Primary Care Otolaryngology

EVALUATING AND KEEPING TRACK OF PATIENTS

The Nose Anterior rhinoscopy should be performed utilizing a bivalve speculum. Evaluate the septum and anterior portions of the inferior turbinates. Topical vasoconstriction with oxymetazoline permits a more thorough examination and allows for assessment of turbinate response to deconges- tion. Nasal patency may be compromised by swollen boggy turbinates, septal deviation, nasal polyps, or masses/tumors. The remainder of the nasal cavity can be more carefully examined by performing flexible fiberoptic or rigid nasal endoscopy . This allows a more thorough evalua- tion of the nasal cavity and mucosa for abnormalities, including obstruc- tion, lesions, inflammation, and purulent sinus drainage. The sense of smell is rarely tested due to the difficulty in objectively quantifying responses. However, ammonia fumes can be useful for distinguishing true anosmics from malingerers because ammonia will stimulate trigeminal endings, and thus produce a response in the absence of any olfaction. The Mouth An adequate light and tongue depressor are necessary for examining the mouth. The tongue depressor should be used to systematically inspect all mucosal surfaces, including the gingivobuccal sulci, the gums and alveo- lar ridge, the hard palate, soft palate, tonsils, posterior oropharynx, buccal mucosa, dorsal and ventral tongue, lateral tongue, and the floor of mouth . Dentures should always be removed to permit a complete examination. The parotid duct orifice ( Stenson’s duct ) can be seen on the buccal mucosa, opposite the upper second molar. Massage of the parotid gland should express clear fluid. The submandibular and sublingual glands empty into the floor of the mouth via Wharton’s ducts . Complete exami- nation of the mouth includes bimanual palpation of the tongue and the floor of the mouth to detect possible tumors or salivary stones. The Pharynx The posterior wall of the oropharynx can be easily visualized via the mouth by depressing the tongue. Inspection of the nasopharynx, hypo- pharynx, and larynx requires an indirect mirror exam or use of a flexible fiberoptic rhinolaryngoscope. All mucosal surfaces are evaluated, to include the eustachian tube openings, adenoid, posterior aspect of the soft palate, tongue base, posterior and lateral pharyngeal walls, vallecula, epi- glottis, arytenoid cartilages, vocal folds (false and true), and pyriform sinuses. Vocal fold mobility should be assessed by asking the patient to alternately phonate and sniff deeply. The glottis opens with inspiration (sniffing) and closes for phonation.

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