ch 18- assessing mouth, throat, nose, sinuses

inspect the posterior pharyngeal wall

A bright red throat with white or yellow exudate indicates pharyngitis. Yellowish mucus on throat may be seen, with postnasal sinus drainage

Herpes simplex type 1 (cold sores)

Clear vesicles surrounded by red indurated base

do you have allergies?

Pollens cause seasonal rhinitis, whereas dust may cause rhinitis year round

gingivitis

Red swollen gums that easily bleed

inspect stensen ducts (parotid ducts) openings of the parotid salivary glands—located on the buccal mucosa across from the second upper molar.

Reddened opening of Stensen ducts is seen with mumps. Fordyce spots or granules, yellowish-whitish raised spots, are normal ectopic sebaceous glands.

Do you have a history of sinus infections? do you use nasal spray?

Some clients are more susceptible to sinus infections, which tend to recur. Overuse of nasal sprays may cause nasal irritation, nosebleeds, and rebound swelling.

percuss the frontal and maxillary sinuses

The frontal and maxillary sinuses are tender upon percussion in clients with allergies or sinus infection.

inspect the hard and soft 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.

A candidal infection may appear as thick white plaques on the hard palate. Deep purple, raised, or flat lesions may indicate a Kaposi sarcoma (seen in clients with AIDS; Abnormal Findings 18-1). A yellow tint to the hard palate may indicate jaundice because bilirubin adheres to elastic tissue (collagen). An opening in the hard palate is known as a cleft palate. A bony protuberance in the midline of the hard palate, called a torus palatinus, is a normal variation.

Have you experienced a change in your ability to smell or taste?

A decrease in the ability to smell may occur with lesions of the Optic nerve (I) or Facial nerve (VII), head injuries, upper respiratory tract infections, conditions affecting the nasal passages, including nasal polyps and sinusitis, and disorders associated with aging or neurologic illnesses such as Parkinson disease or Alzheimer disease. Other less common causes include cigarette smoking, radiation therapy for head and neck cancer, hormone disturbances (especially from estrogen deficiency associated with menopause), certain medications, and rarely, brain tumors (Hummel et al., 2011). Changes in perception of taste and smell also can occur from a zinc deficiency (The Taste and Smell Clinic, 2005). Olfactory dysfunction also predicts 5-year mortality in older adults, and is thus one of the strongest predictors of 5-year mortality. Although a decrease in the sense of both smell and taste is often seen as part of the aging process, the nurse should document any changes the client shares regarding smell and taste.

inspect for wharton ducts openings from the submandibular salivary glands—located on either side of the frenulum on the floor of the mouth.

Abnormal findings include lesions, ulcers, nodules, or hypertrophied duct openings on either side of frenulum.

acute tonsillitis

Acute tonsillitis secondary to infectious mononucleosis. Note the marked tonsillar enlargement with erythema and the large white-gray patches

kaposi's sarcoma lesions

Advanced lesions seen in HIV (human immunodeficiency virus)

Assess the uvula Note the characteristics and positioning of the uvula. Ask the client to say "aaah" and watch for the uvula and soft palate to move.

Asymmetric movement or loss of movement may occur after a cerebrovascular accident (stroke). Palate fails to rise and uvula deviates to normal side with cranial nerve X (vagus) paralysis. Native Americans and Asians may have a split (or bifid) uvula Depress the tongue slightly off-center to avoid eliciting the gag response

tooth care

Brushing twice a day with a soft bristle toothbrush, flossing between teeth once a day, and oral hygiene can prevent dental caries and gum disease (American Dental Association [ADA], 2013). Regular dental checkups, as recommended by dentists, and screening can help to detect the early signs of gum disease and oral cancer, which promotes early treatment.

observe the sides of the tongue

Canker sores may be seen on the sides of the tongue in clients receiving certain kinds of chemotherapy. Leukoplakia, persistent lesions, ulcers, or nodules may indicate cancer and should be further evaluated medically. Induration increases the likelihood of cancer.. The side of the tongue is the most common site of tongue cancer.

do you experience nosebleeds? amount of bleeding and how often it occurs? color of blood?

