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Evaluation of the Patient with Nasal and Pharyngeal Disorders

by Marvin P. Fried, MD

The nose and pharynx (consisting of the nasopharynx, oropharynx, and hypopharynx) may be affected by inflammation, infection, trauma, tumors, and several miscellaneous conditions.

Anatomy

Throat

The uvula hangs in the midline at the far end of the soft palate. It varies greatly in length. A long uvula and loose or excess velopharyngeal tissue may cause snoring and occasionally contribute to obstructive sleep apnea.

Tonsils and adenoids are patches of lymphoid tissue surrounding the posterior pharynx in an area termed Waldeyer’s ring. Their role is to combat infection.

The larynx is discussed in Laryngeal Disorders.


Nose

The nasal cavity is covered with a highly vascular mucosa that warms and humidifies incoming air. Each lateral wall of the cavity has 3 turbinates, which are bony shelves that increase the surface area, thereby allowing more effective heat and moisture exchange. Nasal mucus traps incoming particulate matter. The space between the middle and inferior turbinate is the middle meatus, into which the maxillary and most of the ethmoid sinuses drain. Polyps may develop between the turbinates, often in association with asthma, allergy, aspirin use, and cystic fibrosis.


Sinuses

The paranasal sinuses are mucus-lined bony cavities that connect to the nasopharynx. The 4 types are maxillary, frontal, ethmoid, and sphenoid sinuses. They are located in the facial and cranial bones (see see Figure: Paranasal sinuses.). The physiologic role of the sinuses is unclear.

Paranasal sinuses.


Evaluation

Examination of the nose and pharynx is part of every general physical examination.

History

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 pain, ulcers, and difficulty swallowing or speaking. Nasal and sinus symptoms include presence and duration of congestion, discharge, or bleeding.


Physical examination

Most 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). Better illumination results with a head-mounted convex mirror; 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 (any incandescent light) 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 2 blades open in an anteroposterior (or slightly oblique) direction and do not press against the septum. The physician notes 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 mirrors, which 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. If patients do not tolerate mirror examination, a flexible fiberoptic nasopharyngoscope is helpful. A topical anesthetic (eg, lidocaine 4%) is sprayed in the nose and throat, and the nose is also sprayed with a decongestant (eg, phenylephrine 0.5%). After several minutes, the scope is gently passed through the nares, and the nasal cavity, hypopharynx, and larynx are inspected.

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 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.


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