Assessing Mouth, Throat, Nose, and Sinuses

Nosebleeds

... are most commonly due to dry nasal membranes and nose picking. Other causes include acute and chronic sinusitis, allergies, anticoagulants, cocaine use, common colds, deviated septum, foreign body in nose, nasal sprays, non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, chemical irritants, nonallergic rhinitis, or nose trauma (Mayo Clinic, 2012). Refer a client who experiences frequent ... for further evaluation.

Amylase

... digests carbohydrates

Malocclusion

... may also cause difficulty chewing or swallowing.

Grinding the teeth (bruxism)

... may be a sign of stress or of slight malocclusion. The practice may also precipitate temporomandibular joint (TMJ) problems and pain.

meatus

A ... underlies each turbinate and receives drainage from the paranasal sinuses and the nasolacrimal duct.

chronic allergies

A line across the tip of the nose just above the fleshy tip is common in clients with ...

Acute tonsillitis and pharyngitis.

Abnormalities of the Mouth and Throat

Black hairy tongue.

Abnormalities of the Mouth and Throat

Candida albicans infection (thrush).

Abnormalities of the Mouth and Throat

Canker sore.

Abnormalities of the Mouth and Throat

Carcinoma of lip.

Abnormalities of the Mouth and Throat

Carcinoma of tongue.

Abnormalities of the Mouth and Throat

Cheilosis of lips.

Abnormalities of the Mouth and Throat

Gingivitis

Abnormalities of the Mouth and Throat

Hairy leukoplakia (lateral surface)

Abnormalities of the Mouth and Throat

Herpes simplex type I.

Abnormalities of the Mouth and Throat

Kaposi's sarcoma lesions.

Abnormalities of the Mouth and Throat

Leukoplakia (ventral surface)

Abnormalities of the Mouth and Throat

Receding gums

Abnormalities of the Mouth and Throat

Smooth, reddish, shiny tongue without papillae due to vitamin B12 deficiency.

Abnormalities of the Mouth and Throat

Assess the uvula.

Apply a tongue depressor to the tongue (halfway between the tip and back of the tongue) and shine a penlight into the client's wide-open mouth. Note the characteristics and positioning of the uvula. Ask the client to say "aaah" and watch for the uvula and soft palate to move. The uvula is a fleshy, solid structure that hangs freely in the midline. No redness of or exudate from uvula or soft palate. Midline elevation of uvula and symmetric elevation of the soft palate.

vibrissae

As the person inspires air, nasal hairs (...) filter large particles from the air.

Inspect and palpate the tongue.

Ask client to stick out the tongue. Inspect for color, moisture, size, and texture. Observe for fasciculations (fine tremors), and check for midline protrusion. Palpate any lesions present for induration (hardness). Tongue should be pink, moist, a moderate size with papillae (little protuberances) present. A common variation is a fissured, topographic-map-like tongue, which is not unusual in older clients (Fig. 18-10). No lesions are present.

Inspect the hard (anterior) and soft (posterior) palates and uvula.

Ask the client to open the mouth wide while you use a penlight to look at the roof. Observe color and integrity. The hard palate is pale or whitish with firm, transverse rugae (wrinkle-like folds). Palatine tissues are intact; the soft palate should be pinkish, movable, spongy, and smooth.

Inspect the teeth and gums.

Ask the client to open the mouth. Note the number of teeth, color, and condition. Note any repairs such as crowns and any cosmetics such as veneers. Ask the client to bite down as though chewing on something and note the alignment of the lower and upper jaws. Put on gloves and retract the client's lips and cheeks to check gums for color and consistency. Some clients normally have only 28 teeth if the four wisdom teeth do not erupt. Gums are pink, moist, and firm with tight margins to the tooth. No lesions or masses.

Assess the ventral surface of the tongue.

Ask the client to touch the tongue to the roof of mouth, and use a penlight to inspect the ventral surface of the tongue, frenulum, and area under the tongue. Palpate the area if you see lesions, if the client is over age 50, or if the client uses tobacco or alcohol. Note any induration. Check also for a short frenulum that limits tongue motion (the origin of "tongue-tied"). The tongue's ventral surface is smooth, shiny, pink, or slightly pale, with visible veins and no lesions.

cerebrovascular accident (stroke)

Assess the uvula. Asymmetric movement or loss of movement may occur after a ....

cranial nerve X (vagus)

Assess the uvula. Palate fails to rise and uvula deviates to normal side with ... paralysis.

