History and Examination of Oral Cavity,Throat & Neck

History and Examination of Oral Cavity,Throat & Neck

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  History and Examination of OralCavity,Throat & Neck Dr. Subrat Sanu 1st year Junior Resident Dept. of E.N.T. DMCH, Darbhanga
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  1. Name 2. Age 3.Sex 4. Religion 5. Social status 6. Occupation 7. Address 8. Chief complaints 9. History of present illness (HOPI) 10.Past History:- Drug History, Treatment history, Allergy History 11.Personal History 12.Family History 13.Immunisation history General points in History taking
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  ● Name- identification,buildingrapport, maintaining records, psychological benefits ● Age- young (Nasopharyngeal angiofibroma), Elderly (Cancers),Neonate(Tongue tie,cleft palate), Children(Tonsillitis,Adenoid ● Sex- Female (Thyroid), Male (Laryngeal Ca, Cracked voice) ● Occupation- Teachers/Singers/Public speakers- Vocal nodules, Hoarseness of voice. Tobacco exposure- Leukoplakia , OSMF, Oral cancers ● Healthcare workers- Viral/bacterial pharyngitis ● Industry/Cement workers- Oral ulcers from irritants,Chronic throat irritation, Pharyngitis ● Address- Urban/industrial area- Oral cancer, leukoplakia, Chronic pharyngitis , GERD (d/t chemical,pollution & tobacco exposure) ● Rural/Village area- OSMF, chronic tonsillitis ● Overcrowded area- Oral candidiasis,Diphtheria,TB lymphadenitis,Acute tonsillitis
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  Chief complaints • Inpatient’s own words • Chronological order:- as they occur according to severity and for each complaint mention duration. • Duration:- Short with pain - acute inflammatory Long without pain – neoplastic Long with slight pain – chronic inflammatory Long with severe pain – malignant • Throat :- Oral cavity, Oropharynx, Laryngopharynx Larynx and Neck
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  Chief Complaints inOral Cavity • Pain (site,onset,character,radiation,agg factors,relieving factors,severity) • Dry mouth (Xerostomia)- mouth breathing • Bad smell (Halitosis) –poor hygiene,ulcers,post nasal drip • Ulcer • Loss of taste (Dysgeusia) • Excess salivation - poor hygiene, ulcers • Restricted tongue movement-Tongue tie (Ankyloglossia) • Difficulty in opening mouth (Trismus) – SMF • Swellings • Cleft palate • Bleeding gums - scurvy
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  Chief complaints inOropharynx • Sore throat • F.B Sensation – allergy, post nasal drip, functional, malignancy • Difficulty in swallowing (Dysphagia) • Pain during swallowing (Odynophagia) • Swelling • ulcer • Regurgitation • Snoring
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  Chief complaints inLarynx • Change in voice – hoarse, cracked voice in males(puberphonia), vocal fatigue- elders, functional • Repeated clearing of throat- GERD, Chronic laryngitis • Difficulty in breathing - infections, tumours • Cough and expectoration • Neck swellings
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  History of presentingillness • Mode of onset – sudden, gradual • Site • Any cause of onset • Duration • Progress – slow , rapid, intermittent, continuous, increasing, declining • Factors aggravating or relieving • Treatment for the same, since when and where • How it has impacted life style • LOOK FOR NEGATIVE ANSWERS
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  HOPI of TONSILLITIS •Duration • Onset (acute/insidious) • Progression (is it worsening) • Any associated discharge from oral cavity noticed by the patient • Is it associated with change in voice • Is it associated with breathing difficulty • Is it associated with difficulty in swallowing • Any history of recent cough and cold • Any history of fever • Any history of sleep disturbances • History of missing school/work
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  HOPI of NeckSwelling • Duration • Side (right/left/midline) • Onset (acute/insidious) • Progression • Number of swellings • Painful/painless • Any aggravating/relieving factors • Any skin changes above the swelling
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  HOPI of LaryngealCancer (depends on involved parts-supraglottis,glottis or subglottis) • Any recent change in voice noted (hoarseness). • Lump in the neck. Describe using the above headings. • Any difficulty in breathing • Noisy breathing (stridor)- during inspiration or expiration or both • Any history of weight loss • Any history of smoking • Any history of cough or chest pain or bloody sputum (suggestive of lung metastasis) • Any history of right upper quadrant pain or jaundice (suggestive of hepatic metastasis ) • Any history of bone pains (suggestive of bony metastasis)
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  HOPI of OralCavity Cancer • Onset (insidious/acute,spontaneous) • Duration • Progression (initial size vs present size, any phase of rapid growth) • Exact anatomical location • Painful/painless • Any associated discharge/bleeding • Is it associated with loosening of teeth • Any associated increased salivation/foul smelling breath • Any sensory loss over face • Any loss of taste sensations • Is it associated with any mouth deviation/ inability to close the eyes completely/ excessive lacrimation • Any history of weight loss • Any history of smoking/ tobacco chewing • Any history of change in voice ( laryngeal mets) • Any history of cough or chest pain or bloody sputum ( sugg of lungs mets) • Any history of right upper quadrant pain or jaundice (suggestive of hepatic mets) • Any history of bone pains (sugg of bony mets) • Any other lump in the body
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  Past history • Alldiseases before this disease in chronological order • Diabetes, HTN, Bleeding disorders, TB, Asthma, HIV, HBV, STD • Surgeries, hospital admissions, Trauma • Deliveries and pregnancies • Drug history- steroids, insulin, ocp, anti hypertensives • Allergy history – drugs or diet or allergen • FOR DRUG ALLERGY – WRITE IN RED
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  Personal history • Lifestyle– exercise, sedentary • Food habits – regular-irregular, spicy-non spicy, non veg- veg, excess tea or coffee • Smoking – frequency • IV abuse • Alcohol • Bladder & Bowel habits • Sleep cycle • Menstrual history :- (LMP, cycle length,duration,amount,passage of blood clots, pain severity).
