Shining star 001

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|November 18, 2009

Introduction

"The trouble with doctors is not that they don't know enough, but that they don't see enough."

Sir Dominic John Corrigan (18021880)

The structures in the lower half of the face tend to increase slightly in size with increasing age. Careful examination of the ears, nose, and oral cavity is often very rewarding: Clues of significant illness may hide here and early discovery of dermatologic, infectious, neoplastic, and neurologic lesions can substantially alter the course of illness.

Assessing the Ears Visual Inspection of the Ear

Check both ears for symmetry. Inspect the external ear and look for the following:

If the upper level of the ear rests below the level of the pupils, consider a congenital abnormality such as Down's syndrome. Note: Congenital abnormalities of the ear, in general, may be associated with abnormalities of the kidneys, heart, and great vessels. (Kidney lesions tend to be ipsilateral to the ear abnormality).

Check for basal or squamous cells, solar keratoses, or other potentially harmful skin lesions. For example, a crusted ulcer on the pinna suggests squamous cell carcinoma.

A unilateral painful rash with vesicles on the lower ear suggests herpes zoster of the geniculate ganglion (Ramsay Hunt syndrome). Be sure to check for this in any patient who presents with facial paralysis.[1]

A unilateral bright red swollen ear suggests external otitis.

Red, lax, or floppy ears suggest relapsing polychondritis. It typically occurs with a sudden onset of unilateral or bilateral ear pain, swelling, and redness, sparing the lobules.[2]

In superficial skin infections, such as erysipelas, the ears can be involved, but subcutaneous infections, like cellulitis, spare the ear (Millian's sign).

Long ear hairs suggest normal androgenic function (Hamilton's sign).

Abnormalities to the ear caused by trauma often present as a thick, rubbery painless deformity.

A diagonal ear lobe crease suggests increased risk for coronary artery disease.

Examining the Ears, Nose, and Oral Cavity in the Older Patient Mark E. Williams, MD

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Tender chalky nodules on the pinna suggest gouty tophi in a person who has lived in a cold climate, as lower temperature reduces the solubility of uric acid.

Single nontender nodule on the helix present since birth suggests a Darwinian tubercle (auricular tubercle).

Movement of the ear lobe coincident with the pulse suggests tricuspid insufficiency (Paul Dudley White's winking ear lobe sign).[3]

Palpation of the Ear

Stiffness of the earlobe suggests Addison's disease, while stiffness of the pinna and auricular cartilage suggests other endocrine abnormalities, such as hyperthyroidism, acromegaly, diabetes mellitus, and hypopituitarism. Consider external otitis media if the patient's ear is painful when you tug on it or if you find a tender tragus. Note: This is a potentially serious problem in diabetic or immunocompromised patients because of a risk for progression to osteomyelitis involving the temporal bone (called malignant external otitis). In such patients, check for mastoiditis by palpating the suprameatal triangle of MacEwen, which is the depression at 11 o'clock on the right ear and 1 o'clock on the left ear. (You can locate these little depressions on your own ears.) This area is tender when mastoiditis is present but is not with external otitis media alone.

Screening for Hearing Loss

Hearing loss is the third most common chronic health condition among older Americans after high blood pressure and arthritis; an estimated 25% to 40% of adults over age 65 and 40% to 66% of people 75 years and older have at least some hearing loss.[4] Some evidence suggests that hearing loss may be an indicator of cognitive decline.[5] However, in some older patients thought to be demented or psychiatric, hearing loss may actually be the basis for their odd behavior. If the patient appears to have hearing loss, then the next step would be to refer the patient for audiology testing, typically with a trained audiologist.

Simple Test to Determine Presence of Hearing Loss. One useful initial way to determine whether a patient has hearing loss is to give a simple instruction without providing a visual clue. For example, stand behind the patient during a lung or back examination, and give a simple command, such as "raise your right arm." (The challenge is to remember to do it when you get to the pulmonary examination.)

