INTRODUCTION

The nose, mouth and throat are especially important when considering the nutritional status of the person and their respiratory function. To appreciate the impact of disease, trauma and/or alteration in function of any of these intricate structures you are advised to review the structure and function of the nose, throat and mouth and the relationships to each other.

STRUCTURE AND FUNCTION

 

NOSE

The nose is the first segment of the respiratory system. It warms, moistens and filters the inhaled air, and it is the sensory organ for smell. The external nose is shaped like a triangle with one side attached to the face (Fig 13.1). On its leading edge, the superior part is the bridge and the free corner is the tip. The oval openings at the base of the triangle are the nares; just inside, each naris widens into the vestibule. The columella divides the two nares and is continuous inside with the nasal septum. The ala is the lateral outside wing of the nose on either side. The upper third of the external nose is made up of bone; the rest is cartilage.

Inside, the nasal cavity is much larger than the external nose would indicate (Fig 13.2). It extends back over the roof of the mouth. The anterior edge of the cavity is lined with numerous coarse nasal hairs, or vibrissae. The rest of the cavity is lined with a blanket of ciliated mucous membrane. The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. Nasal mucosa appears redder than oral mucosa because of the rich blood supply present to warm the inhaled air.

The nasal cavity is divided medially by the septum into two slit-like air passages. The anterior part of the septum holds a rich vascular network, Kiesselbach’s plexus, the most common site of nosebleeds. In many people, the nasal septum is not absolutely straight and may deviate towards one passage.

The lateral walls of each nasal cavity contain three parallel bony projections—the superior, middle and inferior turbinates. They increase the surface area so that more blood vessels and mucous membranes are available to warm, humidify and filter the inhaled air. Underlying each turbinate is a cleft, the meatus, which is named for the turbinate above. The sinuses drain into the middle meatus, and tears from the nasolacrimal duct drain into the inferior meatus.

The olfactory receptors (hair cells) lie at the roof of the nasal cavity and in the upper one-third of the septum. These receptors for smell merge into the olfactory nerve, cranial nerve I, which transmits to the temporal lobe of the brain. While smell is not considered necessary for human survival, it reduces the risks of poor nutritional intake by enhancing the smell and taste (flavour) of food (Duffy, 2007; Farmer, Raddin and Roberts, 2009).

The paranasal sinuses are air-filled pockets within the cranium (Fig 13.3). They communicate with the nasal cavity and are lined with the same type of ciliated mucous membrane. They lighten the weight of the skull bones, serve as resonators for sound production and provide mucus, which drains into the nasal cavity. The sinus openings are narrow and easily occluded, which may cause inflammation or sinusitis.

Two pairs of sinuses are accessible to examination: the frontal sinuses in the frontal bone above and medial to the orbits and the maxillary sinuses in the maxilla (cheekbone) along the side walls of the nasal cavity. The other two sets are smaller and deeper: the ethmoid sinuses between the orbits and the sphenoid sinuses deep within the skull in the sphenoid bone. Sinuses support the humidification and warming of inspired air.

Only the maxillary and ethmoid sinuses are present at birth. The maxillary sinuses reach full size after all permanent teeth have erupted. The ethmoid sinuses grow rapidly between 6 and 8 years of age and after puberty. The frontal sinuses are absent at birth, are fairly well developed between 7 and 8 years of age and reach full size after puberty. The sphenoid sinuses are minute at birth and develop after puberty.

MOUTH

The mouth is the first segment of the digestive system and an airway for the respiratory system. The oral cavity is a short passage bordered by the lips, palate, cheeks and tongue. It contains the teeth and gums, tongue and salivary glands (Fig 13.4).

The lips are the anterior border of the oral cavity—the transition zone from the outer skin to the inner mucous membrane lining the oral cavity. The arching roof of the mouth is the palate; it is divided into two parts. The anterior hard palate is made up of bone and is a whitish colour. Posterior to this is the soft palate, an arch of muscle that is pinker in colour and mobile. The uvula is the free projection hanging down from the middle of the soft palate. The cheeks are the side walls of the oral cavity.

The floor of the mouth consists of the horseshoe-shaped mandible bone, the tongue and underlying muscles. The tongue is a mass of striated muscle arranged in a crosswise pattern so that it can change shape and position. The papillae are the rough, bumpy elevations on its dorsal surface. Note the larger vallate papillae in an inverted V shape across the posterior base of the tongue, and do not confuse them with abnormal growths. Underneath, the ventral surface of the tongue is smooth and shiny and has prominent veins. The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth.

