Nose and Nasopharynx

The external nose consists of bone in the proximal third of the nose and cartilage in the lower two thirds covered by skin. The nasal bones arise from extensions of the frontal and maxillary bones, forming the nasal bridge (Figure 13-2). The hard and soft palates form the floor of the nose, and the frontal and sphenoid bones form the roof. The external nose humidifies, filters, and warms inspired air and serves as a passageway for expired air.^1,4,5

The internal nose is divided into two anterior cavities, or vestibules, by the septum. Air enters the nose through the nostrils and passes posteriorly to the nasopharynx through one of the choanae, separated by one of three turbinate bones. The cribriform plate that is part of the ethmoid bone on the roof of the nose houses the sensory endings of the olfactory nerve (i.e., cranial nerve I). A group of small fragile arteries and veins is located on the anterior superior portion of the septum. This group of arteries and veins is called Kiesselbach’s plexus and is often responsible for epistaxis.6,7 The adenoids lie on the posterior wall of the nasopharynx.

Three turbinate bones form the lateral walls of the nose. Covered by vascular mucous membrane, the turbinates separate the nose into a superior meatus, medial meatus, and inferior meatus (Figure 13-3). The turbinates help to increase the surface area for warming, filtering, and humidifying air.

The paranasal sinuses are air-filled spaces within the cranium.2,3 They are generally named for their location and drain into respective nasal cavities. The sinuses lighten the weight of the skull bones and serve as resonators for sound production. They also produce mucus from the membranes that line the cavities, which drains into the nasal cavity. Because the sinus openings are narrow and occlude easily, they are a common site for inflammation.

Mouth, Oropharynx, and Throat

The oral cavity consists of the lips, cheeks, tongue, teeth, and salivary glands (Figure 13-4). It functions in several capacities, including serving as a passage for food as well as the initiation of digestion by mastication and salivary secretion. The mouth and oropharynx also serve to emit air for vocalization and expiration.

The oral cavity may be divided into the mouth and vestibule. The vestibule is the area between the buccal mucosa and the outer surface of the teeth and gums.¹ The roof of the mouth, which is formed by the hard and soft palates, separates the oral cavity from the nasal cavity. The soft palate is muscular tissue covered by mucous membrane that plays an active role in swallowing and vocal resonance. The soft palate, the tonsillar pillars, tonsils, base of the tongue, and posterior pharyngeal walls make up the oropharynx. The tongue is a skeletal muscle covered by mucous membrane, which helps to form the floor of the mouth and is anchored to the floor of the mouth by the frenulum (Figure 13-5).^1,4 Papillae cover the surface of the tongue to assist in movement of food. Taste buds are contained within the papillae, and allow people to taste what they are eating.⁴

Three pairs of salivary glands are located in the mouth. The parotid, submandibular, and sublingual glands secrete saliva to moisten and lubricate food and to begin the digestion process (Figure 13-6). A parotid gland lies within each cheek, just anterior to the ear, and for each gland a duct, known as Stensen’s duct, extends to an opening on the buccal mucosa opposite the second molar.³ The submandibular glands lie beneath the left and right mandibles at the angle of the jaw. For each a duct runs to the floor of the mouth, with the opening on either side of the frenulum. The sublingual glands are the smallest of the three pairs and are located under the tongue.^3,4

The teeth are embedded in the alveolar ridges and are protected by gingivae that cover the neck and roots of each tooth. Adults typically have 32 permanent teeth that are divided into upper and lower rows (Figure 13-7). Each tooth consists of enamel, dentin, and pulp. The enamel is an extremely hard surface that covers the dentin. The periodontal ligament that surrounds the root of the tooth helps keep the tooth stable. The pulp chamber contains the pulp, nerves, and blood vessels (Figure 13-8).¹

The pharynx consists of the combined upper parts of the respiratory and digestive tracts: the nasopharynx, oropharynx, and laryngopharynx (see Figure 7-1).⁴ The larynx functions in respiration, prevents food and saliva from entering the respiratory tract, and produces sound. It is protected anteriorly by the thyroid cartilage and inferiorly by the cricoid cartilage.

