Assessment of Nose, Mouth &

Pharynx

Prepared by
Ms. Beenish Tufail
 Learning Objectives
By the end of the Unit, learners will be able to:
• Describe the component of health history that
should be elicited during the assessment of
nose, mouth and pharynx.
• Identify the structural landmarks of the nose,
mouth and pharynx
• Describe specific assessments to be made
during the physical examination of the above
systems.
• Document findings.
 Nose
Anatomy
• Bridge is the superior part (nasal bone)
• Tip is the anterior part of nose (cartilage)
• The nasal cavity is located between the roof of the
mouth and the cranium
• The nasal septum separates the cavity into two
halve
• The front of the nasal septum contains a rich supply
of blood vessels and is known as Kiesselbach’s
area. This is a common site for nasal bleeding.
• Columella divides the nares
• Ala –lateral outside wing of the nose bilaterally
• Upper 1/3 nose is bone; rest is cartilage
• Hair – Filter coarse matter from entering nasal
cavity
• Ciliated mucous membrane filters dust and
bacteria. The rich blood supply warms and
humidifies the air
• Turbinate's (conchae) increase the surface are
of the nasal cavity so that more air is filtered,
warmed, and humidified
• Meatus - cleft underlying each turbinate.
The sinuses drain into the middle, tears from the
nasolacrimal duct drain into the inferior
• Sinuses
• Paranasal sinuses- air- filled pockets in the
cranium
• Purpose – ↓ wt. of the skull – Serve as
resonators for sound – Provide mucous for the
nasal cavity
• Primary site of infection because they can easily
become blocked & develop inflammation/sinusitis.
• Frontal – Maxillary accessible during
examination
• Ethmoid – Sphenoid
 Structure and Function of Nose

• Nose and Paranasal sinuses are first segment

of the respiratory system
• Responsible for receiving, filtering, warming,
and moistening inhaled air
• Sensory organ for smell, because cranial
nerve I (Olfactory) located in it.
• Nose consists of two portions. – External and
Internal
It is divided into two sections: the vestibule,
the area between the cheeks and the teeth,
and the oral cavity proper

MOUTH
 Landmarks of Mouth
• The palate, which is the roof of the mouth, is
divided into two parts. The front part has
ridges and is hard (hard palate). The back
part is relatively smooth and soft (soft
palate).
• The moist mucous membranes lining the
mouth continue outside, forming the pink and
shiny portion of the lips, which meets the skin
of the face at the vermilion border. The lip
mucosa, although moistened by saliva, is
prone to drying.
• The uvula is a narrow muscular
structure that hangs at the back of the
mouth and can be seen when a person
says "Ahh."
• The tongue lies on the floor of the
mouth and is used to taste and mix food.
The tongue is not normally smooth. It is
covered with tiny projections (papillae)
that contain taste buds, some of which
sense the taste of food.
Gingiva – Mucosal tissue surrounding portions of
the maxillary and mandibular teeth and bone.
Fauces – Passageway from oral cavity to
pharynx.
Palatine rugae – Firm ridges of tissues on the hard
palate.
• The salivary glands produce saliva. There
are three major pairs of salivary glands:
parotid, submandibular, and sublingual.
Besides the major salivary glands, many
tiny salivary glands are distributed
throughout the mouth. Saliva passes from
the glands into the mouth through small
tubes (ducts).
 Landmarks of Tongue

Landmarks of the tongue include the:

• Apex of the tongue – The tip of the tongue.
• Dorsal surface – The top surface of the
tongue.
• Filiform papillae – Fine, small, cone shaped
papillae covering most of the dorsum of the
tongue. They are responsible for giving the
tongue its texture and are responsible for the
sensation of touch.
• Foliate papillae – These papillae are large,
red and leaf-like. They are located on the
posterior, lateral surfaces of the tongue. They
contain some taste buds.
• Fungiform papillae – Deep red in color and
are distributed over the dorsum of the tongue.
Each one of these mushroom shaped papillae
contains a taste bud.
• Median sulcus – Slight depression in the
middle of the dorsum of the tongue running
from the tip to the base of the tongue.
• Ventral surface – The underside of the
tongue
• The lingual frenulum is a band of tissue
connecting the tongue to the bottom of the
mouth.
• The sense of taste is relatively simple,
distinguishing sweet, sour, salty, bitter
These tastes can be detected all over the
tongue, but certain areas are more
sensitive for each taste. Sweet detectors
are located at the tip of the tongue. Salt
detectors are located at the front sides of
the tongue. Sour detectors are located
along the sides of the tongue. Bitter
detectors are located on the back one
third of the tongue.
 Landmarks of Lips
Philtrum: the junction between the left
and right sides of the upper lip
 Labial Tubercle the slight projection of

