Nose, Sinuses, Oral Cavity and Pharynx Exam

1. Nose and Sinus Exam

1. Inspect the nose for skin changes, nodules, and deformities. Slight deviation of the septum is common, and benign if it does not cause airflow obstruction.
2. Press gently on the tip of the nose to widen the nares, and inspect the vestibule with the aid of a pen light.
3. Conduct the nose cavity exam with an otoscope.
   1. Using the largest ear speculum available, inspect the nasal cavity with the otoscope.
   2. Tilt the patient's head back slightly, and holding the otoscope handle perpendicular and away from the patient's chin, gently place the speculum in the nasal vestibule, avoiding contact with the septum.
   3. When looking through the otoscope, gradually move the speculum posteriorly and angle it upward to glimpse the lower and middle turbinates, the nasal septum, and the narrow intervening passage.
   4. Note the color of the mucosa and the presence of any swelling, polyps, ulcerations, bleeding, discharge, blockages, deviations, or perforations.
4. Palpate the frontal and maxillary sinuses for tenderness.
   1. Bilaterally position your first and second fingers on top of the patient's forehead while firmly pressing your thumbs upward under the bony brows. Avoid placing any pressure on the eyes.
   2. Keeping your fingers in place, move your thumbs down and press firmly on the cheeks, just medial and inferior to the zygomatic bone.
5. If sinusitis is suspected, consider performing an illumination test.
   1. Darken the room and direct the brightest light of the otoscope upward beneath each brow, close to the nose.
   2. Look for a red glow illuminating the air-filled frontal sinuses.
   3. Have the patient tilt the head back with the mouth open wide.
   4. After removing any upper dentures, place the light source directly over each air-filled maxillary sinus and look for a red glow illuminating the hard palate on each side. Failure to see the red glow suggests mucosal thickening or secretions in the corresponding sinus.

2. Oral Cavity and Pharyngeal Exam

1. Observe the lips for color, moisture, ulcers, or cracking.
2. With a fresh tongue depressor and bright light in hand, ask the patient to open the mouth wide. Inspect the gums for bleeding, ulcers, or swelling, and check to see if any teeth are missing, discolored, misshapen, or loose.
3. Carefully inspect the buccal mucosa for ulcers, nodules, or white patches.
4. Inspect the tongue.
   1. Ask the patient to protrude the tongue and move it from side to side, assessing for symmetry, and inspect the color and texture of its dorsal surface. Oral cancers most commonly develop on the sides and base of the tongue.
   2. Have the patient touch the tongue to the hard palate, and carefully inspect its undersurface and the floor of the mouth.
   3. Using a gloved hand, gently grasp the tip of the tongue with a square piece of gauze and move it from side to side, inspecting carefully for ulcerations, plaques, masses, or discoloration.
5. Inspect the pharynx.
   1. With the tongue back inside, have the patient open wide and say "ah" or yawn.
   2. If the pharynx cannot be seen clearly, have the patient repeat this maneuver while you firmly press down on the tongue with the tongue depressor. Take care not to gag the patient.
   3. Watch the soft palate rise, and inspect the uvula, anterior and posterior pillars, tonsils (if present), and pharynx. Check for symmetry, discoloration, ulcerations, swelling, masses, or tonsillar exudate.