The tongue’s ability to change shape and position enhances its functions in mastication, swallowing, cleansing the teeth and the formation of speech. The tongue also functions in taste sensation. Microscopic taste buds are in the papillae at the back and along the sides of the tongue and on the soft palate.

The mouth contains three pairs of salivary glands (Fig 13.5). The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. Its duct, Stensen’s duct, runs forwards to open on the buccal mucosa opposite the second molar. The submandibular gland is the size of a walnut. It lies beneath the mandible at the angle of the jaw. Wharton’s duct runs up and forwards to the floor of the mouth and opens at either side of the frenulum. The smallest gland, the almond-shaped sublingual gland, lies within the floor of the mouth under the tongue. It has many small openings along the sublingual fold under the tongue.

The glands secrete saliva, the clear fluid that moistens and lubricates the food bolus, starts digestion and cleans and protects the mucosa.

Adults have 32 permanent teeth—16 in each arch. Each tooth has three parts: the crown, the neck and the root. The gums (gingivae) collar the teeth. They are thick fibrous tissues covered with mucous membrane. The gums are different from the rest of the oral mucosa because of their pale pink colour and stippled surface.

THROAT

The throat, or pharynx, is the area behind the mouth and nose. The oropharynx is separated from the mouth by a fold of tissue on each side, the anterior tonsillar pillar. Behind the folds are the tonsils, each a mass of lymphoid tissue. The tonsils are the same colour as the surrounding mucous membrane, although they look more granular, and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes. The posterior pharyngeal wall is seen behind these structures. Some small blood vessels may show on it.

The nasopharynx is continuous with the oropharynx, although it is above the oropharynx and behind the nasal cavity. The pharyngeal tonsils (adenoids) and the eustachian tube openings are located here (see Fig 13.2).

LYMPHATICS

The oral cavity and throat have a rich lymphatic network (Fig 13.6). (For more discussion of the lymphatic system see Ch 11.) Although sources differ as to their nomenclature, one commonly used system is given here. Note that their labels correspond to adjacent structures.

You also should be familiar with the direction of the drainage patterns of the lymph nodes (Fig 13.7). When nodes are abnormal, check the area they drain for the source of the problem. Explore the area proximal (upstream) to the location of the abnormal node.

The lymphatic system is an extensive vessel system, which is separate from the cardiovascular system and is phylogenetically older. The lymphatics are a major part of the immune system, whose job it is to detect and eliminate foreign substances from the body. The vessels allow the flow of clear, watery fluid (lymph) from the tissue spaces into the circulation. Lymph nodes are small, oval clusters of lymphatic tissue that are set at intervals along the lymph vessels like beads on a string. The nodes filter the lymph and engulf pathogens, preventing potentially harmful substances from entering the circulation. Nodes are located throughout the body but are accessible to examination only in four areas: head and neck, arms, axillae and inguinal region. The greatest supply is in the head and neck.

DEVELOPMENTAL CONSIDERATIONS

CULTURAL AND SOCIAL CONSIDERATIONS

Orofacial clefts describe the incomplete closure of the hard or soft palate of the mouth with or without midline clefting of the upper or lower lip. Clefts are congenital abnormalities arising during development of the oral region. Cleft palate is relatively rare in the Australian population, indicated by rates of around 7.3 per 10 000 live births and even less common in the New Zealand population, at around 5.5 per 10 000 live births (Australian Institute of Health and Welfare (AIHW), 2008a). The incidence of cleft lip, with or without cleft palate, is somewhat higher in both regions at around 9 per 10 000 births (AIHW, 2008a). This rate is about 50% higher in Australian Indigenous infants (AIHW, 2009d).