The Finger Friction Test. Another useful screening test is the finger friction test. Put your forefinger and thumb of each hand at the external auditory canal of each ear. Rub the finger and thumb together on one side and then the other; ask the patient to tell you when the sound is heard.

The Weber Test. The Weber test relies on the observation made by Earnst Heinrich Weber in 1834 that, if the neurologic function is intact, sounds will be perceived to be louder in an occluded ear canal than in an open one.[6] This test employs a 512 Hz tuning fork, as this frequency is in the middle of the normal conversational voice range. Place the vibrating tuning fork on the patient's forehead at an equal distance between the ears and ask whether they hear the sound (not feel the vibration). If they cannot hear it at all, then they have bilateral sensorineural hearing loss and, in fact, probably cannot hear your voice. If they do hear the tone, then ask in which ear they hear the sound. Hearing the sound in both ears or in the midline of the head does not necessarily indicate normal hearing if both ears are equally impaired. If one ear is occluded, then the sound will localize to the ear with impaired hearing. If there is sensorineural hearing loss on one side then the Weber test localizes to the good ear. In this case, slowly move the tuning fork toward the bad ear until the sound is in the midline. Now occlude the good ear (furthest from the tuning fork) and see if the equality of sound changes. If the sound is now louder in the occluded good ear then you have localized the hearing loss to the affected side. If the patient does not appreciate any change when the canal is occluded, then they are responding to the vibration of the tuning fork, not the loudness of the sound.

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The Rinne Test. The Rinne hearing test is based on the acoustic phenomenon that air conduction of sound should be greater than bone conduction. To test this, place the vibrating tuning fork on the patient's mastoid process and ask the patient to tell you when the sound disappears. As soon as the patient answers, shift the tuning fork to the external auditory canal with both tines pointing toward the ear for maximum vibration; then ask if the patient can hear the sound now. If the patient responds, then the test is normal. Not hearing the sound return suggests a conduction hearing loss on that side. If the patient has heard sound in both locations, you might want to ask which place is louder. Obviously, for normal hearing, the sound at the auditory canal should be louder than at the mastoid.

Schwabach's Test. This test uses the examiner's own bone conduction as a comparison with the patient's bone conduction. It employs 5 tuning forks: 512, 1024, 2048, and 4096 Hz. Perform the first part of the test starting with the 1024 Hz fork as you would a Rinne test.[7,8] When the patient can no longer hear the bone conduction, place the tuning fork on your own mastoid and count the seconds while you hear it. If the patient has sensorineural hearing loss you will hear the sound longer than the patient does.

Assessing the Eustachian Tube

Politzer's Test. If a patient has unilateral hearing loss, then check the function of the eustachian tube using Politzer's test. Place a vibrating tuning fork in front of the nose and ask the patient to swallow. If there is unilateral hearing loss, during swallowing, the patient will localize the sound to the good side.

Politzer's Maneuver. Politzer's maneuver uses compressed air injected into the nasal cavity with an atomizer. The patient is asked to swallow, and the examiner visually inspects the tympanic membrane. If the pressure that develops is forced into the middle ear, then the eustachian tube is patent. The examiner should also note any nystagmus or vertigo, which could be due to chronic inner ear infection or caused by a fistula in the horizontal semicircular canal.

Valsalva Maneuver. The Valsalva maneuver is performed while inspecting the tympanic membrane. The patient takes a deep breath and closes the mouth. He or she then pinches the nose firmly, shuts it, and gently blows it. If the tympanic membrane is moving, then the tube is patent.[9]

Examination of the External Auditory Canal

Examine the right ear first by gently pulling up and back on the pinna with your left hand to straighten the canal. Introduce the otoscope under direct visualization using the largest speculum you can comfortably insert.

First, note the skin of the external auditory canal and check for the following:

A red canal with white, cottage cheeselike exudates suggests external otitis media.

