Allergy tests Skin-prick tests for common inhaled allergens, specific immunoglobulin E blood test (RAST)

Computed tomography Inflammatory sinus disease, trauma and malignancy

Demonstrates extent of sinus disease, provides evidence of invasion into local structures and shows detailed bony anatomy,

enabling planning of endoscopic surgical procedures (see Fig. 9.17)

Tests of olfaction Used in specialist clinics only

Include the UPSIT smell test and Sniffin’ Sticks

RAST, radioallergosorbent test; UPSIT, University of Pennsylvania smell identification test.

A B

Fig. 9.17 Computed tomograms of the paranasal sinuses. A Normal scan. B Right-sided chronic sinusitis.

The mucosa of the inferior turbinate on anterior rhinoscopy is

pale, moist and hypertrophied in allergic rhinitis (see Fig. 9.14A).

In chronic rhinitis the mucosa is swollen and red. Large polyps

may be seen on anterior rhinoscopy as pale yellow/grey swellings

(see Fig. 9.14C).

A septal haematoma will appear as a soft, red, fluctuant swelling

of the anterior septum. The septal cartilage receives its blood

supply from the overlying perichondrium; a septal haematoma

interrupts this supply and can result in cartilage necrosis, septal

perforation and ‘saddle deformity’. It must therefore be identified

and referred for early drainage.

Facial swelling is not usually seen in chronic sinusitis but can

occur with dental abscesses and cancer of the maxillary antrum.

Investigations

Initial investigations are summarised in Box 9.7 and Fig. 9.17.

184 • The ear, nose and throat

Teeth

In children the 20 deciduous teeth erupt by 3 years. There are 32

secondary teeth, erupting from ages 6 to 16 or later (Fig. 9.20).

Neck

Anatomically the neck is divided into anterior and posterior

triangles (Fig. 9.21). The anterior triangle is bounded by the

midline, the anterior border of the sternocleidomastoid muscle

and the body of the mandible. The posterior triangle of the neck

is bounded by the posterior border of sternocleidomastoid, the

trapezius muscle and the clavicle. The cervical lymph nodes

drain the head and neck (see Fig. 3.26). Examination of these

nodes is described on page 33 and shown in Fig. 3.27. Palpable

lymphadenopathy is most commonly due to URTI but may be

caused by atypical infection, inflammation, lymphoma or metastatic

malignancy. The neck can also be subdivided further into different

levels that are used to describe the location of enlarged lymph

nodes in the neck (Fig. 9.22).

The history

Common presenting symptoms

Sore mouth

Ask about:

• how long pain has been present and any progression

• trauma to the mouth

• mouth ulcers

• problems with teeth or gums

• associated bleeding.

Aphthous ulcers are small, painful, superficial ulcers on the

tongue, palate or buccal mucosa. They are common and usually

heal spontaneously within a few days. Oral ulcers can be caused

by trauma, vitamin or mineral deficiency, cancer, lichen planus

or inflammatory bowel disease.

Anatomy and physiology

Mouth

The mouth extends from the lips anteriorly to the anterior tonsillar

pillar posteriorly and is divided into the vestibule, between the

buccal (cheek) mucosa and the teeth, and the oral cavity internal

to the teeth. The oral cavity contains the anterior two-thirds of

the tongue, the floor of the mouth, the hard palate and the inner

surfaces of the gums and teeth (Fig. 9.18). The tongue anteriorly

has filiform papillae containing taste buds, giving the tongue its

velvet texture. The circumvallate papillae are groups of taste

buds marking the boundary between the anterior two-thirds

and posterior third of the tongue.

Saliva is secreted into the mouth from the parotid, submandibular

and sublingual salivary glands (Fig. 9.19). The parotid gland is

situated anterior to the ear and has a superficial and deep lobe

relative to the facial nerve that runs through it. The parotid duct

opens into the buccal mucosa opposite the second upper molar.

The submandibular gland lies anterior and medial to the angle

of the mandible and its duct opens into the floor of the mouth

next to the frenulum of the tongue (see Fig. 9.18).

