Ch 18 Mouth, Throat, Nose, & Sinuses (skills)

Focused Specialty Assessment

- Palpate the buccal mucosa and tongue - Assess the ventral surface and sides of the tongue. - Inspect for Wharton ducts and Stensen ducts - Check the strength of the tongue. - Check the anterior tongue's ability to taste. - Inspect the hard (anterior) and soft (posterior) palates and uvula. - Assess the uvula, tonsils, and posterior pharyngeal wall. - Inspect the internal nose with an otoscope and nasal speculum - Palpate, percuss, and transilluminate the sinuses.

Acute tonsillitis:

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

Herpes simplex type I (cold sores):

Clear vesicles surrounded by red indurated base

Candida albicans infection (thrush):

Curdlike patches easily scrape off, leaving a reddened area

Note odor. While the mouth is wide open, note any unusual or foul odor.

Normal: - No unusual or foul odor is noted. Abnormal: - 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.

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.

Normal: - Throat is normally pink, without exudate or lesions Abnormal: - A bright red throat with white or yellow exudate indicates pharyngitis. Yellowish mucus on throat may be seen, with postnasal sinus drainage

Canker sore:

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

Gingivitis:

Red swollen gums that easily bleed

Cheilosis of lips:

Scaling painful fissures at corner of lips

B12 deficiency can cause

Smooth, reddish, shiny tongue without papillae

Structure and function

- The mouth and throat comprise the first part of the digestive system and are responsible for receiving food (ingestion), tasting, preparing food for digestion, and aiding in speech. Cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and XII (hypoglossal) assist with some of these functions. - 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. These receptors are related to the sense of smell.

Do you experience frequent clear or mucous drainage from your 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.

Kaposi's sarcoma lesions:

Advanced lesions seen in HIV (human immunodeficiency virus)

Other problems may cause discomfort and loss of function, and can lead to serious systemic disorders.

For example, malnutrition may develop in a client who cannot eat certain foods because of poorly fitting dentures, impaired dental health, or an edentulous state. A client with frequent sinus infections and headaches may have impaired concentration, which affects job or school performance.

Leukoplakia (ventral surface):

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

Sinusitis

- Acute sinusitis refers to symptoms that last less than 4 weeks, often begin with a common cold, and usually go away within 10 days. Sometimes, however, a bacterial infection develops. - Chronic sinusitis (or chronic rhinosinusitis) usually lasts more than 12 weeks despite medical treatment. - Sinusitis may also be caused by an infection, a fungus, a deviated nasal septum, nasal polyps, or, in rare cases, an immune system deficiency. - Individuals who suffer from chronic rhinitis or asthma are at greater risk for chronic sinusitis due to prolonged inflammation of the airways.

Notes: Nose and Sinuses

- 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. Older adult considerations - The ability to smell and taste decreases with age. Medications can also decrease sense of smell and taste in older people.

Describe how you care for your teeth or dentures. How often do you brush and use dental floss? When was your last dental examination?

- 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 - 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.

Tongue & Mouth

- Do you experience tongue or mouth sores or lesions? If so, explore the symptoms using COLDSPA. Characteristics: Describe the size and texture of the lesions. Onset: When did they first occur? Do you notice these more when you are under stress or taking certain medications? Did they occur after any injury to your mouth? Locations: Describe exactly where these lesions are located in your mouth. Duration: How long have you had these lesions? Have you ever had these before and did they go away? Severity: Do these lesions keep you from eating, talking, or swallowing? Palliative/relieving factors: What aggravates these lesions or makes them go away? What over-the-counter remedies and past prescriptions have you used? Associated Factors: Do you have any other symptoms with these lesions such as stress, pain, bleeding? Describe.

Sinuses

- Four pairs of paranasal sinuses (frontal, maxillary, ethmoidal, and sphenoidal) are located in the skull - These air-filled cavities decrease the weight of the skull and act as resonance chambers during speech. - The paranasal sinuses are also lined with ciliated mucous membrane that traps debris and propels it toward the outside. - The sinuses are often a primary site of infection because they can easily become blocked. - The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are accessible to examination by the nurse. - The ethmoidal and sphenoidal sinuses are smaller, located deeper in the skull, and are not accessible for examination.

