ASSESSMENT OF NOSE, SINUSES, MOUTH, THROAT AND NECK

NOSE EXTERNAL NOSE Location in relation to face Palpate for swelling, lesions, masses Septum deviation, bleeding (epistaxis) INTERNAL NOSE Use of rhinoscope with nasal speculum (avoid septum due to increased sensitivity) Assess for the following: Polyps (smooth, overgrowth, mobile, nontender, decreased or absence of smell) or ulcer Color, discharge and integrity of nasal mucosa Normal: pink or dull red Allergy: white mucosa; clear discharge Virus: red mucosa; colorful discharge CSF leakage: unilateral clear discharge Foreign body: unilateral colorful discharge Septum perforation, bleeding (epistaxis) or any bleeding new or old Turbinates (color, exudates, swelling, polyps) Normal: dull red Allergies: pale pink/gray; swollen; discharge Infection: bright red and swollen Patency of nares (difficulty breathing upon occlusion; mirror mist) SINUSES (Maxillary and frontal accessible to exam) Inspection (swelling) Palpation (firm pressure, nontender) and percussion (resonance) Transillumination (symmetrical glow, pinkish, use very dark room) MOUTH Inspection: Lips (symmetry: smile CN VII, color: [pink, cyanosis, pallor], vesicles, moisture, cracking, lesions) Buccal mucosa (pink, bleeding, swelling), oropharynx Teeth 32 permanent (adult); 20 (children); 3rd molars, color, cavities, dental repair Gingivae covers neck and roots of teeth, not bleeding Tongue (midline, color, texture: surface fissures, moisture, ulcerations) Protrude tongue (CN XII) Lingual frenulum, lingual veins Hard palate, soft palate + uvula (rise with ahhh CN IX, X) Uvula (deviation: peritonsillar abscess) Posterior pharynx noting tonsillar pillars Oral lesions (Candida: white patches on red base) Whartons duct (floor of mouth), Stensens duct (opposite 2nd molar) Palpation: (use gauze to hold tongue; tongue depressor) Roof of mouth in infants Temporomandibular joint (TMJ): Normal: depression in front of tragus felt with fingers; slight pop Abnormal: crepitus, masses Assess for Thrush (Candidiasis), gum hyperplasia, gingivitis

THROAT Location, swelling, exudates or lesions, color Voice (hoarseness) Inspect tonsils (grade tonsils +1 to +4) Assess gag reflex (CN IX, X) (tongue blade, slurred speech, sip of water) Soft palate and uvula rise when patient says ahhh NECK Position symmetry, lumps, visibility of thyroid gland, jugular vein distention (cardiac congestion) Palpate just above the suprasternal notch using the thumb and index finger: Trachea is palpable, midline, straight Lymph nodes (use palmar tips of fingers, systemic circular movements): Normal: may not be palpable, or palpable in thin clients; non tender if palpable; firm smooth; rounded surface; slightly movable; about less than 1 cm in size; Thyroid: Observe movement when standing in front of client and ask client to swallow Palpate thyroid by posterior or anterior approach. Posterior Approach: Let the client sit on a chair while the examiner stands behind him. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is the isthmus. Ask the client to swallow while feeling for any enlargement of the thyroid isthmus. To facilitate examination of each lobe, the client is asked to turn his head slightly toward the side to be examined to displace the sternocleidomastoid, while the other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid lobe to be examined. Ask the patient to swallow as the procedure is being done. The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the sternocleidomastoid muscle, while the index and middle fingers are placed deep to and in front of the muscle. Then the procedure is repeated on the other side. Anterior approach: The examiner stands in front of the client and with the palmar surface of the middle and index fingers palpates below the cricoid cartilage. Ask the client to swallow while palpation is being done. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach. The client is asked to turn his head slightly to one side and then the other of the lobe to be examined. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be examined. Again, the examiner palpates the area and hooks thumb and fingers around the sternocleidomastoid muscle. Thyroid is non palpable Isthmus maybe visible in thin neck No nodules are palpable Auscultation of the thyroid is necessary when there is thyroid enlargement; bruits may be heard Range of movement of the neck