Depress the tongue slightly off center to avoid eliciting the gag response.

CLINICAL TIP

Position the otoscope's handleto the side to improve your view of the structures. If an otoscope is unavailable, use a penlight and hold the tip of the nose slightly up. A nasal speculum with a pen- light also facilitates good visualization.

CLINICAL TIP

Smokers may also have a yellow- brown coating on the tongue, which is not leukoplakia.

CLINICAL TIP

The side of the tongue is the most common site of tongue cancer.

CLINICAL TIP

Upper dentures should be removed so that the light is not blocked.

CLINICAL TIP

A bifid uvula, common in Native Americans, looks like it is split in twoor partially severed. Clients with a bifid uvula may have a submucous cleft palate.

CULTURAL CONSIDERATIONS

A bony protuberance in the midline of the hard palate, called a torus palatinus, is a normal variation seen more often in females, Eskimos, Native Americans, and Asians.

CULTURAL CONSIDERATIONS

A number of tooth variations occur, especially in Asian, Pacific Islanders, and Native Americans, including talon cusps on incisors and circular molars

CULTURAL CONSIDERATIONS

Pink lips are normal in light- skinned clients, as are bluish or freckled lips in some dark-skinned clients, especially those of Mediterranean descent.

CULTURAL CONSIDERATIONS

The buccal mucosa should appear pink in light-skinned clients; tissue pigmentation typically increases in dark-skinned clients.

CULTURAL CONSIDERATIONS

Loss of taste

Check the anterior tongue's ability to taste. ... discrimination occurs with zinc deficiency, a seventh cranial nerve (facial) defect, chronic sinus infections, and certain medication use

Decreased tongue strength

Check the strength of the tongue. ... may occur with a defect of the twelfth cranial nerve—hypoglossal—or with a shortened frenulum that limits motion.

Nasal polyp.

Common Abnormalities of the Nose

Perforated septum.

Common Abnormalities of the Nose

advanced gum disease (periodontitis)

Destruction of the gums with tooth loss occurs in ...

lip cancer

Exposure to the sun is the primary risk factor associated with ...

Transilluminate 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 should be dark). 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. Absence of a red glow usually indicates a sinus filled with fluid or pus.

chronic sinusitis

In ..., the sinuses become inflamed and swollen, but symptoms last 12 weeks or longer even with treatment

bismuth (Pepto-Bismol)

Inspect and palpate the tongue. A black tongue indicative of ... toxicity: Black, hairy tongue

niacin or vitamin B12

Inspect and palpate the tongue. A smooth, reddish, shiny tongue without papillae indicative of ... deficiencies, certain anemias, and antineoplastic therapy

malnutrition

Inspect and palpate the tongue. A very small tongue suggests ...

dehydration

Inspect and palpate the tongue. Among possible abnormalities are deep longitudinal fissures seen in ...

enlarged tongue

Inspect and palpate the tongue. An ... suggests hypothyroidism, acromegaly, or Down's syndrome, and angioneurotic edema of anaphylaxis.

cranial nerve (hypoglossal, CN 12)

Inspect and palpate the tongue. An atrophied tongue or fasciculations point to ... damage.

Koplik's spots

Inspect the buccal mucosa. ... (tiny whitish spots that lie over reddened mucosa) are an early sign of the measles.

Leukoplakia

Inspect the buccal mucosa. ... may be seen in chronic irritation and smoking; a precancerous lesion, and the client should be referred for evaluation.

Canker sores

Inspect the buccal mucosa. ... may be seen, as may brown patches inside the cheeks of clients with adrenocortical insufficiency

"thrush" (Candida albicans)

Inspect the buccal mucosa. Whitish, curd-like patches that scrape off over reddened mucosa and bleed easily indicate... infection.

candidal infection

Inspect the hard (anterior) and soft (posterior) palates and uvula. A ... may appear as thick white plaques on the hard palate.

elastic tissue (collagen)

Inspect the hard (anterior) and soft (posterior) palates and uvula. A yellow tint to the hard palate may indicate jaundice because bilirubin adheres to ...

