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Head and Neck Section A • Oral Cavity and Oropharynx • Examination of Larynx and Laryngopharynx • Thyroid Gland Section B • Examination of Neck • Examination of Salivary Gland Section C • Diseases of Oesophagus • Tracheo-bronchial Tree SECTION A 6 Oral Cavity and Oropharynx Oral cavity: It includes inner surface of lips, cheeks, teeth, gums, anterior 2/3 of tongue, upper jaw, lower jaw, upper and lower gingivo-labial and gingivo-buccal Sulci, retromolar area, hard palate, soft palate and floor of mouth. Oropharynx: Its superior limit is the level of hard palate and where the soft palate touches the posterior pharyngeal wall. Inferior limit is at the level of tip of the epiglottis. It includes tongue posterior to vallate papillae, velleculae, lingual surface of epiglottis, anterior pillars, posterior pillars, faucial tonsils, posterior pharyngeal wall, free margin of soft palate and uvula. The symptoms related to this part of the body are quite common and may be as follows: 1. Pain in throat (sore throat) 2. Difficulty in swallowing/chewing, pain during swallowing 3. Irritation in throat 4. Swelling/mass in oral cavity/throat 5. Ulcers in mouth 6. Trismus 7. Change in voice 8. Cough 118 Clinical Methods in ENT 9. Burning sensation 10. Foul breath 11. Foreign body 12. Dysarthria 13. Dental symptoms (excluded). Associated symptoms: 14. Swelling over face 15. Painful/painless neck swelling 16. Nasal regurgitation 17. Fever with/without rigors. It is usual observation that the symptoms related to throat are vaguely described by the patient and poorly understood by the clinician [if he is not careful enough]. Hence, these symptoms should be asked in greater details to understand the exact problem of the patient. Each symptom should be analysed in proper manner, so as to come to clinical conclusion. PAIN IN THROAT (SORE THROAT) Patient should be asked, “Is it pain, or discomfort? Is it at rest or during movement of oral cavity or during chewing/swallowing. How long he is suffering from this complaint? How it started? Is it progressive. Is it a constant or intermittent. What is exact site of pain? How it starts, How it aggravates and how it gets relieved? How severe is the symptom? Is it just a discomfort or is it sufficient to disturb his work. Is it localised or spreads to the surrounding area. Is it sharp shooting or dull aching?” Associated symptoms like fever, change in voice, swelling should be asked. Common causes of pain in throat are pharyngitis, tonsillitis, quinsy, trauma, malignancy, neuralgias, etc. Pain of acute infection like tonsillitis starts suddenly. It is severe and constant in nature. Pain due to apthous ulcers is very severe and aggravated by taking solids or liquids. Pain may be initiated by the act of swallowing [odynophagia] in pharyngitis, tonsillitis, stylalgia, or malignancy. Pain due to salivary gland stone usually starts at the time of meals and shows swelling in the submandibular area, which gets relieved after sometime. Patients having quinsy/ulcers may locate a specific site for pain. DIFFICULTY IN SWALLOWING This symptom needs proper evaluation. Ask the patient, Is it pain during swallowing or food does not pass down below or is it both? Oral Cavity and Oropharynx Causes • • • • • • Congenital, e.g. cleft palate. Traumatic, e.g. injury to tongue and pharynx. Inflammatory, e.g. acute tonsillitis, pharyngitis, quinsy. Nutritional, e.g. cheilitis, glossitis. Neoplastic, e.g. malignancy of tongue, tonsil or pharyngeal wall. Miscellaneous, e.g. neurological affections of pharynx. Difficulty in chewing may be experienced by the patient when he has painful lesion in oral cavity, trismus, temporomandibular pathologies and dental conditions. IRRITATION/ITCHING IN THROAT Some patients having allergic manifestation may particularly complain of irritation in throat. Exposure to dust or smoke can also cause irritation in throat. Post-nasal drip may be responsible for irritation or itching. SWELLING/MASS IN THROAT Haemangioma, lymphangioma, lingual thyroid, ranula, ectopic salivary tumours, parapharyngeal/ peritonsillar abscess and malignancy are some of the swellings seen in the oral cavity and throat. Proper history should be obtained by following the pattern described in ‘examination of swelling’. Patient should be asked, “How long he has noticed the swelling?” It may be congenital like torus palatinus or may be acquired due to trauma, infection or malignancy. He should be asked whether the swelling is constant or intermittent. Swelling due to stone in submandibular gland duct or parotid gland duct may arise at the time of meals only and may disappear after some time. Swelling may be painful or painless. Peritonsillar abscess is very painful so much, so that patient cannot swallow his own saliva and may drool over cheek. Pain may be aggravated by the act of swallowing in malignant or inflammatory lesions. Radiation of pain to the ear may be seen in tonsillar/base tongue malignancy. ULCERS IN MOUTH Mode of onset: Patient should be asked, How the ulcer/s developed. The ulcer may develop after trauma or spontaneously. Tongue bite may result into an ulcer, which heals within few days. However, if the teeth are sharp and cause repeated trauma to tongue, may give rise to chronic non-healing ulcer and even granuloma. Aphthous ulcers develop suddenly and are very painful. 