06. Assessment of Nose, Mouth and Throat

 

Assessment of Nose, Mouth and Throat

 

The head, face, and neck form a large portion of what is often referred to as the head, eyes, ears, nose, and throat (HEENT) system. This is actually a complex set of varied organs, combined during assessment because of their proximity to one another and the integration among the components of the system. The HEENT encompasses almost all of the systems: integumentary, respiratory, cardiovascular, gastrointestinal, musculoskeletal, neurological, endocrine, and lymphatic. The vascular, neurological, and musculoskeletal components of the HEENT, as well as the eyes and ears are covered in separate chapters. The components addressed in this chapter include the head, face, nose sinuses, neck , mouth ,and pharynx. These components are complex in their actions and are involved in expression, communication, nourishment, respiration, and sensation, among other functions. Furthermore, disorders involving the head and face can be devastating to patients because they can greatly affect appearance. Even minor disorders involving the head, face, or neck can be perceived as disfiguring by patients.

 

Anatomy and Physiology Review

Before you begin your assessment, you need an understanding of these complex structures, their basic anatomy (Figs. 11.1 through 11.10) and function, the ways in which they relate to other systems, and expected normal findings.

Interaction with Other Body Systems

The head, face, and neck include many structures with highly varied functions. Disruption or disease of several other systems can affect the organs of the head, face, and neck. These other systems include those described in the following paragraphs.

The Respiratory System

The nasal and oral cavities are entry points to the respiratory system. Injuries or diseases of these two structures can result in impaired ability to breathe. The ears, nose, and pharynx form the upper respiratory system. These structures communicate with the lower respiratory system through the trachea, so that infections in one area can be transmitted to the other.

 

SYSTEMS PHYSICAL ASSESSMENT

The Cardiovascular System

Many structures of the head, face, and neck system receive rich vascular supply. The mucosa of the nasal cavity includes a plexus of vessels that bleed easily. The temporal arteries are assessed during the examination of the face, as are the carotids during the examination of the neck. Disorders of the cardiovascular system may be reflected in the structures of the head, face, and neck. Infarct or ischemic pain may radiate to the jaw or throat Facial edema can reflect fluid retention

The Musculoskeletal System

Common complaints include headaches, jaw pain, neck pain or stiffness, masses, nasal congestion, epistaxis, mouth or dental pain, mouth lesions, sore throat, and hoarseness. Any such complaints, as well as others that you might identify later, should be explored and developed using an organized system of symptom analysis, such as the PQRST format. Because disorders of several systems can influence the head, face,and neck, it is important to determine the patients overall health status. There will be times, however, when the patients presenting problems are particularly acute or distressful, and the initial history and physical will have to be very focused.

Symptom Analysis

Symptom analysis tables for the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book

Head Pain

Head pain can be associated with a variety of problems including migraines, tension, systemic infections, and trauma.

Jaw Tightness and Pain

When a patient presents with jaw tightness and/or pain, the cause may be TMJ syndrome, but it could also be trauma or infection/inflammation in the structures near the jaw. An important consideration for jaw discomfort is whether it might be caused by cardiovascular disease. Always ask patients if they have a personal or family history of heart disease.

Neck Pain and Stiffness

Neck pain and stiffness can stem from musculoskeletal problems as well as from infections. Symptom analysis can help identify any forgotten trauma or physical exertion that might explain the complaint.

Neck Mass

When a patient complains of a neck mass, it might be a goiter of the thyroid gland or enlarged lymph nodes. Enlarged nodes may signal either an infectious or a malignant disorder.

Nasal Congestion

Nasal congestion is usually caused by an upper respiratory infection or allergy.

Nosebleed

Epistaxis, or nosebleed, is usually self-limited and has relatively benign causes. However, it can be caused by coagulopathies or other hematologic disturbances, malignancies, hypertension, or trauma.

Mouth Lesions

A mouth lesion can be caused by a malignancy, trauma, nutritional deficit, or poorly fitted dentures or orthodontic appliances.

Mouth and Dental Pain

Mouth pain can be caused by ischemic heart disease, musculoskeletal disorders, or dental problems.

Sore Throat

When a patient complains of a sore throat, the most common cause is a bacterial or viral illness. However, throat discomfort can be associated with throat masses, including thyroid hypertrophy or malignancies, foreign objects in the throat, and other causes.

Hoarseness

Another common complaint is hoarseness. Hoarseness may be caused by overuse of the voice, for example, prolonged periods of shouting or loud speech. It can also be an indication of gastroesophageal reflux, malignancies, neuromuscular disorders, or other health problems.

Past Health History

Once you have investigated the patients chief complaint, explore the past health history. This portion of the history includes childhood and adulthood illnesses, surgeries, or major injuries; hospitalizations; major diagnostic procedures; exposures to infectious diseases; and allergies; as well as an immunization and medication history. The muscles of the face (Fig.11.11) are highly involved in expression, communication, and nourishment. Diseases of the musculoskeletal system can have profound effects on these actions. Inflammatory changes of the temporomandibular joint (TMJ) can cause limited jaw motion and jaw pain and can be unilateral or bilateral. Disorders of the cervical vertebrae or strain or inflammation of supporting structures can have profound effects on neck comfort and motion.

The Neurological System

The head, face,and neck are highly involved in many sensory processes. The neurological system includes the structures responsible for olfaction and taste as well as for sensation in the face and related structures. Dysfunction of the neurological system can have intense effects on these senses. Furthermore, the neurological system is involved in the complex movements necessary for speech, feeding, and expression.Altered neurological function is often evident in these actions. For example, Bells palsy, an inflammatory paralysis of the trigeminal nerve, has a profound effect on the function of the motor components on the affected side.

The Endocrine System

The neck houses the thyroid gland, a major endocrine organ. Dysfunction of the thyroid is often accompanied by organ hypertrophy, or enlargement, regardless of whether the dysfunction results in hyperactivity or hypoactivity of the thyroid gland. Enlargements, called goiters, are evident during the examination of the neck. Many endocrine disorders have typical facies. For example, when hypocalcemia develops from parathyroid disease, Chvosteks sign, a facial spasm, may be an early symptom.

The Lymphatic/ Hematologic System

The nasopharynx and oropharynx are rich with mast cells, responsible for allergic control symptoms. After exposure to allergens, the mast cell and basophil mediators are triggered, with resulting inflammatory responses responsible for the typical sneezing, itching, and secretions of the nasal, nasopharyngeal, or pharyngeal, and other linings. The ultimate result can include congestion, drainage, and secondary infections involving additional structures including the sinuses.The cervical nodes are sensitive to infection or inflammatory changes in the regions they drain, with resulting enlargement of nodes often signalling a disorder. Because of the rich vascular supply of the nasal and oral mucosa, hematologic changes may first be reflected here. For instance, thrombocytopenia may first cause petechiae of the mucous membranes or bleeding of the gums or nose.Anemia may be accompanied by pallor of the mucosa or glossitis.

Performing the Head, Face, and Neck Assessment

Assessment of the head,face,and neck involves obtaining a complete health history and performing a physical examination. As you perform the assessment, be alert for signs and symptoms of actual and potential problems of the various components of the head, face, and neck.