tissue that lies at the center of the upper lip

 Vermilion border: the junction between the

lips and the skin of the face

 Labial Commissure: a line lying

off to the side of the mouth,

extending from that point
where the upper and lower lips
join
HISTORY OF PRESENT HEALTH
CONCERN
• Tongue and Mouth
• Do you experience tongue or mouth sores or
lesions? Are they painful? How long have you had
them? Do they recur? Is it single or do you have
many?
• Rational
• Painful, recurrent ulcers in the mouth are seen with
aphthous stomatitis (canker sores) and herpes
simplex (cold sores). Mouth or tongue sores that do
not heal; red or white patches that persist; a lump
or thickening; or rough, crusty, or eroded areas are
warning signs of cancer and need to be referred for
further evaluation
• Do you experience redness, swelling, bleeding, or
pain of the gums or mouth? How long has this
been happening? Do you have any toothache?
Have you lost any permanent teeth?
• Rational
• Red, swollen gums that bleed easily occur in early
gum disease (gingivitis), whereas destruction of the
gums with tooth loss occurs in more advanced
gum disease (periodontitis). Pain can accompany
inflammation and is a later sign of oral cancer.
 Nose and Sinuses
• Do you have pain over your sinuses?
• Rational
• Sinusitis may cause pressure and pain over the
sinuses
• Do you experience nosebleeds? How much
bleeding? What color is the blood?
• Rational
• Nosebleeds may be seen with overuse of nasal sprays,
excessively dry nasal mucosa, hypertension,
leukemia, thrombocytopenia, and other blood
disorders.
• Do you experience frequent clear or mucous
drainage from your nose?
• Rational
• Thin, watery, clear nasal drainage (rhinorrhea)
can indicate a chronic allergy or, in a person with
a past head injury, a cerebrospinal fluid leak.
Mucous drainage, especially yellow, is typical of
a cold, rhinitis, or a sinus infection
• Can you breathe through both of your nostrils?
Do you have a stuffy nose at times during the
day or night?
• Rational
• Inability to breathe through both nostrils may
indicate sinus congestion, obstruction, or a
deviated septum. Nasal congestion can interfere
with daily activities or a restful sleep.
• Do you have seasonal allergies, i.e., hay fever?
Describe the timing of the allergies (e.g., spring,
summer) and symptoms (e.g., sinus problems,
runny nose, or watery eyes).
• Rational
• Pollens cause seasonal rhinitis, whereas dust
may cause rhinitis year round.
• Have you experienced a change in your ability to
smell or taste?
• Rational
• A decrease in the ability to smell may occur with
upper respiratory infections, smoking, cocaine
use, or a neurologic lesion or tumor in the frontal
lobe of the brain or in the olfactory bulb or tract.
• A decreased ability to taste may be reported
by clients with upper respiratory infections or
lesions of the facial nerve (VII). Changes in
perception of smell also occur from a zinc
deficiency and from menopause in some women.
• The ability to smell and taste decreases with
age.
• Medications can also decrease sense of smell
and taste in older people.
• Throat
• Do you have difficulty chewing or swallowing
food? How long have you had this? Do you have
any pain?
• Rational
• Dysphagia (difficulty swallowing) may be seen
in esophageal disorders, anxiety, poorly fitting
dentures, or a neurologic disorder. Dysphagia
increases the risk for aspiration, and clients with
dysphagia may require consultation with a speech
therapist. Difficulty chewing, swallowing, or
moving the tongue or jaws may be a late sign of
oral cancer.
• Do you have a sore throat? How long have you
had it? Describe. How often do you get sore
throats?
• Rational
• Throat irritation and soreness are common with
sinus drainage and may also occur with a viral or
bacterial infection. A sore throat that persists
without healing may signal throat cancer.
• Do you experience hoarseness? How long?
• Rational
• Hoarseness is associated with upper respiratory
infections, allergies, hypothyroidism, overuse of
the voice, smoking or inhaling other irritants,
and cancer of the larynx.
 COLDSPA Example
Use the COLDSPA mnemonic as a guideline to collect
needed information for each symptom the client shares. In
addition, the following questions help elicit important
information.
Mnemonic Question Client Response Example
Character Describe the sign or “My throat is sore and
symptom (feeling, it hurts to swallow.”
appearance,
sound, smell, or taste if
applicable).
Onset When did it begin? “Last night.”
Location Where is it? Does it “Just in my throat.”
radiate? Does it occur
anywhere else?
Duration How long does it last? “The pain is constant,
Does it recur? and getting worse.”
Severity How bad is it? or How “I’m miserable.”
much does it bother you?

