AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 1

cannot be explained by canal occlusion or middle ear infection. It is also an integral part of the evaluation of the patient with vertigo. The Nose Anterior rhinoscopy should be performed using a bivalve speculum. Evaluate the septum and anterior portions of the inferior turbinates. Topical vasoconstriction with oxymetazoline permits a more thorough examination and allows for assessment of turbinate response to decon- gestion. Nasal patency may be compromised by swollen boggy turbi- nates, septal deviation, nasal polyps, or masses/tumors. The remainder of the nasal cavity can be more carefully examined by performing fiber- optic nasal endoscopy . This allows a more thorough evaluation of the nasal cavity and mucosa for abnormalities, including obstruction, lesions, inflammation, and purulent sinus drainage. The sense of smell is infre- quently tested because of the difficulty of objectively quantifying responses. However, ammonia fumes can be useful for distinguishing true anosmics from malingerers, because ammonia will stimulate trigeminal endings and thus produce a response in the absence of any olfaction. The Mouth An adequate light and tongue depressor are necessary for examining the mouth. The tongue depressor should be used to systematically inspect all mucosal surfaces, including the gingivobuccal sulci, gums and alveolar ridge, hard palate, soft palate, tonsils, posterior oropharynx, buccal mucosa, dorsal and ventral tongue, lateral tongue, and floor of the mouth. Dentures should always be removed to permit a complete examination. The parotid duct orifice (Stenson’s duct) can be seen on the buccal mucosa, opposite the upper second molar. Massage of the parotid gland should express clear fluid. The submandibular and sublin- gual glands empty into the floor of the mouth via Wharton’s ducts. Complete examination of the mouth includes bimanual palpation of the tongue and the floor of the mouth to detect possible tumors or salivary stones. The Pharynx The posterior wall of the oropharynx can be easily visualized via the mouth by depressing the tongue. Inspection of the nasopharynx, hypo- pharynx, and larynx requires an indirect mirror exam or use of a flexible fiberoptic endoscope. All mucosal surfaces are evaluated, to include the Eustachian tube openings, adenoid, posterior aspect of the soft palate, tongue base, posterior and lateral pharyngeal walls, vallecula, epiglottis,

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Primary Care Otolaryngology