Throat

The pharynx is a shared upper aerodigestive channel that runs

from the anterior tonsillar pillar to the laryngeal inlet. The larynx

(‘voice box’) is responsible for phonation and also has a protective

function to prevent aspiration. It consists of two external cartilages,

the thyroid cartilage (Adam’s apple) and the cricoid cartilage

(prominence at the top of the trachea; see Fig. 10.1A). The

membrane between the two is called the cricothyroid membrane;

a cricothyroidotomy may be performed by an experienced

clinician at this site as an emergency procedure to obtain an

airway. The sensory supply to the larynx is via the superior and

recurrent laryngeal branches of cranial nerve X (vagus). The motor

supply is mainly from the recurrent laryngeal nerve, which loops

round the aortic arch on the left side and the subclavian artery

on the right.

Hard palate

Posterior

pharyngeal wall

Uvula

Vallate papillae

Dorsum of tongue

Soft palate

Posterior pillar

Tonsil

Anterior pillar

Undersurface

of tongue

Submandibular

duct

Opening of

submandibular

duct

Opening of

parotid duct

Frenulum

Buccal mucosa

A B

Fig. 9.18 Anatomy of the mouth and throat. A Examination with the mouth open. B Examination with the tongue touching the roof of the mouth.

MOUTH, THROAT AND NECK

The history • 185

9

A sore mouth can also be due to conditions of the gums,

including inflammation (gingivitis) or systemic conditions (Box 9.8).

Infections, including candidiasis (caused by Candida albicans),

herpes simplex and herpes zoster, as well as dental sepsis,

can cause a painful mouth. Candidiasis may be secondary to

poorly fitted dentures, the use of inhaled glucocorticoids or

immunodeficiency. Herpes zoster of the maxillary division of

the trigeminal nerve (see Fig. 7.9B) can cause unilateral painful

vesicles on the palate.

Sore throat

Ask about:

• unilateral or bilateral pain

• otalgia (earache)

• difficulty opening the mouth (trismus, due to spasm of the

jaw muscles)

• associated fever, malaise, anorexia, neck swelling

• associated red flag symptoms (dysphagia, odynophagia,

hoarseness, weight loss).

Throat pain can radiate to the ear as a result of the dual

innervation of the pharynx and external auditory meatus via the

vagus nerve (referred pain). The most common cause of sore

throat is pharyngitis (inflammation of the pharynx) and is usually

viral. Acute tonsillitis may be viral or caused by streptococcal

bacterial infection (Fig. 9.23A), and cannot be distinguished

clinically.

Sublingual

gland

Submandibular

gland

Parotid

gland

Fig. 9.19 The position of the major salivary glands.

Secondary dentition

Incisors

Canine

Premolars

Molars

Primary dentition

Fig. 9.20 Primary and secondary dentition.

Posterior

triangle

Anterior

triangle

Fig. 9.21 Sites of swellings in the neck.

I Submental and submandibular nodes

II Upper third sternocleidomastoid (SCM) muscle

III Middle third SCM (between hyoid and cricoid)

IV Lower third SCM (between cricoid and clavicle)

V Posterior to SCM (posterior triangle)

VI Midline from hyoid to manubrium

II

III

VI

I

IV

V

Fig. 9.22 Cervical lymph node levels.

9.8 The gums in systemic conditions

Condition Description

Phenytoin treatment Firm and hypertrophied

Scurvy Soft and haemorrhagic

Acute leukaemia Hypertrophied and haemorrhagic

Cyanotic congenital heart disease Spongy and haemorrhagic

186 • The ear, nose and throat

Globus pharyngeus is a sensation of something in the throat in

the context of a normal clinical examination. Patients classically

describe the feeling of a lump in the throat, usually in the midline,

which fluctuates from day to day and eases when swallowing.

Anxiety, habitual throat clearing and acid reflux are thought to

be contributory factors.

Stridor

Stridor is a high-pitched noise produced by turbulent airflow

through a narrowed, partially obstructed upper airway and can

indicate laryngeal or tracheobronchial (p. 79) obstruction. It most

commonly occurs on inspiration but may also be expiratory or

biphasic. The level of obstruction determines the type of stridor.

