Oto Primary Care FINALhigh

EVALUATING AND KEEPING TRACK OF PATIENTS

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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

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.