Health History

The health history identifies any related symptoms or risk factors and the presence of diseases involving the head, face, and neck. It must also detect any other disorders that may affect these structures. Your history will include obtaining biographical data and asking questions about the patients current health,past health, and family and psychosocial history. It also includes a review of systems (ROS). If you dont have the time to perform a complete health history, make sure to at least perform a focused health history of the head, face, and neck.

Biographical Data

Review the patients biographical information. Note your patients agecertain diseases are more prevalent in specific age groups.For example,children tend to have more upper respiratory problems and pharyngitis than older adults. Also ask about your patients occupation. Does he or she have a job that puts him or her at risk for head injury? Does he or she spend long hours at a computer terminal (may result in tension headaches)? Questions like these will help to identify the potential for exposures to physical and environmental situations that could harm the head, face, and neck structures.

Current Health Status

Determine whether the patient has any specific presenting complaints related to the head, face, or neck. Some common complaints include headaches, jaw pain, neck pain or stiffness, masses, nasal congestion, epistaxis, mouth or dental pain, mouth lesions, sore throat, and hoarseness. Any such complaints, as well as others that you might identify later, should be explored and developed using an organized system of symptom analysis, such as the PQRST format. Because disorders of several systems can influence the head,face,and neck, it is important to determine the patients overall health status.There will be times, however, when the patients presenting problems are particularly acute or distressful, and the initial history and physical will have to be very focused.

Symptom Analysis

Symptom analysis tables for the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book.

Head Pain

Head pain can be associated with a variety of problems, including migraines, tension, systemic infections, and trauma.

Jaw Tightness and Pain

When a patient presents with jaw tightness and/or pain, the cause may be TMJ syndrome, but it could also be trauma or infection/inflammation in the structures near the jaw.An important consideration for jaw discomfort is whether it might be caused by cardiovascular disease. Always ask patients if they have a personal or family history of heart disease.

Neck Pain and Stiffness

Neck pain and stiffness can stem from musculoskeletal problems as well as from infections. Symptom analysis can help identify any forgotten trauma or physical exertion that might explain the complaint.

Neck Mass

When a patient complains of a neck mass, it might be a goiter of the thyroid gland or enlarged lymph nodes. Enlarged nodes may signal either an infectious or a malignant disorder.

Nasal Congestion

Nasal congestion is usually caused by an upper respiratory infection or allergy.

Nosebleed

Epistaxis, or nosebleed, is usually self-limited and has relatively benign causes.However, it can be caused by coagulopathies or other hematologic disturbances, malignancies, hypertension, or trauma.

Mouth Lesions

A mouth lesion can be caused by a malignancy, trauma, nutritional deficit, or poorly fitted dentures or orthodontic appliances.

Mouth and Dental Pain

Mouth pain can be caused by ischemic heart disease, musculoskeletal disorders, or dental problems.

Sore Throat

When a patient complains of a sore throat, the most common cause is a bacterial or viral illness. However, throat discomfort can be associated with throat masses, including thyroid hypertrophy or malignancies, foreign objects in the throat, and other causes.

Hoarseness

Another common complaint is hoarseness. Hoarseness may be caused by overuse of the voice, for example, prolonged periods of shouting or loud speech. It can also be an indication of gastroesophageal reflux, malignancies, neuromuscular disorders, or other health problems.

Past Health History

Once you have investigated the patients chief complaint, explore the past health history. This portion of the history includes childhood and adulthood illnesses, surgeries, or major injuries; hospitalizations; major diagnostic procedures; exposures to infectious diseases; and allergies; as well as an immunization and medication

 

 

 

 

Family History

The purpose of the family history is to identify health problems that are familial or genetic.The history should include information on close relatives, both living and dead. The focus should be on problems that either have a genetic component or are attributed to environmental/ living situations shared with the patient. The genogram described in earlier chapters is a helpful way to organize the information obtained through the family history.

Psychosocial Profile

The psychosocial profile provides information about the patients occupation, social involvement, recreational interests, and daily activities and habits in order to identify factors that can influence the health of the head, face, and neck. It determines risks associated with exposure to hazards, provides information about the patients support system, and helps identify the patients ability to perform self-care activities and obtain and carry out recommended treatments.

Drugs That Adversely Affect the Head, Face, and Neck

When obtaining a health history to assess a patients head and neck, the nurse must ask about current drug

Psychosocial Profile

The psychosocial profile provides information about the patients occupation, social involvement, recreational interests, and daily activities and habits in order to identify factors that can influence the health of the head, face, and neck. It determines risks associated with exposure to hazards, provides information about the patients support system, and helps identify the patients ability to perform self-care activities and obtain and carry out recommended treatments.

 

Anatomical Landmarks

Before you begin your physical assessment of the head, face, and neck, you need to visualize the underlying structures and identify landmarks. Two landmarks on the face that are useful in determining symmetry of facial features are the palpebral fissures and the nasolabial folds (Fig.11.12).The palpebral fissure is the distance between the upper and the lower eyelid .The nasolabial fold is the distance from the corner of the nose to the edge of the lip. This is the facial crease that is often seen when someone smiles. The anterior and posterior triangles (Fig. 11.13) are important landmarks of the neck. The sternocleidomastoid and trapezius muscles form the triangles. Both triangles are helpful in locating the underlying structures of the neck.


Physical Assessment

During the history, you probably developed a sense of the patients concerns and may have begun to cluster the data obtained to help guide your physical examination. You should have an awareness of any physical limitations or discomfort that will influence the physical examination. Throughout the history, you observed the patients body posture, fluidity of movements, facial expressions, and speechall of which are important observations for the head, face, and neck. Now, as you approach the physical examination, you must be very objective in your observations as you inspect the internal structures of the nose, mouth, and throat.

 

Approach

All four techniques of physical assessmentinspection, palpation, percussion, and auscultationare used in the examination of the head, face, and neck. Some structures, like the throat and internal nose, can only be inspected; generally only the sinuses are percussed, and only the vessels of the neck and thyroid are auscultated. The cranial nerve (CN) assessment is generally incorporated in the examination of the face, mouth, nose, throat, and neck. The assessment of the arteries and veins is also incorporated into the examination of the neck and face. Although there is no right sequence to follow for the examination of these structures and organs, you should develop, practice, and adhere to a set routine in order to avoid omitting a test. One common sequence is the head-to-toe approach that begins with inspection of the shape and general placement of the head and facial structures, followed by a thorough inspection of the facial muscles and then the neck. Some examiners prefer to examine the nose, mouth, and throat along with the face, whereas others do this only after they have completed the examination of the neck. No matter what sequence you use, always take into consideration the structures symmetry during your examination.

Performing a General Survey

The first step of the physical examination is a general survey, although in many cases this is accomplished during history taking. Besides providing early information regarding speech and movements, the general survey allows you to detect clues about the patients emotional status,nutritional status,and overall posture.During the general survey,obtain vital signs.Altered pulse can be associated with thyroid disease. Respiratory rate changes can be related to an altered airway,including the nose,mouth,or pharynx.The temperature is an important consideration for infection.Blood pressure elevations may explain epistaxis.Aside from the vital signs, be alert for other signs that may indicate underlying problems with the head,face,and neck.