Children tend to lose deciduous teeth at the rate of about 2–3 per year from the ages of 5 to 10. Australian and New Zealand children generally show good levels of dental health. Australian children particularly appear to have good access to dental care enhancing their good oral health, with 4 in 5 children visiting a dentist each 12 month period (AIHW, 2009a). In 2005, the majority of children and teenagers (approximately 80%) visited a dentist for a check-up and for preventative care treatments, rather than a dental or oral problem. Comparison of the number of decayed, missing or filled teeth in children across the 27 OECD countries indicated that Australian children ranked 7th, while children from New Zealand were at the OECD average, ranked 17th (AIHW, 2009a). The overall incidence of good oral health in children has increased due to factors such as provision of school dental care services, increased access to fluoridated toothpaste and drinking water and improved dental hygiene (AIHW, 2009a). However, the proportion of 6-year-old children who are free from dental decay in Australia declined between 1996 and 2002, to about 53% (AIHW, 2009c). The proportion of older children (12+ years of age) who remain decay free continues to grow, with older boys marginally more likely to develop decay than older girls (60% compared to 56%). However, good oral health varies across the population. Indigenous children, children in remote and very rural areas and those from the lowest socioeconomic groups show approximately twice the incidence of decayed, missing or filled teeth of their urbane counterparts (AIHW, 2009a).

Oral health of adults is also significantly impacted by location and age. Rural residents are twice as likely as city residents to be edentulous (9% compared to 5%) which can impact on diet and nutritional status (AIHW, 2009b). This percentage significantly increases with age; about 15% of Australian adults between 55 and 74 years are likely to have no natural teeth, while about 36% of adults over 75 have no remaining natural teeth (AIHW, 2008b). The health of teeth and gums is clearly related to access to dental care, with about 60% of city dwellers visiting the dentist regularly compared to 46% of non-city dwellers. Apparent lack of access to regular dental care, together with overall rates of dental decay, seems to impact on levels of untreated dental decay. About 20% of capital-city dwellers show previously untreated dental decay compared with about 30% in non-capital city dwellers (AIHW, 2009b).

Overall, however, oral health issues contribute only 0.9 disability-adjusted life years for Australian adults, even though about 600 Australians die each year from oral or oral-related cancers (AIHW, 2008c). Higher rates of lip and oral cancers are reported in Indigenous people, particularly Indigenous males; often presumed to be associated with higher levels of smoking (AIHW, 2008c).

SUBJECTIVE DATA

Disorders in the nose, mouth or throat cause pain, impaired function and in extreme situations could put the person at significant risk of airway obstruction or nutritional impairment. Subjective data collection should be done in conjunction with Chapters 14 and 16.

OBJECTIVE DATA

The purpose of the examination of nose, mouth and/or throat is to assess patterns of pain, or any other abnormalities, and the impact these have on the person’s nutritional state and/or respiratory function. Objective examination should be done in conjunction with Chapters 14 and 16.

Preparation	Equipment needed
Position the person sitting up straight with their head at your eye level. If the person wears dentures, offer a paper towel and ask the person to remove them.	Penlight
	Two tongue blades