119 120 Clinical Methods in ENT Duration: Ulcer of acute onset may heal spontaneously after few days. However, chronic ulcer like tuberculous ulcer, syphilitic ulcer and malignant ulcer may not heal. Pain: Syphilitic ulcers are painless while aphthous ulcers are highly painful. Malignant ulcers may be painless to begin with. Discharge: History of any discharge associated with ulcer may be asked. Associated diseases: Diseases like uncontrolled diabetes, tuberculosis may develop ulcers in the head and neck region. In Behcet syndrome, oropharyngeal ulceration is associated with genital ulceration. Oral ulcerations are seen in pemphigus vulgaris and Stevens-Johnson syndrome. And these conditions should be kept at the back of mind while examining the oral ulcers. TRISMUS: TRISMUS IS INABILITY TO OPEN THE MOUTH It may be seen in a case of tetanus [lockjaw], oral submucous fibrosis, quinsy, cheek malignancy or lesions involving pterygopalatine fossa, muscles of mastication or temporomandibular joint. History of trauma to temporomandibular joint or history of chewing pan masala, tobacco, betel nut must be asked when you suspect oral submucous fibrosis. CHANGE IN VOICE Oral cavity lesions like quinsy, cleft palate, palatal palsy or a big mass in oral cavity/oropharynx can cause change in voice. COUGH Usually it is dry cough due to irritation of throat. Particularly postnasal drip may cause dry irritating cough. Allergen, elongated uvula, drying up of mucosa due to exposure to hot/dry air too can cause cough. Some patients do have acid regurgitation in the throat, which causes dry cough and irritation. BURNING SENSATION Commonly complained by the patient in oral submucous fibrosis or severe anaemia, glossitis, stomatitis, etc. FOUL BREATH (HALITOSIS) Bad oral/dental hygiene, chronic illness, patients who are nil by mouth for a long period can emit foul breath. Oral Cavity and Oropharynx FB IN THROAT Foreign body is quite common in oral cavity and oropharynx. Though children are commonly affected, it is equally common in adults. Particularly fish bones, pins, clips (in female) needles (in tailors) and during influence of alcohol. Old age also predisposes for FB lodgement due to loose teeth and dentures. DYSARTHRIA This is a disorder of articulation. Speech may be slurred and labored or it may be monotonus. Lesions of joints, muscles, ligaments of oral cavity and oropharynx may cause dysarthria, e.g. bilateral corticobulbar tract lesions. Lesions of 7th 10th and 12th cranial nerves. Myasthenia gravis, lesions of extrapyramidal system and cerebellar affections are known to cause affections of articulation. SWELLING OVER FACE Lesions related to teeth like dental cyst, dentigerous cyst, adamantinoma, malignancies of cheek/ alveolus may give rise to swelling over face. PAINFUL/PAINLESS NECK SWELLINGS Lesions in oral cavity and oropharynx may extend in neck, e.g. Ludwig’s angina, parapharyngeal abscess/tumours, etc. In inflammatory conditions of oral cavity and oropharynx, the draining lymph nodes may become enlarged and tender. In malignant lesions, it may be secondary deposits in neck nodes. NASAL REGURGITATION Conditions like palatal palsy, perforated palate can cause nasal regurgitation. Examination of Oral Cavity and Oropharynx INSPECTION In the examination of oral cavity one should examine lips, teeth, mucosa lining the cheeks, gingivobuccal and gingivo-labial gutters, gums, dorsum of tongue, under surface of tongue and floor of mouth for any obvious congenital defect, swelling, foreign body, ulcer or sinus. Later hard palate, soft palate, uvula, anterior pillars, posterior pillars, tonsils, posterior pharyngeal wall may be examined similarly. Movements of soft palate, uvula and tongue should be observed. Lips should be looked for any fissures, clefts, angular stomatitis, etc. (Figure 6-1A). 