Kaposi's sarcoma (seen in clients with AIDS)

Inspect the hard (anterior) and soft (posterior) palates and uvula. Deep purple, raised, or flat lesions may indicate a ...

deviated septum

Inspect the internal nose. A ... may appear to be an overgrowth of tissue. This is a normal finding as long as breathing is not obstructed.

superior turbinate

Inspect the internal nose. The ... will not be visible from this point of view.

Reddish lips

Inspect the lips. ... are seen in clients with ketoacidosis, carbon monoxide poisoning, and chronic obstructive pulmonary disease (COPD) with polycythemia.

Bluish (cyanotic) lips

Inspect the lips. ... may result from cold or hypoxia.

Swelling of the lips (edema)

Inspect the lips. ...is common in local or systemic allergic or anaphylactic reactions.

Pallor around the lips (circumoral pallor)

Inspect the lips. ...is seen in anemia and shock.

pharyngitis

Inspect the posterior pharyngeal wall. A bright red throat with white or yellow exudate indicates ...

postnasal sinus drainage

Inspect the posterior pharyngeal wall. Yellowish mucus on throat may be seen, with ...

Receding gums

Inspect the teeth and gums. ... are abnormal in younger clients; in older clients, the teeth may appear longer because of age-related gingival recession, which is common.

Malocclusion of teeth

Inspect the teeth and gums. ... is seen when upper or lower incisors protrude; can affect chewing, wearing down of teeth, speech, and self-image.

Red, swollen gums

Inspect the teeth and gums. ... that bleed easily are seen in gingivitis, scurvy (vitamin C deficiency), and leukemia

Enlarged reddened gums (hyperplasia)

Inspect the teeth and gums. ... that may cover some of the normally exposed teeth may be seen in pregnancy, puberty, leukemia, and use of some medications, such as phenytoin.

Receding red gums

Inspect the teeth and gums. ... with loss of teeth are seen in periodontitis.

chalky white

Inspect the teeth and gums. A ... area in the tooth surface is a cavity that will turn darker with time.

lead poisoning

Inspect the teeth and gums. A bluish-black or grey-white line along the gum line is seen in ...

antibiotic therapy or tooth trauma

Inspect the teeth and gums. Brown or yellow stains or white spots on teeth may result from ...

tonsillitis

Inspect the tonsils. Tonsils are red, enlarged (to 2+, 3+, or 4+), and covered with exudate in ... They also may be indurated with patches of white or yellow exudate

Inspect the posterior pharyngeal wall.

Keeping the tongue depressor in place,shine the penlight on the back of the throat. Observe the color of the throat, and note any exudate or lesions. Before inspecting the nose, discard gloves and perform hand hygiene. Inspect and palpate the external nose. Note nasal color, shape, consistency, and tenderness. Throat is normally pink, without exudate or lesions Color is the same as the rest of the face; the nasal structure is smooth and symmetric; the client reports no tenderness.

2 weeks

Lesions that last for more than ... need to be explored further and referred.

Percuss the sinuses.

Lightly tap (percuss) over the frontal sinuses and over the maxillary sinuses for tenderness. The frontal and maxillary sinuses are tender upon percussion in clients with allergies or sinus infection.

cancer

Mouth or tongue sores that do not heal; red or white patches that persist; a lump or thickening; or rough, crusty, or eroded areas are warning signs of ... and need to be referred for further evaluation

Foul odors

Note odor. ... may indicate an oral or respiratory infection, or tooth decay.

sulfur odor (fetor hepaticus)

Note odor. ... occurs in end stage liver disease.

kidney disease

Note odor. An ammonia odor is often associated with ...

bowel obstruction

Note odor. Fecal breath odor occurs in ...

diabetic ketoacidosis

Note odor. Fruity or acetone breath is associated with ...

Oral mucosa is often drier and more fragile in the older client because the epithelial lining of the salivary glands degenerates.

OLDER ADULT CONSIDERATIONS

The ability to smell and taste decreases with age. Medica- tions can also decrease sense of smell and taste in older people.

OLDER ADULT CONSIDERATIONS

The gums recede, become ischemic, and undergo fibrotic changes as a person ages. Tooth surfaces may be worn from pro- longed use. These changes make the older client more susceptible to periodontal disease and tooth loss.

OLDER ADULT CONSIDERATIONS

The older client may have varicose veins on the ventral surface of the tongue

OLDER ADULT CONSIDERATIONS

Inspect the lips.