Causes of epistaxis (nosebleeds) can be divided into local causes (e.g., trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors), systemic causes (e.g., blood dyscrasias, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic causes. Local trauma is the most common cause, followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. A large study of epistaxis found an increase in patients with allergic rhinitis, chronic sinusitis, hypertension, hematologic malignancy, coagulopathy, or hereditary hemorrhagic telangiectasia, an association with older age and colder weather (Nguyen, 2015). Refer a client who experiences frequent nosebleeds for further evaluation.

streptococcal pharyngitis

Characterized by an erythematous posterior pharynx (A), palatal petechiae (B), and a white strawberry tongue (C).

tobacco and alcohol use

Cigarette, pipe, or cigar smoking and use of smokeless tobacco increase a person's risk for oral cancer. Tobacco use and heavy alcohol consumption are responsible for 74% of oral cancers (O'Neill, 2015). Cancer of the cheek is linked to chewing tobacco. Smoking a pipe is a risk factor for lip cancer. Clients who want to quit using tobacco may benefit from a referral to a smoking cessation program. Excessive use of alcohol (more than 21 standard drinks per week) increases a person's risk for oral cancer

brushing the tongue

Cleaning the tongue is a way to prevent halitosis (bad breath) resulting from bacteria that accumulates on the posterior tongue.

check patency of air flow through the nostrils

Client cannot sniff through a nostril that is not occluded, nor can he or she sniff or blow air through the nostrils. This may be a sign of swelling, rhinitis, or a foreign object obstructing the nostrils. A line across the tip of the nose just above the fleshy tip is common in clients with chronic allergies.

inspect the teeth and gums

Clients who smoke, drink large quantities of coffee or tea, or have an excessive intake of fluoride may have yellow or brownish teeth. Tooth decay (caries) may appear as brown dots or cover more extensive areas of chewing surfaces. Missing teeth can affect chewing as well as self-image. A chalky white area in the tooth surface is a cavity that will turn darker with time. Malocclusion of teeth is seen when upper or lower incisors protrude. Poor occlusion of teeth can affect chewing, wearing down of teeth, speech, and self-image. Brown or yellow stains or white spots on teeth may result from antibiotic therapy or tooth trauma. Receding gums. In older clients, the teeth may appear longer because of age-related gingival recession, which is common. Red, swollen gums that bleed easily are seen in gingivitis, scurvy (vitamin C deficiency), and leukemia. Receding red gums with loss of teeth are seen in periodontitis. Enlarged reddened gums (hyperplasia) that may cover some of the normally exposed teeth may be seen in pregnancy, puberty, leukemia, and with use of some medications, such as phenytoin. A bluish-black or grey-white line along the gum line is seen in lead poisoning (Khalil, 2009). There is a significant link between periodontal disease and cardiovascular disease

candida albicans infection (thrush)

Curdlike patches easily scrape off, leaving a reddened area

check the strength of the tongue

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

Inspect and palpate the tongue

Dry; nodules, ulcers present; papillae or fissures absent; asymmetrical. Deep longitudinal fissures are seen in dehydration; black hairy tongue seen with conditions causing hyposalivation, heavy smoking, alcohol intake, use of antibiotics that inhibit normal bacteria leading to fungus, use of mouthwashes; also seen with bismuth intake (Pepto-Bismol) (Black hairy tongue, 2014); smooth, red, shiny tongue seen in niacin or vitamin B12 deficiency (see Abnormal Findings 18-1). Raised whitish feathery areas on sides of tongue that cannot be scraped off suggest hairy leukoplakias seen in HIV infection and AIDS. A smooth, reddish, shiny tongue without papillae is indicative of niacin or vitamin B12 deficiencies, certain anemias, and antineoplastic therapy (Stanford Medicine, 2015; Abnormal Findings 18-1). An enlarged tongue suggests hypothyroidism, acromegaly, or Down syndrome, and angioneurotic edema of anaphylaxis. A very small tongue suggests malnutrition. An atrophied tongue or fasciculations point to cranial nerve (hypoglossal, CN 12) damage. A common variation is a fissured, topographic-map-like tongue, which is not unusual in older clients Smokers may also have a yellow-brown coating on the tongue, which is not leukoplakia.

do you have difficulty swallowing or painful swallowing? How long have you had this?

