1 Discharge. Any nasal discharge or runny nose? Continuous?

_ Is the discharge watery, purulent, mucoid, bloody?

`

Rhinorrhea

`

2 Frequent colds. Any unusually frequent or severe colds (upper respiratory infections)? How often do these occur?

`

Most people have occasional colds; thus asking this more precise question yields more meaningful data.

``

3 Sinus pain. Any sinus pain or sinusitis? How is this treated?

_ Do you have chronic postnasal drip?

`

4 Trauma. Ever had any trauma or a blow to the nose?

_ Can you breathe through your nose? Are both sides obstructed or one?

`

Trauma may cause deviated septum, which may cause nares to be obstructed.

`

5 Epistaxis (nosebleeds). Any nosebleeds? How often?

_ How much bleeding—a teaspoonful or does it pour out?

_ Color of the blood—red or brown? Clots?

``

Epistaxis

`

epistaxis (nosebleeds)

_ From one nostril or both?

_ Aggravated by nose-picking or scratching?

_ How do you treat the nosebleeds? Are they difficult to stop?

Person should sit up with head tilted forward, pinch nose between thumb and forefinger for 5 to 15 minutes.

`

6 Allergies. Any allergies or hay fever? To what are you allergic (e.g., pollen, dust, pets)?

_ How was this determined?

_ What type of environment makes it worse? Can you avoid exposure?

`

“Seasonal” rhinitis if due to pollen; “perennial” if allergen is dust.

`

_ Use inhalers, nasal spray, nose drops? How often? Which type?

_ How long have you used this?

`

Misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, a common problem.

`

7 Altered smell. Experienced any change in sense of smell?

`

Sense of smell diminishes with cigarette smoking, chronic allergies, aging.

`

Mouth and Throat

1 Sores or lesions. Noticed any sores or lesions in the mouth, tongue, or gums?

_ How long have you had it? Ever had this lesion before?

_ Is it single or multiple?

_ Does it seem to be associated with stress, season change, food?

_ How have you treated the sore? Applied any local medication?

`

History helps determine whether oral lesions have infectious, traumatic, immunologic, or malignant etiology.

`

2 Sore throat. How about sore throats? How frequently do you get them? Have a sore throat now? When did it start?

_ Is it associated with cough, fever, fatigue, decreased appetite, headache, postnasal drip, or hoarseness?

_ Is it worse when arising? What is the humidity level in the room where you sleep? Any dust or smoke inhaled at work?

_ Usually get a throat culture for the sore throats? Were any documented as streptococcal?

_ How have you treated this sore throat: medication, gargling? How effective are these? Have your tonsils or adenoids been taken out?

`

Untreated strep throat may lead to the complication of rheumatic fever.

`

3 Bleeding gums. Any bleeding gums? How long have you had this?

4 Toothache. Any toothache? Do your teeth seem sensitive to hot, cold? Have you lost any teeth?

`

5 Hoarseness. Any hoarseness, voice change? For how long?

_ Feel like having to clear your throat? Or like a “lump in your throat?”

_ Use your voice a lot at work, recreation?

_ Does the hoarseness seem associated with a cold, sore throat?

`

Hoarseness of the larynx has many causes: overuse of the voice, upper respiratory infection (URI), chronic inflammation, lesions, or a neoplasm.

`

6 Dysphagia. Any difficulty swallowing? How long have you had it?

_ Feel like food gets stopped at a certain point?

_ Any pain with this?

`

Dysphagia

`

7 Altered taste. Any change in sense of taste?

`

8 Smoking, alcohol consumption. Do you smoke? Pipe or cigarettes? Smokeless tobacco? How many packs per day? For how many years?

`

Chronic tobacco use leads to tooth loss, coronal and root caries, and periodontal disease in older adults.

`

_ When was your last alcohol drink? How much alcohol did you drink that time? How much alcohol do you usually drink?

`

Chronic tobacco use and heavy alcohol consumption highly increase risk for oral and pharyngeal cancers.