For example:

Note facial expression.Is it appropriate? Nervousness or a flat expression may be associated with thyroid disease. A masklike expression is seen with Parkinsons disease.

Note any gross abnormalities, such as exophthalmus, which is seen with thyroid disease.

Consider dress and grooming. Are they appropriate? Temperature intolerance associated with thyroid disease may cause people to overdress or underdress.

Note speech and thought processes. Are responses appropriate? Are thought processes intact? Problems with focusing may be related to thyroid disorders.

Look for changes in weight or weight distribution. A buffalo hump (fat pads on the lower midcervical and upper thoracic areas) is associated with Cushings disease or steroid use.

Performing a Head-to-Toe Physical Assessment

The head, face, and neck reflect many different systems, so look for changes that may indicate underlying pathology. Next, perform a head-to-toe physical assessment, checking for specific signs of disease in other organ systems that might be reflected in the head, face, and neck.

Performing the Physical Assessment for the Head, Face, and Neck

After the general survey and head-to-toe assessment, perform a physical examination that focuses on the head, face, and neck. Although inspection and palpation are discussed separately below, they are not distinct, sequential activities. They are actually performed almost in concert. Although you inspect an area or structure before touching or moving it, this takes only a moment and is usually followed immediately by touching or palpating the area. The only area of the head, face, and neck to be percussed is the sinus area,and this generally occurs after you have applied pressure over the sites during palpation. The only areas to be auscultated are the carotids and jugulars and, if it is enlarged, the thyroid.

Assessing the Head and Face

Examination of the head and face involves inspection and palpation.

Inspection

Have patients remove hats,wigs, or hair ornaments if present. Put on gloves in case there are open lesions under the hair. Begin with inspection. Identify the prominences of the brows, cheeks, mastoids, and occiput.

 

Palpation

Next, palpate the head and face. There should be no tenderness and, except in infants, no soft areas in the head. As you palpate the TMJ, ask the patient to open and close his or her mouth and deviate his or her jaw from side to side. Determine sensation, motion, and strength of the face, as described in Chapter 20, assessing the Motor- Musculoskeletal System, and assess the temporal artery/Assessing the Peripheral Vascular and Lymphatic Systems.

Assessing the Sinuses

Assessment of the sinuses includes inspection (with transillumination), palpation,and percussion.Only the frontal and maxillary sinuses are readily accessible for assessment. Envision the areas of the face that overlay the sinuses. Remember, the frontal sinuses are located above the eye brow sand the maxillary sinuses are located below the eyes.

Inspection

The sinus areas are inspected for edema and discoloration. If you suspect a sinus problem after regular inspection, palpation, and percussion, you can also transilluminatethe sinuses. A transilluminator should be used; however, either a penlight or an otoscope with a speculumattached are good alternatives. Transilluminationrequires a darkened room. To transilluminate the frontal sinuses, hold the light source so that the light is directed upward from just below the brows. A glow of light may be detected over the brow. To transilluminate the maxillary sinuses, have the patient open her or his mouth and position her or his head so that you can observe the roof of the mouth. Place the light source below the eyes and above the cheek, with the patients mouth opened, and look for a glow on the roof of the mouth. Absence of transilluminationsuggests sinus fullness or thickening. Any glow noted with transillumination of either the frontal orthe maxillary sinus should be symmetrical. However, absence of transillumination may not always indicate pathology. It may simply be a normal variant caused byte thickness of the bones overlying the sinuses or underdevelopment of the sinuses.

 

 

Palpation

Palpate the sinuses for tenderness. To palpate the frontal sinuses, press upward just below the medial third of each eyebrow. To palpate the maxillary sinuses, apply pressure to the lower portion of the cheeks, below the eyes.

Percussion

Percussion is performed to further assess for sinus discomfort. If tenderness is elicited with palpation, omit percussion over that area. Otherwise, you should percuss the sinuses by tapping over these same areas. Direct percussion, using the tapping finger to strike directly over the bony prominence, is most frequently used. Because the sinuses are normally filled with air, percussion should elicit somewhat of a resonant tone.

Assessing the Nose

To examine the nose, inspect the external structures, palpate the external structures, and then inspect the internal structures (nasal cavity).

Inspection

Inspection of the internal structures includes the septum, nasal mucosa, and medial and inferior turbinates. If you are using an otoscope with a wide-tipped speculum, stabilize the patients head with one hand and then slowly and gently insert the speculum into the nares. If you are using a penlight and nasal speculum, insert the closed speculum and then gently open it once it is in the nose,being careful not to open it too much.Take care not to scrape or press on the central septum because this area is sensitive.During your assessment,take note of any sounds the patient is making with his or her nose,such as sniffing or snorting

 

 

Palpation

Palpate the bony ridge and soft tissues of the external nose. The cartilaginous, distal two-thirds of the nose should be mobile, without pain. Gently occlude one nostril at a time and have the patient inhale through the nose to determine patency.

Assessing the Mouth and Throat

The mouth and throat are components of both the respiratory and the digestive tracts. Assessment involves inspection and palpation. The assessment begins with examination of the lips, then the structures of the mouth and throat. Remember to wear gloves when examining the internal structures of the mouth. You will also need a penlight and tongue depressor to perform the examination.

Inspection

Inspect the lips, gingiva, buccal mucosa, tongue, and pharynx for colour, lesions, and exudates. Note the colour, number, condition, and occlusion of the teeth. The upper and lower molars should approximate with the jaw closed. The front teeth should slightly override the lower ones. Observation of the teeth with a physical assessment does not replace a dental examination, so remind the patient of the importance of maintaining routine dental care. Using the tongue blade to displace the cheeks and lips, first inspect the buccal mucosa. The Stensens ducts, openings for the parotid glands,are located on the buccal mucosa at the point of the second upper molars.

The Whartons ducts, openings for the submandibular glands, are located on either side of the frenulum under the tongue. Inspect all aspects of the tongue: dorsal, ventral, and lateral edges. Note the color, moisture, and surface texture and observe for any swelling. Observe the frenulum and the mobility of the tongue.

Palpation

Palpate the tongue for nodules or areas of thickening. Palpate the floor of the mouth for nodules or masses.To palpate the floor of the mouth, use your nondominant hand to press upward beneath the patients chin to provide support while palpating downward with a gloved hand inside the mouth. The support provided externally helps ensure that the examining hand actually palpates a mass and does not merely push it away. The use of two hands will help to assess any mass, examining the dimensions, consistency, tenderness, and texture.

The parotid, submandibular, and sublingual glands should also be palpated for enlargement and tenderness. The parotid glands are located anterior to the ear, and the submandibular and sublingual glands are located under the mandible.

 

 

Assessing the Neck

Examination of the neck integrates components of the vascular, respiratory, musculoskeletal, neurological, lymphatic, and endocrine systems. This chapter focuses on the lymphatic and endocrine systems, primarily on assessment of the cervical lymph nodes and the thyroid through inspection, palpation, and auscultation.

Inspection

You will be inspecting the cervical lymph nodes and thyroid gland. Remember, lymph nodes drain toward the center of the body. When examining the thyroid gland, focus your attention on the middle to lower third of the anterior neck, checking for enlargements.

