Mouth, Throat, Nose, Mouth, Throat, Nose, and Sinus Assessmentand Sinus Assessment

The mouth and throat make up the The mouth and throat make up the first part of the digestive system and first part of the digestive system and are responsible for receiving food. are responsible for receiving food. Cranial nerves V"trigeminal", Cranial nerves V"trigeminal", VII"facial", IX "glosopharyngeal", VII"facial", IX "glosopharyngeal", and IIX"hypoglossal" assist with and IIX"hypoglossal" assist with some of the digestive functions.some of the digestive functions.

Thank you! Thank you!

The nose and paranasal sinuses The nose and paranasal sinuses constitute the first part of the constitute the first part of the respiratory system and are respiratory system and are responsible for receiving, filtering, responsible for receiving, filtering, warming, and moistening air to be warming, and moistening air to be transported to the lungs. transported to the lungs.

Receptors of cranial nerve I Receptors of cranial nerve I "olfactory" are also located in the "olfactory" are also located in the nose.nose.

MouthMouth

The roof of the oral cavity is The roof of the oral cavity is formed by the anterior hard palate formed by the anterior hard palate and the posterior hard palate. An and the posterior hard palate. An extension of the soft palate is the extension of the soft palate is the uvula.uvula.

Contained within the mouth are the Contained within the mouth are the tongue, teeth, gums, and the opening of tongue, teeth, gums, and the opening of the salivary glands "parotid, the salivary glands "parotid, submandibular, sublingual". The three submandibular, sublingual". The three pairs of salivary glands secrete saliva pairs of salivary glands secrete saliva "watery, serous fluid contains salts, "watery, serous fluid contains salts, mucous, and salivary amylase" into the mucous, and salivary amylase" into the mouth. mouth. The parotid glandsThe parotid glands, located , located below, and in front of the ears, empty below, and in front of the ears, empty through Stensen's ducts, which are through Stensen's ducts, which are located inside the check across from the located inside the check across from the second upper molar.second upper molar.

The submandibular glandsThe submandibular glands, located , located in the lower jaw, open under the in the lower jaw, open under the tongue on either side of the frenulum tongue on either side of the frenulum through opening called Wharton's through opening called Wharton's ducts. ducts. The sublingual glandsThe sublingual glands, , located under the tongue, open located under the tongue, open through several ducts located on the through several ducts located on the floor of the mouth.floor of the mouth.

Mouth and throatMouth and throat LipsLips CheeksCheeks Buccal mucosaBuccal mucosa Hard palateHard palate Soft palateSoft palate TonsilsTonsils Oropharynx and nasopharynxOropharynx and nasopharynx UvulaUvula Tongue – taste (CN VII)Tongue – taste (CN VII)

Salivary glandsSalivary glands ParotidParotid SubmandibularSubmandibular SublingualSublingual TeethTeeth CrownCrown NeckNeck RootRoot

Assessment of the MouthAssessment of the Mouth

Inspection (use good light source)Inspection (use good light source) Lips (color, moisture, cracking, Lips (color, moisture, cracking,

lesions) – smile for symmetry lesions) – smile for symmetry (CNVII)(CNVII)

Tongue (color, surface fissures, Tongue (color, surface fissures, moisture) – stick out for deviation moisture) – stick out for deviation (CN VII)(CN VII)

Gums, buccal mucosa (check for Gums, buccal mucosa (check for pink color, bleeding, swelling)pink color, bleeding, swelling)

Teeth (#, molars, color, cavities, Teeth (#, molars, color, cavities, dental repair) 32 adult – 20 dental repair) 32 adult – 20 children (3rd molars may be children (3rd molars may be missing – wisdom teeth)missing – wisdom teeth)

Hard palate & soft palateHard palate & soft palate Floor of mouth (Wharton’s Floor of mouth (Wharton’s

duct/Submandibular gland, duct/Submandibular gland, Sublingual gland)Sublingual gland)

Parotid gland (in cheek in front of Parotid gland (in cheek in front of ear) and Stensen’s duct (opposite ear) and Stensen’s duct (opposite 2nd molar)2nd molar)

Tongue (Lingual frenulum, lingual Tongue (Lingual frenulum, lingual veins)veins)