A red tender spot suggests a furuncle.

Brown debris suggests a cerumen impaction.

Blood in the external canal suggests local trauma from a foreign body (such as a toothpick) or furuncle. In the appropriate setting (such as after a fall, with head trauma) blood in the external canal can be a clue to fracture of the temporal bone.

Bony exostoses that appear as domeshaped nodules (resembling a torus mandibularis in the mouth) suggest that the patient has been a coldwater swimmer.

Gently touch the posterior auditory canal and note any hypesthesia. Increased sensitivity (Hitselberger's sign) suggests an acoustic neuroma.

Examining the Tympanic Membrane

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Once you have examined the auditory canal, focus your attention on the tympanic membrane.

The normal color is a pale shiny gray. Diffuse erythema suggests otitis media, but be careful in interpreting redness, since touching the posterior canal can produce a vascular flush that looks like a lacy, reticular net along the handle of the malleolus.

Serous or bloody vesicles on the eardrum suggest bullous myringitis from mycoplasma pneumonia. Sometimes herpes virus infection will produce serous vesicles (Ramsay Hunt syndrome).

Note the normal concave shape of the eardrum. Bulging is often a sign of infection.

Blood behind the eardrum suggests basilar skull fracture (Laugier's sign).

Retraction of the eardrum implies eustachian tube obstruction. The umbo will be prominent and the tympanic membrane will drape posteriorly like a circus tent seen from the air (Dumbo's view of the umbo).

Bubbles behind the eardrum suggest serous otitis media; in such a case, an airfluid level may be seen.

Next, carefully look for perforations in the eardrum.

Then, check all along the border (annulus) of the tympanic membrane. Defects along this margin can suggest cholesteatoma, which looks like a shiny pearly grey or white basal celllike lesion. The pars flaccida, just above the malleus in the superior portion of the tympanic membrane, is a key location for cholesteatomas, particularly if the patient has facial paralysis. (In fact, any patient with facial paralysis should be checked for a cholesteatoma). Note: If you are tall, you may need to bend so that you are lower than the patient's ear in order to look up to see the pars flaccida.

Next, examine the bony landmarks: Look at the anterior orientation of the light reflection and then examine the malleus. Look at the umbo (central and most prominent point of the eardrum) and the handle (manubrium) of the malleus.

Numbness of the tympanic membrane suggests nerve damage from otosclerosis (ItardCholewa symptom).

Evaluating Abnormal Sounds

If the patient reports hearing abnormal sounds, check for the following:

An unusual rushing sound may be due to a fistula involving the carotid artery. To check for this, auscultate the artery for a bruit. If present, gently pressing on the artery should change the quality of the sound perceived by the patient.

Patients with a ventriculoperitoneal shunt (for low pressure hydrocephalus) may hear a flowing sound.

Patients with myoclonus may hear clicking sounds.

Inadvertent catheterization of the internal jugular vein with subclavian line placement can produce a bubbling sensation in the ears.

Inflammation of the eustachian tube can produce a bright clicking sound heard by the examiner through the otoscope while the patient experiences it as tinnitus (Leudet's sign).

In otitis media patients may hear their own breath sounds.

Tinnitus with dizziness and vertigo that improves at high altitude such as in an airplane suggests Ménière's disease (Bigger's sign).

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Tinnitus associated with crepitus in the jaw, headache, and ear pain suggest temporomandibular joint syndrome. [10]

Assessing the Nose

The nasal examination can provide valuable information on the patient's general health status, including identifying specific systemic diseases. In addition, this examination provides information on the part of the respiratory system that warms, moistens, and filters inhaled air, and also serves as the sensory organ for smell.

Prepare the patient for the nasal examination by explaining the procedure to the patient in simple terms. The patient should be sitting up straight with his or her head at eye level.

Visual Inspection of the External Nose

The nose is shaped like a triangle and is composed of the following:

The bridge is the superior part of the triangle.