Palpation

The order in which you palpate the cervical lymph nodes is not important, although it is best to develop a sequence and be consistent to ensure that you do not omit a group.One common sequence is to start with the preauricular nodes, followed by the postauricular nodes, then move to the tonsillar,submandibular, and submental nodes along the mandible. Next, palpate the occipital area, followed by the superficial and deep cervical, posterior cervical, and supraclavicular nodes. Palpate node groups gently with one or two fingers, applying alternate pressure. Palpate any identified nodes between two fingers to establish their dimensions, texture, consistency, and shape. Although the lymph nodes are generally not palpable, it is not unusual to identify them at 1 cm or less in size. Palpable lymph nodes should be described according to their location, size, shape, consistency, mobility, and tenderness. Palpable small nodes should be soft to rubbery in consistency and be freely mobile, distinct, round, and nontender.

The term used to describe enlarged nodes (_1 cm in diameter) is lymphadenopathy. Lymphadenopathy can be regional (involving one or two groups) or more generalized (involving three or more groups). To palpate the thyroid, use an anterior or posterior approach. Some examiners combine both approaches when assessing a thyroid nodule or enlargement. Both approaches are depicted here, so that you can determine which works best for you. Begin by locating the thyroid gland. Although the thyroid is usually nonpalpable, you may be able to feel the isthmus, which connects the two lobes and lies below the cricoid cartilage. The lobes are located behind the sternocleidomastoid muscle.The likelihood of palpating the isthmus increases with very thin or pregnantpatients.You may be able to feel the edge of the gland,especially in women,who have larger thyroid glands than men. The thyroid gland moves as the individual swallows. Therefore, have the patient drink water while you palpate the gland, to facilitate detection. Instruct her or him to take a sip from the cup and hold it in the mouth until you ask her or him to swallow. Do this at least twice, as you examine both the left and the right thyroid lobes. To use the posterior approach, stand behind the patient and ask him or her to flex his or her neck slightly forward and to the left.This relaxes the muscles and the skin overlying the left side of the neck, making it easier to detect the tissue of the left thyroid lobe.Using the fingers of your left hand, locate the cricoid process. Push the trachea slightly to the left with your right hand as you palpate just below the cricoid process and between the trachea and the sternocleidomastoid muscle with your left hand. As you palpate, ask the patient to swallow the water he or she is holding in the mouth. Now, repeat the steps with the patients head flexed slightly forward and to the right. This time, displace the trachea slightly to the right with your left hand and palpate the right lobe of the thyroid with your right hand. To use the anterior approach, stand in front of the patient and ask her or him to flex the neck slightly forward and in the direction you intend to palpate. Place your hands on the neck and apply gentle pressure to one side of the trachea while palpating the opposite side of the neck for the thyroid. The patient should take a sip of water during this approach as well thyroid. The patient should take a sip of water during this approach as well.

Auscultation

The final portion of the neck examination, auscultation of the thyroid gland, is generally reserved for situations in which the thyroid is enlarged or a mass is palpated. To auscultate the gland, place the bell of your stethoscope over one lobe, then the other. Ask the patient to briefly stop breathing as you auscultate, to optimize your ability to hear without the distraction of the tracheal breath sounds. There should be no thyroid sounds. Because the thyroid is a very vascular organ, vascular sounds are sometimes present in hyperthyroidism.

 

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Assessing the Nose

The nasal examination can provide valuable information on the patient's general health status, including identifying specific systemic diseases. In addition, this examination provides information on the part of the respiratory system that warms, moistens, and filters inhaled air, and also serves as the sensory organ for smell.

Prepare the patient for the nasal examination by explaining the procedure to the patient in simple terms. The patient should be sitting up straight with his or her head at eye level.

Visual Inspection of the External Nose

The nose is shaped like a triangle and is composed of the following:

Inspect the external surface of the nose from all angles. Normally the skin is intact and similar in color to the face. The surface should be smooth and uniform. Check the nasolabial folds for skin lesions such as basal cell carcinoma. Pay special attention to areas of redness, pigmented lesions, lumps, crusts, scaliness, and a visible vascular pattern. Also check for the following:

Examination of the Nasal Cavity and Paranasal Sinuses

The nasal cavity has the following characteristics:

The paranasal sinuses are air-filled areas in the skull bones that serve as resonators for sound production and provide mucus that lubricates the nasal cavity.

Nasal Patency. Check the patency of each naris by standing directly in front of the patient and occluding the patient's left naris with the index finger of your right hand. Ask the patient to breathe normally through the right naris. Repeat by occluding the patient's right naris with the index finger of your left hand and ask the patient to breathe through the left naris. Normally the patient will be able to exhale through the unoccluded naris. Nasal obstruction is present if the patient is unable to exhale through the nares.

Evaluating the Nasal Septum. Inspect the nasal septum by holding a light and standing directly in front of the patient. Gently press the tip of the patient's vestibule with the thumb of your left hand. Shine the light onto the patient's vestibule with your right hand aiming the light parallel to the floor.

Normally, the nasal septum is pink, in the midline, and intact. Common deviations from normal findings include the following:

The next step is to transilluminate the nasal septum to look for perforations. Shine the light on one side of the septum and look at the other side. Light shining through suggests a septal perforation. (Try to avoid contact with septum -- it is very sensitive.) Common causes of septal perforations include nose picking, infection, syphilis, tuberculosis, collagen vascular disease, Wegener's granulomatosis, systemic lupus erythematosus, rheumatoid arthritis, exposure to toxins, previous cocaine use, and chromium poisoning.

Also look for nasal septal deformities. Deformities of the vomer ("plowshare"), the unpaired flat bone that forms the inferior and posterior part of the nasal septum, are common after vaginal deliveries.

Examining the Walls and Turbinates. The inferior and middle turbinates and the middle meatus between them should be pink, intact, smooth, and moist. The area should be free of foreign body(s). Note any masses and any deviations from normal, such as a red, pale, or bluish-gray color, bogginess, dryness, fissures, crusts, exudate, edema, polyps, ulcers, watery discharge (rhinorrhea), mucopurulent discharge, or bloody discharge. Drainage and polyps are abnormal. Polyps are usually nontender and a sign of allergy. Consider aspirin sensitivity if the patient also has asthma. Purulent mucus suggests upper respiratory infection or sinusitis. Bloody discharge suggests local trauma or a platelet abnormality. Pulsation of the nasal arteries in the mucus membrane is increased in thoracic aortic aneurysm (Bozzolo's sign).

Nasal Discharge

Clear nasal discharge most commonly suggests allergic rhinitis or viral infection. Purulent discharge suggests bacterial infection.

If the patient has nasal discharge along with "raccoon" eyes and a history of head trauma, suspect basilar skull fracture. Check the glucose level of the nasal fluid for a clue to a CSF leak (usually above 30 mg/dL). If the nasal discharge is bloody, see if it clots. If it does not, also consider a CSF leak An additional useful test for basilar skull fracture is to place a drop of the bloody fluid on a white paper towel or piece of filter paper. Seeing a clear wet ring around a red dot suggests basilar skull fracture.