Procedures and normal findings	Abnormal findings and clinical alerts
INSPECT AND PALPATE THE NOSE
External nose
Normally, the nose is symmetrical, in the midline and in proportion to other facial features (Fig 13.8). Inspect for any deformity, asymmetry, inflammation or skin lesions. If an injury is reported or suspected, palpate gently for any pain or break in contour.
Test the patency of the nostrils by pushing each nasal wing shut with your finger while asking the person to sniff inwards through the other naris. This reveals any obstruction, which later is explored using the nasal speculum. The sense of smell, mediated by cranial nerve I, is usually not tested in a routine examination. The procedure for assessing smell is presented with cranial nerve testing in Chapter 22.	Absence of sniff indicates obstruction (e.g. common cold, nasal polyps, rhinitis).
PALPATE THE SINUS AREAS
Using your thumbs, press over the frontal sinuses below the eyebrows (Fig 13.9, A) and over the maxillary sinuses below the cheekbones (Fig 13.10, B). Take care not to press directly on the eyeballs. The person should feel firm pressure but no pain.	Sinus areas are tender to palpation in persons with chronic allergies and acute infection (sinusitis).
PALPATE THE TRACHEA
Normally, the trachea is midline; palpate for any tracheal shift. Place your index finger on the trachea in the sternal notch, and slip it off to each side (Fig 13.10). The space should be symmetrical on both sides. Note any deviation from the midline.	Conditions of tracheal shift: • The trachea is pushed to the unaffected (or healthy) side with an aortic aneurysm, a tumour, unilateral thyroid lobe enlargement and pneumothorax. • The trachea is pulled towards the affected (diseased) side with large atelectasis, pleural adhesions or fibrosis. • Tracheal tug is a rhythmic downwards pull that is synchronous with systole and that occurs with aortic arch aneurysm.
INSPECT THE MOUTH
Begin with anterior structures and move posteriorly. Use a tongue blade to retract structures and a bright light for optimal visualisation.
Lips
Inspect the lips for colour, moisture, cracking or lesions. Retract the lips and note their inner surface as well (Fig 13.11).	In light-skinned people: circumoral pallor occurs with shock and anaemia; cyanosis with hypoxaemia and chilling; cherry red lips with carbon monoxide poisoning, Herpes simplex, other lesions (see Table 13.2).
Tongue
Check the tongue for colour, surface characteristics and moisture. The colour is pink and even. The dorsal surface is normally roughened from the papillae. A thin white coating may be present. Ask the person to touch the tongue to the roof of the mouth. Its ventral surface looks smooth, glistening and shows veins. Saliva is present. If the person is able to move their own tongue, ask them to move it so you can visualise the ventral and lateral surfaces. Inspect for any white patches or lesions—normally none are present. If any occur, palpate these lesions for induration.	Beefy red swollen tongue. Smooth glossy areas (see Table 13.5). Enlarged tongue occurs with mental retardation, hypothyroidism, acromegaly.
Palate
Observe the uvula; it normally looks like a fleshy pendant hanging in the midline (Fig 13.12). Ask the person to say ‘ahhh’ and note the soft palate and uvula rise in the midline. This tests one function of cranial nerve X, the vagus nerve.	A bifid uvula looks like it is split in two (see Table 13.6). Any deviation to the side or absent movement indicates nerve damage, which might occur following a stroke or head injury. Clinical alert: this finding may indicate a raised risk of potential airway compromise and aspiration. Further assessment of swallow and airway patency is required.
INSPECT THE THROAT
With your light, observe the oval, rough-surfaced tonsils behind the anterior tonsillar pillar (see Fig 13.12). Their colour is the same pink as the oral mucosa, and their surface is peppered with indentations or crypts. In some people the crypts collect small plugs of whitish cellular debris. This does not indicate infection. However, there should be no exudate on the tonsils. Tonsils are graded in size as follows: 1+ Visible 2+ Halfway between tonsillar pillars and uvula 3+ Touching the uvula 4+ Touching each other You may normally see 1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty.	With an acute infection, tonsils are bright red, swollen and may have exudate or large white spots. A white membrane covering the tonsils may accompany infectious mononucleosis, leukaemia and diphtheria. Tonsils are enlarged to 2+, 3+ or 4+ with an acute infection.
Enlarge your view of the posterior pharyngeal wall by depressing the tongue with a tongue blade (Fig 13.13). Push down halfway back on the tongue. Press slightly off centre to avoid eliciting the gag reflex. You can help the person whose gag reflex is easily triggered by offering a tongue blade to depress their own tongue. (Some people can lower their own tongue so the tongue blade is not needed.) Scan the posterior wall for colour, exudate or lesions. When finished, discard the tongue blade.
During the examination, notice any breath odour. This is common and usually is due to a local cause, such as poor oral hygiene, heavy smoking. Occasionally it may indicate a systemic disease.	A foul, fetid odour may be noticed as occurs in dental or respiratory infections.
DEVELOPMENTAL CONSIDERATIONS
Infants and children
Because the oral examination is intrusive for the infant or young child, the timing is best towards the end of the complete examination, along with the ear examination. But if any crying episodes occur earlier, seize the opportunity to examine the open mouth and oropharynx.
As with the ear examination, let the parent help position the child. Place the infant supine on the examining table, with the arms restrained (Fig 13.14). The older infant and toddler may be held on the parent’s lap with one of the parent’s hands holding the arms down and the other hand securing the child’s head against the parent’s chest. Although not often needed, the parent’s leg can reach over and capture the child’s legs between the parent’s own (Fig 13.15).
Use a game to help prepare the young child. Encourage the preschool child to use a tongue blade to look into a puppet’s mouth. Or place a mirror so that the child can look into the mouth while you do. The school-age child is usually cooperative and loves to show off missing or new teeth (Fig 13.16).
Be discriminating in your use of the tongue blade. It may be necessary for a full view of oral structures, but it produces a strong gag reflex in the infant. You may avoid the tongue blade completely with a cooperative preschooler and school-age child. Try asking the young child to open the mouth ‘as big as a lion’ and to move the tongue in different directions. To enlarge your view of the oropharynx, ask the child to stick out the tongue and ‘pant like a dog’. At some point, you will encounter an uncooperative young child who clenches the teeth and refuses to open the mouth. If all your other efforts have failed, slide the tongue blade along the buccal mucosa and turn it between the back teeth. Push down to depress the tongue. This stimulates the gag reflex, and the child opens the mouth wide for a few seconds. You will have a brief look at the throat. Make the most of it.