Pattern What makes it better or “Ibuprofen helps

worse? some but it never
goes away
completely.”

Associated What other symptoms “Headache, 101 fever,

factors/How it occur with it? How does and my friend says
Affects the client it affect you? I have bad breath.”
 PAST HEALTH HISTORY
• Have you ever had any oral, nasal, or sinus surgery?
• Rationale
• Present symptoms may be related to past problems.
• Do you have a history of sinus infections?
Describe your symptoms. Do you use nasal
sprays? (What type? How much? How often?)
• Rationale
• Some clients are more susceptible to sinus
infections, which tend to recur. Overuse of nasal
sprays may cause nasal irritation, nosebleeds,
and rebound swelling.
 FAMILY
HISTORY
• Is there a history of mouth, throat, nose, or sinus
cancer in your family?
• Rationale
• There is a genetic risk factor for mouth, throat,
nose, and sinus cancers.
 Lifestyle and Health Practices
• Do you smoke or use smokeless tobacco? If so,
how much? Are you interested in quitting this
habit?
• Rationale
• Cigarette, pipe, or cigar smoking and use of
smokeless tobacco increase a person’s risk for
oral cancer. Tobacco use and heavy alcohol
consumption are responsible for 75% of the oral
cancers
• Do you drink alcohol? How much and how often?
• Rationale
• Excessive use of alcohol increases a person’s risk
for oral cancer.
• Do you grind your teeth?
• Rationale
• Grinding the teeth (bruxism) may be a sign of
stress or of slight malocclusion. The practice may
also precipitate temporomandibular joint (TMJ)
problems and pain.
• Describe how you care for your teeth or dentures.
How often do you brush and use dental floss?
When was your last dental examination?
Rationale
• Proper brushing, flossing, and oral hygiene can
prevent dental caries and gum disease. Regular
dental checkups and screening can help to detect
the early signs of gum disease and oral cancer,
which promotes early treatment.
• If the client wears braces: How do you care for
your braces? Do you avoid any specific types of
foods? Describe your usual dietary intake for a
day.
• Rationale
• Clients with braces should avoid crunchy, sticky,
and chewy foods when wearing braces. These
foods can damage the braces and the teeth. Poor
nutrition also increases one’s risk for oral cancers.
• If the client wears dentures: How do your
dentures fit?
• Rationale
• Poorly fitting dentures may lead to poor eating
habits, a reluctance to speak freely, and mouth
sores or leukoplakia (thick white patches of
cells). Leukoplakia is a precancerous condition.
• Do you brush your tongue?
• Rationale
• Cleaning the tongue is a way to prevent bad
breath resulting from bacteria that
accumulates on the posterior tongue.
• How often are you in the sun? Do you use lip
sunscreen products?
• Rationale
• Exposure to the sun is the primary risk factor
associated with lip cancer.
 Components of Health History
Demographical data
Patient name, age, sex,
occupation, socioeconomic
status etc
Chief complain
Pain in teeth
History of present illness
Detailed history of chief complain e.g
dental pain
• Quality_ dull, sharp, trobbing, constant
• Quantity, Frequency e.g (daily, once a time
etc) and duration
• Location- Localized, diffuse, referred or
radiating
• Duration of complain- onset, spontaneous, on
stimulation, intermittent
• Aggravated by- cold, heat, palpation and
percussion
• Relieved by- cold, heat, any medication,
sleep
 Medical history

