Post on 20-Dec-2015
description
Mouth, Throat, Nose, and Sinus Assessment
The mouth and throat make up the first part of the digestive system and are responsible for receiving food. Cranial nerves V"trigeminal", VII"facial", IX "glosopharyngeal", and IIX"hypoglossal" assist with some of the digestive 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.
MouthThe roof of the oral cavity is formed by the anterior hard palate and the posterior hard palate. An extension of the soft palate is the uvula.
Contained within the mouth are the tongue, teeth, gums, and the opening of the salivary glands "parotid, submandibular, sublingual". The three pairs of salivary glands secrete saliva "watery, serous fluid contains salts, mucous, and salivary amylase" into the mouth. The parotid glands, located below, and in front of the ears, empty through Stensen's ducts, which are located inside the check 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 opening called Wharton's ducts. The sublingual glands, located under the tongue, open through several ducts located on the floor of the mouth.
Mouth and throat– Lips– Cheeks– Buccal mucosa– Hard palate– Soft palate– Tonsils– Oropharynx and nasopharynx– Uvula– Tongue – taste (CN VII)– Salivary glands– Parotid– Submandibular– Sublingual– Teeth– Crown– Neck– Root
Throat The throat "pharynx", located behind the mouth and nose, serves as a muscular passage for food
and air. The upper part is called the nasopharynx. Below it lays laryngopharynx.
The soft palate, anterior and posterior pillars, and uvula connect behind the tongue to form arches.
The lingual tonsils lie at the base of the tongue. Pharyngeal tonsils "adenoid" are found high in
the nasopharynx.
1
External Nose and Mouth
NoseIt composed of bone and cartilage and is lined with mucous membrane. The nasal cavity is located.
External nose Internal nose Nasal cavity Paranasal Sinuses
– Frontal– Maxillary– Sphenoid– Ethmoid
Turbinates – Projections in nasal cavity that increase surface area– Superior, middle and inferior turbinates
Nasal mucosa Olfactory receptor cells (CN I)
2
Functions of Nose
Identify odors (upper 1/3 of septum) CN I
Air passageway (obligate in newborns)
“Air conditioning”
– Humidify
– Warms/cools air
– Cleans and filters air of dust and bacteria
– Voice resonance
Common Chief Complaints
Nasal blockage or congestion
Halitosis – breath odor
– Fruity (acetone) – diabetic ketoacidosis
– Foul – URI, sinus, tonsil or mouth infection
– Ammonia – renal problems (uremia)
– Fecal – GI obstruction
Oral lesions
Ear, Nose & Throat Assessment: History ReviewPresent Problem
– dizziness or vertigo– earache– hearing loss– nasal discharge– snoring– nosebleed– dental problems– mouth lesions– sore throat
3
– difficulty swallowing
Past Medial History– systemic diseases
– Ear- frequent problems in childhood
- surgery- labrynthitis- antibiotic use
– Nose- trauma- surgery- chronic nosebleeds
– Sinuses- chronic postnasal drip- repeated sinusitis- allergies
– Throat- frequent, documented strep infections- tonsillectomy- adenoidectomy
Assessment of the Nose
Inspection of internal nose
Otoscope with nasal speculum – avoid septum d/t increased sensitivity
Color & integrity of nasal mucosa
Septum deviation, perforation, bleeding (epistaxis)
New/old bleeding anywhere
Turbinates (color, exudate, swelling, polyps) Note the middle and inferior turbinates
Normal – dull red
Allergies – pale pink/gray, swollen (polyps & a clear, watery discharge are also common)
Acute rhionitis infection – bright red & swollen
Normal findings
– Located in midline of face
– No swelling, bleeding, lesions, or masses
– Both nostrils patent
– Septum midline
– Nasal mucosa is pink or dull red
Abnormal findings – Broken, misshapen, swollen nose– Occluded nasal passages– Septum is deviated– Nasal mucosa is red and swollen
4
Nasal Polyp;
Smooth, pale gray nodule
Overgrowths of mucosa
Chronic allergic rhinitis
Mobile, nontender
Decrease/absence of smell
Assessment of the Sinuses
Inspection
Palpation, percussion & transillumination (very dark room)
Normal findings
– No evidence of swelling
– Resonance heard on direct percussion
– Will feel firm pressure with palpation, but no pain normally
– Healthy sinuses contain air and may light up symmetrically
Assessment of the Mouth
Inspection (use good light source)
– Lips (color, moisture, cracking, lesions) – smile for symmetry (CNVII)
– Tongue (color, surface fissures, moisture) – stick out for deviation (CN VII)
– Gums, buccal mucosa (check for pink color, bleeding, swelling)
– Teeth (#, molars, color, cavities, dental repair) 32 adult – 20 children (3rd molars may be missing – wisdom teeth)
– Hard palate & soft palate
– Floor of mouth (Wharton’s duct/Submandibular gland, Sublingual gland)
– Parotid gland (in cheek in front of ear) and Stensen’s duct (opposite 2nd molar)
– Tongue (Lingual frenulum, lingual veins)
5
Palpate– Roof of mouth in infants– Lips, cheek, tongue, floor of mouth– Use gauze to hold tongue– Find Stensen’s duct (parotid salivary gland) opposite upper second molar– Check temporomandibular joint (TMJ) – depression in front of tragus felt with fingers
(slight pop can be normal; crepitus and masses are abnormal)