`

9 Self-care behaviors. Tell me about your daily dental care. How often do you use a toothbrush and floss?

`

Assess self-care behaviors for oral hygiene.

`

_ Last dental examination? Do dental problems affect which foods you eat?

_ Do you have a dental appliance: braces, bridge, headgear?

_ Wear dentures? All the time? How long have you had this set? How do they fit?

`

Periodic dental screening is necessary to note caries.

`

_ Any sores or irritation on the palate or gums?

_ Any problems with talking—do the dentures whistle or drop? Can you chew all foods with them? How do you clean them?

`

Lesions may arise from ill-fitting dentures, or the presence of dentures may mask the eruption of new lesions.

`

Additional History for the Aging Adult

1.

`

Xerostomia

(`

Additional History for the Aging Adult

2.Have you lost any teeth? Can you chew all types of food?

`

Note a decrease in eating meat, fresh vegetables, and cleansing foods such as apples.

`

Additional History for the Aging Adult

3.Are you able to care for your own teeth or dentures?

`

Self-care may be decreased by physical disability (arthritis), vision loss, confusion, or depression.

`

Additional History for the Aging Adult

4.Noticed a change in your sense of taste or smell?

`

Some people add extra salt and sugar to enhance food when taste begins to wane.

Also, diminished smell may decrease the person's ability to detect food spoilage, natural gas leaks, or smoke from a fire

`

External Nose

Normally, the nose is symmetric, in the midline, and in proportion to other facial features (Fig. 16-7). 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 inward 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 not tested in a routine examination. The procedure for assessing smell is presented with cranial nerve testing in Chapter 23.

`

Absence of sniff indicates obstruction (e.g., common cold, nasal polyps, rhinitis).

`

Nasal Cavity

Attach the short wide-tipped speculum to the otoscope head and insert this combined apparatus into the nasal vestibule, avoiding pressure on the nasal septum. Gently lift up the tip of the nose with your finger before inserting.

View each nasal cavity with the person's head erect and then with the head tilted back. Inspect the nasal mucosa, noting its normal red color and smooth, moist surface (Fig. 16-8). Note any swelling, discharge, bleeding, or foreign body.

`

Rhinitis—nasal mucosa is swollen and bright red with URI.

Discharge is common with rhinitis and sinusitis, varying from watery and copious to thick, purulent, and green-yellow.

With chronic allergy, mucosa looks swollen, boggy, pale, and gray.

`

Observe the nasal septum for deviation (Fig. 16-9). A deviated septum is common and is not significant unless air flow is obstructed. (If present in a hospitalized patient, document the deviated septum in the event that the person needs nasal suctioning or a nasogastric tube.) Also note any perforation or bleeding in the septum.

`

A deviated septum looks like a hump or shelf in one nasal cavity.

Perforation is seen as a spot of light from a penlight shining in the other naris and occurs with cocaine use.

Epistaxis commonly comes from anterior septum

`

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 color 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.

Note any polyps (benign growths that accompany chronic allergy), and distinguish them from the normal turbinates.

`

Polyps are smooth, pale gray, avascular, mobile, nontender (see Table 16-1).

`

PALPATE THE SINUS AREAS

Using your thumbs, press the frontal sinuses by pressing up and under the eyebrows (Fig. 16-10, A) and over the maxillary sinuses below the cheekbones (Fig. 16-10, 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).

`

Transillumination

There is no evidence to support the practice of transillumination of the frontal or maxillary sinuses when you suspect sinus inflammation.¹⁰ The diagnosis requires distinct differences in the illumination of one of the sinus pair. Thus the technique would not help in chronic sinusitis that has diffuse swelling of all sinus mucosa. Although there is more fluid collection with acute sinusitis, the asymmetry of light illumination still is not valid because many healthy sinuses normally will not transilluminate.

`

INSPECT THE MOUTH

Begin with anterior structures and move posteriorly. Use a tongue blade to retract structures and a bright light for optimal visualization.