Nose. The newborn may have milia across the nose. There should be no nasal flaring or narrowing with breathing.	Nasal flaring in the infant indicates respiratory distress.
It is essential to determine the patency of the nares in the immediate newborn period because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are suctioned gently with a bulb syringe. Avoid the nasal speculum when examining the infant and young child. Instead, gently push up the tip of the nose with your thumb while using your other hand to shine the light into the naris. With a toddler, be alert for the possible foreign body lodged in the nasal cavity (see Table 13.1). Only in children older than 8 years do you need to palpate the child’s sinus areas. In younger children, sinus areas are too small for palpation.	A transverse ridge across the nose occurs in a child with chronic allergy from wiping the nose upwards with palm (see Table 13.3). Nasal narrowing on inhalation is seen with chronic nasal obstruction and mouth breathing. Inability to pass catheter through nasal cavity indicates choanal atresia, which needs immediate intervention (see Table 13.1).
On the palate, Epstein pearls are a normal finding in newborns and infants (Fig 13.17). They are small, whitish, glistening, pearly papules along the median raphe of the hard palate and on the gums, where they look like teeth. They are small retention cysts and disappear in the first few weeks.	A high-arched palate is usually normal in the newborn, but a very narrow or high arch also occurs with Turner’s syndrome, Ehlers-Danlos syndrome, Marfan’s syndrome and Treacher Collins syndrome, or develops in the mouth-breather in chronic allergies.
The tonsils are not visible in the newborn. They gradually enlarge during childhood, remaining proportionately larger until puberty. Tonsils appear still larger if the infant is crying or gagging. Normally the newborn can produce a strong, lusty cry. Insert your gloved finger into the baby’s mouth and palpate the hard and soft palate as the baby sucks. The sucking reflex can be elicited in infants up to 12 months old.
FURTHER OBJECTIVE ASSESSMENT FOR ADVANCED PRACTICE
The assessments that are described in the following sections require advanced skill and scope of practice. Nurses working in specialist units and some community nurses need to develop these skills.
Inspect and palpate the nose
Nasal cavity
Inspect the turbinates, the bony ridges curving down from the lateral walls. The superior turbinate will not be in your view, but the middle and inferior turbinates appear the same light red colour as the nasal mucosa. Note any swelling but do not try to push the speculum past it. Turbinates are quite vascular and tender if touched.	Turbinates swell marginally in a cyclical manner, thus apparent abnormalities, particularly asymmetries, need to be repeatedly assessed over time.
Note any polyps, benign growths that accompany chronic allergy, and distinguish them from the normal turbinates.	Polyps are smooth, pale grey, avascular, mobile, nontender (see Table 13.1).
The sinus areas
Transillumination
You may use this technique when you suspect sinus inflammation, although it is of limited usefulness. Darken the examining room. Affix a strong narrow light to the end of the otoscope and hold it deep under the superior orbital ridge against the location of the frontal sinus area (Fig 13.18). Cover with your hand. A diffuse red glow is a normal response. It comes from the light shining through the air in the healthy sinus.	An inflamed sinus filled with fluid does not transilluminate.
You may use the same technique with the maxillary sinuses, providing the person has no upper denture that would impede the light. Ask the person to tilt the head back and open the mouth. Shine the light on each cheek just under the inner corner of the eye. Note a dull glow inside the mouth on the hard palate as the light transmits through the sinuses. Healthy sinuses contain air and may light up symmetrically. But be aware that asymmetry is not a reliable sign of sinus inflammation because many healthy sinuses normally will not transilluminate.	A significant finding is one sinus illuminated and the other clouded. If one has fluid, it looks darker than the healthy one.
Palpate the lymph nodes in the neck area
Using a gentle circular motion of your fingerpads, palpate the lymph nodes (Fig 13.19). (Normally, the salivary glands are not palpable. When symptoms warrant, check for parotid tenderness by palpating in a line from the outer corner of the eye to the lobule of the ear.) Beginning with the preauricular lymph nodes in front of the ear, palpate the 10 groups of lymph nodes in a routine order. Many nodes are closely packed, so you must be systematic and thorough in your examination. Once you establish your sequence, do not vary or you may miss	The parotid is swollen with mumps (see Table 13.7).
Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, comparing the two sides symmetrically. However, the submental gland under the tip of the chin is easier to explore with one hand. When you palpate with one hand, use your other hand to position the person’s head. For the deep cervical chain, tip the person’s head towards the side being examined to relax the ipsilateral muscle (Fig 13.20). Then you can press your fingers under the muscle. Search for the supraclavicular node by having the person hunch the shoulders and elbows forwards (Fig 13.21); this relaxes the skin. The inferior belly of the omohyoid muscle crosses the posterior triangle here; do not mistake it for a lymph node.
If nodes are enlarged or tender, check the area they drain for the source of the problem. For example, those in the upper cervical or submandibular area often relate to inflammation or a neoplasm in the head and neck. Follow up on or refer your findings. An enlarged lymph node, particularly when you cannot find the source of the problem, deserves prompt attention.	The following criteria are common clues but are not definitive in all circumstances. • Acute infection—nodes are bilateral, enlarged, warm, tender and firm but freely movable. • Chronic inflammation (e.g. in tuberculosis the nodes are clumped). • Cancerous nodes are hard, unilateral, nontender and fixed. • Nodes with HIV infection are enlarged, firm, nontender and mobile. Occipital node enlargement is common with HIV infection. • A single, enlarged, nontender, hard, left supraclavicular node (Virchow’s node) may indicate neoplasm in thorax or abdomen. • Painless, rubbery, discrete nodes that gradually appear occur with Hodgkin’s lymphoma.

