ABNORMAL FINDINGS OF MOUTH AND

NECK
OBJECTIVES
BY THE END OF THIS DISCUSSION WE WILL KNOW
INSPECTIVE METHODS OF MOUTH AND NECK
COMMON ABNORMALITIES REALATED TO MOUTH AND NECK
DIFFERENT TYPES OF THYROIDISM WITH THEIR RESPECTIVE SIGNS
AND SYMPTOMS
CONCEPT MAP
Inspection of throat and neck

Normal findings

Abnormal findings in the mouth Abnormal findings in the neck

GUMS ENLARGEME THYROIDIS

LIPS PHARYNX TEETH NT M
MOUTH

 Assess moisture, lesions, swelling, drainage, teeth and gums

 Lips – color, moisture, cracking (Cheilitis) or lesions
Retract lips and note inner surface
 Teeth and gums
An adult mouth has 32 teeth
Diseased, missing, loose or abnormally positioned teeth
Decayed teeth  caries
Gingival hypertrophy
Bleeding gums
Tongue
Pink and even
Dorsal surface rough with papillae
Thin white coating
Ask patient to touch tongue to roof of mouth
oVentral surface should be smooth, glistening, showing veins
Saliva is present
Enlarged tongue abnormal
oMental retardation, hypothyroidism, acromegaly
 Mouth
Dry mouth – dehydration
Excessive drooling
Look for lesions e.g. canker sores, white patches (thrush) (malignancies)
 Uvula
Ask person to say ‘aahh’
oSoft palate and uvula rise in the midline (CN X)
 o Throat
 Inspect for lesions
 Tonsils
Acute infection
White membrane covering tonsils  mononucleosis, leukemia, diphtheria
Enlargement; Acute infection, 2+, 3+, or 4+
o1+ - visible
o2+ halfway between tonsillar pillars
o3+ touching uvula
o4+ touching each other
MALLAMPATI
CLASSIFICATION
Modified Mallampati classification
Class 0: Ability to see any part of the epiglottis upon mouth opening and tongue
protrusion
Class I: Soft palate, fauces, uvula, pillars visible
Class II: Soft palate, fauces, uvula visible
Class III: Soft palate, base of uvula visible
Class IV: Soft palate not visible at all
The assessment is performed with the patient sitting up straight, mouth open and
tongue maximally protruded, without speaking or saying “ahh.”
MALLAMPATI
Mallampati classification is only one of 11 nonreassuring findings during airway
examination
PREDICTIVE VALUE OF
MODIFIED MALLAMPATI
CLASSIFICATION
See the list below:
Difficult laryngoscopy: Good accuracy (area under summary receiver operating
characteristic [SROC] curve 0.89 ± 0.05)
Difficult intubation: Good accuracy (area under sROC curve 0.83 ± 0.03)
Difficult mask ventilation: Poor predictor
Used alone, the Mallampati tests have limited accuracy for predicting the difficult
airway and thus are not useful screening tests
NECK

o Inspect the Neck

 Symmetry – head position midline
 Head tilt in muscular spasm
 Trachea in midline
 ROM
Chin to chest
Head to shoulder
Turn head to R and L (say “no”).
oPerson turns shoulders instead of neck
Note pain, ratchety movement, limited ROM due to arthritis or inflammation of neck
muscles
 o Lymph nodes
Note:
 Size and shape
 Delimitation
 Mobility
 Consistency – hard or soft
 Tenderness (with acute infection)
 Lymph Nodes
Preauricular
Posterior auricular
Occipital: base of the skull
Submental
Submandibular: halfway between the angle and the tip of the mandible
Jugulodigastric (tonsilar)
Superficial cervical
Deep cervical
Posterior cervical
Supraclavicular
Tonsillar
o Thyroid Gland
 Goiter
Throat/Mouth
 Oral mucosa pink, dentition good, pharynx without exudates.
 Tonsils symmetric, no adenopathy.
 No buccal nodules or lesions.