Examination of the Nose and Nasopharynx

Nasal disorders may present with local symptoms or may be a result of disorders from other structures, such as the paranasal sinuses. The major nontraumatic problems related to the nose are nasal obstruction, drainage, facial pain or headache, epistaxis, and change in smell or taste.⁷ A thorough history of symptoms will help the examiner determine the nature of the nasal disorder.

The examiner asks the patient about the onset and duration of the symptoms. In the case of nasal obstruction, it is important to determine whether trauma was involved or whether the nasal obstruction or congestion onset was insidious. It is also important to determine whether the obstruction is bilateral or unilateral and whether it is constant or intermittent. Assessment of inspiratory and expiratory airflow is done by occluding one nostril at a time while the patient inspires (Figure 13-12).

Unilateral obstruction may indicate an anatomical problem, such as a deviated septum or polyp, whereas bilateral obstruction could arise from a simple cold.⁷ If drainage is present, it is helpful to determine its characteristics. Is it unilateral or bilateral? Is it clear or discolored? Clear drainage suggests rhinitis, either allergic or nonallergic, whereas yellow, green, or brown drainage suggests bacterial or viral infection (Table 13-2). Straw-colored drainage occurring after a head injury could be cerebrospinal fluid (CSF) and an indicator of possible brain injury. If discharge is present, the examiner should wear gloves for the examination.

The patient may also experience facial pain and headache. Many nasal or sinus disorders will present with headaches but should be differentiated from headache or face pain caused by migraine, tension headache, or temporomandibular joint (TMJ) pain. Dental disorders may also cause diffuse facial pain. When pain and swelling occur over the sinuses accompanied by purulent drainage, sinusitis may be suspected.

During or after the history, the clinician visually examines the external nose, noting its shape, size, and color. The athlete is asked whether there are subtle changes in shape. Sometimes standing behind the patient and looking down the nose while the patient is sitting allows better visualization of whether the nose is straight. Next, the nares are examined for discharge as well as any unilateral flaring or narrowing.

Palpation may reveal swelling, tenderness, or masses, as well as any displacement of bone or cartilage. The patency of the nares is evaluated by gently squeezing the nares together. Unilateral variations may indicate a deviated septum or polyp in the nose. One must remember that recent trauma may cause ecchymosis and edema of the nose and surrounding areas as well as localized tenderness.

The examiner palpates the facial bones and the sinuses to determine any areas of tenderness, swelling, or deformity. The facial areas over the frontal sinus are palpated by the examiner positioning the thumb up and under the athlete’s eyebrow (Figure 13-13, A). The maxillary sinus is palpated by pressing with thumbs up under the zygomatic process (Figure 13-13, B). Healthy sinuses are not generally tender to the touch, and pain with palpation of the facial bones over the sinuses often indicates inflammation from infection or allergy.

Transillumination

The sinuses also may be transilluminated. This is often performed by the physician; however, the athletic trainer may elect to try the technique. Transillumination is done in a darkened room, using a penlight or an otoscope. The frontal sinus may be transilluminated by placing a light against the medial aspect of each supraorbital rim while looking for a slight red glow of light just above the eyebrow.1,5 An absence of a glow in the sinus indicates that the sinus contains secretions. Likewise, the maxillary sinus may be illuminated by placing the light lateral to the athlete’s nose beneath the medial aspect of the eye while asking the athlete to open the mouth. If the sinus is clear, the hard palate will be illuminated (Figure 13-14).

Speculum Examination

To view the septum and turbinates the examiner tips the patient’s head slightly backward. The nares of the nose may be dilated and viewed by the use of a speculum and a light, or the speculum on an otoscope may be used. The speculum is held in one hand while the other guides the patient’s head.

