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What are the structures of the Nose?
- 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
What is the purpose of the 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
Describe the placement of the nasal cavity located, and what it contains?
- Extends back over the roof of the mouth.
- Nasal hair( vibrissae)
- Ciliated mucous membrane(filters out dust and bacteria)
Describe the nasal hair, and it's purpose
- Coarse hair (vibrissae) - lines the anterior edge of nose
- They filter the coarsest matter from inhaled air
Why is it so important to teach patients NOT to pluck nose hairs?
Plucking nose hairs may result in brain abscess
Describe the nasal mucosa (color)
- Red (due to rich blood supply)
- Redder than buccal mucosa
Describe the Kiesselbach's Plexus
- Blood vessel network
- Anterior portion of nasal septum
- The most common site of nosebleeds(epistaxis)
What does the nasal septum do?
separates the nares
What are the turbinates, how many are there and what do they do?
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
What is the purpose of the different meatus, where they located?
- 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
What are olfactory receptors?
- 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.
What is the purpose of the sinuses?
- Air filled pockets in skull bones
- Helps resonate sound
- Provides mucus to drain into nasal cavity(keeps nares moist)
Name the four sets of sinuses, and their location
- 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
Which sinuses are present at birth, and when do they mature? When do the others appear?
Maxillary & Frontal only two that are present at birth (mature at 12 years)
What is the vermilion border of lips?
Transition from outer skin to inner mucous membrane.
What does the roof of mouth contain?
- Anterior (hard palate = bone) whitish, behind front teeth
- Posterior (soft palate = muscle) pink, soft, mobile
What is the uvula?
- Is a free projection hanging down from the middle of the soft palate
- May contribute to snoring
Describe the dorsal side of the tongue
- Dorsal surface- contains papillae with larger vallate papillae on posterior tongue.
- Taste buds are located around papillae
Describe the ventral surface of the tongue
- Shinny with prominent veins.
- Frenulum -connects tongue to floor of mouth
What are the functions of the salivary glands?
Secrete saliva containing salivary amylase(ptyalin) to start digestion in mouth.
Name the three pairs of salivary glands
- Parotid Gland
- Submandibular Gland
- Sublingual Gland
Describe the parotid gland, and where is it located?
- 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
Describe the Submandibular Gland, and where is it located, what duct is it associated with?
- 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
Describe the Sublingual Gland, where is it located, and where are the ducts from this 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.
What are the parts of a tooth?
Crown, Neck & Root
How many permanent teeth do adults have?
32 - 16 teeth in each arch, including 3rd molars (wisdom teeth)
How many baby teeth are there, when do they erupt, when are they lost?
- 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)
What is gingiva?
- They are thick fibrous tissue covered with mucous membranes
- Pale pink to darker pink( in darker skinned people)
What is the pharynx, what are the two parts?
- 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.
Describe the tonsils
Mass of lymphiod tissue( appear granular with deep crypts) located between anterior and posterior pillars
What are some subjective questions that you could ask someone regarding the nose?
- 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)
What are some subjective questions that you could ask someone regarding the mouth and Throat?
- 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)
What is Rhinorrhea?
Occurs with colds, allergies, sinus infection, trauma
What can trauma do to the nose?
Cause a deviated septum, which may cause nares to be obstucted.
What is epistaxis?
- Occurs with trauma, vigorous nose blowing, foreign body
What is dysphagia?
- Difficultly swallowing.
- Occurs with pharyngitis, gastroesophageal reflux disease, pharyngitis, stroke and other neurological disease, esophageal cancer.
When and why might you see an allergic salute?
- May see with allergies.
- Common in children with colds, because they are rubbing their noses constantly.
- Nasal crease
How can you test CN 1?
- 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
What should a normal nasal cavity look like when inspecting?
Red, smooth, moist surface
When inspecting the nasal cavity and you see clear nasal discharge or runny nose, you would document?
What is acute rhinitis?
- Swelling with bright red mucosa
- Discharge (watery, may be purulent
- Often viral, seen in the nasal cavity
What is allergic rhinitis?
- Pale mucosa
- associated with itchy eyes, sneezing
- look for allergic salute in children
If looking in the nasal cavity and you see a foreign body, what may you also see?
- Purulent unilateral discharge, without upper respiratory symptoms
- Sore/lesion - furuncle (boil) cancer
Inspect the lips for...?
- Color- pallor , cyanosis
- Cracking or Cheilosis- angular stomatistis- cracking at the corners, may be caused by riboflavin & niacin deficiency
- Lesions- herpes simplex, cancer
When might the sinuses become tender after palpation?
If lips are pallor this is a sign of?
If lips show cyanosis this is a sign of?
- Angular stomastitis
- Cracking at the corners of the mouth
- Caused by riboflavin & niacin deficiency
What are two types of lesions found around the mouth, that we covered?
- 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
When looking at the condition of the teeth, what might you assess for?
- Loss of enamel (may be associated with bulimia) (teeth grinding)
- Caries- cavities
Why might you see brown, yellow or dark brown discolored teeth?
- Brown- excessive fluoride
- Yellow- tobacco use
- Dark Brown- tetracycline during last trimester of pregnancy
What is a malocclusion?
- If tooth loss occurs, the remaining teeth drift causing a malocclusion
- It is a poor biting relationship, protrusion of upper or lower incisors
Why should you ask a patient to remove their dentures?
A malignancy may be hidden under the dentures.
What is gingivitis?
- Swelling, hypertrophy of gums- usually related to poor dental hygiene
- Gums bleed with slight pressure
What is gingival hyperplasia?
- Painless enlargement of the gums, sometimes overreaching the teeth.
- This can occur with puberty, pregnancy, leukemia, and use of Dilantin.
What does dry mouth indicate?
Dehydration or medication SE....antihistamines
What is Atrophic Glossitis?
- 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)
What is leukoplakia?
White patch- non painful precancerous lesion, does not scrape off tongue
What is Candidiasis or Monilial Infection?
- 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
What is Bismuth?
- 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
What are Aphthous Ulcers?
- Canker Sores
- Cause unknown, maybe acidic foods, stress, autoimmune, food allergy
What is torus palatinus?
- A normal variation, nodular bony ridge down the middle of the hard palate (insignificant)
- More common in Native Americans & Asians
What is Bifid uvula?
- Partial or complete split of uvula
- Not significant, more common in Native Americans and Asians
How can you test CN 10 and the uvula?
- 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
Describe a cleft lip & cleft palate and it's significance.
- Incomplete fusion of maxillary process, congenital defect
- Affects sucking
- More common in Native Americans & Asians
How are tonsils graded?
- They are graded by size:
- 1+ Visible
- 2+ Halfway between tonsillar pillars and uvula
- 3+ Touching the uvula
- 4+ Touching each other
What are the signs of acute tonsillitis?
Bright red, swollen tonsils, with exudate- may occlude airway
What are signs of post nasal drip?
- Yellow mucoid film in back of throat
- Secondary to sinus drainage
How can you test CN IX or CN X?
With the gag reflex ( press the tongue or posterior oral pharynx
What are the names of CN IX & CN X?
- CN IX = glossopharyngeal
- CN X = Vagus nerve
How can you test CN XII?
- 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
What are some developmental Considerations of the Infant and Child?
- 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)
What are some considerations with pregnancy?
- Nasal stuffiness & epistxis ( nosebleeds) due to increased vascularity
- Gums may hypertrophy (may bleed with normal brushing)
What are some considerations with the aging adult?
- 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.