TABLE 13.1 Abnormalities of the nose

Choanal atresia

A bony or membranous septum between the nasal cavity and the pharynx of the newborn. When the condition is bilateral, it requires the immediate insertion of an oral airway to prevent asphyxia because most newborns are obligate nose breathers. When the condition is unilateral, the infant may be asymptomatic until the onset of the first respiratory infection.

Epistaxis

The most common site of a nosebleed is Kiesselbach’s plexus in the anterior septum. It may be spontaneous from a local cause or a sign of underlying illness. Causes include nose picking, forceful coughing or sneezing, fracture, foreign body, rhinitis, heavy exertion or a coagulation disorder. Bleeding from the anterior septum is easily controlled and rarely severe. A posterior haemorrhage is less common (<10%) but is more profuse, harder to manage and more serious.

Foreign body

Children particularly are apt to put an object up the nose (here, yellow plastic foam), producing unilateral mucopurulent drainage and foul odour. Because some risk for aspiration exists, removal should be prompt.

Perforated septum

A hole in the septum, usually in the cartilaginous part, may be caused by snorting cocaine, chronic infection, trauma from continual picking of crusts or nasal surgery. It is seen directly, or as a spot of light when the penlight is directed into the other naris. © Dr P. Marazzi/SCIENCE PHOTO LIBRARY

Furuncle

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

Acute rhinitis

The first sign is a clear, watery discharge, rhinorrhoea, which later becomes purulent. This is accompanied by sneezing and swollen mucosa, which causes nasal obstruction. Turbinates are dark red and swollen. Reprinted from Fireman: Atlas of Allergies, 2nd edn. Fireman P, 1995, Mosby, by permission of the publisher.

Allergic rhinitis

Rhinorrhoea, itching of nose and eyes, lacrimation, nasal congestion and sneezing are present. Note serous oedema and swelling of turbinates to fill the air space. Turbinates are usually pale (although may appear violet), and their surface looks smooth and glistening. May be seasonal or perennial, depending on allergen. Individual has a strong family history of seasonal allergies.

Sinusitis

Facial pain, after upper respiratory infection; signs include red swollen nasal mucosa, swollen turbinates and purulent discharge. Person also has fever, chills, malaise. With maxillary sinusitis, dull throbbing pain occurs in cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge.

Nasal polyps

Smooth, pale grey nodules, which are overgrowths of mucosa, most commonly caused by chronic allergic rhinitis. May be stalked. A common site is protrusion from the middle meatus. Often multiple, they are mobile and nontender in contrast to turbinates. They may obstruct air passageways as they get larger. Symptoms include the absence of a sense of smell and a ‘valve that moves’ in the nose as the person breathes.