Do you experience redness, swelling, bleeding, or pain of the gums or mouth? How long has this been happening? Do you have any toothache? Have you lost any permanent teeth?

- 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.

Do you have a sore throat? How long have you had it? Describe. How long have you had it? How often do you get sore throats?

- 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. - A sore throat that persists without healing may signal throat cancer. 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

Oropharyngeal Cancer

- The fact that the oral cavity and oropharynx, along with other parts of the head and neck, contribute to the ability to chew, swallow, breathe, and talk, oropharyngeal cancer can have significant effects on well-being - oropharyngeal cancer: Two of the most common types of cancer in this anatomical region are cancer of the oral cavity (mouth and tongue) and cancer of the oropharynx (the middle of the throat, from the tonsils to the tip of the larynx); more than 90% of oral and oropharyngeal cancers are squamous cell carcinoma.

The superior, middle, and inferior turbinates

- are bony lobes, sometimes called conchae, that project from the lateral walls of the nasal cavity. - These three turbinates increase the surface area that is exposed to incoming air - As the person inspires air, nasal hairs (vibrissae) filter large particles from the air. - Ciliated mucosal cells then capture and propel debris toward the throat, where it is swallowed. - The rich blood supply of the nose warms the inspired air as it is moistened by the mucous membrane. - A meatus underlies each turbinate and receives drainage from the paranasal sinuses and the nasolacrimal duct. - Receptors for the first cranial nerve (olfactory) are located in the upper part of the nasal cavity and septum.

The Nursing Health History

- collecting subjective data - This examination also allows the nurse to evaluate the client's health practices. For example, improper use of nasal decongestants may explain recurrent sinus congestion and infection, and improper oral hygiene practices may cause tooth decay or gum disease. The nurse should provide teaching for a client with these health practices.

The nose

- consists of an external portion covered with skin and an internal nasal cavity. - It is composed of bone and cartilage, and is lined with mucous membrane. - The external nose consists of a bridge (upper portion), tip, and two oval openings called nares. - The nasal cavity is located between the roof of the mouth and the cranium. It extends from the anterior nares (nostrils) to the posterior nares, which open into the nasopharynx. - The nasal septum separates the cavity into two halves. - The front of the nasal septum contains a rich supply of blood vessels and is known as Kiesselbach area. This is a common site for nasal bleeding.

Subjective data related to the mouth, throat, nose, and sinus can aid in

- detecting diseases and abnormalities that may affect the client's activities of daily living (ADLs). - Screening for cancer of the mouth, throat, nose, and sinuses is an important area of this assessment. These cancers are highly preventable. - Data collected regarding the client's risk factors may form the basis for preventive teaching.

The mouth—or oral cavity—

- is formed by the lips, cheeks, hard and soft palates, uvula, and the tongue and its muscles - The mouth is the beginning of the digestive tract and serves as an airway for the respiratory tract. - The upper and lower lips form the entrance to the mouth, serving as a protective gateway to the digestive and respiratory tracts. - The roof of the oral cavity is formed by the anterior hard palate and the posterior soft palate. An extension of the soft palate is the uvula, which hangs in the posterior midline of the oropharynx. - The cheeks form the lateral walls of the mouth, whereas the tongue and its muscles form the floor of the mouth. - The mandible (jaw bone) provides the structural support for the floor of the mouth.

The throat (pharynx)

- located behind the mouth and nose, serves as a muscular passage for food and air. - The upper part of the throat is the nasopharynx. Below the nasopharynx lies the oropharynx, and below the oropharynx lies the laryngopharynx. - The soft palate, anterior and posterior pillars, and uvula connect behind the tongue to form arches. - Masses of lymphoid tissue referred to as the palatine tonsils are located on both sides of the oropharynx at the end of the soft palate between the anterior and posterior pillars. - The lingual tonsils lie at the base of the tongue. Pharyngeal tonsils, or adenoids, are found high in the nasopharynx. Because tonsils are masses of lymphoid tissue, they help protect against infection

