Nose, Mouth and Pharynx PDF

# 4 Nose, mouth, throat, and neck ## Made by Haidar Nisar ### I just "nose" that there's some good assessment advice in here. - Anatomy 50 - Assessment 54 - Nose abnormalities 60 - Mouth abnormalities 60 - Throat abnormalities 62 - Neck abnormalities 64 - Vision quest 66 # 50 Nose, mouth, throa...

# 4 Nose, mouth, throat, and neck ## Made by Haidar Nisar ### I just "nose" that there's some good assessment advice in here. - Anatomy 50 - Assessment 54 - Nose abnormalities 60 - Mouth abnormalities 60 - Throat abnormalities 62 - Neck abnormalities 64 - Vision quest 66 # 50 Nose, mouth, throat, and neck ## Anatomy ### Nose - The lower two-thirds of the external nose consists of flexible cartilage, and the upper one-third is rigid bone. - Posteriorly, the internal nose merges with the pharynx, which is divided into the nasopharynx, oropharynx, and laryngopharynx. - Anteriorly, it merges with the external nose. - More than just the sensory organ of smell, the nose also plays a key role in the respiratory system by filtering, warming, and humidifying inhaled air. - The internal and external nose are divided vertically by the nasal septum. - Kiesselbach's area, the most common site of nosebleeds, is located in the anterior portion of the septum. - Air entering the nose passes through the vestibule, which is lined with coarse hair that helps filter dust. ### Nasopharyngeal structures - Frontal sinus - Sella turcica - Sphenoid sinus - Ethmoidal sinus - Maxillary sinus - Pharyngeal tonsil - Eustachian tube opening - Hard palate - Soft palate - Nasopharynx - Palatine tonsil - Tongue - Oropharynx - Laryngopharynx # 51 Anatomy ## Paranasal sinuses ### Sinuses - Four pairs of paranasal sinuses open into the internal nose: - Maxillary sinuses, located on the cheeks below the eyes - Frontal sinuses, located above the eyebrows - Ethmoidal and sphenoidal sinuses, located behind the eyes and nose in the head. - The sinuses serve as resonators for sound production and provide mucus. - You'll be able to assess the maxillary and frontal sinuses, but the ethmoidal and sphenoidal sinuses aren't readily accessible. ### Anterior view - Frontal sinus - Ethmoidal sinus - Nasal cavity - Middle nasal concha - Middle nasal meatus - Maxillary sinus - Inferior nasal concha - Inferior nasal meatus - Nasal septum ### Lateral view - Frontal sinus - Ethmoidal sinuses - Posterior - Middle - Anterior - Sphenoidal sinus - Nasal cavity - Maxillary sinus - Middle nasal meatus - Inferior nasal meatus # 52 Nose, mouth, throat, and neck ## Mouth and throat - The mouth is bounded by the lips, cheeks, palate, and tongue and contains the teeth. - The throat, or pharynx, contains the hard and soft palates, the uvula, and the tonsils. ### Structures of the mouth and throat - Hard palate - Soft palate - Tongue - Teeth - Parotid gland - Oropharynx - Epiglottis - Mandible - Sublingual gland - Submandibular gland - Trachea - Esophagus ### Mouth and oropharynx - Soft palate - Uvula - Palatine tonsil - Palatoglossal arch - Dorsum of tongue - Incisors - Canines - Premolars - Molars # 53 Anatomy ## Neck - The neck is formed by the cervical vertebrae, the major neck and shoulder muscles, and their ligaments. - Other important structures of the neck include the trachea, thyroid gland, and chains of lymph nodes. - The thyroid gland lies in the anterior neck, just below the larynx. Its two cone-shaped lobes are located on either side of the trachea and are connected by an isthmus below the cricoid cartilage, which gives the gland its butterfly shape. ### Structures of the neck - Hyoid bone - Sternomastoid muscle - Thyroid cartilage - Cricoid cartilage - Isthmus of thyroid - Thyroid gland - Trachea - Clavicle - Sternal notch - Manubrium ### Lymph node locations - Occipital - Tonsillar - Superficial cervical - Anterior cervical - Posterior cervical - Supraclavicular - Preauricular - Postauricular - Submandibular - Submental # 54 Nose, mouth, throat, and neck ## Assessment ### Nose and sinuses - Inspecting the nose: - Observe the patient's nose for position, symmetry, and color. - Note variations, such as discoloration, swelling, or deformity. - Variations in size and shape are largely caused by differences in cartilage and in the amount of fibro-adipose tissue. - Observe for nasal discharge or flaring. - If discharge is present, note the color, quantity, and consistency. - If you notice flaring, observe for other signs of respiratory distress. - Then inspect the nasal cavity. - Check patency by occluding one nostril and asking the patient to breathe in through the other nostril. - Repeat