Epistaxis. The vascular network in the anterior medial nasal septum is called Kiesselbach's plexus, the most common location of nosebleeds. Epistaxis (nasal bleeding) has been reported to occur in up to 60% of the general population and has 2 peaks -- 1 in childhood and 1 in people over 60. Most people do not require medical attention and the nosebleed can be managed with simple instructions, including application of direct pressure to the septal area and plugging the affected nostril with gauze or cotton.[

Some causes of epistaxis include the following:

 

Assessing the Mouth and Throat

Assessing Breath Sound and Odor

Listen to the sound of the breath. A soft swish of air coincident with the pulse can be heard through the open mouth in thoracic aortic aneurysm (Drummond's sign). Soft wheezing over the open mouth suggests foreign body in the bronchus (Jackson's sign).

Note the breath for unusual odors. This sensory component is very useful because there are a number of odors characteristic of important conditions (Table 1). If you feel uneasy just take your time and move in from a distance. Have the patient say his or her name and address while you smell the breath. If poor oral hygiene is the cause of bad breath, have the patient breathe through the nose with the mouth closed.

Table 1. Possible Causes of Some Unusual Breath Odors

Character of Breath Odor

Possible Cause

Fishy ammonia (urine-like)

Renal failure

Fishy sweetness

Liver failure

Musty ammonia

Liver disease (fetor hepaticus)

Fruity chewing gum or acetone

Diabetic ketoacidosis

Apples

Chloroform or salicylate ingestion

Grapes

Pseudomonas infection

Fruity yeast

Alcohol ingestion

Fresh-baked bread

Typhoid fever

Stale or musty (sourdough) bread

Pellagra (severe niacin deficiency)

Fresh meat

Yellow fever

Stale beer

Mycobacteria (scrofula)

Landfill or garbage dump

Oral infection, bronchiectasis esophageal diverticulum, gastroparesis

Putrid

Anaerobic infection

Very putrid

Lung abscess

Stale smoke

Cigarette smoking

Burning rope

Marijuana smoking

Shoe polish

Nitrobenzene ingestion

Bitter almonds

Cyanide ingestion

Garlic

Arsenic, organophosphorus, or tellurium ingestion

Metallic

Iodine ingestion

Solvent

Hydrocarbon ingestion

Violets

Turpentine ingestion

 

Assessing the Temporomandibular Joint

If the patient has jaw pain, place your forefinger of each hand on each temporomandibular joint (just in front of the ear) and have the patient open and close their mouth. Normally the patient's mouth should open wide enough for 3 of their fingers to be inserted vertically. A small oral opening suggests scleroderma, temporomandibular joint arthritis, or tetanus. See if there is crepitus and any shift in jaw when the patient opens their mouth, which suggests temporomandibular joint arthritis, particularly if other symptoms are present, such as headache, dizziness, tinnitus, and ear pain. Jaw aching or claudication suggests temporal arteritis. If the patient has a fever along with drooling and exquisite pain when opening the mouth, consider peritonsillar abscess.

Assessing Perioral Lesions

Cracks and Fissures. Fissures in the corners of the lips suggest Candida infection, B vitamin deficiencies, or persistent drooling. Vertical cracking along the lower lip suggests cheilitis, which can be caused by alcoholism, B vitamin deficiency, iron deficiency, malnutrition, and Crohn's disease. Congenital syphilis can produce lines radiating from the mouth (rhagades). Rarely, a history of syphilis can produce permanent cracks that are epithelialized and radiate from the corners of the mouth.

Other Lesions. Other lesions and possible causes include the following:

         Red macular lesions resembling cherry angiomas suggest Osler-Weber-Rendu syndrome. 

         Freckles on the lips suggest Peutz-Jeghers syndrome. 

         A blue-purple nodule on the lip border suggests a mucocele. 

         Vesicles around the lip suggest herpes simplex virus. 

         Petechiae may sometimes be seen, suggesting platelet abnormalities. 

         A painless ulcer on the lower lip suggests squamous cell cancer. 

         A hard nodule on the lower lip suggests epidermoid carcinoma.

Swelling and Color. Swelling of the upper lip suggests angioedema. Swelling of the upper and lower lips with hemorrhage suggests Stevens-Johnson syndrome. Pallor around the mouth in a febrile patient suggests scarlet fever (Filatov's sign).

Assessing Mucous Membranes

The next part of the oral examination involves inspecting the mucous membranes. For this exam you will need a bright light and a tongue blade.

First, notice the color of the mucosa, which is one of the most sensitive places for hyperpigmentation. For example, brown spots suggest Addison's disease. Note that African Americans sometimes have brown spots adjacent to the molars.

Next, estimate the amount of moisture. If the tongue blade sticks to the mucosa, it is too dry and lacks saliva (xerostomia). No saliva under the tongue in the oral vestibule or between the gums and cheek is a key sign of dehydration.

After checking the degree of moisture, look carefully for mucosal lesions (Table 2).

Table 2. Lesions on Mucous Membranes of the Mouth

Description of Lesion

Possible Causes and Comments

Painless ulcer

Squamous cell cancer

Multiple painful small round ulcers

Aphthous stomatitis (consider: autoimmune processes, stress, systemic lupus erythematosus, vitamin B12 deficiency, inflammatory bowel disease, or Behçet's syndrome)

Ulcers with irregular borders

Systemic lupus erythematosus, pemphigus, viral illness

Unilateral painful vesicles

Herpes zoster

Scattered painful vesicles and pustules

Herpes simplex

Painful ulcers on posterior pharynx

Coxsackie A virus (herpangina)

Mucosal bulla

Pemphigus, pemphigoid, erythema multiforme, lichen planus

Red nodule

Malignancy, pyogenic granuloma

White spots

Measles, Coxsackie A-16, ECHO 9 virus

White plaque with ulceration (leukoplakia)

Most commonly caused by chronic irritation -- typically from tobacco; suspect squamous cell carcinoma

White coating on red base

Oral candidiasis

Irregular line on posterior buccal mucosa

Linea alba, caused by minor trauma

Lacy white patches on inner cheek (Wickham's sign)

Lichen planus

Dark patch adjacent to tooth filling

Dental amalgam pigmentation

Pigmentation with ulceration

Malignant melanoma

Pigmentation adjacent to front teeth

Smoker's gingiva

Small red spots with central blue-white dot (Koplik's sign)

Measles

 

Assessing Stensen's Duct (Parotid Duct)

Check the Stensen's duct on the lateral cheeks. Excessive redness or purulent drainage suggests a stone in the duct. A red spot sometimes appears on Stensen's duct in patients with mumps (Tresilian's sign). Tenderness at the angle of the jaw (Hatchcock's sign) suggests parotid gland inflammation and is also associated with mumps. Parotid pain on tasting vinegar suggests parotid gland inflammation (Mirchamp's sign).

Assessing the Gingiva

The next step in the oral examination is to examine the gums. Red and swollen gingiva suggests gingivitis, which can lead to periodontal disease and is usually caused by bacterial plaque that accumulates in the spaces between the gums and the teeth and in calculus (tartar) that forms on the teeth. Gingivitis may also be due to other conditions:

         Phenytoin effect; 

         Acute monocytic leukemia; 

         Platelet abnormalities (but not coagulopathies); 

         Vitamin C deficiency (but never in edentulous patients); and 

         Wegener's granulomatosis (gingivitis resembles a mulberry).