Neck
 Trachea is midline
 Neck supple;
 Thyroid isthmus palpable, lobes not felt.
 No cervical lymphadenopathy.
 Full range of motion of neck in anterior-posterior, lateral, and side-to-side [shaking head]
directions
Abnormalities of the Lips
CHEILITIS
Inflammation of the lips or of a lip
This inflammation may include the perioral skin (the skin around the mouth), the
vermilion border, and/or the labial mucosa.
The skin and the vermilion border are more commonly involved, as the mucosa is
less affected by inflammatory and allergic reactions.
 Angular Cheilitis
 Actinic Cheilitis
ABNORMALITY CHARACTERISTICS PICTURE

Angular cheilitis Both lips symmetrical

Pink in color
Lips are Dry
Presence of fissure
Angles of lips are mainly
effected

Actinic cheilitis Upper lip symmetrical

Pale in color
Scaly lips
Lesions on the lower lip
Lower lip affected

Herpes Simplex (Cold Sore, Symmetrical on both lips

Fever Blister) Pink in color
Lips are moist
Presence of vesicular eruptions
Angles of lips
ABNORMALITY CHARACTERISTICS PICTURE
Angioedema Either one of the lips will be
symmetrical or both as it can
effect both lips
Red in color
Lips are moist
Swelling No lesions
Lower lip affected sometimes
both lips

Hereditary Hemorrhagic Both lips symmetrical

Telangiectasia (Osler-Weber- Red in color
Rendu syndrome) Lips are dry
Small spots/ lesions on both lips
Both lips affected

Peutz–Jeghers Syndrome Both lips are symmetrical

Brown in color
Dry scaly lips
Brown pigmented spots
Dermis of both lips
ABNORMALITY CHARACTERISTICS PICTURE

Chancre of Primary Syphilis Symmetry on one lip or

asymmetry as both lips can be
affected
Pink in color
Solitary lesion
Both lips are affected