Contained within the mouth are the

- tongue, teeth, gums, and the openings of the salivary glands (parotid, submandibular, and sublingual). - The tongue is a mass of muscle, attached to the hyoid bone and styloid process of the temporal bone. It is connected to the floor of the mouth by a fold of tissue called the frenulum. The tongue assists with moving food, swallowing, and speaking. - The gums (gingiva) are covered by mucous membrane and normally hold 32 permanent teeth in the adult - The top, visible, white enameled part of each tooth is the crown. The portion of the tooth that is embedded in the gums is the root. The crown and root are connected by the region of the tooth referred to as the neck. - Small bumps called papillae cover the dorsal surface of the tongue. - Taste buds, scattered over the tongue's surface, carry sensory impulses to the brain. The three pairs of salivary glands secrete saliva (watery, serous fluid containing salts, mucus, and salivary amylase) into the mouth - Saliva helps break down food and lubricates it. Amylase digests carbohydrates. The parotid glands, located below and in front of the ears, empty through Stensen ducts, which are located inside the cheek 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 openings called Wharton ducts. The sublingual glands, located under the tongue, open through several ducts located on the floor of the mouth.

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.

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. Changes in perception of taste and smell also can occur from a zinc deficiency. Olfactory dysfunction also predicts 5-year mortality in older adults, and is thus one of the strongest predictors of 5-year mortality.

Do you experience nosebleeds? Describe the amount of bleeding you have and how often it occurs. What color is the 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

Streptococcal pharyngitis:

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

Do you smoke or use smokeless tobacco? If so, how much? Are you interested in quitting this habit?

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

Do you brush your tongue?

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

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 & Mouth COLDSPA

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.

General Routine Screening or Focused Specialty Assessment for the Mouth, Nose, Throat, and Sinuses

General Routine Screening - Inspect the lips - Note odor from the mouth - Inspect the teeth, gums, and tongue, and buccal mucosa - Inspect the external nose - Check patency of air flow through the nostrils - Inspect the throat

Do you grind your teeth?

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? For how long?

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.

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.

Check patency of air flow through the nostrils by occluding one nostril at a time and asking client to sniff or exhale.

Normal: - Client is able to sniff through each nostril while other is occluded. Abnormal: - 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.

Put on gloves and retract the client's lips (Fig. 18-7) and cheeks to check gums for color and consistency

Normal: - Color and consistency of tissues along cheeks and gums are even. - In older clients, the teeth may appear longer because of age-related gingival recession, which is common. - A number of tooth variations occur, especially in Asian, Pacific Islanders, and Native Americans, including talon cusps on incisors and circular cusps on molars - Gums are pink, moist, and firm with tight margins to the tooth. No lesions or masses. Abnormal: - Receding gums. - 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

Inspect and palpate the external nose. Note nasal color, shape, consistency, and tenderness.

Normal: - Color is the same as the rest of the face; the nasal structure is smooth and symmetric; the client reports no tenderness. Abnormal: - Nasal tenderness on palpation accompanies a local infection.

Palpate the sinuses. When an infection is suspected, the nurse can examine the sinuses through palpation, percussion. 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.

Normal: - Frontal and maxillary sinuses are nontender to palpation, and no crepitus is evident. Abnormal: - 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).

Inspect the buccal mucosa. Use a penlight and tongue depressor to retract the lips and cheeks to check color and consistency

Normal: - In all clients, tissue is smooth and moist without lesions. - The buccal mucosa should appear pink in light-skinned clients; tissue pigmentation typically increases in dark-skinned clients, which may include freckling or dark pigmentation on ventral surface of tongue and floor of mouth; hard and soft palate may also be darkly pigmented. - Oral mucosa is often drier and more fragile in the older client because the epithelial lining of the salivary glands degenerates. Abnormal: - 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).

Inspect the lips. Observe lip consistency and color.

Normal: - Lips are smooth and moist without lesions or swelling. - Pink lips are normal in light-skinned clients, as are bluish or freckled lips in some dark-skinned clients, especially those of Mediterranean descent. Abnormal: - 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.

Observe the sides of the tongue. Use a square gauze pad to hold the client's tongue to each side (Fig. 18-13). Palpate any lesions, ulcers, or nodules for induration.

