N202 Nose, Mouth & Throat

• Bridge (superior part of nose)
• Tip( end of nose)
• Nares (nasal passage)
• Columella (tissue between 2 nares)
• Ala Nasi (ala) - "around nostril"- lateral outside wing of nose

• Warms, moistens and fliters the inhaled air.
• Senory organ for smell (olfactory receptors in nasal mucosa)
• Aid is phonation (production of sound) - nasal congestion affects sound

• Extends back over the roof of the mouth.
• Nasal hair( vibrissae)
• Ciliated mucous membrane(filters out dust and bacteria)

• Coarse hair (vibrissae) - lines the anterior edge of nose
• They filter the coarsest matter from inhaled air

Plucking nose hairs may result in brain abscess

• Red (due to rich blood supply)
• Redder than buccal mucosa

• Blood vessel network
• Anterior portion of nasal septum
• The most common site of nosebleeds(epistaxis)

separates the nares

Lateral walls of each nasal cavity

• There are three:
• Superior, middle and inferior (3 bony projections)
• They increase surface area to warm, humidify and filter air
• Superior turbinate is not visualized

• They are underlying each turbinate (a cleft, named for the turbinate above it)
• Sinuses drain into the middle meatus
• Nasolacrimal duct drains into inferior meatus

• Hair cells that lie at the roof of the nasal cavity and in the upper one third of the septum.
• They are smell receptors that transmit sensation to the olfactory nerve (CN 1) and to temporal lobe of brain.

• Air filled pockets in skull bones
• Helps resonate sound
• Provides mucus to drain into nasal cavity(keeps nares moist)

• Frontal(in frontal bone above and medial to orbits) & Maxillary(in maxilla or cheek bone)- only ones that are accessible to examination
• Ethmoid- deep between the orbits
• Sphenoid- deep in sphenoid bone

Maxillary & Frontal only two that are present at birth (mature at 12 years)

Transition from outer skin to inner mucous membrane.

• Anterior (hard palate = bone) whitish, behind front teeth
• Posterior (soft palate = muscle) pink, soft, mobile

• Is a free projection hanging down from the middle of the soft palate
• May contribute to snoring

• Dorsal surface- contains papillae with larger vallate papillae on posterior tongue.
• Taste buds are located around papillae

• Shinny with prominent veins.
• Frenulum -connects tongue to floor of mouth

Secrete saliva containing salivary amylase(ptyalin) to start digestion in mouth.

• Parotid Gland
• Submandibular Gland
• Sublingual Gland

• Largest
• Embedded in the cheeks, anterior to ear & down to angle of jaw
• It's duct (Stensen's duct) located by upper 2nd molar-drains gland

• Lies beneath mandible at the angle of jaw (size of a walnut)
• Whaton's duct opens on both sides of freulum (under tongue)-drains the gland

• Smallest (almond shaped)
• Located on the floor of the mouth
• Many small openings along the sublingual fold of the tongue(not visible)-drains the gland.

Crown, Neck & Root

32 - 16 teeth in each arch, including 3rd molars (wisdom teeth)

• 20 deciduous teeth (another name for baby teeth)
• Erupt between 6 months and 30 months
• Lost at age 6 & 12 (loss begins with central incisors)

• Gums
• They are thick fibrous tissue covered with mucous membranes
• Pale pink to darker pink( in darker skinned people)

• It is the throat, the area behind mouth and nose.
• Oropharynx- anterior tonsillar pillars separate mouth from oral pharynx
• Nasopharynx- above oropharynx, behind nasal cavity( where pharyngeal tonsils (adeniods) and eustachian tube outlet are located.

Mass of lymphiod tissue( appear granular with deep crypts) located between anterior and posterior pillars

• Any nasal discharge? What color?
• Frequent or severe colds?
• Sinus pain?
• Epistaxis (nosebleeds)?
• Allergies? (season rhinitis) rhinitis= congestion of the nose
• Medications? (antihistamines, decongestants, nasal sprays)
• Anosmia( change in the sense of smell)
• Any trauma
• Habits? (smoking, alcohol, cocaine use)

• Sores or lesions?
• Sore throats & associated Sx
• Bleeding gums?
• Tooth ache?
• Hoarseness, lumps in the throat?
• Dysphagia( difficulty swallowing)?
• Changes in taste?
• Bruxism (grinding) may lead to malocclusion & TMJ
• Self care (teeth, dentures)-brushing, flossing
• Habits? (smoking & alcohol-increased cancer risk)

Occurs with colds, allergies, sinus infection, trauma

Cause a deviated septum, which may cause nares to be obstucted.

• Nosebleeds
• Occurs with trauma, vigorous nose blowing, foreign body

• Difficultly swallowing.
• Occurs with pharyngitis, gastroesophageal reflux disease, pharyngitis, stroke and other neurological disease, esophageal cancer.