The tip is the outer corner of the triangle.

The nares are the oval openings at the base of the triangle.

The vestibule is the widened area just inside each naris.

The columella divides the nose into 2 nares and is continuous with the nasal septum.

The ala is the lateral outside wing of the nose on either side.

Inspect the external surface of the nose from all angles. Normally the skin is intact and similar in color to the face. The surface should be smooth and uniform. Check the nasolabial folds for skin lesions such as basal cell carcinoma. Pay special attention to areas of redness, pigmented lesions, lumps, crusts, scaliness, and a visible vascular pattern. Also check for the following:

Note any discharge from the nares and flaring with respiration. Nasal flaring is an important sign of respiratory distress. It is sometimes seen in upper abdominal inflammation.

Excessive nose picking, in the presence of other symptoms, can be seen in early meningitis (Lafora's sign).

Swelling over the bridge of nose and bloody discharge suggests nasal fracture (palpate for instability of the nasal cartilage).

Indentation and erythema with a turned up appearance suggests Wegener's granulomatosis.

An enlarged thickened nose suggests acromegaly or rhinophyma (with erythema and telangiectasias).

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Asymmetry suggests infections, trauma, neoplasm, or leprosy.

Examination of the Nasal Cavity and Paranasal Sinuses

The nasal cavity has the following characteristics:

The medial wall is composed of the septum that divides the nasal cavity into 2 oval air passages.

The lateral walls have turbinates that project into the nasal cavity and add surface area for warming, moistening, and filtering inhaled air. The inferior and middle turbinates can be seen on examination but superior turbinate is not accessible to examination.

Under each turbinate is a meatus.

The paranasal sinuses are airfilled areas in the skull bones that serve as resonators for sound production and provide mucus that lubricates the nasal cavity.

The frontal sinus is in the lower forehead just above and medial to the eyes.

The maxillary sinuses are in the maxilla along the sidewalls of the nasal cavity.

The ethmoid sinuses are in between the eyes.

The sphenoid sinus is just anterior to the pituitary gland in the sphenoid bone.

Nasal Patency. Check the patency of each naris by standing directly in front of the patient and occluding the patient's left naris with the index finger of your right hand. Ask the patient to breathe normally through the right naris. Repeat by occluding the patient's right naris with the index finger of your left hand and ask the patient to breathe through the left naris. Normally the patient will be able to exhale through the unoccluded naris. Nasal obstruction is present if the patient is unable to exhale through the nares.

Evaluating the Nasal Septum. Inspect the nasal septum by holding a light and standing directly in front of the patient. Gently press the tip of the patient's vestibule with the thumb of your left hand. Shine the light onto the patient's vestibule with your right hand aiming the light parallel to the floor.

Normally, the nasal septum is pink, in the midline, and intact. Common deviations from normal findings include the following:

A nasal septum deviated from midline;

Red and swollen mucosa, which suggests acute allergic rhinitis;

Pale and boggy mucosa, which suggests chronic allergy; and

Red and dry mucosa, which suggests decongestant use or anticholinergic effect.

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The next step is to transilluminate the nasal septum to look for perforations. Shine the light on one side of the septum and look at the other side. Light shining through suggests a septal perforation. (Try to avoid contact with septum it is very sensitive.) Common causes of septal perforations include nose picking, infection, syphilis, tuberculosis, collagen vascular disease, Wegener's granulomatosis, systemic lupus erythematosus, rheumatoid arthritis, exposure to toxins, previous cocaine use, and chromium poisoning.

Also look for nasal septal deformities. Deformities of the vomer ("plowshare"), the unpaired flat bone that forms the inferior and posterior part of the nasal septum, are common after vaginal deliveries.