Carcinoma

Any skin growth that doesn’t heal or bleeds easily should be referred to a medical practitioner as it could be a malignant growth. © Dr P. Marazzi/SCIENCE PHOTO LIBRARY

TABLE 13.2 Abnormalities of the lips

Cleft lip

Orofacial clefts are the most common congenital deformities of the head and neck. The incidence of orofacial clefts in infants born in Australia is 17 per 10 000. The incidence is 50% higher among Indigenous infants (AIHW, 2009d). Early treatment preserves the functions of speech and language formation and deglutition (swallowing).

Herpes simplex 1

The cold sores are groups of clear vesicles with a surrounding indurated erythematous base. These evolve into pustules, which rupture, weep and crust, and heal in 4 to 10 days. The most likely site is the lip–skin junction; infection often recurs in same site. Caused by the herpes simplex virus (HSV-1), the lesion is highly contagious and is spread by direct contact. Recurrent herpes infections may be precipitated by sunlight, fever, colds, allergy. It is a very common lesion, affecting 50% of adults.

Angular cheilitis (stomatitis, perlèche)

Erythema, scaling, shallow and painful fissures at the corners of the mouth occur with excess salivation and Candida infection. It is often seen in edentulous persons and in those with poorly fitting dentures causing folding in of corners of mouth, creating a warm and moist environment favouring growth of yeast.

Carcinoma

The initial lesion is round and indurated, then it becomes crusted and ulcerated with an elevated border. The majority occur between the outer and middle thirds of lip. Any lesion that is still unhealed after 2 weeks should be referred. © Dr P. Marazzi/SCIENCE PHOTO LIBRARY

Retention ‘cyst’ (mucocele)

A round, well-defined translucent nodule that may be very small or up to 1 or 2 cm. It is a pocket of mucus that forms when a duct of a minor salivary gland ruptures. The benign lesion also may occur on the buccal mucosa, on the floor of the mouth or under the tip of the tongue.

TABLE 13.3 Abnormalities of the teeth and gums

Baby bottle tooth decay

Destruction of numerous deciduous teeth may occur in older infants and toddlers who take a bottle of milk, juice or sweetened drink to bed and prolong bottle feeding past the age of 1 year. Liquid pools around the upper front teeth. Mouth bacteria act on carbohydrates in the liquid, especially sucrose, forming metabolic acids. Acids break down tooth enamel and destroy its protein.

Malocclusion

Upper or lower dental arches are not in alignment and incisors protrude from developmental problem of mandible or maxilla, or incompatibility between jaw size and tooth size. The condition increases risk of facial deformity, negative body image, chewing problems or speech dysfluency.

Dental caries

Progressive destruction of tooth. Decay initially looks chalky white. Later, it turns brown or black and forms a cavity. Early decay is apparent only on x-ray study. Susceptible sites are tooth surfaces where food debris, bacterial plaque and saliva collect.

Epulis

A nontender, fibrous nodule of the gum, seen emerging between the teeth; an inflammatory response to injury or haemorrhage.

Gingival hyperplasia

Painless enlargement of the gums, sometimes overreaching the teeth. This occurs with puberty, pregnancy, leukaemia and with long-term therapeutic use of phenytoin (Dilantin).

Gingivitis

Gum margins are red, swollen and bleed easily. This case is severe; gingival tissue has desquamated, exposing roots of teeth. Inflammation is usually due to poor dental hygiene or vitamin C deficiency. The condition may occur in pregnancy and puberty because of changing hormonal balance.

Meth mouth

Illicit methamphetamine abuse (crystal meth, meth ice) leads to extensive dental caries, gingivitis, tooth cracking and edentulism. Methamphetamine causes vasoconstriction and decreased saliva, and its use increases the urge to consume sugars and starches and to give up oral hygiene. Absence of the buffering saliva leads to increased acidity in the mouth, and the increased plaque encourages bacterial growth. These conditions and the presence of carbohydrates set up an oral environment prone to caries, cracking of enamel and the damage seen here.

From Neville BW et al: Oral and Maxillofacial Pathology, 3rd edn. St Louis, 2009, Saunders.

TABLE 13.5 Abnormalities of the tongue

Ankyloglossia

(Tongue-tie.) A short lingual frenulum, here fixing the tongue tip to the floor of the mouth and gums. This limits mobility and will affect speech (pronunciation of a, d, n) if the tongue tip cannot be elevated to the alveolar ridge. A congenital defect.

Fissured or scrotal tongue

Deep furrows divide the papillae into small irregular rows. The condition occurs in 5% of the general population and in Down syndrome. The incidence increases with age. (Vertical, or longitudinal, fissures also occur with dehydration because of reduced volume of the tongue.)