Carcinoma of the Lip Upper lip is symmetrical

Pink in color
Dry lips
Ulcer with or without a crust
Nodular lesions
Lower lip is affected
Findings in the Pharynx, Palate, and Oral Mucosa
LARGE NORMAL TONSILS
Normal tonsils may be large without being infected, especially in children.
They may protrude medially beyond the pillars and even to the midline.
Touch the sides of the uvula and obscure the pharynx.
Their color is pink.
The white marks are light reflections, not exudate
EXUDATIVE TONSILLITIS
This red throat has a white exudate on the tonsils.
This, together with fever and enlarged cervical nodes, increases the probability of
group A streptococcal infection or infectious mononucleosis.
Anterior cervical lymph nodes are usually enlarged in the former, posterior nodes in
the latter.
PHARYNGITIS
Redness and vascularity of the pillars and uvula are mild to moderate.
Redness is diffuse and intense. Each patient would probably complain of a sore
throat, or at least a scratchy one.
Causes are both viral and bacterial.
PHARYNGITIS
If the patient has no fever, exudate, or enlargement of cervical lymph nodes, the
chances of infection by either of two common causes—
 Group A streptococci
 Epstein-Barr virus (infectious mononucleosis)—are reduced
DIPHTHERIA
Diphtheria, an acute infection caused by Corynebacterium diphtheriae, is now rare
but still important.
Prompt diagnosis may lead to life-saving treatment.
The throat is dull red, and a gray exudate (pseudomembrane) is present on the
uvula, pharynx, and tongue.
The airway may become obstructed.
Prompt diagnosis may lead to life-saving treatment
THRUSH ON THE PALATE
(CANDIDIASIS)
Thrush is a yeast infection from Candida species. Shown here on the palate, it may
appear elsewhere in the mouth
Thick, white plaques are somewhat adherent to the underlying mucosa.
Predisposing factors include
 Prolonged treatment with antibiotics or corticosteroids
 AIDS
KAPOSI SARCOMA IN AIDS
The deep purple color of these lesions suggests Kaposi sarcoma, a low-grade
vascular tumor associated with human herpesvirus 8.
The lesions may be raised or flat
About a third of patients with Kaposi sarcoma have lesions in the oral cavity
TORUS PALATINUS
A torus palatinus is a midline bony growth in the hard palate that is fairly common
in adults.
Its size and lobulation vary.
Although alarming at first glance, it is harmless
FORDYCE SPOTS (FORDYCE
GRANULES)
Fordyce spots are normal sebaceous glands that appear as small yellowish spots in
the buccal mucosa or on the lips.
These spots are usually not numerous
KOPLIK SPOTS
Koplik spots are an early sign of measles (rubeola).
Search for small white specks that resemble grains of salt on a red background.
They usually appear on the buccal mucosa near the first and second molars.
Look also in the upper third of the mucosa. The rash of measles appears within a
day
PETECHIAE
Petechiae are small red spots caused by blood that escapes from capillaries into the
tissues.
Petechiae in the buccal mucosa are often caused by accidentally biting the cheek.
Oral petechiae may be due to infection or decreased platelets, and trauma
LEUKOPLAKIA
A thickened white patch (leukoplakia) may occur anywhere in the oral mucosa.
The extensive example shown on this buccal mucosa resulted from frequent
chewing of tobacco, a local irritant.
This benign reactive process of the squamous epithelium may lead to cancer and
should be biopsied.
Another risk factor is human papillomavirus infection
Findings in the Gums and Teeth
MARGINAL GINGIVITIS
Marginal gingivitis is common during adolescence, early adulthood, and pregnancy.
The gingival margins are reddened and swollen, and the interdental papillae are
blunted, swollen, and red.
 Brushing the teeth often makes the gums bleed.
 Plaque—the soft white film of salivary salts, protein, and bacteria that covers the
teeth and leads to gingivitis—is not readily visible.
ACUTE NECROTIZING
ULCERATIVE GINGIVITIS
This uncommon form of gingivitis occurs suddenly in adolescents and young adults
and is accompanied by fever, malaise, and enlarged lymph nodes.
Ulcers develop in the interdental papillae.
Then the destructive (necrotizing) process spreads along the gum margins, where a
grayish pseudomembrane develops.
 The red, painful gums bleed easily; the breath is foul
GINGIVAL HYPERPLASIA
Gums enlarged by hyperplasia are swollen into heaped-up masses that may even
cover the teeth.
The redness of inflammation may coexist
Causes include
 Phenytoin therapy
 Puberty
 Pregnancy
 Leukemia
PREGNANCY TUMOR
(PREGNANCY EPULIS OR
PYOGENIC GRANULOMA)
Red purple papules of granulation tissue form in the gingival interdental papillae, in
the nasal cavity, and sometimes on the fingers.
They are red, soft, painless, and usually bleed easily.
They occur in 1% to 5% of pregnancies and usually regress after delivery.
Note the accompanying gingivitis.
ATTRITION OF TEETH;
RECESSION OF GUMS
In many elderly people, the chewing surfaces of the teeth are worn down by
repetitive use so that the yellow-brown dentin becomes exposed—a process called
attrition.
Note also the recession of the gums, which has exposed the roots of the teeth,
giving a “long in the tooth” appearance
EROSION OF TEETH
Teeth may be eroded by chemical action.
Note here the erosion of the enamel from the lingual surfaces of the upper incisors,
exposing the yellow-brown dentin.
This results from recurrent regurgitation of stomach contents, as in bulimia.
ABRASION OF TEETH WITH
NOTCHING
The biting surface of the teeth may become abraded or notched by recurrent trauma,
such as holding nails or opening bobby pins between the teeth.
Unlike Hutchinson teeth, the sides of these teeth show normal contours; size and
spacing of the teeth are unaffected
HUTCHINSON TEETH IN
CONGENITAL SYPHILIS
Hutchinson teeth are smaller and more widely spaced than normal and are notched
on their biting surfaces.
 The sides of the teeth taper toward the biting edges.