`

Lips

Inspect the lips for color, moisture, cracking, or lesions. Retract the lips and note their inner surface as well (Fig. 16-11). All racial groups have lips that are deeper or pinker than facial skin. However, some African Americans normally may have bluish lips and a dark line on the gingival margin.

`

In light-skinned people: circumoral pallor occurs with shock and anemia; cyanosis with hypoxemia and chilling; cherry red lips with carbon monoxide poisoning, acidosis from aspirin poisoning, or ketoacidosis.

Cheilitis (perlèche)—cracking at the corners.

Herpes simplex, other lesions (see Table 16-2, Abnormalities of the Lips, p. 375).

`

Teeth and Gums

The condition of the teeth is an index of the person's general health. Your examination should not replace the regular dental examination, but you should note any diseased, absent, loose, or abnormally positioned teeth. The teeth normally look white, straight, evenly spaced, and clean and free of debris or decay.

`

Discolored teeth appear brown with excessive fluoride use, yellow with tobacco use.

`

Compare the number of teeth with the number expected for the person's age. Ask the person to bite as if chewing something and note alignment of upper and lower jaw. Normal occlusion in the back is the upper teeth resting directly on the lowers; in the front, the upper incisors slightly override the lower incisors.

`

Grinding down of tooth surface; plaque—soft debris; caries—decay.

Malocclusion (poor biting relationship), protrusion of upper or lower incisors (see Table 16-3).

`

Normally, the gums look pink or coral with a stippled (dotted) surface. The gum margins at the teeth are tight and well defined (Fig. 16-12). Check for swelling; retraction of gingival margins; and spongy, bleeding, or discolored gums. Some African Americans normally may have a dark melanotic line along the gingival margin.

`

Gingival hyperplasia (see Table 16-3), crevices between teeth and gums, pockets of debris.

Gums bleed with slight pressure, indicating gingivitis.

Dark line on gingival margins occurs with lead and bismuth poisoning.

`

Tongue

Check the tongue for color, surface characteristics, and moisture. The color is pink and even. The dorsal surface is normally roughened from the papillae. A thin white coating may be present (Fig. 16-13). Ask the person to touch the tongue to the roof of the mouth. Its ventral surface looks smooth and glistening and shows veins. Saliva is present.

`

Beefy red, swollen tongue. Smooth glossy areas (see Table 16-5).

Enlarged tongue occurs with mental retardation, hypothyroidism, acromegaly; a small tongue accompanies malnutrition.

Dry mouth occurs with dehydration, fever; tongue has deep vertical fissures.

Saliva is decreased when taking anticholinergic and other medications.

Excess saliva and drooling occur with gingivostomatitis and neurologic dysfunction.

`

With a glove,* hold the tongue with a cotton gauze pad for traction and swing the tongue out and to each side (Fig. 16-14). Inspect for any white patches or lesions—normally none are present. If any occur, palpate these lesions for induration.

Inspect carefully the entire U-shaped area under the tongue behind the teeth. Oral malignancies are most likely to develop here. Note any white patches, nodules, or ulcerations. If lesions are present or with any person older than 50 years or with a positive history of smoking or alcohol use, use your gloved hand to palpate the area. Place your other hand under the jaw to stabilize the tissue and to “capture” any abnormality (Fig. 16-15). Note any induration.

`

Any lesion or ulcer persisting for more than 2 weeks must be investigated.

An indurated area may be a mass or lymphadenopathy, and it must be investigated.

`

Buccal Mucosa

Hold the cheek open with a wooden tongue blade, and check the buccal mucosa for color, nodules, or lesions. It looks pink, smooth, and moist, although patchy hyperpigmentation is common and normal in dark-skinned people.

`

Dappled brown patches are present with Addison's disease (chronic adrenal insufficiency).

`

An expected finding is Stensen's duct, the opening of the parotid salivary gland. It looks like a small dimple opposite the upper second molar. You also may see a raised occlusion line on the buccal mucosa parallel with the level the teeth meet. This is caused by the teeth closing against the cheek.

`

Orifice of Stensen's duct looks red with mumps.