Geographic tongue (migratory glossitis)

Pattern of normal coating interspersed with bright red, shiny, circular bald areas with raised pearly borders. Pattern resembles a map, and changes in a few days. Not significant, and its cause is not known.

Smooth, glossy tongue (atrophic glossitis)

The surface is slick and shiny; the mucosa thins and looks red from decreased papillae. Accompanied by dryness of tongue and burning. Occurs with vitamin B12 deficiency (pernicious anaemia), folic acid deficiency and iron deficiency anaemia. Here, also note angular cheilitis.

Black hairy tongue

This is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. Colour varies from black-brown to yellow. It occurs after use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus.

Enlarged tongue (macroglossia)

The tongue is enlarged and may protrude from mouth. The condition is not painful but may impair speech development. Here, it occurs with Down syndrome; it also occurs with cretinism, myxoedema, acromegaly. Also a transient swelling occurs with local infections.

Carcinoma

An ulcer with rolled edges; indurated. Occurs particularly at sides, base and under the tongue. When it is in the floor of mouth, it may cause painful movement or limited movement of tongue. Risk of early metastasis is present because of rich lymphatic drainage. Heavy smoking and heavy alcohol use place persons at greater risk.

TABLE 13.6 Abnormalities of the oropharynx

Cleft palate

A congenital defect, the failure of fusion of the maxillary processes. Wide variation occurs in the extent of cleft formation, from upper lip only, palate only, uvula only, to cleft of the nostril and the hard and soft palates.

Bifid uvula

The uvula looks partly severed. May indicate a submucous cleft palate, which feels like a notch at the junction of the hard and soft palates. The submucous cleft palate may affect speech development because it prevents necessary air trapping. The incidence of bifid uvula varies among racial groups: it is common in Native Americans, uncommon in Caucasians and rare in African-Americans. © Dr P. Marazzi/SCIENCE PHOTO LIBRARY

Oral Kaposi’s sarcoma

Bruise-like, dark red or violet, confluent macule, usually on the hard palate, may be on soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.

Acute tonsillitis and pharyngitis

Bright red throat; swollen tonsils; white or yellow exudates on tonsils and pharynx; swollen uvula; and enlarged, tender anterior cervical and tonsillar nodes. Accompanied by severe sore throat, painful swallowing, fever >38°C of sudden onset. Caution: One cannot discriminate bacterial from viral infection on clinical data alone; all sore throats need a throat culture. Bacterial pharyngitis caused by group A β-haemolytic Streptococcus, if untreated, may lead to the complication of rheumatic fever. This is a serious complex illness characterised by fever, malaise, swollen joints, rash and scarring on the heart valves. © Dr P. Marazzi/SCIENCE PHOTO LIBRARY

TABLE 13.7 Swelling on the neck

Parotid gland enlargement

Rapid painful inflammation of the parotid occurs with mumps. Parotid swelling also occurs with blockage of a duct, abscess or tumour. Note swelling anterior to lower ear lobe. Stensen duct obstruction can occur in ageing adults dehydrated from diuretics or anticholinergics.

DOCUMENTATION AND CRITICAL THINKING

ABNORMAL FINDINGS

TABLE 13.4 Abnormalities of the buccal mucosa

Aphthous ulcers

A ‘canker sore’ is a vesicle at first, then a small, round, ‘punched-out’ ulcer with white base surrounded by a red halo. It is quite painful and lasts for 1 to 2 weeks. The cause is unknown, although it is associated with stress, fatigue and food allergy. It is common, affecting 20% to 60% of the population.

Koplik’s spots

Small blue-white spots with irregular red halo scattered over mucosa opposite the molars. An early sign, and pathognomonic, of measles.

Leucoplakia

Chalky white, thick, raised patch with well-defined borders. The lesion is firmly attached and does not scrape off. It may occur on the lateral edges of tongue. It is due to chronic irritation, and occurs more frequently with heavy smoking and heavy alcohol use. Lesions are precancerous, and the person should be referred. (Here, the lesion is associated with squamous carcinoma.)

Candidiasis or monilial infection

A white, cheesy, curd-like patch on the buccal mucosa and tongue. It scrapes off, leaving raw, red surface that bleeds easily. Termed ‘thrush’ in the newborn. It is an opportunistic infection that occurs after the use of antibiotics, corticosteroids and in immunosuppressed persons.