on the other side. - Examine the nostrils by direct inspection using a nasal speculum, a penlight or small flashlight, or an otoscope with a short, wide-tip attachment. - I'd need a colossal otoscope or nasal speculum to examine these nostrils! - Inspecting the nasal cavity: - To inspect the nose, ask the patient to tilt his head back slightly, and then push up the tip of the nose and gently insert the otoscope. - Use the light from the otoscope to illuminate the nasal cavities. - Check for severe deviation or perforation of the nasal septum. - Examine the vestibule and turbinates for redness, softness, swelling, and discharge. # 55 Assessment ### Inspecting the nostrils - Have the patient sit in front of you with his head tilted back. - Put on gloves and insert the tip of the closed nasal speculum into one nostril to the point where the blade widens. - Slowly open the speculum as wide as possible without causing discomfort, as shown. - Shine the flashlight in the nostril to illuminate the area. - Observe the color and patency of the nostril, and check for exudate. - The mucosa should be moist, pink to light red, and free from lesions and polyps. - After inspecting one nostril, close the speculum, remove it, and inspect the other nostril. - **Nasal septum** - **Nasal airway** - **Middle turbinate** - **Middle meatus** - **Inferior meatus** - **Inferior turbinate** ### Palpating the nose - Palpate the patient's nose with your thumb and forefinger, assessing for pain, tenderness, swelling, and deformity. ### Examining the sinuses - Begin by checking for swelling around the eyes, especially over the sinus area. - Then palpate the sinuses, checking for tenderness. - If the patient complains of tenderness during sinus palpation, transilluminate the sinuses to see if they're filled with fluid or pus. - Transillumination can also help reveal tumors and obstructions. - Remember, only the frontal and maxillary sinuses are accessible; you won't be able to palpate the ethmoidal and sphenoidal sinuses. ### best picture ### Palpating the maxillary sinuses - To perform transillumination, darken the room and have the patient close his eyes. - Place a penlight under the eyebrow and direct the light upward to illuminate the frontal sinuses. - Place the penlight on the patient's cheekbone just below the eye and ask the patient to open his mouth. - A red glow inside the oral cavity indicates normal maxillary sinuses. - To palpate the maxillary sinuses, gently press your thumbs on each side of the nose just below the cheekbones. - **Frontal sinuses** - **Maxillary sinuses** # 56 Nose, mouth, throat, and neck ## Mouth and throat - Inspect the patient's lips, noting any lumps or surface abnormalities. - Then, using a tongue blade and a bright light, inspect the mouth. - Have the patient open his mouth, then place the tongue blade on top of his tongue. - Observe the gingivae, or gums. - Then inspect the teeth, note their number, condition, and whether any are missing or crowded. - If the patient is wearing dentures, ask him to remove them so you can inspect the gums underneath. - Next, inspect the tongue and oropharynx. ### The lateral borders of the tongue should be smooth and even-textured. ### best picture ### Inspecting the tongue - Ask the patient to raise the tip of her tongue and touch her palate directly behind her front teeth. - Inspect the ventral surface of the tongue and the floor of the mouth. - Next, wrap a piece of gauze around the tip of the tongue and move the tongue first to one side then the other to inspect the lateral borders. - **Lips:** The lips should be pink, moist, symmetrical, and without lesions. They may have a bluish hue or flecked pigmentation in dark-skinned patients. - **Oral mucosa:** The oral mucosa should be pink, smooth, moist, and free from lesions and unusual odors. Increased pigmentation may occur in dark-skinned patients. - **Gingivae (gums):** The gums should be pink, smooth, and moist, with clearly defined margins at each tooth. They shouldn't be retracted, red, or inflamed. # 57 Assessment ## Inspecting the oropharynx - Inspect the patient's oropharynx by asking him to open his mouth while you shine the penlight on the uvula and palate. - You may need to insert a tongue blade into the mouth and depress the posterior tongue. - Place the tongue blade slightly off center to avoid eliciting the gag reflex. - Ask the patient to say "Ahhh." - Observe for movement of the soft palate and uvula. - Note lumps, lesions, ulcers, or edema of the lips or tongue. - **Soft palate** - **Uvula** - **Palantine tonsil** - **Nasopharynx** - Finally, assess