = deviated uvula

Pediatric Variations

 Essential to determine nasal patency of newborn (channel atresia) Bilaterally will

need immediate intervention d/t obligate nose breathing
 Only the maxillary and ethmoid sinuses are present at birth
(easier to trans illuminate)
 Tonsils vary widely in size during childhood
 3 month old begins salivation (drooling)
 Teeth/tooth may be present at birth, most infants start between 6-10 months, will lose
teeth between 6-12 yrs

Gerontological Variations

 Nose may appear more prominent d/t loss of SQ fat in face.

 Diminished sense of smell and taste (decreased # of olfactory nerve fibers in nose
and papilla on tongue)
  Periodontal disease
 Gum lines recede
 Oral alterations due to disease or side effects of medications
 Tooth loss
 Teeth will darken with age d/t exposed dentin

Lifestyle and Health Practices

Predisposing factors for oral cancer:
 Cigarette smoking
 Excessive use of alcohol
 Age over 40
 Male gender
 Genetic predisposing
 Vitamin A deficiency

Grinding the teeth is a sign of stress or slight malocclusion

Proper brushing, flossing, and oral hygiene can prevent dental caries and gum diseases
Cleaning the tongue is a way to prevent bad breath resulting from bacteria that
accumulates on the posterior tongue
Elderly and some disabled clients may have difficult caring properly for teeth or
dentures because of poor vision or impaired extremities

Collecting Objective Data

- Examination of the mouth and throat can help the nurse detect abnormalities of the lips, gums,
teeth, oral mucosa, tonsils, and uvula.
- It allows for early detection of oral cancer
- Examination top detect oral problems, septum defects, patency of the nose and nasopharynx.
- Early detection of impaired oral mucous membrane s or poor dental hygiene conditions may
require a change in client's diet. Early detection of septum deviation help the nurse determines
which nostrils to use to insert a NGT or suction tube.
 ASESSMENT OF THE NOSE & MOUTH

A: Preparation
1. Introduce yourself
2. Explained examination to the patient
3. Give proper instruction to the client
4. Assembled equipment
5. Arranged for proper environment

B: History
6. Reviewed systems for pathological condition or injuries

C: Nose and paranasal sinuses.

7. Inspected and palpated external nose.
8. Determined patency.
9. Tested olfactory nerve (CN I)
10. Inspected nasal cavities bilaterally.
11. Inspect, Palpate and Purcuss sinuses
 Frontal sinuses
 Maxillary sinuses
12. Trans illumination of the Sinuses

D: Mouth and Oropharynx

13. Smell the breath of the patient
14. Inspected and palpate lips and facial structures.
15. Inspected buccal mucosa
16. Inspected teeth and gums.
17. Inspected hard and soft palate
18. Inspected posterior pharyngeal wall
19. Inspected and palpate the tongue and floor of mouth
20. Inspect the throat and observe tonsillar pillar
 21. Palpated temporomandibular joint
22. Tested hypoglossal nerve (CN XII)
23. Tested gloss pharyngeal nerve (CN IX) and vagus nerve (CN X)

 Movement of uvula and soft palate

 Gag reflex

H: Approach to the client

24. Followed logical exam sequence
25. Properly positioned client.
26. Findings explained to client
27. Palpation effective but gentle.

OVERALL COMMENTS
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
A: Preparation
28. Introduce yourself
29. Explained examination to the patient
30. Give proper instruction to the client
31. Assembled equipment
32. Arranged for proper environment

B: History
33. Reviewed systems for pathological condition or injuries
34. Probed positive symptoms.
35. Ask health history related ear (Discharge, Ear pain, Vertigo
Care habits and hearing ability
C: Ears
36. Inspected and palpated auricles and mastoid area.
37. Inspected auditory meatus.
38. Performed otoscope examination of auditory canal.
39. Determined color of and presence of cerumen and exudates in canal.
40. Performed otoscope examination of tympanic membrane.
41. Described membrane color and landmarks.
42. hearing test (CN VIII )
a. Whisper Voice Test
b. Rinne test
c. Weber test

OVERALL COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
____

Student name: _________________ Date: _____________ Faculty name: _______________

Sign off: _____________________
A: Preparation
43. Introduce yourself
44. Explained examination to the patient
 45. Give proper instruction to the client
46. Assembled equipment
47. Arranged for proper environment

B: History
48. Reviewed systems for pathological condition or injuries
49. Probed positive symptoms.
50. Ask health history related ear (Discharge, Ear pain, Vertigo
Care habits and hearing ability
C: Ears
51. Inspected and palpated auricles and mastoid area.
52. Inspected auditory meatus.
53. Performed otoscope examination of auditory canal.
54. Determined color of and presence of cerumen and exudates in canal.
55. Performed otoscope examination of tympanic membrane.
56. Described membrane color and landmarks.
57. hearing test (CN VIII )
d. Whisper Voice Test
e. Rinne test
f. Weber test
 Ear Assessment Documentation
Student Name:________________________Faculty Name:___________________

EAR:
Inspection Contour of Ear , color______________________________________________________________

( Auditory Meatus)_________________________________________________________________________
Palpation________________________________________________________________________________
OtoscopicExamination
Color of membrane
/landmark_______________________________________________________________________________
Hearing Test
Whisper Voice Test________________________________________________________________________
Rinne Test_______________________________________________________________________________
Weber Test______________________________________________________________________________
Date:        

Client Initials
Diagnosis:
Faculty signature / comments

CHECKLIST MENTAL STATUS AND NEUROSENSORY SYSTEM

1. Appearance
  Grooming
 Posture
 Level of consciousness

2. Behavior
 Mood
 Characteristics of speech
 Facial expressions
3. Cognitive Function
 Orientation
 Thought process
o Logic
o Coherence, relevance
o Speech progressing towards logical goal

 Thought content
o Compulsion
o Obsessions
o Delusions
 Perception
o Illusions
o Hallucinations
 Insight
 Judgment
 Memory
o Immediate
o Recent
o Remote

4. Intellectual functions
 Abstraction ability
 Computation
 Ability to read
 Similarities
5. Cerebellar function
 Point to pint testing
 Rapid alternating movements
 Romberg test
 Pronator drift
6. Motor function
 Gait and posture
 Balance
7. Sensory assessment
 Light touch
  Pain
 Temperature
 Vibration
 Discriminative sensations
o Stereognosis
o Graphesthesia
o Two point discrimination
o Point localization
o Extinction
8. Deep tendon reflexes
 Biceps
 Triceps
 Brachioradialis
 Patellar
 Achilles
9. Cranial nerves
 Olfactory
 Optic
 Occulomotor
 Trochlear
 Trigeminal
 Abducens
 Facial
 Auditory
 Glassopharyngeal
 Vagus
 Spinal accessory
 Hypoglossal