Koplik spots—early prodromal (early warning) sign of measles.

`

A larger patch also may be present along the buccal mucosa. This is leukoedema, a benign, milky, bluish white, opaque area, more common in Blacks and East Indians. When it is mild, the patch disappears as you stretch the cheeks. It is always bilateral. With age, it looks grayish white and thickened. The cause is unknown. Do not mistake leukoedema for oral infections such as candidiasis (thrush).

`

Candida

`

Fordyce granules

Fig. 16-16

`

The chalky white raised patch of leukoplakia is abnormal (see Table 16-4, Abnormalities of the Buccal Mucosa).

`

Palate

Shine your light up to the roof of the mouth. The more anterior hard palate is white with irregular transverse rugae. The posterior soft palate is pinker, smooth, and upwardly movable. A normal variation is a nodular bony ridge down the middle of the hard palate, a torus palatinus (Fig. 16-17). This benign growth arises after puberty and is a more common finding in American Indians, Inuits, and Asians.

`

The hard palate appears yellow with jaundice. In Blacks with jaundice, it may look yellow, muddy yellow, or green-brown.

Oral Kaposi sarcoma is the most common early lesion in people with AIDS (see Table 16-6).

`

Observe the uvula; it normally looks like a fleshy pendant hanging in the midline (Fig. 16-18). 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; more common in American Indians (see Table 16-6).

Any deviation to the side or absent movement indicates nerve damage, which also occurs with poliomyelitis and diphtheria.

`

INSPECT THE THROAT

With your light, observe the oval, rough-surfaced tonsils behind the anterior tonsillar pillar (see Fig. 16-18). Their color 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+

2+

3+

4+

`

With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots.

A white membrane covering the tonsils may accompany infectious mononucleosis, leukemia, and diphtheria.

`

You may normally see 1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty.

`

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. 16-19). Push down halfway back on the tongue; if you push on its tip, the tongue will hump up in back. Press slightly off center to avoid eliciting the gag reflex. You can help the person whose gag reflex is easily triggered by offering a tongue blade to depress his or her own tongue. (Some people can lower their own tongue so the tongue blade is not needed.) Scan the posterior wall for color, exudate, and lesions. When finished, discard the tongue blade.

Although usually it is not done in the screening examination, touching the posterior wall with the tongue blade elicits the gag reflex. This tests cranial nerves IX and X, the glossopharyngeal and vagus.

`

Test cranial nerve XII, the hypoglossal nerve, by asking the person to stick out the tongue. It should protrude in the midline. Children enjoy this request! Note any tremor, loss of movement, or deviation to the side.

`

With cranial nerve XII damage, the tongue deviates toward the paralyzed side.

A fine tremor of the tongue occurs with hyperthyroidism; a coarse tremor occurs with cerebral palsy and alcoholism.

`

During the examination, notice any breath odor, halitosis. This is common and usually has a local cause, such as poor oral hygiene, consumption of odoriferous foods, alcohol consumption, heavy smoking, or dental infection. Occasionally it may indicate a systemic disease.

`

Diabetic ketoacidosis has a sweet, fruity breath odor; this acetone smell also occurs in children with malnutrition or dehydration. Others are an ammonia breath odor with uremia; a musty odor with liver disease; a foul, fetid odor with dental or respiratory infections; an alcohol odor with alcohol ingestion or chemicals; a mouse-like smell of the breath with diphtheria.

`

The Pregnant Woman

Gum hypertrophy (surface looks smooth and stippling disappears) may occur normally at puberty or during pregnancy (pregnancy gingivitis) (Fig. 16-23).

`

The Aging Adult

The nose may appear more prominent on the face from a loss of subcutaneous fat. In the edentulous person, the mouth and lips fold in, giving a “purse-string” appearance. The teeth may look slightly yellowed, although the color is uniform. Yellowing results from the dentin visible through worn enamel. The surface of the incisors may show vertical cracks from a lifetime of exposure to extreme temperatures. The teeth may look longer as the gum margins recede (Fig. 16-24).