the patient's gag reflex by gently touching the back of the pharynx with a cotton-tipped applicator or the tongue blade. - Doing so should produce a bilateral response - **Tongue:** The tongue should be midline, moist, pink, and free from lesions. It should have a smooth posterior surface and slightly rough anterior surface with small fissures. It should move easily in all directions and lie straight to the front at rest. - **Oropharynx and uvula:** These structures should be pink and moist, without inflammation or exudates. - **Tonsils:** The tonsils should be pink and without hypertrophy. # 58 Nose, mouth, throat, and neck ## Neck ### Inspection - Observe the patient's neck. It should be symmetrical, and the skin should be intact. - Note any scars. - No visible pulsations, masses, swelling, venous distention, or thyroid gland or lymph node enlargement should be present. - Ask the patient to move his neck through the entire range of motion and to shrug his shoulders. ### Palpation - Palpate the patient's neck using the finger pads of both hands. - Assess the lymph nodes for size, shape, mobility, consistency, temperature, and tenderness, comparing nodes bilaterally. ### best picture ### Palpating the lymph nodes - Using the finger pads of both hands, bilaterally palpate the chain of lymph nodes in the following sequence: - Preauricular-in front of the ear - Postauricular-behind the ear, superficial to the mastoid process - Occipital-at the base of the skull - Tonsillar-at the angle of the mandible - Submandibular-between the angle and the tip of the mandible - Submental-behind the tip of the mandible - Superficial cervical-superficially along the sternomastoid muscle - Posterior cervical-along the edge of the trapezius muscle - Deep anterior cervical-deep under the sternomastoid muscle - Supraclavicular-just above and behind the clavicle, in the angle formed by the clavicle and sternomastoid muscle. - Preauricular - Submandibular - Supraclavicular ### Memory board - When assessing the neck, remember to SPEND some time evaluating these findings: - Swelling - Pulsations - Enlargement (of thyroid gland or lymph node) - Neck masses - Distention. - Then palpate the trachea, which is normally located midline in the neck, and the thyroid. ### Palpating the trachea - Place your finger along one side of the trachea. - Assess the distance between the trachea's outer edge and the sternocleidomastoid muscle. - Then assess the distance on the other side, and compare the two distances. - They should be the same. ### Palpating the thyroid - To palpate the thyroid, stand behind the patient and put your hands around his neck, with the fingers of both hands over the lower trachea. - Ask him to swallow as you feel the thyroid isthmus. - The isthmus should rise with swallowing because it lies across the trachea, just below the cricoid cartilage. - Displace the thyroid to the right and then to the left, palpating both lobes for enlargement, nodules, tenderness, or a gritty sensation. - Lowering the patient's chin slightly and turning toward the side you're palpating helps relax the muscle and may facilitate assessment. # 59 Assessment ### Auscultation - Using light pressure on the bell of the stethoscope, listen over the carotid arteries. - Ask the patient to hold his breath while you listen to prevent breath sounds from interfering with the sounds of circulation. - Listen for bruits, which signal turbulent blood flow. - If you detect an enlarged thyroid gland during palpation, also auscultate the thyroid area with the bell. - Check for a bruit or a soft rushing sound, which indicates a hypermetabolic state. ### Take note ### Documenting a thyroid bruit - 4/25/10 0800 Thyroid gland found to be enlarged on palpitation. Bruit heard over the lateral lobes of the thyroid gland. - Lucinda Stevens, RN - Palpating the thyroid - Normal thyroid swallowing # 60 Nose, mouth, throat, and neck ## Nose abnormalities - outside the norm ### Symptom synopsis: The nose | Symptom | Key facts | Possible causes | |---|---|---| | Epistaxis | Refers to nosebleed | Coagulation disorders <br> Trauma <br> Other hematologic disorders <br> Renal disorders <br> Hypertension | | Flaring | Refers to nostril dilation that occurs during inspiration <br> Normal to some extent during quiet breathing but marked regular flaring is abnormal | Respiratory distress | | Stuffiness and discharge | Refers to obstruction of the nasal mucous membranes accompanied by secretions | Common cold <br> Sinusitis <br> Trauma <br> Allergies <br> Exposure to irritants <br> Deviated septum | - Get to "nose" these