Examining the Walls and Turbinates. The inferior and middle turbinates and the middle meatus between them should be pink, intact, smooth, and moist. The area should be free of foreign body(s). Note any masses and any deviations from normal, such as a red, pale, or bluishgray color, bogginess, dryness, fissures, crusts, exudate, edema, polyps, ulcers, watery discharge (rhinorrhea), mucopurulent discharge, or bloody discharge. Drainage and polyps are abnormal. Polyps are usually nontender and a sign of allergy. Consider aspirin sensitivity if the patient also has asthma. Purulent mucus suggests upper respiratory infection or sinusitis. Bloody discharge suggests local trauma or a platelet abnormality. Pulsation of the nasal arteries in the mucus membrane is increased in thoracic aortic aneurysm (Bozzolo's sign).

Nasal Discharge

Clear nasal discharge most commonly suggests allergic rhinitis or viral infection. Purulent discharge suggests bacterial infection.

If the patient has nasal discharge along with "raccoon" eyes and a history of head trauma, suspect basilar skull fracture. Check the glucose level of the nasal fluid for a clue to a CSF leak (usually above 30 mg/dL). If the nasal discharge is bloody, see if it clots. If it does not, also consider a CSF leak An additional useful test for basilar skull fracture is to place a drop of the bloody fluid on a white paper towel or piece of filter paper. Seeing a clear wet ring around a red dot suggests basilar skull fracture.

Epistaxis. The vascular network in the anterior medial nasal septum is called Kiesselbach's plexus, the most common location of nosebleeds. Epistaxis (nasal bleeding) has been reported to occur in up to 60% of the general population and has 2 peaks 1 in childhood and 1 in people over 60. Most people do not require medical attention and the nosebleed can be managed with simple instructions, including application of direct pressure to the septal area and plugging the affected nostril with gauze or cotton.[11]

Some causes of epistaxis include the following:

Chronic sinusitis or rhinitis;

Nose picking;

Foreign bodies;

Intranasal neoplasm or polyps;

Pollutants (eg, cigarette smoke);

Medications (eg, aspirin, anticoagulants, nonsteroidal antiinflammatory drugs);

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Septal deviation or perforation;

Trauma;

Vascular malformation or telangiectasia ( Note: multiple mucosal telangiectasias suggests OslerWeberRendu syndrome[12]);

Hypertension;

Leukemia;

Cirrhosis; and

Bleeding disorders.

Assessing the Mouth and Throat Assessing Breath Sound and Odor

Listen to the sound of the breath. A soft swish of air coincident with the pulse can be heard through the open mouth in thoracic aortic aneurysm (Drummond's sign). Soft wheezing over the open mouth suggests foreign body in the bronchus (Jackson's sign).

Note the breath for unusual odors. This sensory component is very useful because there are a number of odors characteristic of important conditions (Table 1). If you feel uneasy just take your time and move in from a distance. Have the patient say his or her name and address while you smell the breath. If poor oral hygiene is the cause of bad breath, have the patient breathe through the nose with the mouth closed.

Table 1. Possible Causes of Some Unusual Breath Odors

Character of Breath Odor Possible Cause

Fishy ammonia (urinelike) Renal failure

Fishy sweetness Liver failure

Musty ammonia Liver disease (fetor hepaticus)

Fruity chewing gum or acetone Diabetic ketoacidosis

Apples Chloroform or salicylate ingestion

Grapes Pseudomonas infection

Fruity yeast Alcohol ingestion

Freshbaked bread Typhoid fever

Stale or musty (sourdough) bread Pellagra (severe niacin deficiency)

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Fresh meat Yellow fever

Stale beer Mycobacteria (scrofula)

Landfill or garbage dump Oral infection, bronchiectasis esophageal diverticulum, gastroparesis