•Allergies
•Bleeding disorder
•Kidney disease
•Cardiovascular disorder
•Diabetes
•Respiratory infection etc
Past Dental history
History of dental treatment
History of complication
 • Family History
• Presence of genetic or inherited
abnormalities
• Personal
History
• Birth injuries
• Breast feeding
• Vaccination
• Oral hygiene Practices
• Regularity of brushing
• Frequency and method of
brushing
• Which kind of toothpaste used
• Adverse Habits
• Smoking
• Tobacco chewing
• Alcohol consumption
 Inspect the Mouth and Throat
• Inspect the patient lips, nothing any lumps
or abnormalities. Then using a tongue
blade and bright light, inspect the mouth.
Have the patient open his mouth, then
place the tongue blade on top of his
tongue. Observe the gingivae, or gums.
Then inspect the teeth, note their numbers,
condition, and whether any are missing or
crowded. If the patient is wearing dentures,
ask him to remove them so u can inspect
the gums underneath. Next inspect the
tongue and oropharynx
Inspect and palpate the inner lips and buccal
mucosa for colors, moisture, texture and
presence of lesions
• Apply clean gloves
• Ask the client to relax the mouth and for
better visualization, pull the lip outward and
away from teeth.
• Grasp the lip one each side between the
thumb and index finger.
• Palpate any lesion for size, tenderness and
consistency.
• Inspect the front teeth and gums
 Inspecting the tongue
• Ask the patient to raise the tip of her tongue
and touch her palate directly behind her front
teeth. Inspect the ventral surface of tongue
and the floor of mouth. Next, wrap a piece of
gauze around the tip of the tongue and move
the tongue first to one side then the other to
inspect the lateral borders
 Inspecting the Oropharynx
• Inspect the Oropharynx by asking him to open
his mouth while u shine the penlight on the
uvula and palate. Insert a tongue blade into
mouth and depress the posterior tongue. Place
the tongue blade slightly off center to avoid
eliciting the gag reflex. Ask the patient to say
Ahhh. Observe movements of the soft palate
and uvula. Note lumps, lesions, ulcers or
edema of lips or tongue
Finally assess the patient’s
gag reflex by gently
touching the back of the
pharynx with a cotton-
tripped applicator or the
tongue blade. Doing so
should produce a bilateral
response.
Lips
• The lips should be pink, moist, symmetrical
and without lesions. They may have bluish
hue or flecked(small dots/patches)
pigmentation in dark skinned patients. Ask
the client to purse the lips as if to whistle.
Oral Mucosa
• The oral mucosa should be pink, smooth,
moist and free from lesions and unusual
odors. Increased pigmentation may occur in
dark skinned patients.
Gingivae
• The gums should be pink, smooth, moist with
clearly defined margins at each tooth. They
should not be retracted or inflamed.
Tongue
• The tongue should be midline, moist, pink
and free from lesions. It should have a
smooth posterior surface and slightly
rough anterior surface with small fissures.
It should move easily in all directions and
lie straight to the front at rest.
Oropharynx and uvula
These structures should be pink and moist
without inflammation or exudates
Tonsils
The tonsils should be pink and without
hypertrophy
 Normal findings
• Pink
• Moist
• Symmetric
• Smooth surface
• Free from lesions
 Abnormal findings

• Dry
• Cracked Lips (Cheilitis)
• Lip ulceration
• Cyanosis
 MOUTH
ABNORMALITIES
• Dental Caries
• Cavities refer to tooth decay, which occurs when
specific types of bacteria produce acid that
destroys the tooth’s enamel and its underlying
layer, the dentin
• Signs & Symptoms
• Cavity symptoms include:
• Toothache
• Sensitivity to sweet, hot or cold foods or drinks
• Pain when chewing
• Dental plaque is a biofilm (any group
of microorganisms in which cells stick to each
other and often also to a surface mass
of bacteria that grows on surfaces within
the mouth). It is a sticky colorless deposit at
first, but when it forms tartar, it is often brown
or pale yellow. It is commonly found between
the teeth, on the front of teeth, behind teeth, on
chewing surfaces, along the gum line
• Tartar is a visible, hard deposit of plaque and
dead bacteria that forms at the gum lines. Tartar
buildup can alter the fibers that attach the teeth to
the gum and eventually disrupt bone tissue.

• Gingivitis
Inflammation of gums (red and swollen gum)
• Glossitis
Inflammation of tongue
• Stomatitis is inflammation of the mouth and
lips. It refers to any inflammatory process
affecting the mucous membranes of the mouth
and lips
• Cheilosis is a painful inflammation and
cracking of the corners of the mouth. It also is
called cheilitis.
• Cold sores/Fever blister - painful sores
on the lips and around the mouth, caused
by a virus

• Canker sores - painful sores in the

mouth, caused by bacteria or viruses
• Oral Thrush - a yeast infection
that causes white patches in your
mouth

• Xerostomia (Dry mouth) - a lack of

enough saliva, caused by some
medicines and certain diseases
 Herpes Simplex Type 1