The septum may be visualized by tipping the speculum toward the midline (Figure 13-15). The septum is normally pink and glistening and should be thicker anteriorly. The examiner checks for any discoloration, perforations, bleeding, or crusting and notes differences such as polyps (Figure 13-16, A), holes (Figure 13-16, B), swelling, or abnormal coloring.^3,5 The septum should be straight and positioned close to the midline. To determine the position of the septum, it is best to compare sides bilaterally, ensuring that the space between the lateral wall of the nose and the septum is the same in both nostrils.

After determining the integrity of the septum, the vestibule and the turbinates can be visualized with the patient’s head fairly erect. The examiner tilts the patient’s head backward to see the middle meatus and middle turbinates. (Figure 13-17)The turbinates should be pink, moist, and free of any lesions or discoloration.

Examination of the Mouth and Throat

The assessment of the mouth and oropharynx starts with inspection of the face, head, and neck. The face, ears, and neck are observed, noting any asymmetry or changes on the skin. The neck is palpated, with the examiner paying special attention to the hyoid bone, thyroid and cricoid cartilages, and the thyroid gland. Special attention should be paid to the size of the various glands in the face and neck including the parotid glands in the cheeks over the mandible, the submandibular glands that lie beneath the mandible at the “angle” of the jaw, and the thyroid gland. During palpation, the examiner should also note swelling or tenderness of the lymph nodes in the neck and along the jaw. Examination continues with evaluation of the lips with the mouth both open and closed, noting the texture, color, and any surface abnormalities (Figure 13-18, A).

The examiner asks the athlete to open the mouth to visually examine the labial mucosa as well as the maxillary and mandibular vestibules and notes the color and texture as well as any swelling of the mucosa or gingivae. The buccal mucosa is examined, extending from the labial commissure back to the anterior tonsillar pillar. A tongue depressor or gloved finger may be used to pull the buccal mucosa away from the teeth (Figure 13-18, B). The examiner notes pigmentation, color, texture, mobility, and other abnormalities of the mucosa.

First, the examiner examines the buccal and labial aspects of the gingivae and alveolar ridges (i.e., processes) by starting with

the right maxillary posterior gingivae and alveolar ridge and then moving around the arch to the left posterior area.1,5 The inspection continues with the left mandibular posterior gingivae and alveolar ridge and moves around the arch to the right posterior area. The examiner looks for any abnormal lesions, especially white or dark pigmented areas. Stensen’s duct, the opening of the parotid gland, will look like a small dimple opposite the upper second molar.

With the patient’s tongue at rest and mouth partially open, the dorsum of the tongue is inspected for any swelling, ulceration, coating, or variation in size, color, or texture. The examiner visualizes the papillary pattern on the surface of the tongue, asks the athlete to stick out the tongue, and notes any abnormality of mobility or positioning. Then the tip of the tongue is grasped with a piece of gauze to assist in its full protrusion and to aid in examination of the more posterior aspects of the tongue’s lateral borders (Figure 13-19). The ventral surface of the tongue is examined along with the floor of the mouth.

The examiner is looking for changes in color, texture, swelling, or other surface abnormalities. With the mouth wide open and the patient’s head tilted back, the base of the tongue is gently depressed with a tongue blade. The hard palate is examined, followed by the soft palate and oropharyngeal tissues. Movement of the soft palate may be evaluated by asking the athlete to say “ah.” This also tests cranial nerves IX and X, the glossopharyngeal and vagus nerves, respectively.

Next, the oropharynx is inspected while keeping the tongue depressed with a tongue blade. The tonsillar pillars should be pink and blend in with the integrity of the retropharyngeal wall. Hypertrophied or reddened tonsils that may be covered in exudates indicate a viral or bacterial infection. The posterior wall is normally pink and smooth, although some irregular spots of lymphatic tissue may be present. A yellowish film may indicate postnasal drip. The examiner may elicit the gag reflex at this point in the examination, which also tests the glossopharyngeal and vagus nerves.

Signs and Symptoms

The patient experiences difficulty in hearing in either general or specific situations. Often the athlete will complain of hearing loss after bathing or swimming and may also note hearing loss associated with upper respiratory infection. It should be noted whether the athlete has any pain, dizziness, or tinnitus.