Blue-grey dots along the gums suggest lead poisoning (Burton's sign). Pale purple discoloration along the gum line near the teeth suggests copper poisoning (Corrigan's sign).

Assessing the Teeth

After examining the gums look carefully at the teeth. Erosion on a tooth suggests dental caries or wear and tear. If the gingiva is red and swollen and you note an opening at the base of a decayed tooth, consider a periapical dental abscess. In a patient with fever of unknown origin, gently tap each tooth to check for the increased tenderness of an apical abscess.

Poor dental hygiene may predispose to more serious medical conditions, such as aspiration pneumonia. (Of interest, an edentulous state reduces the likelihood of aspiration pneumonia.) An aspirated tooth can cause an abscess in the lung, so count the teeth and ask about any missing ones. Increased space between the teeth is common, but it can suggest acromegaly (patient may complain of food sticking between the teeth).

Stains on the teeth and their color can be informative. Greenish teeth suggest that the patient had jaundice as an infant. Dead teeth look darker gray compared with other teeth. Fluoride toxicity in childhood can cause dark brown pits. Chewing tobacco stains the teeth in a predictable manner. Lipstick sticking on the teeth suggests xerostomia because saliva reduces the adhesion of lipstick. Calculus develops as chalky white debris along gingival margin.

A small protrusion lingual to the mesial portion of the first maxillary molar is Carabelli's tubercle. Long teeth suggest periodontal disease with retraction of the gums.

Assessing the Tongue

Next, examine the tongue for abnormalities.

Tongue Discolorations and Lesions. See Table 3.

Table 3. Tongue Discolorations and Lesions

Lesions or Discoloration

Possible Causes and Comments

Soft nodule resembling a skin tag

Suggests a papilloma, which is a premalignant lesion

A soft red mass at the base of the tongue

May represent a lingual thyroid

Red, shiny surface

Vitamin B12 deficiency and pellagra

Red with white exudate

Thrush

Strawberry or raspberry

Scarlet fever

Magenta cobblestone

Riboflavin deficiency

Pale tongue

Giant-cell arteritis

Pale areas on tongue

Bacterial endocarditis

Sharply defined pale area on half of tongue (Liebermeister's sign)

Air embolism

White hairy plaques (hairy leukoplakia)

Epstein-Barr virus in HIV patients

Black coat

Aspergillus niger colonization

Nodularity from neuromas

Sipple's syndrome (medullary carcinoma of the thyroid, pheochromocytoma and multiple mucosal neuromas [MEA-II])

Transverse fissures

Congenital condition

Longitudinal fissures

Dehydration, syphilis

Irregular fissures (geographic tongue)

Not significant

Shiny red tip on furred tongue (Marfan's sign)

Typhoid fever

Posterior lateral ulcers

Malignancy

Ragged ulcers under tongue

Behçet's syndrome

Midline ulcers

Tuberculosis or histoplasmosis; usually not malignant

Multiple painful ulcers

Tuberculosis (almost always pulmonary)

Ulcer on tip

Syphilis

 

Shape and Size of the Tongue. A large tongue (macroglossia) could suggest hypothyroidism, acromegaly, pemphigus vulgaris, or amyloidosis. Amyloid may also produce palpable stiffness with the enlargement.

Tongue Inflammation (Glossitis). Early glossitis produces papillary hypertrophy; the next phase produces papillary flattening. If the inflammation progresses further, the tongue atrophies and becomes smooth and shiny. Glossitis can be caused by iron deficiency, B vitamin deficiency, alcoholism, malnutrition, amyloidosis, and carcinoid syndrome.

Tongue Movements. The ability to easily touch the tip of the nose with the tongue can indicate Ehlers-Danlos syndrome (Gorlin's sign).

Involuntary tongue movements or tremors are also instructive. Fine tremor of the tongue suggests hyperthyroidism or trypanosomiasis (Castellani-Low sign). To check for chorea, ask the patient to stick out the tongue and keep it out. The tongue cannot stay protruded in chorea. If the patient is unable to voluntarily protrude the tongue consider shortened frenulum, oral carcinoma, or louse-borne typhus (Sterling-Okuniewski's sign).

A useful technique for detecting certain neuromuscular conditions involves placing a tongue blade across the lower teeth and asking the patient to drape their tongue over the tongue blade. Tapping the tongue may produce jerking in patients with myotonia. In patients with hypocalcemia, tapping the tongue causes the lips to protrude (Escherich's sign) or may cause a curved distortion of the tongue (Schultze's sign).

The Oral Vestibule. It is important to look under the tongue just behind the lower front teeth. Secretions pool there, so it is a prime site for oral tumors. Increased central venous pressure can produce dilated sublingual veins.

Look for cysts. A ranula (a cyst of the sublingual salivary gland) appears as a translucent mass near the frenulum. A sublingual dermoid cyst is usually white and opaque, while a mucous gland retention cyst is blue and translucent.

Assessing the Palate and Posterior Pharynx

The Hard Palate. After the tongue examination, focus your attention on the hard palate. A nontender lump on the hard palate is a torus palatinus, which is normal and benign. An arched palate can suggest Sipple's syndrome, Marfan's syndrome, or homocystinuria. Defects or ulcers in the hard palate are seen in infection, radiation therapy, or neoplasms.

The Soft Palate. Next, examine the soft palate. The juncture of the hard and soft palate is often a place to see petechiae. Edema of the soft palate suggests gamma heavy chain disease.

The Posterior Pharynx. The next step of the oral examination is to check the posterior pharynx. Significant asymmetry of the tonsillar pillars and the anteroposterior and lateral dimensions suggests peritonsillar abscess. Diminished area (particularly in the horizontal plane) suggests a predisposition for obstructive sleep apnea. White plaques that bleed when scraped suggest Candida infection, while exudate suggests bacterial infection. A dark red color to the anterior and inferior pillars of the posterior pharynx suggests syphilis (Biederman's sign).

The Uvula. Finally, check the uvula. Note the elevation of the uvula by having the patient say the familiar "AHHHH." Asymmetry suggests neurologic disease or peritonsillar abscess. A bifid uvula suggests a submucosal cleft palate. Flushing (Stone's sign) or pulsation (Mueller's sign) of the uvula suggests aortic insufficiency. Swelling suggests infection, obstructive sleep apnea, or gamma heavy chain disease. Redness of the uvula is seen in viral infection or bacterial infection. Seeing the epiglottis suggests acute epiglottitis.

The functions of the nose The nose, the first segment of the respiratory system, warms, moistens, and filters inhaled air. It is also the sensory organ of smell, innervated by CN # I.

The anatomic landmarks of the external nose

The external nose, shaped like a triangle, consists of:

 The bridge or superior part
 The free corner or the tip
 The openings at the base of the triangle - the nares
 A vestibule
 The columella that divides the two nares and is continuous inside with the nasal septum

The ala - the lateral outside wing of the nose on each side

 

Describe the nasal cavity
The nasal cavity extends back over the roof of the mouth
The anterior edge is lined with coarse nasal hair that filter the coarsest matter from inhaled air.