PalpatePalpateRoof of mouth in infantsRoof of mouth in infantsLips, cheek, tongue, floor of Lips, cheek, tongue, floor of

mouthmouthUse gauze to hold tongueUse gauze to hold tongue

Find Stensen’s duct (parotid Find Stensen’s duct (parotid salivary gland) opposite upper salivary gland) opposite upper second molarsecond molar

Check temporomandibular joint Check temporomandibular joint (TMJ) – depression in front of (TMJ) – depression in front of tragus felt with fingers (slight pop tragus felt with fingers (slight pop can be normal; crepitus and masses can be normal; crepitus and masses are abnormal)are abnormal)

Mouth ProblemsMouth Problems

Dental caries also known as Dental caries also known as tooth tooth decaydecay or a  or a cavitycavity, is an , is an infectioninfection usually  usually bacterialbacterial in origin that causes  in origin that causes demineralization of the hard tissues demineralization of the hard tissues (enamel, dentin and cementum) and (enamel, dentin and cementum) and destruction of the organic matter of destruction of the organic matter of the tooth, usually by production of the tooth, usually by production of acid by hydrolysis of the food debris acid by hydrolysis of the food debris accumulated on the tooth surface.accumulated on the tooth surface.

  If demineralization exceeds saliva and If demineralization exceeds saliva and other remineralization factors such as other remineralization factors such as from calcium and fluoridated from calcium and fluoridated toothpastes, these tissues progressively toothpastes, these tissues progressively break down, producing dental caries break down, producing dental caries (cavities, holes in the teeth). The two (cavities, holes in the teeth). The two bacteria most commonly responsible bacteria most commonly responsible for dental cavities are for dental cavities are Streptococcus Streptococcus mutansmutans and  and LactobacillusLactobacillus..

••Plaque  is a Plaque  is a biofilmbiofilm, usually a pale , usually a pale yellow, that develops naturally on yellow, that develops naturally on the the teethteeth. Like any . Like any biofilmbiofilm, dental , dental plaque is formed by colonizing plaque is formed by colonizing bacteria trying to attach themselves bacteria trying to attach themselves to a smooth surface (of a tooth)to a smooth surface (of a tooth)[1][1]. It . It has been also speculated that plaque has been also speculated that plaque forms part of the defense systems of forms part of the defense systems of the host by helping to prevent the host by helping to prevent colonizationcolonization by  by microorganismsmicroorganisms which may be  which may be pathogenicpathogenic..

Tartar sometimes called calculus, is Tartar sometimes called calculus, is plaqueplaque that has hardened on your  that has hardened on your teeth. Tartar can also form at and teeth. Tartar can also form at and underneath the underneath the gumlinegumline and can  and can irritate gum tissues. Tartar gives irritate gum tissues. Tartar gives plaque more surface area on which to plaque more surface area on which to grow and a much stickier surface to grow and a much stickier surface to adhere, which can lead to more serious adhere, which can lead to more serious conditions, such as cavities and conditions, such as cavities and gum diseasegum disease. .

Gingivitis ("inflammation of the gum Gingivitis ("inflammation of the gum tissue") is a term used to describe non-tissue") is a term used to describe non-destructive periodontal disease. The most destructive periodontal disease. The most common form of gingivitis is in response common form of gingivitis is in response to bacterial biofilms (also called plaque) to bacterial biofilms (also called plaque) adherent to tooth surfaces, adherent to tooth surfaces, termed termed plaque-induced gingivitisplaque-induced gingivitis, and is , and is the most common form of periodontal the most common form of periodontal disease. In the absence of treatment, disease. In the absence of treatment, gingivitis may progress to gingivitis may progress to periodontitisperiodontitis, , which is a destructive form of periodontal which is a destructive form of periodontal disease.disease.

Parotitis is an inflammation of one or Parotitis is an inflammation of one or both parotid glands, the both parotid glands, the major salivary glands located on major salivary glands located on either side of the face, in humans. either side of the face, in humans. The parotid gland is the salivary The parotid gland is the salivary gland most commonly affected by gland most commonly affected by inflammation. inflammation.