Putrid Anaerobic infection

Very putrid Lung abscess

Stale smoke Cigarette smoking

Burning rope Marijuana smoking

Shoe polish Nitrobenzene ingestion

Bitter almonds Cyanide ingestion

Garlic Arsenic, organophosphorus, or tellurium ingestion

Metallic Iodine ingestion

Solvent Hydrocarbon ingestion

Violets Turpentine ingestion

Assessing the Temporomandibular Joint

If the patient has jaw pain, place your forefinger of each hand on each temporomandibular joint (just in front of the ear) and have the patient open and close their mouth. Normally the patient's mouth should open wide enough for 3 of their fingers to be inserted vertically. A small oral opening suggests scleroderma, temporomandibular joint arthritis, or tetanus. See if there is crepitus and any shift in jaw when the patient opens their mouth, which suggests temporomandibular joint arthritis, particularly if other symptoms are present, such as headache, dizziness, tinnitus, and ear pain. Jaw aching or claudication suggests temporal arteritis. If the patient has a fever along with drooling and exquisite pain when opening the mouth, consider peritonsillar abscess.

Assessing Perioral Lesions

Cracks and Fissures. Fissures in the corners of the lips suggest Candida infection, B vitamin deficiencies, or persistent drooling. Vertical cracking along the lower lip suggests cheilitis, which can be caused by alcoholism, B vitamin deficiency, iron deficiency, malnutrition, and Crohn's disease. Congenital syphilis can produce lines radiating from the mouth (rhagades). Rarely, a history of syphilis can produce permanent cracks that are epithelialized and radiate from the corners of the mouth.

Other Lesions. Other lesions and possible causes include the following:

Red macular lesions resembling cherry angiomas suggest OslerWeberRendu syndrome.

Freckles on the lips suggest PeutzJeghers syndrome.

A bluepurple nodule on the lip border suggests a mucocele.

Vesicles around the lip suggest herpes simplex virus.

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Petechiae may sometimes be seen, suggesting platelet abnormalities.

A painless ulcer on the lower lip suggests squamous cell cancer.

A hard nodule on the lower lip suggests epidermoid carcinoma.

Swelling and Color. Swelling of the upper lip suggests angioedema. Swelling of the upper and lower lips with hemorrhage suggests StevensJohnson syndrome. Pallor around the mouth in a febrile patient suggests scarlet fever (Filatov's sign).

Assessing Mucous Membranes

The next part of the oral examination involves inspecting the mucous membranes. For this exam you will need a bright light and a tongue blade.

First, notice the color of the mucosa, which is one of the most sensitive places for hyperpigmentation. For example, brown spots suggest Addison's disease. Note that African Americans sometimes have brown spots adjacent to the molars.

Next, estimate the amount of moisture. If the tongue blade sticks to the mucosa, it is too dry and lacks saliva (xerostomia). No saliva under the tongue in the oral vestibule or between the gums and cheek is a key sign of dehydration.

After checking the degree of moisture, look carefully for mucosal lesions (Table 2).

Table 2. Lesions on Mucous Membranes of the Mouth

Description of Lesion Possible Causes and Comments

Painless ulcer Squamous cell cancer

Multiple painful small round ulcers

Aphthous stomatitis (consider: autoimmune processes, stress, systemic lupus erythematosus, vitamin B12 deficiency, inflammatory bowel disease, or Behçet's syndrome)

Ulcers with irregular borders

Systemic lupus erythematosus, pemphigus, viral illness

Unilateral painful vesicles Herpes zoster

Scattered painful vesicles and pustules

Herpes simplex

Painful ulcers on posterior pharynx

Coxsackie A virus (herpangina)

Mucosal bulla Pemphigus, pemphigoid, erythema multiforme, lichen planus

Red nodule Malignancy, pyogenic granuloma

White spots Measles, Coxsackie A16, ECHO 9 virus

White plaque with Most commonly caused by chronic irritation typically from tobacco; suspect

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ulceration (leukoplakia) squamous cell carcinoma

White coating on red base Oral candidiasis

Irregular line on posterior buccal mucosa

Linea alba, caused by minor trauma

Lacy white patches on inner cheek (Wickham's sign)