Inspiratory stridor suggests narrowing at the level of the vocal

cords, biphasic stridor suggests subglottic/tracheal obstruction,

and stridor on expiration suggests tracheobronchial obstruction.

Common causes of stridor include infection/inflammation, trauma,

foreign bodies (particularly in children) and tumours. Stridor should

always be urgently evaluated.

Ask about:

• sudden or gradual onset

• associated fever

• associated hoarseness.

Stertor differs from stridor. It is a low-pitched snoring or gasping

sound audible during inspiration and is due to obstruction at the

level of the nasopharynx or oropharynx. This can be as a result

of enlarged inflamed tonsils, a peritonsillar abscess or tongue

swelling (trauma, anaphylaxis).

Dysphonia

Ask about:

• how long dysphonia (hoarseness) has been present

• whether it is persistent or intermittent

• progression

• voice quality (croaky, breathy, weak)

• associated stridor, dysphagia, otalgia or weight loss.

If hoarseness has been present continuously for more than

3 weeks, urgent laryngoscopy is indicated to exclude laryngeal

cancer. If voice quality is breathy and associated with a weak

(bovine) cough (p. 78), a recurrent laryngeal nerve palsy

due to lung or oesophageal cancer should be considered.

Recurrent laryngeal nerve palsy may also be iatrogenic (thyroid

surgery) or secondary to trauma or neurological conditions

(Box 9.9).

Dysphagia

The approach to dysphagia is described on page 98.

Neck lump

Neck lumps are common; they may be reported by patients or

found incidentally on physical examination. While many lumps

are benign, there may be a more serious underlying diagnosis

(Box 9.10).

Ask about:

• sudden or gradual onset

• progression

• associated pain

• associated hoarseness or dysphagia

• fever or other systemic symptoms (weight loss, night

sweats).

Infectious mononucleosis caused by Epstein–Barr virus

(glandular fever) results in tonsil erythema and swelling, a

white pseudomembrane covering the tonsil, palatal petechiae

(Fig. 9.23B), cervical lymphadenopathy and sometimes

hepatosplenomegaly. A peritonsillar abscess (quinsy) can lead

to unilateral throat pain, trismus, drooling of saliva, soft-palate

swelling, deviation of the uvula to the opposite side (Fig. 9.23C)

and ‘hot-potato voice’ (like you were trying to speak with a hot

potato in your mouth).

It is important to establish whether there are any ‘red flag’

symptoms associated with sore throat. Progressive dysphagia or

hoarseness associated with weight loss should raise suspicion

of malignancy. A mass or ulcer on the tonsil associated

with throat pain may be a tonsil squamous cancer. Human

papillomavirus-related oropharyngeal cancer is the now most

common primary head and neck malignancy in young, sexually

active non-smokers.

$

%

&

Fig. 9.23 Sore throat. A Acute tonsillitis. The presence of pus strongly

suggests a bacterial (streptococcal) aetiology. B Glandular fever showing

palatal petechiae. C A left peritonsillar abscess. (A) From Bull TR. Color

Atlas of ENT Diagnosis. 3rd edn. London: Mosby–Wolfe; 1995.

The physical examination • 187

9

Past medical history

It is important to establish whether there are any previous dental

problems or systemic disease, particularly those affecting the

gastrointestinal tract, as the mouth is part of this. Neurological

conditions may affect swallowing and cause drooling or dry mouth

with secondary infection. Previous head and neck surgery and

trauma should be noted.

Any prior intubations or admissions to intensive care should

be recorded, as repeated or prolonged intubation can result in

subglottic stenosis and stridor.

Drug history

Many drugs, including tricyclic antidepressants and anticholinergics,

cause a dry mouth. Multiple, repeated courses of antibiotics

increase the risk of oral candidiasis, as does any prolonged illness.

Social and family history

Risk factors for head and neck squamous cancer include

alcohol and smoking. Oral cancer is more common in those who

experience orogenital contact and in those who chew tobacco

or betel nuts. Any history of head and neck cancer in the family

should be established.