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  Family history • Enquireabout parents, siblings and children • Familial diseases like Peptic ulcer, cancers, allergies, diabetes and HTN, otosclerosis • Infectious diseases- by contact – TB , acute infections
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  General Physical Examination Afterexplaining the procedures and taking informed consent from the patient:- • Mental state • Consciousness • Built and nutrition • Attitude and gait • Facies • Pallor- palmar creases, lips,cheeks, conjunctiva,nail beds • Cyanosis- tongue(central), nail bed,tip of nose,palmar skin • Jaundice- sclera, nail bed, ear lobule, tip of nose • Skin eruptions- macules (change in skin colour), papules, vesicles,pustules (solid projections) • Lymphadenopathy- Neck nodes
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  VITALS • Pulse -rate,rhythm (regular, irregular) • Respiratory rate - fast,slow • Temperature - continuous (fluctuates less than 1 degree), remittent (fluctuates more than 2 degrees), intermittent • Blood pressure
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  Local Examination • Examinethe affected region • Inspection • Palpation • Movements • Lymph nodes Systemic Examination • CVS • Respiratory • CNS - cranial nerve examination,GCS • Abdominal
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  • Lips andLabial Mucosa • Buccal Mucosa • Mucobuccal Fold • Hard Palate • Soft Palate and Uvula • Oropharynx & Nasopharynx •Tongue •Floor of Mouth •Teeth Complete examination of the oral cavity includes:
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  Examination of Lipsand Labial Mucosa
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  Exam: Lips • Observethe color ,scar,ulcer,swelling-intra- orally and externally • Is the vermillion border distinct? • Bi-digitally palpate the tissue around the lips. Check for nodules, bullae, abnormalities, mucocele, fibroma
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  Exam: Lips • Evertthe lip and examine the tissue • Observe frenum attachment/tissue tension • Clear mucous filled pockets may be seen on the inner side of the lip (mucocele). This is a frequent, non-pathologic entity which represents a blocked minor salivary gland
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  Exam: Lips • Frenulum: –Attachment – Level of attached gingiva
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  Examination: Buccal Mucosa ●Observe color, character of the mucosa Normal variations in color among ethnic groups Amalgam tattoo ● Palpate tissue ● Observe Stenson’s duct opening for inflammation or signs of blockage(upper second molar) (pus,bloody discharge)
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  Palpation of theBuccal Mucosa and Mucobuccal Fold
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  Gingiva • Note color,tone, texture, architecture & mucogingival relationships
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  Examination of Oralcavity Inspection Tongue * Volume * Colour * Cracks or fissures * Fur * Papillae (any atrophy or abnormally like geographical tongue) * Tongue tie (if present) * Any swelling (if present) * Any ulcer (aphthous/dental/tubercular/syphilitic/carcinomatous) * Mobility: on protrusion and side-to-side movement
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  Palate * Any perforation/cleftpalate/swelling/ulceration/growth Floor of Mouth * Any growth/cyst/ulcer Cheek * Any ulcer/leukoplakia/hyperpigmentation/growth Retromolar Trigone * Inspect for any lesion Gum * Inspect for swelling/bleeding/growth Teeth * Colour, shape, ridging, abnormal positioning Tonsils Any enlargement/medial deviation/pus spots/membrane on the surface of tonsils
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  Palpation Tongue * Keep thepatient’s tongue inside the oral cavity as it causes relaxation of the tongue muscles. * Protruded tongue causes contraction of muscles and may give rise to false impression of induration. * Induration may be present at the base of gummatous ulcer but is absent in tuberculous ulcer. * Malignant ulcer bleeds during palpation. * Palpate the back of the tongue for any ulcer or swelling. * Lingual thyroid should not be mistaken for any growth. * Also palpate for a sharp tooth against an ulcer of tongue. Palate * Any ulcer or cyst (nasoalveolar or nasopalatine cyst) is examined in the usual way. * Alveolar abscess causes tender fluctuating swelling close to the alveolar process.
