ear, nose, and throat disorders
Evaluation of the Patient with Nasal and Pharyngeal Symptoms
Evaluation of the Nose and Pharynx
Examination of the nose and pharynx is part of every general otorhinolaryngologic examination. General information includes use of alcohol or tobacco (both major risk factors for head and neck cancer) and systemic symptoms, such as fever and weight loss. Oropharyngeal symptoms include Mouth and throat pain Mouth and throat ulcers Difficulty swallowing or speaking Nasal and sinus symptoms include Congestion (noting presence and duration) Nasal discharge Loss of smell and/or taste Bleeding from the nose Some otorhinolaryngologic physicians use a head-mounted light. However, because the light cannot be precisely aligned on the axis of vision, it is difficult to avoid shadowing in narrow areas (eg, nasal cavity). Illumination is better if the head-mounted mirror is convex; the physician looks through a hole in the center of the mirror, so the illumination is always on-axis. The head mirror reflects light from a source placed behind the patient and slightly to one side and requires practice to use effectively. The nose is examined using a nasal speculum, which is held so that the two blades open in an anteroposterior (or slightly oblique) direction and do not press against the septum. The physician notes any crusting, discharge, septal deviation, or perforation; whether mucosa is erythematous, boggy, or swollen; and presence of polyps. The skin over the frontal and maxillary sinuses is examined for erythema and tenderness, suggesting sinus inflammation. If necessary, the nasopharynx and hypopharynx can be examined with a flexible nasopharyngoscope. A topical anesthetic (eg,lidocaine4%) is sprayed in the nose and throat, and the nose is also sprayed with a decongestant (eg,phenylephrine0.5%). After several minutes, the scope is gently passed through the nares, and the nasal cavity, hypopharynx, and larynx are inspected. A nasal endoscopic examination can also be done using a rigid scope, which provides excellent views inside of the nose but requires skill to use without causing the patient discomfort. Alternatively, a mirror examination can be done. A topical pharyngeal anesthetic for the throat is required for this examination. The mirror should be warmed before use to avoid fogging. A small mirror is used for the nasopharynx. It is held just below the uvula, angling upward; the tongue is pushed down with a tongue blade. A larger mirror is used for the hypopharynx and larynx. The tongue is retracted by grasping it with a gauze pad, and the mirror is placed against the soft palate, angling downward. Neck examination consists of inspection and palpation for masses. If masses are found, the physician notes whether they are tender; fluctuant, firm, or stony hard and whether they are movable or fixed. Masses caused by infection are tender and mobile; cancers tend to be nontender, hard, and fixed. Particular attention is paid to the cervical lymph nodes and thyroid and parotid glands. 