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.