A B

Fig. 9.16 Nasal examination. A Elevation of the tip of the nose to give a clear view of the anterior nares. B Anterior rhinoscopy using an otoscope

with a large speculum.

9.7 Investigations in nasal disease

Investigation Indication/comment

Plain X-ray Not indicated for nasal bone fracture

Only required if associated facial fracture is suspected

Nasal endoscopy Inflammatory sinus disease, malignancy

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