`

The Aging Adult

`The surfaces look worn down or abraded. Old dental work deteriorates, especially at the gum margins. The teeth loosen with bone resorption and may move with palpation.

The tongue looks smoother as a result of papillary atrophy. The aging adult's buccal mucosa is thinned and may look shinier, as though it were “varnished.”

`

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 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 hemorrhage 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 odor. Because some risk for aspiration exists, removal should be prompt. A further problem comes from impaction from a small button battery from an electronic device (watch, video game). Once occluding the nostril, the battery can release voltage or chemicals that cause burns, necrosis, or perforation.

`

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.

`

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, rhinorrhea, which later becomes purulent. This is accompanied by sneezing and swollen mucosa, which causes nasal obstruction. Turbinates are dark red and swollen.

`

Allergic Rhinitis

`

Rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing are present. Note serous edema 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 gray 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.

`

Cleft Lip

`

Maxillofacial clefts are the most common congenital deformities of the head and neck. The incidence varies among racial groups, being highest in American Indians and in Asians and lowest in Blacks. 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, and 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, moist environment favoring growth of yeast.

`

Carcinoma

`

The initial lesion is round and indurated, and 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.

`

Retention “Cyst” (Mucocele)

`

A round, well-defined, translucent nodule that may be very small or up to 1 to 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.

`

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 for 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 hemorrhage.

`

Gingival Hyperplasia

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

`

Gingivitis

`

Gum margins are red and 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.

`

Aphthous Ulcers

`

A “canker sore” is a vesicle at first and then a small, round, “punched-out” ulcer with a 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 Spots

`

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

`

Leukoplakia

`

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, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that bleeds easily. Termed “thrush” in the newborn. It is an opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed persons.

`

Herpes Simplex 1

`

Herpes infection on the hard palate (see discussion in Table 16-2).

`

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.

`

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 anemia), folic acid deficiency, and iron deficiency anemia. Here, also note angular cheilitis.

`

Black Hairy Tongue

`

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

`

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.)

`

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 for early metastasis is present because of rich lymphatic drainage. Heavy smoking and heavy alcohol use place persons at greater risk.

`

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, myxedema, acromegaly. Also, a transient swelling occurs with local infections.

`

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 American Indians, uncommon in whites, and rare in Blacks.

`

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.

`

Acute Tonsillitis and Pharyngitis

`

Bright red throat; swollen tonsils; white or yellow exudate on tonsils and pharynx; swollen uvula; and enlarged, tender anterior cervical and tonsillar nodes. Accompanied by severe sore throat, painful swallowing, fever >101° F of sudden onset.

Evidence-based practice recommends using the criteria listed above to determine when to seek further testing.²⁹ A rapid antigen test or standard throat culture will then diagnose streptococcal pharyngitis and limit antibiotic therapy to those who test positive. If untreated, group A beta-hemolytic streptococcal pharyngitis may lead to glomerulonephritis and rheumatic fever. This is a serious complex illness characterized by fever, malaise, swollen joints, rash, and scarring on the heart valves.

`

Oral Kaposi Sarcoma

`

Bruiselike, 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.

`

Summary Checklist: Nose, Mouth, and Throat Examination

`

Nose

1 Inspect external nose for symmetry, any deformity, or lesions

2 Palpation—test patency of each nostril

3 Inspect with nasal speculum:

Color and integrity of nasal mucosa

Septum—note any deviation, perforation, or bleeding

Turbinates—note color, any exudate, swelling, or polyps

4 Palpate the sinus areas—note any tenderness

Mouth and Throat

1 Inspect with penlight:

Lips, teeth and gums, tongue, buccal mucosa—note color; whether structures are intact; any lesions

Palate and uvula—note integrity and mobility as person phonates

Grade tonsils

Pharyngeal wall—note color, any exudate, or lesions

2 Palpation:

When indicated in adults, bimanual palpation of mouth

With the neonate, palpate for integrity of palate and to assess sucking reflex

`