The remainder of the cavity is lined with ciliated mucous membrane that filters out dust and bacteria.
Because of its rich blood supply, the nasal mucosa appears redder than the oral mucosa. The increased blood supply warms inhaled air.
Kiesselbauch's Plexus a rich network of veins located on the anterior part of the septum, which divides the nasal cavity into two air passages.
Kiesselbauch's Plexus is the most common site of most nosebleeds.
The superior, middle, and inferior turbinates increase the surface area of the nose so that more blood vessels and mucous membrane are available to warm humidify, and filter the inhaled air.

Under each turbinate is a cleft, the meatus, named for the turbinate above.
The sinuses drain into the middle meatus and tears from the nasolacrimal duct drain into the inferior meatus.

The paranasal sinuses and their functions
There are four pairs of sinuses, two of which are accessible to examination

 The frontal -above and medial to the orbits
 The maxillary - in the cheekbones along the walls of the nasal cavity

The ethmoid -between the orbits
The sphenoid sinuses are smaller and deeper

The sinuses lighten the weight of the skull bones, serve as resonators for sound production and provide mucus
The maxillary and ethmoid sinuses are present at birth
The maxillary sinuses reach full size after permanent teeth have erupted
The ethmoid sinuses grow rapidly between 6 - 8 years of age
The fontal sinuses, absent at birth, develop between 7-8 years of age, reach full size after puberty
The sphenoid are minute at birth and develop after puberty

Structures of the oral cavity
The lips, insides of both cheeks, roof of the mouth or palate, the mandible, and maxilla form the oral cavity.
The teeth, both sets, begin development in utero
Children have 20 deciduous, or temporary teeth.
An adult mouth has 32 teeth, the tongue, gums, and openings for three pairs of salivary glands.

 The palantine tonsils are in the posterior end of the oral cavity
 The lingual tonsils are at the base of the tongue bilaterally
 The pharangeal tonsils(adenoids) are in the posterior nasopharnyx. 

 

List the functions of the mouth
The mouth is the first segment of the digestive system and an airway for the respiratory system. In addition, the mouth contains taste buds and aids in speech production.

Age related changes that take place in the mouth
Salivation starts at 3 months
Drooling occurs until the infant learns to swallow. Drooling does not mean the infant is teething Deciduous teeth should appear between 6 months and 2 years of age. All present by 2 1/2 years

Decidious teeth lost between 6 and 12 years
The pregnant female
Nasal stuffiness and epistaxis may occur during pregnancy. The gums may be hyperemic
and softened - may bleed with normal tooth brushing
The aging adult
Loss of subcutaneous fat makes the nose appear more prominent in some people.
A decrease in smell may diminish after age 60 because of a decrease in the number of olfactory nerve fibers.
In the oral cavity, soft tissue atrophy can result in loss of taste buds with up to an 80% reduction in taste functioning.
Tooth loss causes a series of difficulties including TMJ pain and osteoarthritis.
A decrease in sensation of smell may affect appetite and contribute to malnutrition.
The problems created by tooth loss may also cause the older person to eat soft foods, high in CHO, and decrease meat and fresh vegetables intake, adding to risk of malnutrition.
Transcultural Considerations
Cleft lip and palate more common in Asians and Native Americans; least common in blacks

May see teeth in the newborn; Tlingit Indians and Inuit.
Size of teeth vary culturally. Smallest in whites, largest in Inuits and Australian Aborignies Denser and harder tooth enamel in blacks - less tooth decay.


Examination
External assessment
Nose - deformity, symmetry, flaring, presence of lesions, patency

Inspect mucosa for colour, swelling, discharge, bleeding, foreign body Assess sinuses - using thumbs, press over frontal sinus below eyebrows;
For maxillary sinuses, apply pressure below cheekbones

These areas are tender in the presence of chronic allergies and acute infections.
Mouth - Assess colour, moisture, cracking, lesions, Gag reflex
Teeth/Gums - Assess teeth for diseased, absent, loose, abnormally positioned teeth

Note bite alignment, presence of gingivitis.
Tongue - Assess for colour, surface characteristics, moisture.
Assess buccal mucosa, palate, uvula, tonsils, gag reflex, presence of halitosis.

Key terms

Fetid - Foul odor
Kiesselbach's Plexus - A rich network of veins on the nasal septum
Caries - cavaties
Turbinates - 3 bones that project into the nasal cavity
Malocclusion - Poor biting relationship
Paranasal Sinuses (4 pairs) - Air filled pockets within the cranium
Dysphagia - Difficulty swallowing
Halitosis - bad breath
Epistaxis - Nose bleed
Torus Palatinus - A nodular bony ridge down the middle of the hard palate
Rhinitis - Reddened swollen nasal mucosa with a clear watery discharge
Leukoplakia - White patches on the tongue/baccal mucosa. May be cancerous. Should be checked if present > 2 weeks

Nasendoscopy

Used for nasal, pharyngeal and laryngeal cancers

A nasendoscopy is an examination of the nose and throat using a flexible fibre-optic tube with a light and camera on the end of it (endoscope). A local anaesthetic spray is squirted gently into the nose to numb the back of your nose and throat. You may find that the spray tastes bitter. 

The doctor will insert the endoscope into your nose to look at your nasal cavity, nasopharynx, oropharynx, hypopharynx and larynx. Images from the endoscope may be projected onto a screen. The test isn't painful as the tube is soft and flexible. However, it can feel unusual. You'll be asked to breathe lightly through your nose and mouth. You may be asked to swallow and to make some vocal noises. The doctor may also take some tissue samples.

The test takes 5 to 15 minutes. Afterwards, you can't eat or drink for about 30 minutes, but you can go home straightaway.

Laryngoscopy

Used for pharyngeal and laryngeal cancers

A laryngoscopy is a procedure that allows a doctor to examine your larynx and pharynx, and take a tissue sample from your voice box. A tube with a light and camera on it (laryngoscope) is inserted into your mouth and throat and shows the area on a screen.

The procedure is done under a general anaesthetic so that you don't feel anything. It will take 10 to 40 minutes, and you can go home when you've recovered from the anaesthesia. Afterwards, you may have a sore throat for a couple of days. 

A bronchoscopy is similar to a laryngoscopy, but it allows doctors to examine the airways to see if cancer has spread to the lungs. The tube (bronchoscope) is inserted into the lungs via the mouth and throat. It may be done under a local or general anaesthetic. 

Tissue sampling (biopsy)

Used for all head and neck cancers

A biopsy is when the doctor removes a small amount of tissue for examination under a microscope. It shows whether cancer cells are present and what type of cancer it is. A biopsy can often be done during a physical or visual examination. You'll have either a local or general anaesthetic so that you don't feel the procedure. Biopsy results are usually available in about a week. 

If you have a biopsy on a lump in your neck or on a tumour that's difficult to access, it will probably be done with a needle that's guided using an ultrasound or a CT scan (see below). 

Imaging tests

CT scan

Used for all head and neck cancers

A computerised tomography (CT) scan is a procedure that uses x-ray beams to take pictures of the body. Before the scan, you may have dye called contrast solution injected into your veins to show the blood vessels and make the pictures clearer. The dye may make you feel flushed or hot for a few minutes.