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  Floor of Mouth *It should be palpated bimanually. * Translucency is tested if there is any cystic swelling. * Ranula is translucent but sublingual dermoid cyst is not translucent. * Submandibular duct is palpated for any stone. Cheek * Mucous membrane and cheek should be carefully palpated to know involvement of skin or cheek by malignant growth. Tonsils * Press the tonsillar substance to observe for any extravasation of pus.
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  Tonsils
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  • Tucked inat base of anterior & posterior tonsillar pillars • Squeezing-pus(acute),cheesy(chronic) Grades of Tonsillar Hypertrophy * Grade 0: Tonsils in the fossa * Grade 1: Tonsils outside the fossa or occupy <25% of oropharyngeal width * Grade 2: Tonsils occupy 26–50% of oropharyngeal width * Grade 3: Tonsils occupy 51–75% of oropharyngeal width * Grade 4: Tonsils occupy >75% of oropharyngeal width
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  Cervical Lymph Nodes *Examination should be done by standing behind the patient. * Ask the patient to slightly flex the neck on the examining side to relax neck muscles. * Palpate along: * Lower border of mandible * Along sternocleidomastoid muscle * Posterior triangle of neck * Supraclavicular fossa * Anterior part of neck Levels of Cervical Lymph Nodes *Level I: Submental group * Level II: Submandibular group * Level III: Upper jugular group * Level IV: Middle jugular group * Level V: Lower jugular group * Level VI: Posterior triangle group * Level VII: Anterior part of neck (Delphian lymph nodes)
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  Hard Palate 1. IncisivePapilla 2. Palatine Rugae 3. Palatine Raphe 4. Fovea Palatina 5. Vibrating Line 6. Uvula Indirect Visual Inspection Direct Visual Inspection Palpation
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  Cleft,Perforation,Scar,Ulcer,High arched Minor salivaryglands, attached gingiva Note presence of tori: tx plan any pre-prosthetic surgery Hard Palate
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  Examined by eitherindirect visualization or palpation. Palpation is completed by using the index finger and pressing upward Soft palate and Uvula
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  Soft Palate andUvula Ask the patient to say “aah” Examine – Tonsils, Tonsillar Pillars and Oropharynx,uvula Deviation- vagus palsy
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  Oropharynx • Occasionally smallgoblets of pink/transparent tissue are normal and may have lymphoid tissue. • Base of tongue,vallecula-IDL, palpation (ulcer,swelling) • Anterior pillar- congestion,edema,ulcer • Posterior pillar • Tonsil- size,congestion, ulcer, abscess,membrane • Palpation- hard(tonsillolith, malignancy), on squeezing- pus(acute), cheesy material (chronic) • Posterior pharyngeal wall- congestion,discharge,swelling,ulcer,post nasal drip( children-adenoid infection,adult-sinusitis)
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  • Soft palate-congestion, ulcer, movement • Gag reflex • Pulsation- ICA aneurysm • Bimanual palpation- styloid • Uvula- bifid (submucous cleft) • X C.N. palsy- deviation of soft palate and uvula to healthy side
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  Tongue Visual Inspection Palpation(insideoral cavity)
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  Tongue • You mayobserve lingual varicosities
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  Exam: Tongue • Youmay observe geographic tongue (erythema migrans)
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  Exam: Tongue • Youmay observe drug reaction
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  Exam: Tongue • Observesigns of nutritional deficiencies, immune dysfunction
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  Exam: Tongue • Youmay observe oral cancer
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  Floor of Mouth
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  Floor of Mouth
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  Squamous Cell Carcinoma
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  Tooth Examination • CariesPattern • Missing Teeth • Size, Color, and Structural Changes • Eruption Pattern • Percussion • MOBILITY
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  Examination of Larynx •External examination of neck • Inspection- Observe the Adam’s apple,whether distorted or not. Angle- 90 degrees in males, 120 degrees in females • Broadening ,thickening,redness,position, movement on deglutition and breathing • Palpation • Laryngeal crepitus (move side to side), tenderness(perichondritis) • Scars, Neck nodes • Auscultation- vascular swelling,stridor • Voice
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  Indirect laryngoscopy Procedure forIndirect Laryngoscopy 1. First explain the whole procedure to the patient. 2. Warm the mirror side of the indirect laryngoscopy mirror, tested on examiner’s hand for heat, and hold it like a pen with right hand. 3. Alternatively, the mirror can be dipped in savlon solution or rubbed against buccal mucosa to prevent fogging. 4. Ask the patient to open the mouth and protrude the tongue. 5. Grasp the anterior part of tongue with left hand. 6. Ask patient to breathe gently through mouth and place the warm mirror inside throat gently against anterior surface of uvula.