The upper central incisors of the permanent (not the deciduous) teeth are most often
affected.
These teeth are a sign of congenital syphilis
Findings in or Under the Tongue
GEOGRAPHIC TONGUE
In this benign condition, the dorsum shows scattered smooth red areas denuded of
papillae.
Together with the normal rough and coated areas, they give a map like pattern that
changes over time.
BLACK HAIRY TONGUE
Note the “hairy” yellowish to brown and black hypertrophied and elongated
papillae on the tongue’s dorsum.
This benign condition is associated with Candida and bacterial overgrowth,
antibiotic therapy, and poor dental hygiene.
It also may occur spontaneously
FISSURED TONGUE
Fissures appear with increasing age, sometimes termed furrowed tongue.
Food debris may accumulate in the crevices and become irritating, but a fissured
tongue is benign.
SMOOTH TONGUE (ATROPHIC
GLOSSITIS)
A smooth and often sore tongue that has lost its papillae, sometimes just in patches,
suggests
 Deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron/
 Treatment with chemotherapy.
CANDIDIASIS
Note the thick white coating from Candida infection.
The raw red surface is where the coat was scraped off.
Infection may also occur without the white coating.
It is seen in immunosuppression from chemotherapy or prednisone therapy.
ORAL HAIRY LEUKOPLAKIA
These whitish raised asymptomatic plaques with a feathery or corrugated pattern
occur most often on the sides of the tongue.
Unlike candidiasis, these areas cannot be scraped off.
This condition is caused by Epstein-Barr virus infection and is seen in HIV and
AIDS infection.
VARICOSE VEINS
Small purplish or blue-black round swellings appear under the tongue with age.
These dilatations of the lingual veins have no clinical significance.
APHTHOUS ULCER (CANKER
SORE)
A painful, shallow whitish-gray oval ulceration surrounded by a halo of reddened
mucosa.
It may be single or multiple and may also occur on the gingiva and oral mucosa.
It heals in 7–10 days, but may recur, as in Bechet disease
MUCOUS PATCH OF SYPHILIS
This painless lesion of secondary syphilis is highly infectious. It is slightly raised,
oval, and covered by a grayish membrane.
 It may be multiple and occur elsewhere in the mouth
LEUKOPLAKIA
With this persisting painless white patch in the oral mucosa, the under surface of
the tongue appears painted white.
Patches of any size raise the possibility of squamous cell carcinoma and require
biopsy
TORI MANDIBULARES
Rounded bony growths on the inner surfaces of the mandible are typically bilateral,
asymptomatic, and harmless.
CARCINOMA, FLOOR OF THE
MOUTH
This ulcerated lesion is in a common location for carcinoma.
Medially, note the reddened area of mucosa, called erythroplakia, that is suspicious
for malignancy and should be biopsied
Thyroid Enlargement and Function
DIFFUSE ENLARGEMENT
 Includes the isthmus and lateral lobes; there are no discretely palpable nodules.
Causes include
Graves disease
Hashimoto thyroiditis
Endemic goiter
SINGLE NODULE
May be a cyst, a benign tumor, or one nodule within a multinodular gland. It raises
the question of malignancy.
Risk factors are prior irradiation, hardness, rapid growth, fixation to surrounding
tissues, enlarged cervical nodes, and occurrence in men.
MULTINODULAR GOITER
An enlarged thyroid gland with two or more nodules suggests a metabolic rather
than a neoplastic process.
Positive family history and continuing nodular enlargement are additional risk
factors for malignancy.
Hyperthyroidism
SIGNS
#Warm, smooth, moist skin
#With Graves disease, eye signs such as stare, lid lag, and exophthalmos
#Increased systolic and decreased diastolic blood pressures
#Tachycardia or atrial fibrillation
#Hyper dynamic cardiac pulsations with an accentuated S1
#Tremor and proximal muscle weakness
SYMPTOMS
*Nervousness
*Weight loss despite increased appetite
*Excessive sweating and heat intolerance
*Palpitations
*Frequent bowel movements
*Tremor and proximal muscle weakness
Hypothyroidism
SIGNS
#Dry, coarse, cool skin, sometimes yellowish from carotene, with non pitting
myxedema and loss of hair
#Periorbital myxedema
#Low-pitched speech
#Decreased systolic and increased diastolic blood pressures
#Bradycardia and, in late stages, hypothermia
#Sometimes decreased intensity of heart sounds
#Prolonged relaxation phase during ankle reflex Impaired memory, mixed hearing
loss, somnolence, peripheral neuropathy, carpal tunnel syndrome
SYMPTOMS
*Fatigue, lethargy
*Modest weight gain with anorexia
*Dry, coarse skin and cold intolerance
*Swelling of face, hands, and legs
*Constipation Weakness, muscle cramps, arthralgias, paresthesias, impaired memory
and hearing
CLINICAL CORRELATION
A 32-year-old female patient reported with the complaint of ulceration on the left
lateral border of the tongue since past 20 days.
No history of similar ulceration in the past. Extra-oral examination did not reveal
anything significant.
On intra-oral examination, a single ulcer was seen on the left lateral border of the
tongue.
It was mildly tender on palpation and the margins were slightly indurated. Margins
of the left first and second mandibular molars were sharp and coronoplasty was
advised to remove the source of irritation.
Following that, a steroid ointment was advised for topical application.
On follow-up after 7 days, no significant difference was noticed.
Then considering the duration and location of the lesion, biopsy was done to rule
out the dysplasia.
Histopathological examination showed presence of atypical squqmous cells with
nuclear enlargement and hyperchromasia.
REFERENCES
BATES GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING 12TH
EDITION
www.elcamino.edu/faculty/kbaily/Documents/.../N155%20HEENT%20Outline.doc
https://www.clinicaladvisor.com/the-waiting-room/mallampati-score-anesthesia-obs
tructive-sleep-apnea/article/471394/

https://www.medicalnewstoday.com/articles/216095.php
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483004/
SALAMAT PO