Lichen planus

Dark patch adjacent to tooth filling

Dental amalgam pigmentation

Pigmentation with ulceration

Malignant melanoma

Pigmentation adjacent to front teeth

Smoker's gingiva

Small red spots with central bluewhite dot (Koplik's sign)

Measles

Assessing Stensen's Duct (Parotid Duct)

Check the Stensen's duct on the lateral cheeks. Excessive redness or purulent drainage suggests a stone in the duct. A red spot sometimes appears on Stensen's duct in patients with mumps (Tresilian's sign). Tenderness at the angle of the jaw (Hatchcock's sign) suggests parotid gland inflammation and is also associated with mumps. Parotid pain on tasting vinegar suggests parotid gland inflammation (Mirchamp's sign).

Assessing the Gingiva

The next step in the oral examination is to examine the gums. Red and swollen gingiva suggests gingivitis, which can lead to periodontal disease and is usually caused by bacterial plaque that accumulates in the spaces between the gums and the teeth and in calculus (tartar) that forms on the teeth. Gingivitis may also be due to other conditions:

Phenytoin effect;

Acute monocytic leukemia;

Platelet abnormalities (but not coagulopathies);

Vitamin C deficiency (but never in edentulous patients); and

Wegener's granulomatosis (gingivitis resembles a mulberry).

Bluegrey dots along the gums suggest lead poisoning (Burton's sign). Pale purple discoloration along the gum line near the teeth suggests copper poisoning (Corrigan's sign).

Assessing the Teeth

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After examining the gums look carefully at the teeth. Erosion on a tooth suggests dental caries or wear and tear. If the gingiva is red and swollen and you note an opening at the base of a decayed tooth, consider a periapical dental abscess. In a patient with fever of unknown origin, gently tap each tooth to check for the increased tenderness of an apical abscess.

Poor dental hygiene may predispose to more serious medical conditions, such as aspiration pneumonia. (Of interest, an edentulous state reduces the likelihood of aspiration pneumonia.) An aspirated tooth can cause an abscess in the lung, so count the teeth and ask about any missing ones. Increased space between the teeth is common, but it can suggest acromegaly (patient may complain of food sticking between the teeth).

Stains on the teeth and their color can be informative. Greenish teeth suggest that the patient had jaundice as an infant. Dead teeth look darker gray compared with other teeth. Fluoride toxicity in childhood can cause dark brown pits. Chewing tobacco stains the teeth in a predictable manner. Lipstick sticking on the teeth suggests xerostomia because saliva reduces the adhesion of lipstick. Calculus develops as chalky white debris along gingival margin.

A small protrusion lingual to the mesial portion of the first maxillary molar is Carabelli's tubercle. Long teeth suggest periodontal disease with retraction of the gums.

Assessing the Tongue

Next, examine the tongue for abnormalities.

Tongue Discolorations and Lesions. See Table 3.

Table 3. Tongue Discolorations and Lesions

Lesions or Discoloration Possible Causes and Comments

Soft nodule resembling a skin tag Suggests a papilloma, which is a premalignant lesion

A soft red mass at the base of the tongue

May represent a lingual thyroid

Red, shiny surface Vitamin B12 deficiency and pellagra

Red with white exudate Thrush

Strawberry or raspberry Scarlet fever

Magenta cobblestone Riboflavin deficiency

Pale tongue Giantcell arteritis

Pale areas on tongue Bacterial endocarditis

Sharply defined pale area on half of tongue (Liebermeister's sign)

Air embolism

White hairy plaques (hairy leukoplakia) EpsteinBarr virus in HIV patients

Black coat Aspergillus niger colonization

Nodularity from neuromas Sipple's syndrome (medullary carcinoma of the thyroid, pheochromocytoma and multiple mucosal neuromas [MEAII])

Transverse fissures Congenital condition

Longitudinal fissures Dehydration, syphilis

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Irregular fissures (geographic tongue) Not significant