common nasal problems. # 61 Mouth abnormalities - outside the norm ## Herpes simplex (type 1) - Herpes simplex, a recurrent viral infection, is caused by human herpesvirus. - It's transmitted by oral and respiratory secretions, affects the mucous membranes, and produces painful cold sores and fever blisters. - After a brief period of prodromal tingling and itching, the primary lesions erupt as vesicles on an erythematous base, eventually rupturing and leaving ulcers, followed by a yellow crust. - Vesicles may form on any part of the oral mucosa, especially the lips, tongue, chin, and cheek. # Mouth abnormalities ## Angioedema - Angioedema, commonly associated with urticaria, is usually caused by an allergic reaction. - It presents subcutaneously or dermally and produces nonpitted swelling of subcutaneous tissue and deep, large wheals usually on the lips, hands, feet, eyelids, or genitalia. - These swellings don't itch but may burn or tingle. ## Leukoplakia - Leukoplakia involves painless, white patches that appear on the tongue or the mucous membranes of the mouth. - It results from chronic irritation of the membranes due to tobacco use, poor-fitting dentures, use of some medications, or a rough tooth. - The white patches are considered precancerous lesions. - Biopsy determines whether the lesions are malignant. ## Candidiasis - Candidiasis of the oropharyngeal mucosa causes cream-colored or white patches on the tongue, mouth, or pharynx. - Most cases of this infection are caused by Candida albicans. - Although these fungi are part of the body's normal flora, they can cause infection when changes—such as an elevated blood glucose level in a patient with diabetes, immunosuppression in a patient with human immunodeficiency virus, or use of antibiotics—allow for their sudden proliferation.. # 62 Nose, mouth, throat, and neck ## Throat abnormalities - outside the norm ### Symptom synopsis: The throat | Symptom | Key facts | Possible causes | |---|---|---| | Dysphagia | Refers to difficulty swallowing | Esophageal disorders <br> Oropharyngeal, respiratory, neurologic, or collagen disorders <br> Certain toxins and treatments | | Throat pain | Commonly known as a sore throat <br> Refers to discomfort in any part of the pharynx <br> Ranges from a sensation of scratchiness to severe pain | Infection such as pharyngitis or tonsillitis <br> Trauma <br> Allergies <br> Cancer or a systemic disorder <br> Surgery <br> Endotracheal intubation <br> Mouth breathing <br> Alcohol consumption <br> Inhaling smoke or chemicals such as ammonia <br> Vocal strain | - See if you can swallow this information about common throat-related symptoms. # 63 Throat abnormalities ## Tonsillitis - Acute tonsillitis commonly begins with a mild to severe sore throat. - Tonsillitis may also produce dysphagia, fever, swelling and tenderness of the lymph nodes, and redness in the throat. - With exudative tonsillitis, a white exudate appears on the tonsils. ## Pharyngitis - Pharyngitis is an acute or chronic inflammation of the pharynx that produces a sore throat and slight difficulty swallowing. - It's usually caused by a virus, such as a rhinovirus, coronavirus, or adenovirus. - It may also be caused by a bacterial infection, such as from group A beta-hemolytic streptococci. ## Diphtheria - Diphtheria is an acute, highly contagious, toxin-mediated infection caused by Corynebacterium diphtheriae. - It causes a sore throat with rasping cough and leads to airway obstruction. - The throat appears red with a thick, gray membrane covering the back of the throat. # 64 Nose, mouth, throat, and neck ## Neck abnormalities - outside the norm ## Simple (nontoxic goiter) - A simple or nontoxic goiter involves thyroid gland enlargement that isn't caused by inflammation or a neoplasm. - It's commonly classified as endemic or sporadic. - Thyroid enlargement may range from a mildly enlarged gland to massive multinodular goiter. - I vant to assess your neck. # 65 Neck abnormalities ## Graves' disease (toxic goiter) - Graves' disease is the most common form of thyrotoxicosis, a metabolic imbalance that results from thyroid hormone overproduction. - The classic features of Graves' disease are an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, sweating, frequent bowel movements, tremor, palpitations, and exophthalmos. ## Toxic multinodular goiter - Common in the elderly, toxic multinodular goiter is a form of thyrotoxicosis that involves overproduction of thyroid hormone by one or more autonomously functioning nodules within a diffusely enlarged gland. - Multiple thyroid nodules can be felt on palpation.