Table of Contents

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Preparation
Inspection
Lips
Oral mucosa
Gingivae
Teeth
Tongue
Palates & Pharynx
Floor of the mouth
Palpation
Palpate the tongue
Palpate the floor
Other palpation
References

Preparation

  1. Seat the patient and assure that their face is well illuminated.
  2. If the patient wears dentures, offer them some paper towel and ask them to remove the dentures.
  3. If a headlamp is available, put it on.
  4. Put on gloves.

Note the patient's voice while you are speaking with them as it can give some indication of possible OTOHNS pathology. For example:

  • Hyponasality in a child who has large adenoids
  • "Marbled" voice in a person with enlarged tonsils (either acutely due to infection or due to chronic hypertrophy)
  • "Hot-potato" voice as seen in epiglottits
  • Hoarseness as seen in many laryngeal pathologies

Inspection

The lips

  1. Note color (cyanosis, changes in pigmentation) and moisture of the lips.
  2. Note any abnormal lesions such as ulcers, masses, cracking, cleft lip, scale or abnormal swellings
  3. As always, characterize any abnormal findings using the mnemonic CCSSS LMNOP.

System for Describing Masses & Lesions
Click to enlarge

The oral mucosa

  1. Using a light source such as a headlight, penlight or otoscope, use a tongue depressor to inspect the mucosa. To avoid missing structures, develop an organized process (for example, by starting anteriorly and working your way back). Begin by pulling back the lower and upper lips to reveal the labial and alveolar mucosa. Next, use the tongue depressor to reveal and inspect the buccal mucosa.
  1. Note the color and moisture. Keep an eye out for any changes to the mucosa such as erythema (dilation of the blood vessels), central cyanosis (under the tongue) or changes in pigmentation.
  2. Note any abnormal lesions such as discoloured patches, ulcers, or masses. Characterize all lesions by noting their location, distribution, shape, size, color, consistency and texture. Make sure to note whether the lesions are erosive or non-erosive.

It is important to differentiate between painful and painless oral lesions as the differential diagnosis differs between the two.

  1. Make sure to inspect the opening of the parotid (Stensen's) duct near the top 2nd molars

The gingivae

  1. Note the color of the gums. The gingivae should be pink, firm and mottled. Note, some brown patchiness can be normal on the gums, especially in people with dark skin colour.
  2. Check for swelling, bleeding or discharge from the gingivae. Note any gum line recession (ie: the roots of the teeth are visible) or gingival hyperplasia.

The teeth

  1. Note the general condition of the dentition.

It is important to take note of any significant halitosis as it can be a sign of head and neck cancer (the smell originates from necrotic tissue).

The tongue

  1. Ask the patient to stick out their tongue. Check for fasciculations and symmetry; deviation is a sign of hypoglossal nerve (CN-12) dysfunction. If the patient's tongue seems to deviate, ask the patient to move their tongue around rapidly in all directions. Failure to do so may be a sign of neuromuscular weakness.
  2. If you suspect ankyloglossia ("Tongue Tie"), measure the distance that the patient can stick out their tongue. Is it past the vemillion border? Does it make it to the mental crease?
  3. Inspect the dorsal surface of the tongue, as well as the lateral and ventral surfaces. Note the color and the moisture of the tongue. Inspect for any changes in pigmentation or texture of the tongue. If present, remark any fissuring of the tongue (aka scrotal tongue, a normal variation; 5%).
  4. If present, note any lesions such as masses, varices, ulcerations or candidiasis (thrush). As always characterize these lesions by describing their location, distribution, shape, size, color, consistency and texture
  5. Inspect the papillae. Note any smooth areas that have been denuded of filiform papillae (as seen in geographic tongue) or elongation and pigmentation of the filiform papillae (as seen in black hairy tongue).

The hard palate, the soft palate & the pharynx

  1. Note their color.
  2. Inspect for any lesions or deformities such as ulcerations, petechiae, masses, bifid uvula or cleft palate. Remember to characterize all lesions systematically (tap here to be reminded how).
  3. Ask the patient to stick out their tongue and use a tongue depressor to hold it down. Using a handheld light source (such as a penlight or otoscope), inspect the uvula and palatine tonsils for candidiasis, erythema, swelling, purulent discharge or other exudate.
  4. Note the tonsil size (graded on a scale of 0-4, see below). Note their color, as well as the presence of any abnormalities such as crypts, exudate, ulcerations or tonsilliths (white particles stuck in the crypts of the tonsils).

Tonsil Grading 101

  1. Tonsils are not visible
  2. Tonsils assume less than 25% of the space in between the pillars
  3. Tonsils assume more than 50% of the space in between the pillars
  4. Tonsils assume more than 75% of the space in between the pillars
  5. "Kissing tonsils" (the two tonsils are touching)

The floor of the mouth

  1. Ask the patient to lift their tongue. Inspect for the opening of Wharton's duct (the submandibular duct) on either side of the lingual frenulum.
  2. Inspect for any masses, plaques, or swellings (such as a ranula, a large mucous retention cyst).

Palpation

Palpate the tongue

  1. Ask the patient to stick out their tongue. Using a piece of gauze, grab the tongue with your right hand and pull it to the patient's left. Palpate the right side of the tongue for any nodules, tenderness, or induration (hardening).
  2. Reverse the procedure and repeat on the opposite side.

Palpate the floor of the mouth

  1. Ask the patient to open their mouth and lift their tongue.
  2. With your right hand, gently squeeze inwards on their cheeks with your thumb and third finger. This will prevent them from biting down on your finger. Slide your right index finger under their tongue and palpate the floor of the mouth.
  3. Simultaneously place your left index & third fingers under the person's chin and palpate upwards.
  4. Note & describe any thickening, masses, induration or tenderness felt between the fingers of your right and left hands.

Other palpation

  1. Palpate over the parotid and submandibular glands (which should NOT be visible at their normal size). Note the consistency as well as any enlargement or tenderness.
  2. All visible lesions should be palpated for induration or the presence of a mass. You should also assess the fragility of the tissue and assess for any pain.

It is especially important to carefully examine and describe all ulcerated lesions!

  1. We can't stress enough the importance of describing all lesions, including their color (is it red? white? black?), their size, their location, their surface (is it ulcerated?). It is also important to note any tenderness and associated lymphadenopathy.

References

Schwartz, M. Textbook of Physical Diagnosis. 6th Edition. Chapter 11.

Bickley, L. Bates' Guide to Physical Examination and History Taking. 10th Edition. Chapter 7.

Martini, F., et al. Human Anatomy. 5th Edition.

Drake, R., et al. Gray's Anatomy for Students. 1st edition.

Ireland, R. A Dictionary of Dentistry. Oxford University Press. Online resource.

Gady, H., et al. Essentials of Otolaryngology. 5th edition. Chapter 2.

Gross, N., et al. UpToDate: Treatment of early (stage I and II) head and neck cancer: The oral cavity. Last update: May 19, 2010.

Lalwani, A. Current Diagnosis & Treatment in Otolaryngology. 2nd edition. Chapter 1.

Fauci, A., et al. Harrision's Principles of Internal Medicine. 17th edition. Chapter 31.

Section Author

Scott Kohlert
Medical Student (MS-4)
University of Ottawa

Section Editors

Laurie McLean, MD1,2
Nita Scherer, MD1,2
Safeena Kherani, MD1,2

1The Ottawa Hospital, Deptartment of Otolaryngology

2Faculty of Medicine, University of Ottawa