121 122 Clinical Methods in ENT Figure 6-1A: Showing growth on vermilion surface of lip Tongue Patient is asked to open the mouth widely. Anterior 1/3 of the tongue may be examined without using tongue depressor. Size: Note the size of the tongue. It may be too large (macroglossia) due to lymphangioma or haemangioma or even congenitally and teeth marks may be seen on the margins of the tongue. In long-standing paralysis of tongue, the affected side may show atrophy and wrinkling (Figure 6-1B). Figure 6-1B: Lymphangioma on tongue Oral Cavity and Oropharynx Appearance: Tongue is normally pink in colour. But may become pale in severe anaemia or may show white patch ‘leucoplakia’ in patients having chronic tobacco/betel nut use. It is considered as premalignant condition. Black hairy tongue may be seen in few patients. Patients having B-complex deficiency may show red, smooth tongue with loss of normal papillae. Fissures may be seen over tongue in nutritional deficiencies. Swelling: Note down the number, site, size, shape, surface and other features of the swelling. Ulcer: Size, shape, number margins and base of the ulcer should be described in details. Mobility: Ask the patient to protrude out his tongue. If the patient has ‘tongue tie’ he cannot protrude out his tongue properly. In case of hypoglossal nerve injury or malignancy, the affected side may show wrinkling due to fibrosis of the tongue on that side and may be deviated to the same side. Ask the patient to touch the palate with his tip of tongue. This gives you an opportunity to examine undersurface of tongue and floor of mouth. Floor of mouth is the part extending from innerside of arch of lower jaw to the attachment of tongue. Floor of mouth may have swelling, mass, ulcer or foreign body and should be carefully inspected. Wharton’s duct openings should be seen. Posterior part of floor of mouth unto tonsillo lingual sulcus is not easily visible and you have to retract the side of the tongue with tongue depressor to see it (Figure 6-1C). Figure 6-1C: Showing ‘floor of mouth’. (1) Tongue, (2) Floor or mouth, and (3) Warton’s duct 123 124 Clinical Methods in ENT Teeth and Gums While examining oral cavity a definite look at the teeth and gum condition is needed. There may be carious teeth, loosening or absence of teeth. Patient may be using artificial teeth or dentures, which should be removed before examination. Diseases of teeth give rise to many oral cavity manifestations. Ulcers, epulis or growth in the vicinity of gums and teeth may be looked for. Cheeks and Gingivo-labial Gutters Patient is asked to open his mouth and cheeks are retracted with tongue depressor to see mucosal surface. Gingivo-labial and gingivo-buccal gutters on right and left side in upper and lower jaw are examined carefully with the help of tongue depressor upto the last molar tooth. Stenson’s duct [parotid gland duct], which opens in the close vicinity of 2nd molar tooth, is carefully examined on both sides. This part of oral cavity should be looked for any swelling, ulcer, congestion or foreign body. Mucosa lining the cheeks may show typical Koplik’s spots in measles. Cheek mucosa may be stained dark due to chronic tobacco use. Or may show white patch (leucoplakia) red patch (erythroplakia). Upper gingivo-buccal sulcus may be obliterated in carcinoma maxilla. Hard Palate, Soft Palate, Uvula (Figure 6-1D) Patient is asked to open the mouth while his head is tilted back. Patient is asked to say “aha” to see palatal and uvula movements. Figure 6-1D: Showing perforation in hard palate Oral Cavity and Oropharynx Patient may have congenital cleft palate, bifid uvula, or fibrous swelling over palate called “torus palatinus”. Chronic smokers may show prominent mouth of salivary glands over hard palate. In case of diphtheria or vagal palsy, movements of soft palate and uvula may be restricted or lost. Soft palate and uvula deviates to normal side on saying “aha” (Figure 6-2). 1. 2. 3. 4. 5. 6. ‘ Arrow’ – Uvula Posterior pillar Anterior pillar Trigone Tongue Soft palate Hard palate Figure 6-2: Photograph of oropharynx Anterior Pillars, Tonsils and Posterior Pillars Lateral surface of the tongue is depressed with the help of tongue depressor, to visualise tonsil and its pillars. Tongue depressor should not be put too posteriorly, otherwise patient would get gag reflex. Neither it should be kept too anteriorly lest, middle part of the tongue would bump up preventing proper vision. • Anterior pillars: These are basically muco-muscular folds containing the palatoglossus muscle. They cover the anterior surface of tonsil partly. In normal condition they are pink in colour. Congestion along anterior pillar suggests infection in tonsil. • Tonsils: Colour—(normal-pink infection-congested, red Size of the tonsil is graded by few as follows: Grade I Medial surface of tonsil hidden behind anterior pillar Grade II Medial surface of tonsil just at the level of anterior pillar Grade III Size in between Gr II and Gr IV Grade IV Tonsils touching each other (Kissing tonsils). Any other abnormalities—like follicles, membrane, cyst, FB, keratosis, ulcer, growth, etc. may be noted. 125