The physical examination

Mouth and throat

Examination sequence

• Listen to the patient’s voice (rough, breathy, wet, muffled,

nasal escape).

• Use a head light to leave both of your hands free to use

instruments.

Inspection

• Ask the patient to remove any dentures.

• Look at their lips. Ask them to half-open their mouth and

inspect the mucosa of the vestibule, buccal surfaces and

buccogingival sulci for discoloration, inflammation or

ulceration, then at bite closure. Inspect the parotid duct

opening opposite the second upper molar for any pus or

inflammation.

• Ask the patient to open their mouth fully and put the tip of

their tongue behind their upper teeth. Check the mucosa

of the floor of the mouth and the submandibular duct

openings.

• Ask them to stick their tongue straight out, noting any

deviation to either side (XII nerve dysfunction), mucosal

change, ulceration, masses or fasciculation.

• Ask them to deviate their tongue to one side. Retract the

opposite buccal mucosa with a tongue depressor to view

the lateral border of the tongue. Repeat on the other side.

• Inspect the hard palate (Fig. 9.25) and note any cleft,

abnormal arched palate or telangiectasia.

• Inspect the oropharynx. Ask the patient to say ‘Aaah’ and

use a tongue depressor to improve visualisation.

• Assess the soft palate for any cleft, bifid uvula, swelling or

lesions.

Sudden, painful, unilateral salivary gland swelling (sialadenopathy)

is due to a stone obstructing the duct (sialolithiasis). Other

causes of enlarged salivary glands are mumps (usually bilateral),

sarcoidosis, human immunodeficiency virus-related cysts, bacterial

infection (suppurative parotitis; Fig. 9.24) and cancer. The clinical

features of important neck lumps are summarised in Box 9.10.

9.9 Causes and features of dysphonia

Causes Features

Neonate

Congenital abnormality Laryngomalacia most frequent cause

More common in preterm neonates

Associated stridor due to immature

larynx folding in on inspiration

Neurological disorder Examples include vocal cord palsy

Unilateral causing weak, breathy cry

Bilateral may cause stridor and airway

obstruction

Child

Infection:

Croup

(laryngotracheobronchitis)

Barking cough, stridor, hoarse voice

Laryngitis Bacterial or viral

Voice abuse (screamer’s

nodules)

History of voice abuse

Adult

Infection:

Upper respiratory tract

infection

Laryngitis

Associated features of upper

respiratory tract infection

Trauma Mechanical or chemical injury

Cigarette smoking

Gastro-oesophageal reflux disease

(reflux laryngitis)

Lung cancer Vocal cord paralysis, breathy voice

Vocal cord nodules (singer’s

nodules)

Prolonged vocal strain

Rough voice

Reduced vocal range

Vocal fatigue

Neurological disorder Weak, wet or dysarthric voice

Cancer of the larynx Rough voice, constant, progressive,

often affects smokers

Associated with dysphagia,

odynophagia, otalgia

Functional cause

Fig. 9.24 Pus discharging from the parotid duct.

188 • The ear, nose and throat

9.10 Causes and features of neck lumps

Location in neck Diagnosis Clinical features

Midline Thyroglossal cyst Smooth, round, cystic lump that moves when patient sticks out

tongue

Submental lymph nodes Associated infection of lower lip, floor of mouth, tip of tongue or

cheek skin

Thyroid isthmus swelling Lump moves on swallowing

Dermoid cyst Small, non-tender, mobile subcutaneous lump

Lateral

Anterior triangle Thyroid lobe swellings:

Simple, physiological goitre

Multinodular goitre

Solitary nodule

Thyroid tumours: benign (adenoma) and malignant

(papillary, follicular, medullary, anaplastic)

Lump moves with swallowing but not on tongue protrusion

Submandibular gland swelling:

Infection, stones, autoimmune disease

Benign or malignant tumours

Swelling below the angle of the mandible. Can be felt bimanually.

Involvement of more than one gland suggests a systemic condition.