Normal findings– Pink, moist lips– Tongue midline, adequate movement– No lesions– Tongue, gums, buccal mucosa are pink, moist, smooth– No bleeding– Smooth, white teeth, no dental caries
Abnormal findings– Lesions, growths– Dry, cracked lips– Vesicles or blisters– Red, tender, inflamed tongue, gums, buccal mucosa– Thrush– Coating on tongue– Bleeding gums
Thrush – Candidiasis Scrapes off easily Leaves red, raw surface that may bleed Can occur after antibiotics, corticosteroids, and with immunosupression
Gum Hyperplasia
Painless enlargement Occurs with puberty, pregnancy, leukemia, and extensive use of phenytoin (Dilantin)
Gingivitis Gum margins red, swollen, bleed easily Gums will recede and produce purulent drainage with chronicity Poor dental hygiene, vitamin C deficiency More common in pregnancy & puberty
Inspection of the Throat Gag reflex (CN IX & X) Posterior pharynx and oropharynx Presence of swelling, exudate or lesions. Note color. Inspect tonsils Grade tonsils (+1 – +4)
Normal findings Soft palate and uvula rise when patient says, “ahhh” (CN IX & X) Uvula is midline No swelling, exudate, or lesions Gag reflex is present (CN IX & X)
6
Abnormal findings Posterior pharynx is red with white patches Tonsils and uvula are red and swollen Hoarse voice Grayish membrane covering tonsils, uvula, soft palate
Tonsil Exudate Streptococcal pharyngitis and acute tonsillitis Bright red pharynx with red, swollen tonsils, pillar and uvula Patches of white/yellow exudate
Family History– hearing problems/loss– Meniere’s disease– allergies– hereditary renal disease
Personal & Social History– employment…hazards– nutrition– oral care pattern– tobacco use– alcohol use– intranasal cocaine use– OTC nasal spray use
Infants and Children– prenatal history– prematurity– infection
- meningitis/encephalitis- recurrent otitis media
– congenital defects– playing with small objects– behaviors indicating hearing loss– dental care
Pregnant Women– weeks gestation/postpartum– symptoms before pregnancy– pattern of dental care
Older Adults– hearing loss– physical disability– deterioration of teeth– dry mouth– medications – salivation
NOSE & NASOPHARYNX
Warm/humidify/moisten air and resonate sound
7
Floor is hard and soft palate
Roof is sphenoid and frontal bone
Mucous membrane caries debris
Turbinates increase surface area
Sinuses
- maxillary and frontal accessible to exam
- ethmoid and sphenoid behind frontal
- mucous and cilia move mucous
Check patency of nares
Percuss and palpate sinuses
Observe mucosa color and discharge
allergy = white mucosa with clear discharge
virus = red mucosa with colorful discharge
?CSF = unilateral clear discharge
foreign body = unilateral colorful discharge
Assess polyps or ulcer
MOUTH & OROPHARYNX
Passage of food/fluid, emit air & speech, initiate digestion & identify taste
Gingivae cover neck and roots of teeth
Teeth - 32 permanent (4 incisors, 2 canines, 4 premolars and 6 molars)
Oropharynx separated from mouth by tonsilar pillars
Assess lips, buccal mucosa, teeth and gums
Observe occlusion of clenched teeth (CN VIII)
Inspect tongue color, texture, ulcerations and note movement (CN XII)
Assess soft palate and rise of posterior curtain with “ahh” (CN IX/X)
Inspect posterior pharynx noting tonsillar pillars
Lips- cyanosis = hypoxia- pallor = poor perfusion- vesicles = HSV
Oral lesions- Candida = white patches on red base
Pharynx - viral vs bacterial pharyngitis- Peritonsillar abcess = deviated uvula
Pediatric Variations
Essential to determine nasal patency of newborn (choanal atresia) Bilaterally will need immediate intervention d/t obligate nose breathing
Only the maxillary and ethmoid sinuses are present at birth (easier to transilluminate)
8
Tonsils vary widely in size during childhood
3 month old begins salivation (drooling)
Teeth/tooth may be present at birth, most infants start between 6-10 months, will lose teeth between 6-12 yrs
Gerontological Variations
Nose may appear more prominent d/t loss of SQ fat in face.
Diminished sense of smell and taste (decreased # of olfactory nerve fibers in nose and papilla on tongue)
Periodontal disease
Gum lines recede
Oral alterations due to disease or side effects of medications
Tooth loss
Teeth will darken with age d/t exposed dentin
Lifestyle and Health Practices
Predisposing factors for oral cancer : Cigarette smoking Excessive use of alcohol Age over 40 Male gender Genetic predisposing Vitamin A deficiency
Grinding the teeth is a sign of stress or slight malocclusionProper brushing, flossing, and oral hygiene can prevent dental caries and gum diseasesCleaning the tongue is a way to prevent bad breath resulting from bacteria that accumulates on the posterior tongueElderly and some disabled clients may have difficult caring properly for teeth or dentures because of poor vision or impaired extremities
Collecting Objective Data
- Examination of the mouth and throat can help the nurse detect abnormalities of the lips, gums, teeth, oral mucosa, tonsils, and uvula.
- It allows for early detection of oral cancer
- Examination top detect oral problems, septum defects, patency of the nose and nasopharynx.
- Early detection of impaired oral mucous membrane s or poor dental hygiene conditions may require a change in client's diet. Early detection of septum deviation help the nurse determines which nostrils to use to insert a NGT or suction tube.
9