Assessing the Mouth and Assessing the Mouth and OropharynxOropharynx

Inquire if the client has any history Inquire if the client has any history of the following:of the following:

Routine pattern of dental care, last Routine pattern of dental care, last visit todentistvisit todentist

Length of time ulcers or other lesions Length of time ulcers or other lesions havebeen presenthavebeen present

Denture discomfortDenture discomfort Medications client is receivingMedications client is receiving

Lips and Buccal MucosaLips and Buccal Mucosa Inspect the outer lips for symmetry of Inspect the outer lips for symmetry of

contour, color, and texturecontour, color, and texture Uniform pink color, soft, moist Uniform pink color, soft, moist

smooth texture.smooth texture. Ability to purse lipsAbility to purse lips Symmetry of contourSymmetry of contour

Teeth and GumsTeeth and Gums Inspect the teeth and gums while Inspect the teeth and gums while

examining theinner lips and buccal examining theinner lips and buccal mucosamucosa

Inspect the denturesTongue/Floor of Inspect the denturesTongue/Floor of the Mouththe Mouth

Inspect the surface of the tongue for Inspect the surface of the tongue for position,color and texture.position,color and texture.

Inspect the tongue movementInspect the tongue movement Inspect the base of the tongue, the Inspect the base of the tongue, the

mouth floor,and the frenulummouth floor,and the frenulum Palpate the tongue and the floor of Palpate the tongue and the floor of

the mouth for any lumps, nodules or the mouth for any lumps, nodules or excoriated areas.excoriated areas.

Inspection of the ThroatInspection of the Throat Gag reflex (CN IX & X)Gag reflex (CN IX & X) Posterior pharynx and oropharynx Posterior pharynx and oropharynx Presence of swelling, exudate or Presence of swelling, exudate or

lesions. Note color.lesions. Note color. Inspect tonsilsInspect tonsils Grade tonsils (+1 – +4)Grade tonsils (+1 – +4)

NoseNose It composed of bone and cartilage It composed of bone and cartilage

and is lined with mucous membrane. and is lined with mucous membrane. The nasal cavity is located.The nasal cavity is located.

External noseExternal nose Internal nose Internal nose Nasal cavityNasal cavity

Paranasal SinusesParanasal Sinuses FrontalFrontal MaxillaryMaxillary SphenoidSphenoid EthmoidEthmoid

Turbinates Turbinates Projections in nasal cavity that Projections in nasal cavity that

increase surface area.increase surface area.

Superior, middle and inferior Superior, middle and inferior turbinatesturbinates

Nasal mucosaNasal mucosa Olfactory receptor cells (CN I)Olfactory receptor cells (CN I)

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 naresCheck patency of nares Percuss and palpate sinuses Percuss and palpate sinuses Observe mucosa color and Observe mucosa color and

dischargedischarge allergy = white mucosa with clear allergy = white mucosa with clear

dischargedischarge virus = red mucosa with colorful virus = red mucosa with colorful

dischargedischarge

CSF = unilateral clear dischargeCSF = unilateral clear discharge foreign body = unilateral colorful foreign body = unilateral colorful

dischargedischarge Assess polyps or ulcerAssess polyps or ulcer

Assessment of the NoseAssessment of the Nose Inspection of internal noseInspection of internal nose Otoscope with nasal speculum – Otoscope with nasal speculum –

avoid septum d/t increased sensitivityavoid septum d/t increased sensitivity Color & integrity of nasal mucosaColor & integrity of nasal mucosa Septum deviation, perforation, Septum deviation, perforation,

bleeding (epistaxis)bleeding (epistaxis) New/old bleeding anywhere.New/old bleeding anywhere.

Turbinates (color, exudate, swelling, Turbinates (color, exudate, swelling, polyps) Note the middle and inferior polyps) Note the middle and inferior turbinatesturbinates

Normal – dull redNormal – dull red Allergies – pale pink/gray, swollen Allergies – pale pink/gray, swollen

(polyps & a clear, watery discharge (polyps & a clear, watery discharge are also common)are also common)

Acute rhionitis infection – bright red Acute rhionitis infection – bright red & swollen& swollen

NOSE: Inspection and Palpation NOSE: Inspection and Palpation Inspect and palpate the external Inspect and palpate the external nose.nose.