Normal: - No lesions, ulcers, or nodules are apparent. Abnormal: - 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.

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

Normal: - Stensen ducts are visible with flow of saliva. No redness, swelling, pain, or moistness in area. Fordyce spots or granules, yellowish-whitish raised spots, are normal ectopic sebaceous glands. Abnormal: - Reddened opening of Stensen ducts is seen with mumps.

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.

Normal: - The client can distinguish between sweet and salty. Abnormal: - 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 for Wharton ducts —openings from the submandibular salivary glands—located on either side of the frenulum on the floor of the mouth.

Normal: - The frenulum is midline; Wharton ducts are visible, with salivary flow or moistness in the area. The client has no swelling, redness, or pain. Abnormal: - Abnormal findings include lesions, ulcers, nodules, or hypertrophied duct openings on either side of frenulum.

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.

Normal: - The hard palate is pale or whitish with firm, transverse rugae (wrinkle-like folds). - A bony protuberance in the midline of the hard palate, called a torus palatinus, is a normal variation. Tori, both palatinus and mandibular (also normal variation), tend to occur more in Native Americans, Eskimos, and women; in some countries, they are more prevalent in Caucasians than in Blacks - Palatine tissues are intact; the soft palate should be pinkish, movable, spongy, and smooth. Abnormal: - 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.

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).

Normal: - 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. - The superior turbinate will not be visible from this point of view - A deviated septum may appear to be an overgrowth of tissue. This is a normal finding as long as breathing is not obstructed. Abnormal: - 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

Percuss the sinuses. Lightly tap (percuss) over the frontal sinuses and over the maxillary sinuses for tenderness.

Normal: - The sinuses are not tender on percussion. Abnormal: - The frontal and maxillary sinuses are tender upon percussion in clients with allergies or sinus infection.

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.

Normal: - The tongue offers strong resistance. Abnormal: - Decreased tongue strength may occur with a defect of the twelfth cranial nerve—hypoglossal—or with a shortened frenulum that limits motion.

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 (Fig. 18-9B). Palpate 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").

Normal: - The tongue's ventral surface is smooth, shiny, pink, or slightly pale, with visible veins and no lesions. - The older client may have varicose veins on the ventral surface of the tongue Abnormal: - Leukoplakia, persistent lesions, ulcers, or nodules may indicate cancer and should be referred. Induration increases the likelihood of cancer.

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.

Normal: - 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. Abnormal: - 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.

Inspect the teeth and gums. Ask the client to open the mouth (Fig. 18-6). 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.

Normal: - Thirty-two pearly whitish teeth with smooth surfaces and edges. Upper molars should rest directly on the lower molars and the front upper incisors should slightly override the lower incisors. Some clients normally have only 28 teeth if the four wisdom teeth do not erupt. - No decayed areas; no missing teeth. - Client may have appliances on the teeth (e.g., braces). - Client may have evidence of repair work done on teeth (e.g., fillings, crowns, or cosmetics such as veneers). - Jaws are aligned with no deviation seen with biting down. Abnormal: - 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.

Inspect and palpate the tongue. Ask client to stick out the tongue (Fig. 18-9A). Inspect for color, moisture, size, and texture. Observe for fasciculations (fine tremors), and check for midline protrusion. Palpate any lesions present for induration (hardness).

Normal: - 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 - No lesions are present. Abnormal: - 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. - Smokers may also have a yellow-brown coating on the tongue, which is not leukoplakia.

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.

Normal: - Tonsils may be present or absent. They are normally pink and symmetric and may be enlarged to 1+ in healthy clients (Fig. 18-17). No exudate, swelling, or lesions should be present. Abnormal: - 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

Black hairy tongue:

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

Notes: tongue & mouth

Older adult considerations - 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. Cultural considerations -Periodontal disease varies in prevalence and severity by ethnic group: worldwide, blacks have a three times higher risk than whites

Do you have pain over your sinuses (cavities around nasal passages)?passages)?

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

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

Is there a history of mouth, throat, nose, or sinus cancer in your family?

There is a genetic risk factor for mouth, throat, nose, and sinus cancers (especially those with genetic syndromes Fanconi anemia or dyskeratosis congenita)