• Herpes simplex is recurrent viral

infection is caused by human herpes
virus. It is transmitted by oral and
respiratory secretions, affects the mucus
membranes and produces painful cold
sores and fever blister. After a brief
period of prodromal tingling and itching,
the primary lesions erupt as vesicles on
an erythematous base, eventually
rupturing and leaving ulcers, followed by
yellow crust
• Vesicles may form on any part of the oral
mucosa, especially the lips, tongue, chin and
cheek

Angioedema
• Commonly associated with urticaria, is
usually caused by an allergic reaction. It
presents subcutaneously or dermal and
produce non pitted swelling of subcutaneous
tissues and deep, large wheals usually on
lips, hands, feet, eyelids or genitalia.
• These swelling don’t itch but may burn
or tingle
 Leukoplakia
• Involves painless, white patches that appear
on the tongue or the mucous membranes of
the mouth. It result from chronic irritation of
the membranes due to tobacco use, poor
fitting dentures, use of some medications, or
a rough tooth. The white patches are
considered precancerous lesions. Biopsy
determines whether the lesions are malignant.
 Candidiasis
• Candidiasis of the oropharyngeal mucosa
causes cream colored or white patches on
the tongue, mouth and pharynx. Infection
caused by candida albicans. Although these
fungi are part of the body normal flora, they
can cause infection when changes,
• such as an elevated blood glucose level in
patient with diabetes, immunosupression in
a patient with human immunodeficiency
virus, or use of antibiotics allow for their
sudden proliferation
 Throat
Abnormalities
• Dysphagia
• Difficulty swallowing
• Possible Causes
• Esophageal disorder e.g GERD
Gastroesophageal refers to the stomach and
esophagus. Reflux means to flow back or
return. Therefore, gastroesophageal reflux is
the return of the stomach's contents back up
into the esophagus.
• In normal digestion, the lower esophageal
sphincter (LES) opens to allow food to pass into
the stomach and closes to prevent food and acidic
stomach juices from flowing back into the
esophagus.
• Gastroesophageal reflux occurs when the LES
is weak or relaxes inappropriately, allowing
the stomach's contents to flow up into the
esophagus
• Orophrayngeal, respiratory disorder and
Neurological disorder (As a neurological
disorder, Parkinson’s disease (PD) has been
shown to affect motor skills in the limbs, inhibit
muscle coordination, and sometimes contribute
to dysphagia).
• Collagen disorders e,g Systemic sclerosis
(SS) is an autoimmune disorder. This means
it’s a condition in which the immune
system attacks the body. Healthy tissue is
destroyed because the immune system
mistakenly thinks it’s a foreign substance
or infection. E,g GERD
• Certain toxins (Botulinum toxin (Botox) —
commonly used if the muscles in the
esophagus have become stiff (achalasia).
Botulinum toxin is a strong toxin that can
paralyze the stiff muscle, reducing
constriction and treatment)
 Throat Pain
• Commonly known as sore throat
• Refers to discomfort in any part of the
pharynx
• Ranges from sensation of scratchiness to
severe pain
• Possible Causes
• Infections such as Pharyngitis or
tonsillitis
• Trauma
• Allergies
• Cancer
• Surgery
• Endotracheal intubation
• Alcohol consumption
• Inhaling smoking or chemicals such as
ammonia
• Vocal strain
 Tonsillitis
• Acute tonsillitis begins with a mild to severe
sore throat. Tonsillitis may also produce
dysphagia, fever, swelling and tenderness of
the lymph nodes, and redness in the throat
with exudative tonsillitis, a white exudate
appear on the tonsils
 Pharyngitis
• Acute or chronic inflammation of the
pharynx that produces a sore throat and
slight difficulty swallowing. It is usually
caused by rhinovirus, coronavirus, or
adenovirus. It may also caused by bacterial
infections, such as from group of A beta
hemolytic streptococci.
 Diphtheria
• Highly contagious toxin mediated infection
caused by corynbecterium diphtheria. It
causes sore throat with rasping cough and
lead to airway obstruction.
• The throat appear red with thick, gray
membrane covering back of the throat.
References
• Rushforth, H. (2009). Assessment made
incredibly easy!(2nd edition). Wolters
Kluwer
• Video Link:
https://www.youtube.com/watch?v=ryQh39
mA6Hg
• https://www.youtube.com/watch?v=KJkbkd
Wvusk
• https://www.youtube.com/watch?v=gmJxLh
CpCQw
• https://www.youtube.com/watch?v=yY9-
7pOTROM