Dysphagia (difficulty swallowing) or odynophagia (painful swallowing) may be seen with tumors of the pharynx, esophagus, or surrounding structures, narrowing of the esophagus such as in postradiation, gastroesophageal reflux disease (GERD), anxiety, poorly fitting dentures, or neuromuscular disorders. Dysphagia increases the risk for aspiration, and clients with dysphagia may require consultation with a speech therapist. Difficulty chewing, swallowing, or moving the tongue or jaws may be a late sign of oral cancer. Malocclusion may also cause difficulty chewing or swallowing.

Tongue or mouth sores or lesions. use coldspa to assess

Exploring the symptoms with COLDSPA can provide data to determine if lesions are related to medications, stress, infection, trauma, or malignancy. Lesions that last for more than 2 weeks need to be explored further and referred. Painful, recurrent ulcers in the mouth are seen with aphthous stomatitis (canker sores) and herpes simplex (cold sores). 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 cancer and need to be referred for further evaluation

sun exposure

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

palpate the sinuses 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 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 crepitus upon palpation over the maxillary sinuses. This may also be present with a viral upper respiratory infection (URI).

Note odor

Fruity or acetone breath is associated with diabetic ketoacidosis. An ammonia odor is often associated with kidney disease. Foul odors may indicate an oral or respiratory infection, or tooth decay. Alcohol or tobacco use may be identified by breath odor. Fecal breath odor occurs in bowel obstruction; sulfur odor (fetor hepaticus) occurs in end-stage liver disease.

teeth grinding

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.

receding gums

Gum tissue surrounding tooth pulls back, exposing more of tooth or root of tooth

do you experience hoarseness?

Hoarseness is associated with upper respiratory infections, allergies, hypothyroidism, overuse of the voice, smoking or inhaling other irritants, and cancer of the larynx. If hoarseness lasts 2 weeks or longer, refer the client for further evaluation.

tonsillitis detection and grading

In a client who has both tonsils and a sore throat, tonsillitis can be identified and ranked with a grading scale from 1-4 as follows: 1+ Tonsils are visible. 2+ Tonsils are midway between tonsillar pillars and uvula. 3+ Tonsils touch the uvula. 4+ Tonsils touch each other.

can you breathe through both of your nostrils? Do you have a stuffy nose at times during the day or night?

Inability to breathe through both nostrils may indicate sinus congestion, obstruction, or a deviated septum. Nasal congestion can interfere with daily activities or a restful sleep.

braces care

It is important that clients follow their orthodontist's prescribed routine for cleaning and caring for their teeth while wearing braces to avoid staining and cavities. Clients with braces should avoid crunchy, sticky, and chewy foods when wearing braces. These foods can damage the braces and the teeth.

Do you regularly use any treatments or medications for conditions that affect the mouth, nose, or throat or to control pain in the mouth, nose, throat, or sinuses (e.g., saline spray or use of over-the-counter nasal irrigations, nasal sprays, throat spray, ibuprofen)? What are the results?

It is important to know what remedies have worked for the client in the past and what has been used that does not relieve symptoms.

inspect the buccal mucosa

Leukoplakia (chalky white raised patches) may be seen in chronic irritation, heavy smoking, and alcohol use. These are precancerous lesions and should be referred to the client's primary health care provider for further assessment. Whitish, curd-like patches that scrape off over reddened mucosa and bleed easily indicate "thrush" (Candida albicans) infection. Koplik spots (tiny whitish spots that lie over reddened mucosa) are an early sign of the measles. Canker sores may be seen. Brown patches inside the cheeks of clients with Addison disease (chronic adrenocortical insufficiency) Oral mucosa is often drier and more fragile in the older client because the epithelial lining of the salivary glands degenerates.

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 (Fig. 18-11) 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").

Leukoplakia, persistent lesions, ulcers, or nodules may indicate cancer and should be referred. Induration increases the likelihood of cancer. The area underneath the tongue is the most common site of oral cancer. The older client may have varicose veins on the ventral surface of the tongue

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.