Note nasal color, shape,consistency, Note nasal color, shape,consistency, and tenderness.and tenderness.

Check patency of air flow Check patency of air flow throughthe nostrilsthroughthe nostrils

by occluding onenostril at a time and by occluding onenostril at a time and asking clientto sniff.asking clientto sniff.

Inspect the internal nose.Inspect the internal nose. To inspect the internal nose, use an To inspect the internal nose, use an

otoscope with a short wide-tip otoscope with a short wide-tip attachment ( or you can also use attachment ( or you can also use anasal speculum and penlight). Use anasal speculum and penlight). Use your nondominant hand to stabilize your nondominant hand to stabilize and gently tilt the client's head back. and gently tilt the client's head back.

Insert the short wide tip of the Insert the short wide tip of the otoscope into the client's nostril otoscope into the client's nostril without touching the sensitive nasal without touching the sensitive nasal septum.septum.

Slowly direct the otoscope back and Slowly direct the otoscope back and upto view the nasal mucosa, nasal upto view the nasal mucosa, nasal septum, the inferior and middle septum, the inferior and middle turbinates, and the nasal passage(the turbinates, and the nasal passage(the narrow space between theseptum and narrow space between theseptum and the turbinates).the turbinates).

Color is the same as the rest of the Color is the same as the rest of the face; the nasal structure is smooth face; the nasal structure is smooth and symmetric; the client reports no and symmetric; the client reports no tenderness. Client is able to sniff tenderness. Client is able to sniff through each nostril while other is through each nostril while other is occluded. The nasal mucosa is dark occluded. The nasal mucosa is dark pink, moist, and free of exudate.pink, moist, and free of exudate.

The nasal septum is intact and free The nasal septum is intact and free of ulcers or perforations. Turbinates of ulcers or perforations. Turbinates are dark pink ( redder than are dark pink ( redder than oralmucosa), moist, and free oralmucosa), moist, and free of lesions.of lesions.

Possible causes of epistaxis include Possible causes of epistaxis include coagulopathy, ITP, tumor, lesions of coagulopathy, ITP, tumor, lesions of herpes simplex virus (HSV), and Kaposi herpes simplex virus (HSV), and Kaposi sarcoma (KS). Suspect ITP if the platelet sarcoma (KS). Suspect ITP if the platelet count is low and bleeding is difficult to count is low and bleeding is difficult to control.control.

Acute infection of one or more of the Acute infection of one or more of the paranasal sinuses is paranasal sinuses is common. common. Streptococcus Streptococcus pneumoniaepneumoniae, , Haemophilus influenzaeHaemophilus influenzae, , and and Moraxella catarrhalisMoraxella catarrhalis are seen in both  are seen in both HIV-uninfected and HIV-infected patients, HIV-uninfected and HIV-infected patients,

Streptococcus Streptococcus pneumoniaepneumoniae, , Haemophilus Haemophilus influenzaeinfluenzae, and , and Moraxella Moraxella catarrhaliscatarrhalis are seen in both HIV- are seen in both HIV-uninfected and HIV-infected patients,uninfected and HIV-infected patients,

whereas whereas Staphylococcus Staphylococcus aureusaureus and  and Pseudomonas Pseudomonas aeruginosaaeruginosa are found more often in  are found more often in HIV-infected patients. Fungi may be HIV-infected patients. Fungi may be the causative agents, especially in the causative agents, especially in patients with severe patients with severe immunosuppression. immunosuppression.

Chronic sinusitis occurs frequently in Chronic sinusitis occurs frequently in patients with HIV infection and may patients with HIV infection and may be polymicrobial or anaerobic. In be polymicrobial or anaerobic. In patients with low CD4 cell counts, patients with low CD4 cell counts, fungal sinusitis may occur.fungal sinusitis may occur.

Nasal obstruction may be caused by Nasal obstruction may be caused by adenoidal hypertrophy, chronic adenoidal hypertrophy, chronic sinusitis, allergic rhinitis, or sinusitis, allergic rhinitis, or neoplasm.neoplasm.