Observe lip consistency and color. Lips are smooth and moist without lesions or swelling.

Check patency of air flow through the nostrils

Occlude one nostril at a time and asking client to sniff. Client is able to sniff through each nostril while other is occluded.

Inspect for Wharton's ducts

Openings from the submandibular salivary glands— located on either side of the frenulum on the floor of the mouth. The frenulum is midline; Wharton's ducts are visible, with salivary flow or moistness in the area. The client has no swelling, redness, or pain.

acute sinusitis

Pain, tenderness, swelling and pressure around the eyes, cheeks, nose or forehead is seen in ...

aphthous stomatitis (canker sores)

Painful, recurrent ulcers in the mouth are seen with ... and herpes simplex (cold sores).

crepitus

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

Check the anterior tongue's ability to taste.

Place drops of sugar and salty water on the tip and sides of tongue with a tongue depressor. The client can distinguish between sweet and salty.

Check the strength of the tongue.

Place your fingers on the external surface of the client's cheek. Ask the client to press the tongue's tip against the inside of the cheek to resist pressure from your fingers. Repeat on the opposite cheek. The tongue offers strong resistance.

early gum disease (gingivitis)

Red, swollen gums that bleed easily occur in ...

neck

The crown and root are connected by the region of the tooth referred to as the ...

Stensen's ducts

The parotid glands, located below and in front of the ears, empty through ... , which are located inside the cheek across from the second upper molar.

Wharton's ducts

The submandibular glands, located in the lower jaw, open under the tongue on either side of the frenulum through openings called ...

conchae

The superior, middle, and inferior turbinates are bony lobes, sometimes called .. , that project from the lateral walls of the nasal cavity.

temporal bone

The tongue is a mass of muscle, attached to the hyoid bone and styloid process of the ...

rhinorrhea

Thin, watery, clear nasal drainage (...) can indicate a chronic allergy or, in a client with a past head injury, a cerebrospinal fluid leak. Mucous drainage, especially yellow, is typical of a cold, rhinitis, or a sinus infection.

Inspect the internal nose.

To inspect the internal nose, use an otoscope with a short wide-tip attachment or you can also use a nasal 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 up to view the nasal mucosa, nasal septum, the inferior and middle turbinates, and the nasal passage (the narrow space between the septum and the turbinates). 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 oral mucosa), moist, and free of lesions.

2+

Tonsillitis (Detecting and Grading) Tonsils are midway between tonsillar pillars and uvula.

1+

Tonsillitis (Detecting and Grading) Tonsils are visible.

4+

Tonsillitis (Detecting and Grading) Tonsils touch each other.

3+

Tonsillitis (Detecting and Grading) Tonsils touch the uvula.

Inspect the buccal mucosa.

Use a penlight and tongue depressor to retract the lipsand cheeks to check color and consistency. Also note Stenson's ducts (parotid ducts) located on the buccal mucosa across from the second upper molars. In all clients, tissue is smooth and moist without lesions. Stenson's ducts are visible with flow of saliva and with no redness, swelling, pain, or moistness in area. Fordyce spots or granules, yellowish-whitish raised spots, are normal ectopic sebaceous glands.

Observe the sides of the tongue.

Use a square gauze pad to hold the client's tongue to each side. Palpate any lesions, ulcers, or nodules for induration. No lesions, ulcers, or nodules are apparent.

Inspect the tonsils.

Using the tongue depressor to keep the mouth open wide, inspect the tonsils for color, size, and presence of exudate or lesions. Grade the tonsils. Tonsils may be present or absent. They are normally pink and symmetric and may be enlarged to 1+ in healthy clients No exudate, swelling, or lesions should be present.

Palpate the sinuses.

When an infectionis suspected, the nurse can examine the sinuses through palpation, percussion, and transillumination. Palpate the frontal sinuses by using your thumbs to press up on the brow on each side of nose. Palpate the maxillary sinuses by pressing with thumbs up on the maxillary sinuses. Frontal and maxillary sinuses are nontender to palpation, and no crepitus is evident.

Note odor.

While the mouth is wide open, note any unusual or foul odor. No unusual or foul odor is noted.

root

he portion of the tooth that is embedded in the gums is the ...

crown

he top, visible, white enameled part of each tooth is the ... T