Loss of taste discrimination occurs with trauma, viral infections, sinusitis and polyposis, increasing age, neurologic illnesses such as Parkinson's or Alzheimer's; and zinc deficiency, or use of certain medication that affect smell threshold

Inspect the internal nose

Nasal mucosa is swollen and pale pink or bluish gray in clients with allergies. Nasal mucosa is red and swollen with upper respiratory infection. Exudate is common with infection and may range from large amounts of watery discharge to thick yellow-green, purulent discharge. Purulent nasal discharge is seen with acute bacterial rhinosinusitis. Bleeding (epistaxis) or crusting may be noted on the lower anterior part of the nasal septum with local irritation. Ulcers of the nasal mucosa or a perforated septum may be seen with use of cocaine, trauma, chronic infection, or chronic nose picking. Small, pale, round, firm overgrowths or masses on mucosa (polyps) are seen in clients with chronic allergies A deviated septum may appear to be an overgrowth of tissue (Fig. 18-20). This is a normal finding as long as breathing is not obstructed.

inspect and palpate external nose

Nasal tenderness on palpation accompanies a local infection.

black hairy tongue

Not hair, but elongated filiform papillae seen with use of antibiotics that inhibit normal bacteria

pain over your sinuses

Pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, or forehead are seen in acute sinusitis, which is an infection of the sinuses. In chronic sinusitis, the sinuses become inflamed and swollen, but symptoms last 12 weeks or longer even with treatment

canker sore

Painful small ulcers inside mouth; do not occur on lip surface; non-contagious

inspect the lips

Pallor around the lips (circumoral pallor) is seen in anemia and shock. Bluish (cyanotic) lips may result from cold or hypoxia. Reddish lips are seen in clients with ketoacidosis, carbon monoxide poisoning, and chronic obstructive pulmonary disease (COPD) with polycythemia. Swelling of the lips (edema) is common in local or systemic allergic or anaphylactic reactions.

dietary intake

Poor nutrition increases one's risk for oral cancers

dentures

Poorly fitting dentures may lead to poor eating habits, a reluctance to speak freely, and mouth sores or leukoplakia (thick white patches of cells). Leukoplakia is a precancerous condition. Older adults and some disabled clients may have difficulty caring properly for teeth or dentures because of poor vision or impaired dexterity.

redness, swelling, pain, or bleeding in gums or mouth

Red, swollen gums that bleed easily occur in early gum disease (gingivitis), whereas destruction of the gums with tooth loss occurs in more advanced gum disease (periodontitis). Dental pain may occur with dental caries, abscesses, or sensitive teeth. Periodontal disease is highly correlated with cardiovascular disease. The gums recede, become ischemic, and undergo fibrotic changes as a person ages. Tooth surfaces may be worn from prolonged use. These changes make the older client more susceptible to periodontal disease and tooth loss.

carcinoma of tongue

Round indurated lesion becomes crusty and ulcerated with elevated border

carcinoma of lip

Round, indurated lesion becomes crusted and ulcerated with elevated border

Cheilosis of lips

Scaling painful fissures at corner of lips

Do you have a sore throat?

Sore throat refers to pain, itchiness, or irritation of the throat. Hoarseness may be present as well. Throat irritation and soreness are commonly seen with viral infections such as the flu, colds, measles, chicken pox, whooping cough, croup, or infectious mononucleosis, with bacterial infections such as streptococcus, and are often present with HIV. Additional causes include: Allergies to pollens, molds, cat and dog dander, house dust Irritation due to dry heat, chronic stuffy nose, pollutants, and voice straining Reflux of stomach acids up into the back of the throat Tumors of the throat, tongue, and larynx with pain radiating to the ear and/or difficulty swallowing Tonsillitis A sore throat that persists without healing may signal throat cancer.

frequent clear or mucous drainage from nose

Thin, watery, clear nasal drainage (rhinorrhea) 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. The overwhelming majority of upper respiratory illnesses are viral.

inspect the tonsils

Tonsils are red, enlarged (to 2+, 3+, or 4+), and covered with exudate in tonsillitis. They also may be indurated with patches of white or yellow exudate (Abnormal Findings 18-1). Grading of tonsils in tonsillitis is depicted in

vitamin b12 deficiency

smooth, reddish, shiny tongue without papillae

leukoplakia (ventral surface)

thick raised patch does not scrape off; seen in heavy tobacco or alcohol use