A lump within the gland suggests a tumour. Uniform enlargement

with pain suggests infection or stones

Parotid gland swelling:

Mumps, parotitis, stones, autoimmune disease

Swelling in the preauricular area or just below the ear

Parotid gland mass:

Benign

Malignant tumours

Hard, fixed mass with facial nerve weakness suggests a malignant

tumour of the parotid gland

Branchial cyst Smooth, non-tender, fluctuant mass. Not translucent. Slowly

enlarging, may increase after upper respiratory tract infection

Lymph nodes:

Malignant: lymphoma, metastatic cancer Large, hard, fixed, matted, painless mass suggests malignancy

Infection: bacterial infection of head and neck,

viral infection (e.g. infectious mononucleosis),

human immunodeficiency virus, tuberculosis

Lymph nodes can be reactive to infection and are usually smooth,

firm, mobile and tender

Posterior triangle Lymph nodes:

Malignant

Benign

See p. 32

Carotid body tumour Firm, rubbery, pulsatile neck mass, fixed vertically due to attachment

to bifurcation of common carotid. A bruit may be present

Carotid artery aneurysm Rare, present as pulsatile neck mass

Cystic hygroma Soft, fluctuant, compressible and transilluminable mass, usually seen

in children

Cervical rib Hard, bony mass

Supraclavicular fossa Supraclavicular lymphadenopathy Left supraclavicular (Virchow’s) node may suggest gastric

malignancy

Fig. 9.25 Torus palatinus. This benign asymptomatic central palatal bony

mass is more common in Asian populations. From Scully C. Oral and

Maxillofacial Medicine. 2nd edn. Edinburgh: Churchill Livingstone; 2008.

• Inspect the tonsils, noting size, symmetry, colour and any

pus or membrane.

• Touch the posterior pharyngeal wall gently with the tongue

depressor to stimulate the gag reflex. Check for

symmetrical movement of the soft palate.

Palpation

• If any lesion is seen in the mouth or salivary glands,

palpate it (wearing gloves) with one hand outside on the

patient’s cheek or jaw and a finger of your other hand

inside the mouth (bimanual palpation).

• Feel the lesion and identify its characteristics (p. 32).

• If the base of the tongue or the tonsils are asymmetrical,

palpate it using a gloved finger.

• If the parotid gland is enlarged or abnormal on inspection,

examine the facial nerve and check if the deep lobe (tonsil

area) is displaced medially.

• Palpate the parotid and submandibular duct, feeling for

stones.

• Palpate the cervical lymph nodes (p. 33).

The physical examination • 189

9

biopsy (Fig. 9.27B). Cancers (usually squamous) may occur at

any site in the mouth. Any painless persistent mass in the mouth

should be assumed to be oral cancer and referred urgently for

biopsy. Similarly, any mouth ulcer persisting for over 3 weeks

requires biopsy to exclude cancer (Fig. 9.27C).

A stone may be felt in the submandibular (or, rarely, the parotid)

duct. Rotten teeth (dental caries) are common in patients with

poor oral hygiene (Fig. 9.27D).

Neck

The neck must be examined in all patients with mouth or throat

symptoms, or a neck mass.

Examination sequence

• With the patient sitting down and their neck fully exposed

(ties and scarves removed and shirt unbuttoned), look at

their neck from in front. Inspect for scars, masses or

pulsation.

• From behind, palpate the neck. Work systematically

around the neck. Start in the midline and gently palpate

the submental, submandibular and preauricular areas,

assessing for the presence of any masses or swelling.

Then palpate down the anterior border of the

sternocleidomastoid muscle to the midline inferiorly.

• Palpate the midline structures of the neck from inferior to

superior up to the submental area, noting any masses.

• If a midline mass is present, ask the patient to swallow

(offer a glass of water if needed) and then instruct them to

stick out their tongue while you palpate the mass.

Movement superiorly on swallowing suggests a thyroid

Cracking of the lips can be the result of cold exposure (‘chapped

lips’), riboflavin deficiency, chronic atrophic candidiasis or iron

deficiency (Fig. 9.26). Squamous and basal cell cancers occur

on the lips and are associated with smoking and sun exposure.

The normal tongue appearance includes areas of smooth

mucosa (‘geographic tongue’) or, conversely, excessive furring.