You'll lie still on a table that moves slowly through the CT scanner. The scanner is large and round like a doughnut. The CT scan itself takes a few minutes and is painless, but the preparation takes 10 to 30 minutes. You can go home when the scan is complete. 

Tips:

Before a CT or MRI scan, you may have a blood test to check that the medical dye is safe for your kidneys.

Tell the doctor if you're allergic to iodine, seafood or dyes, as this may prevent you from having the dye injected.

If you have a reaction during the procedure, such as breathing difficulties, tell your doctor or nurse immediately. 

MRI scan

Used for many head and neck cancers

Magnetic resonance imaging (MRI) uses magnetism and radio waves to build up detailed cross-section pictures of the body. If you have a pacemaker that isn't compatible with an MRI, or if you have another iron-based metallic object in your body, you can't have an MRI scan due to the effect of the magnet.

As with a CT scan, a dye may be injected into your veins before the scan to make the pictures clearer. The pictures are taken while you lie on a table that slides into a narrow metal cylinder  a large magnet  that is open at both ends.

An MRI is painless, but some people find lying in the cylinder too confined and noisy. If you think this will be a problem, let the doctor or nurse know beforehand as they can give you medication to ease this feeling or earplugs to reduce the noise. You can usually have someone in the room for company. The test takes about an hour and you can go home once it's over. If you've had medication, ask someone to drive or accompany you home. 

PET scan

Used for many head and neck cancers

A positron emission tomography (PET) scan produces a threedimensional colour image that shows where some cancers are in the body. It's sometimes recommended to help diagnose oral, pharyngeal or laryngeal cancer, or to see if the cancer has spread. It's only available at some hospitals.

You'll be injected in the arm with a radioactive glucose solution that takes 30 to 90 minutes to go through the body. You'll need to lie quietly during this time. You'll then be scanned for high levels of radioactive glucose.

This shows where cancer cells are in the body, as they take up more glucose than normal cells.

You'll be asked to not eat for several hours before the scan.

You probably won't have to stay in hospital for the test, but it will take several hours to prepare for and have the scan. Drinking plenty of water afterwards will help flush the radioactive material out of your body. 

If you have diabetes, you may need to follow a different procedure for a PET scan, as the test may be affected by the way your body processes sugar. Your blood sugar levels may be checked before the scan. Tell your doctor so the test can be adjusted. 

Ultrasound scan

Used for many head and neck cancers

An ultrasound is a painless scan that uses soundwaves to create a picture of part of your body. It's sometimes used to diagnose pharyngeal cancer or to see if another type of cancer has spread (metastasised). You'll probably have the scan as an outpatient.

A gel will be spread over your neck, and a paddle-shaped device called a transducer will be moved over the same area. It creates soundwaves that echo when they meet something dense like an organ or a tumour. These echoes are turned into a picture on a computer, allowing the doctor to see any abnormal areas.

X-rays

Used for many head and neck cancers

You may need x-rays of your head and neck to check for tumours or damage to the bones. The x-rays are quick and painless. There are different types of x-rays, some of which include:

Orthopantomogram (OPG): This is used to examine the jaw and teeth of people with mouth cancer.

Chest x-ray: This is sometimes done for people with mouth, pharyngeal or laryngeal cancer to check their general health and see whether the cancer has spread to the lungs.

X-ray of facial bones: If you have a nasal or paranasal sinus cancer, the bones in your face will be checked for signs of cancer spreading. 

Cancer staging

If tests show you have cancer, your doctor will give the cancer a stage from 1 to 4 to indicate how large it is and how far it's spread. Staging helps the doctor work out the best type of treatment.

Ask the doctor to explain what your stage of cancer means for you. The staging system used for head and neck cancer is called the TNM system. This system is also commonly used to stage cancers in other parts of the body. 

TNM system

T (Tumour) 1-4 

Refers to the size of the primary tumour. The higher the number, the larger the cancer. 

N (Nodes) 0-3 

Shows whether the cancer has spread to the regional lymph nodes of the neck. No nodes affected is 0; increasing node involvement is 1, 2 or 3. 

M (Metastasis) 0-1 

Cancer has either spread (metastasised) to other organs (1) or it hasn't (0).  

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it's not possible for any doctor to predict the exact course of the disease. Test results, the type of cancer you have, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as age, fitness and medical history are all important factors in working out your prognosis. 

Rene's story

The first indications of a problem were food getting stuck in my throat and soreness there. Later a lump developed on the right side of my neck. My GP referred me to an ENT specialist. He did a biopsy of the lump on my neck, which showed it was a squamous cell carcinoma. I also had x-rays, a CT scan, and a second biopsy in my throat area. They found a primary oropharyngeal cancer in my tonsil and at the back of my tongue. The lump on my neck was a secondary tumour.

In hospital, I had several scans to see whether the cancer had spread beyond my neck. I had radiotherapy to both sides of my throat, as well as chemotherapy. I had to have my back teeth removed as they were in the path of the radiation.

Six months later, I had a neck dissection to remove the lymph nodes on the left side. I now have a dry mouth and difficulty swallowing. Exercises to strengthen my neck muscles have improved my swallowing. I am grateful for the wonderful care I received in hospital during pre/post treatment and the supportive friendships found at my head and neck cancer support group.

Which health professionals will I see?

Your GP will arrange the first tests to assess your symptoms. If these tests don't rule out cancer, you'll be referred to a specialist (also called a physician) who will arrange further tests, make a diagnosis and advise you about treatment options. The specialist consults with a team of health professionals involved in your care (multidisciplinary team).  

Specialists

ENT specialist

treats disorders of the ear, nose and throat  

head and neck surgeon

an ear, nose and throat surgeon or a general surgeon with further training to operate on cancer in the head and neck 

oral (maxillofacial) surgeon 

has qualifications in medicine, dentistry and surgery, and specialises in surgery to the face and jaws 

dentist or oral medicine specialist 

evaluates and treats the mouth and teeth  

prosthodontist 

a dentist who specialises in replacing any missing teeth 

reconstructive surgeon 

restores, repairs or reconstructs the bodys appearance and function using surgery  

medical oncologist 

prescribes and coordinates the course of chemotherapy 

radiation oncologist 

prescribes and coordinates the course of radiotherapy 

gastroenterologist 

specialises in disorders of the digestive system, and inserts a feeding tube if required  

ophthalmologist 

deals with surgery affecting the eyes  

Allied health professionals

cancer nurse coordinator or clinical nurse consultant 

coordinates your care and supports you throughout treatment 

dietitian 

supports and educates patients about nutrition, diet and tube feeding 

audiologist 

diagnoses and treats hearing problems 

social worker, psychologist and counsellor 

link you to support services and help you with any emotional, financial or practical problems 

speech pathologist 

assesses and helps people with communication and swallowing difficulties using rehabilitation techniques 

   

 

S U M M A R Y

Disorders of the head, face, and neck have the potential to exert profound influence over the morbidity and mortality of patients.

The physical changes associated with these disorders can have devastating effects. The structures and function of the head, face,and neck are greatly influenced by changes in other systems.

It is essential that nurses be skilled in performing examinations of this system and differentiating between normal and abnormal findings.