Shiny red tip on furred tongue (Marfan's sign)

Typhoid fever

Posterior lateral ulcers Malignancy

Ragged ulcers under tongue Behçet's syndrome

Midline ulcers Tuberculosis or histoplasmosis; usually not malignant

Multiple painful ulcers Tuberculosis (almost always pulmonary)

Ulcer on tip Syphilis

Shape and Size of the Tongue. A large tongue (macroglossia) could suggest hypothyroidism, acromegaly, pemphigus vulgaris, or amyloidosis. Amyloid may also produce palpable stiffness with the enlargement.

Tongue Inflammation (Glossitis). Early glossitis produces papillary hypertrophy; the next phase produces papillary flattening. If the inflammation progresses further, the tongue atrophies and becomes smooth and shiny. Glossitis can be caused by iron deficiency, B vitamin deficiency, alcoholism, malnutrition, amyloidosis, and carcinoid syndrome.

Tongue Movements. The ability to easily touch the tip of the nose with the tongue can indicate EhlersDanlos syndrome (Gorlin's sign).

Involuntary tongue movements or tremors are also instructive. Fine tremor of the tongue suggests hyperthyroidism or trypanosomiasis (CastellaniLow sign). To check for chorea, ask the patient to stick out the tongue and keep it out. The tongue cannot stay protruded in chorea. If the patient is unable to voluntarily protrude the tongue consider shortened frenulum, oral carcinoma, or louseborne typhus (SterlingOkuniewski's sign).

A useful technique for detecting certain neuromuscular conditions involves placing a tongue blade across the lower teeth and asking the patient to drape their tongue over the tongue blade. Tapping the tongue may produce jerking in patients with myotonia. In patients with hypocalcemia, tapping the tongue causes the lips to protrude (Escherich's sign) or may cause a curved distortion of the tongue (Schultze's sign).

The Oral Vestibule. It is important to look under the tongue just behind the lower front teeth. Secretions pool there, so it is a prime site for oral tumors. Increased central venous pressure can produce dilated sublingual veins.

Look for cysts. A ranula (a cyst of the sublingual salivary gland) appears as a translucent mass near the frenulum. A sublingual dermoid cyst is usually white and opaque, while a mucous gland retention cyst is blue and translucent.

Assessing the Palate and Posterior Pharynx

The Hard Palate. After the tongue examination, focus your attention on the hard palate. A nontender lump on the hard palate is a torus palatinus, which is normal and benign. An arched palate can suggest Sipple's syndrome, Marfan's syndrome, or homocystinuria. Defects or ulcers in the hard palate are seen in infection, radiation therapy, or neoplasms.

The Soft Palate. Next, examine the soft palate. The juncture of the hard and soft palate is often a place to see petechiae. Edema of the soft palate suggests gamma heavy chain disease.

The Posterior Pharynx. The next step of the oral examination is to check the posterior pharynx. Significant asymmetry of the tonsillar pillars and the anteroposterior and lateral dimensions suggests peritonsillar abscess. Diminished area (particularly in the horizontal plane) suggests a predisposition for obstructive sleep apnea. White plaques that bleed when scraped suggest Candida infection, while exudate suggests bacterial infection. A dark red color to the anterior and

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inferior pillars of the posterior pharynx suggests syphilis (Biederman's sign).

The Uvula. Finally, check the uvula. Note the elevation of the uvula by having the patient say the familiar "AHHHH." Asymmetry suggests neurologic disease or peritonsillar abscess. A bifid uvula suggests a submucosal cleft palate. Flushing (Stone's sign) or pulsation (Mueller's sign) of the uvula suggests aortic insufficiency. Swelling suggests infection, obstructive sleep apnea, or gamma heavy chain disease. Redness of the uvula is seen in viral infection or bacterial infection. Seeing the epiglottis suggests acute epiglottitis.