• May see with allergies.
• Common in children with colds, because they are rubbing their noses constantly.
• Nasal crease

• Test with concern of anosmia (decrease or loss of smell) - may be due to smoking, cocaine, allergic rhinitis, temporal lobe lesion.
• Test with a familiar aromatic substance (coffee, orange, vanilla, soap)
• Close eyes (occlude one nares while testing the other)
• Use different scent on each side

Red, smooth, moist surface

Rhinorrhea

• Swelling with bright red mucosa
• Discharge (watery, may be purulent
• Often viral, seen in the nasal cavity

• Pale mucosa
• associated with itchy eyes, sneezing
• look for allergic salute in children

• Purulent unilateral discharge, without upper respiratory symptoms
• Sore/lesion - furuncle (boil) cancer

• Color- pallor , cyanosis
• Moisture
• Cracking or Cheilosis- angular stomatistis- cracking at the corners, may be caused by riboflavin & niacin deficiency
• Lesions- herpes simplex, cancer

With sinusitis

Anemia

Central hypoxia

• Angular stomastitis
• Cracking at the corners of the mouth
• Caused by riboflavin & niacin deficiency

• Herpes simplex- cold sore, fever blisters- viral lesion that may break the vermilion border, seen with stress
• Cancer- smoker, sun exposure, seen in lesions/sores that don't heal

• Loss of enamel (may be associated with bulimia) (teeth grinding)
• Caries- cavities

• Brown- excessive fluoride
• Yellow- tobacco use
• Dark Brown- tetracycline during last trimester of pregnancy

• If tooth loss occurs, the remaining teeth drift causing a malocclusion
• It is a poor biting relationship, protrusion of upper or lower incisors

A malignancy may be hidden under the dentures.

• Swelling, hypertrophy of gums- usually related to poor dental hygiene
• Gums bleed with slight pressure

• Painless enlargement of the gums, sometimes overreaching the teeth.
• This can occur with puberty, pregnancy, leukemia, and use of Dilantin.

Dehydration or medication SE....antihistamines

• Smooth Glossy tongue
• Surface is slick and shiny, mucosa thins and looks red from decreased papillae
• Occurs with B12 deficiency(pernicious anemia), folic acid deficiency, and iron deficiency (anemia)

White patch- non painful precancerous lesion, does not scrape off tongue

• Also called Thrush
• A white cheesy, curd-like patch on the buccal muscosa and tongue.
• It can scrape off, leaving raw, red surface that bleeds
• Can occur after the use of antibiotics, or corticosteroids causing a proliferation of a fungus on tongue

• Black hairy tongue
• Not really hair but an elongation of filiform papillae, painless overgrowth, fungus infection
• Occurs after use of antibiotics, or over use of Peptobismal

• Canker Sores
• Cause unknown, maybe acidic foods, stress, autoimmune, food allergy

• A normal variation, nodular bony ridge down the middle of the hard palate (insignificant)
• More common in Native Americans & Asians

• Partial or complete split of uvula
• Not significant, more common in Native Americans and Asians

• Ask to say "ahhh" (uvula rises at the midline, soft palate rises)
• Any deviation to the side or absent movement indicates nerve damage, tonsilar abscess, polio, diptheria

• Incomplete fusion of maxillary process, congenital defect
• Affects sucking
• More common in Native Americans & Asians

• They are graded by size:
• 1+ Visible
• 2+ Halfway between tonsillar pillars and uvula
• 3+ Touching the uvula
• 4+ Touching each other

Bright red, swollen tonsils, with exudate- may occlude airway

• Yellow mucoid film in back of throat
• Secondary to sinus drainage

With the gag reflex ( press the tongue or posterior oral pharynx

• CN IX = glossopharyngeal
• CN X = Vagus nerve

• CN XII = hypoglossal nerve
• Ask person to stick out tongue (should be midline)
• Test strength against resistance (push tongue against cheek)
• Damage to CN XII (tongue deviates toward the paralyzed side

• Check nose for nasal flaring( newborns are nose breathers, so patency of the nares needs to be checked immediately at birth)
• Choanal atresia ( congenital bony or membranous septum between nose & pharynx)
• Check tongue mobility- short frenulum may impair speech (ankyloglossia = tongue tied)
• Nose develops during adolescence ( female 16 yrs, male 18 years)
• Malocclusion (often r/t thumb sucking)

• Nasal stuffiness & epistxis ( nosebleeds) due to increased vascularity
• Gums may hypertrophy (may bleed with normal brushing)

• Larger appearing nose ( due to decreased elastic & sub-q tissue)
• Longer nasal hairs
• Decreased sense of smell
• Xerostomia(dryness of the mouth)- often due to medications(diuretics, antihistamines, antidepressants, antipsychotics)
• Dental changes- receding gums, teeth may be worn down, tooth loss, malocclusion(due to tooth loss) TMJ, arthritis.