Mouth, Throat, Nose, and Sinus Assessment

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

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The nose and paranasal sinuses constitute the first part of the respiratory system and are responsible for receiving, filtering, warming, and moistening air to be transported to the lungs. Receptors of cranial nerve I "olfactory" are also located in the nose.

Mouth

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

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

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

Mouth and throat Lips Cheeks Buccal mucosa Hard palate Soft palate Tonsils Oropharynx and nasopharynx Uvula Tongue taste (CN VII)

Salivary glands Parotid Submandibular Sublingual Teeth Crown Neck Root

Assessment of the Mouth

Inspection (use good light source) Lips (color, moisture, cracking, lesions) smile for symmetry (CNVII) Tongue (color, surface fissures, moisture) stick out for deviation (CN VII) Gums, buccal mucosa (check for pink color, bleeding, swelling)

Teeth (#, molars, color, cavities, dental repair) 32 adult 20 children (3rd molars may be missing wisdom teeth) Hard palate & soft palate Floor of mouth (Whartons duct/Submandibular gland, Sublingual gland)

Parotid gland (in cheek in front of ear) and Stensens duct (opposite 2nd molar) Tongue (Lingual frenulum, lingual veins)

Palpate Roof of mouth in infants Lips, cheek, tongue, floor of mouth Use gauze to hold tongue

Find Stensens duct (parotid salivary gland) opposite upper second molar Check temporomandibular joint (TMJ) depression in front of tragus felt with fingers (slight pop can be normal; crepitus and masses are abnormal)

Mouth Problems

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

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

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

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

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

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

Assessing the Mouth and Oropharynx

Inquire if the client has any history of the following: Routine pattern of dental care, last visit todentist Length of time ulcers or other lesions havebeen present Denture discomfort Medications client is receiving

Lips and Buccal Mucosa Inspect the outer lips for symmetry of contour, color, and texture Uniform pink color, soft, moist smooth texture. Ability to purse lips Symmetry of contour

Teeth and Gums Inspect the teeth and gums while examining theinner lips and buccal mucosa Inspect the denturesTongue/Floor of the Mouth Inspect the surface of the tongue for position,color and texture.

Inspect the tongue movement Inspect the base of the tongue, the mouth floor,and the frenulum Palpate the tongue and the floor of the mouth for any lumps, nodules or excoriated areas.

Inspection of the Throat Gag reflex (CN IX & X) Posterior pharynx and oropharynx Presence of swelling, exudate or lesions. Note color. Inspect tonsils Grade tonsils (+1 +4)

Nose It composed of bone and cartilage and is lined with mucous membrane. The nasal cavity is located. External nose Internal nose Nasal cavity

Paranasal Sinuses Frontal Maxillary Sphenoid Ethmoid Turbinates Projections in nasal cavity that increase surface area.

Superior, middle and inferior turbinates Nasal mucosa 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 nares Percuss and palpate sinuses Observe mucosa color and discharge allergy = white mucosa with clear discharge virus = red mucosa with colorful discharge

CSF = unilateral clear discharge foreign body = unilateral colorful discharge Assess polyps or ulcer

Assessment of the Nose Inspection of internal nose Otoscope with nasal speculum avoid septum d/t increased sensitivity Color & integrity of nasal mucosa Septum deviation, perforation, bleeding (epistaxis) New/old bleeding anywhere.

Turbinates (color, exudate, swelling, polyps) Note the middle and inferior turbinates Normal dull red Allergies pale pink/gray, swollen (polyps & a clear, watery discharge are also common) Acute rhionitis infection bright red & swollen

NOSE: Inspection and Palpation Inspect and palpate the external nose. Note nasal color, shape,consistency, and tenderness. Check patency of air flow throughthe nostrils by occluding onenostril at a time and asking clientto sniff.

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

Insert the short wide tip of the otoscope into the client's nostril without touching the sensitive nasal septum. Slowly direct the otoscope back and upto view the nasal mucosa, nasal septum, the inferior and middle turbinates, and the nasal passage(the narrow space between theseptum and the turbinates).

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

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

Possible causes of epistaxis include coagulopathy, ITP, tumor, lesions of herpes simplex virus (HSV), and Kaposi sarcoma (KS). Suspect ITP if the platelet count is low and bleeding is difficult to control. Acute infection of one or more of the paranasal sinuses is common. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are seen in both HIV-uninfected and HIV-infected

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are seen in both HIVuninfected and HIV-infected patients, whereas Staphylococcus aureus and Pseudomonas aeruginosa are found more often in HIV-infected patients. Fungi may be the causative agents, especially in patients with severe immunosuppression.

Chronic sinusitis occurs frequently in patients with HIV infection and may be polymicrobial or anaerobic. In patients with low CD4 cell counts, fungal sinusitis may occur. Nasal obstruction may be caused by adenoidal hypertrophy, chronic sinusitis, allergic rhinitis, or neoplasm.

Tumors may be caused by KS, squamous papilloma, or lymphoma; biopsy is necessary for determining the cause. Painful, ulcerated vesicles in the nasal mucosa may be caused by HSV or other infections

Common problems : - Sinusitis ( Acute, Chronic ) - Allergic Rhiitis - Nasal Obstruction - Epistaxis

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

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

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

SINUS: PercussionPercuss the sinuses. Lightly tap(percuss ) over the frontal sinuses and over the maxillary sinuses for tenderness. SINUS: TransilluminationTransilluminate the sinuses.

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

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

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

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