Tumors may be caused by KS, Tumors may be caused by KS, squamous papilloma, or lymphoma; squamous papilloma, or lymphoma; biopsy is necessary for determining biopsy is necessary for determining the cause.the cause.

Painful, ulcerated vesicles in the Painful, ulcerated vesicles in the nasal mucosa may be caused by HSV nasal mucosa may be caused by HSV or other infectionsor other infections

Common problems :Common problems :- Sinusitis ( Acute, Chronic )- Sinusitis ( Acute, Chronic )

- Allergic Rhiitis- Allergic Rhiitis

- Nasal Obstruction- Nasal Obstruction

- Epistaxis- Epistaxis

SINUS: PalpationPalpate the SINUS: PalpationPalpate the sinuses.sinuses.

When an infection is suspected, the When an infection is suspected, the nurse can examine the sinuses, nurse can examine the sinuses, through palpation, percussion and through palpation, percussion and transillumination. Palpate the frontal transillumination. Palpate the frontal sinuses by using your thumbs to sinuses by using your thumbs to press up on Frontal and maxillary press up on Frontal and maxillary sinuses are non tender to palpation, sinuses are non tender to palpation, and crepitus is evident.and crepitus is evident.

Frontal or maxillary sinuses are Frontal or maxillary sinuses are tender to palpation in clients with tender to palpation in clients with allergies or acute bacterial rhino allergies or acute bacterial rhino sinusitis. If the client has a large sinusitis. If the client has a large amount of exudate, you may feel amount of exudate, you may feel crepitus upon palpation over the crepitus upon palpation over the maxillary sinuses.maxillary sinuses.

the brow on each side of the nose. the brow on each side of the nose. Palpate the maxillary sinuses by Palpate the maxillary sinuses by pressing with thumbs up on the pressing with thumbs up on the maxillary sinuses.maxillary sinuses.

SINUS: PercussionPercuss the SINUS: PercussionPercuss the sinuses.sinuses.

Lightly tap(percuss ) over the frontal Lightly tap(percuss ) over the frontal sinuses and over the maxillary sinuses and over the maxillary sinuses for tenderness.sinuses for tenderness.

SINUS: SINUS: TransilluminationTransilluminate TransilluminationTransilluminate the sinuses.the sinuses.

If sinus tenderness was detected If sinus tenderness was detected during palpation and during palpation and percussion,transillumination will let percussion,transillumination will let you see if the sinuses are filled with you see if the sinuses are filled with fluid orpus. Transilluminate the frontal fluid orpus. Transilluminate the frontal sinuses by holding a strong, narrow sinuses by holding a strong, narrow light source snugly under the light source snugly under the eyebrows ( the room shouldbe dark ). eyebrows ( the room shouldbe dark ). Use your other hand to shield the light.Use your other hand to shield the light.

Repeat this technique for the other Repeat this technique for the other frontal sinus.Transilluminate the frontal sinus.Transilluminate the maxillary sinuses by holding a maxillary sinuses by holding a strong,narrow light source over the strong,narrow light source over the maxillary sinus and asking the client maxillary sinus and asking the client to open his or her mouth. Repeat this to open his or her mouth. Repeat this technique for the other maxillary technique for the other maxillary sinus. sinus.

The sinuses are not tender on The sinuses are not tender on percussion. A red glow percussion. A red glow transilluminates the frontal sinuses. transilluminates the frontal sinuses. This indicates a normal, air-filled This indicates a normal, air-filled sinus. A red glow transilluminates the sinus. A red glow transilluminates the maxillary sinuses. The red glow will maxillary sinuses. The red glow will be seen on the hard palate.The frontal be seen on the hard palate.The frontal and the maxillary sinuses are tender and the maxillary sinuses are tender upon percussion in clients with upon percussion in clients with allergies or sinus infection.allergies or sinus infection.

Absence of a red glow usually Absence of a red glow usually indicates a sinus filled with fluid or indicates a sinus filled with fluid or pus. Absence of a red glow usually pus. Absence of a red glow usually indicates a sinus filled with fluid, indicates a sinus filled with fluid, pus or thick mucus (from chronic pus or thick mucus (from chronic sinusitis).sinusitis).