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  Examination under IndirectLaryngoscopy: * Epiglottis – size and color, swollen or not. * Vocal cords * Color * Edema, presence of any nodule/polyp/cyst/growth * Movement on: * Gentle breathing * Forced inspiration * Phonation * Coughing * At rest * Position – median, paramedian, cadaveric, gentle abduction and full abduction * Arytenoids * Aryepiglottic folds * Interarytenoid area * Glottic chink * Post cricoid area (if any growth is present) * Pyriform fossa (and whether any fullness is present) * Upper few cm of trachea * Base of tongue * Vallecula
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  • Movement ofvocal cords • Ee, ah ( adduction), breathe quietly (abduction)
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  Areas not visibleunder IDL ● Infrahyoid epiglottis ● Ant.commissure of VC ● Subglottis ● Laryngeal ventricles ● Post-cricoid region
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  Indirect vs DirectLaryngoscopy
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  Examination of ulcer •Ulcer – Break in the continuity of covering epithelium (skin, mucous memb) • Inspection • Site – malignant ulcer in oral cavity, larynx • Size and shape – tubercular (oval), malignant (irregular), size both horizontal and vertical • Number • Position and extent • Edge – tubercular (undermined), carcinoma (everted), inflamed in spreading ulcer, bluish in healing ulcer
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  PALPATION • Tenderness • Margins( between normal epithelium and ulcer) • Edge (between margin and floor) • Base (on which ulcer rests) • Floor (exposed surface) • Depth of ulcer • Bleeding • Relation with deeper structures • (Fixed – malignancy)
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  Neck Swellings • Reactivenodes (MC) • Age – sternomastoid tumour (newborn), malignancy • Duration • Mode of onset – sudden, gradual • Pain • Progress • Site at which started • Associated symptoms – weight loss, appetite, voice change, dysphagia, resp distress • Fever • Recurrence • Family history
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  Inspection Always from front •Site • Number • Size • Extent – ant to post, med to lat, sup to inf • Colour (blue- ranula) • Surface (irregular – malignancy, smooth – cyst) • Skin over swelling – colour, ulcer, scar • Edge – smooth(benign), irregular – malignancy
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  Palpation ALWAYS FROM BEHIND.NECK FLEXED • Surface – smooth, irregular • Fixation of skin – malignancy, seb cyst • Edge – irregular, smooth and well defined (benign) • Pulsations – vascular tumours ( CB, aneurysms) • Temperature • Tenderness • Consistency – soft, hard • Reducibility – totally disappears (meningocele) • Compressibility- haemangiomas • Relation to Sternocleidomastoid- superficial(prominent on contraction), deep(disappear on contraction) • Translucency – any fluid ie lymph, water (cystic hygroma) • Mobility
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  • Percussion –Laryngocele (tympanic note) • Auscultation – bruits and murmurs (vascular swellings) • Impulse on coughing – if swelling in continuity with cranial or spinal cavity – meningocele • Movement on deglutition – if fixed to larynx or trachea – thyroid • Movement on protrusion of tongue – thyroglossal cyst
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  Thyroid Palpation • Patientin sitting position, examiner standing behind/front. • Neck slightly flexed. • Thumb behind the neck and other fingers on front,palpate with finger tips in rolling fashion
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  Different Methods Lahey’s method- •Normal lobe is pushed to the side of nodules so that it becomes prominent. • It is better for palpating posterior surface of thyroid. • Ideal for palpating margins.
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  Crile’s Method- • Placethe thumb on thyroid gland and ask to swallow. • Small nodule can be palpated by this method
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  Pizzillo’s Method- Patient’s handbehind the head and asked to push against clasped hand. • uniform enlargement-physiological goitre,colloid goitre,hashimoto’s disease. • Isolated nodules of diff size-nodular goitre • swelling lat to thyroid-aberrant gland or node from ca larynx
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  Lymph Node (The areasthey drain helps in backtracking the source of an infection and malignancy.)
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  • Location • Laterality •Number • Surface,Shape,Size,Skin above it. • Consistency – hard, rubbery, soft • Discrete or matted • Tender • Fixation to skin, deeper structures • Mobility (both transverse and vertical planes).
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  LEVELS OF NECKLYMPH NODES