Examination of the Nose and Oral Cavity

External Inspection of the Nose:

Examine the external nose. Note any skin lesions, deformity, or trauma.
Note the presence of dark circles under the eyes (“allergic shiners”) or a transverse nasal crease (due to upward wiping motion across the nose, or “allergic salute”).
Note the color, consistency, and odor of any discharge from the nares.
In a trauma setting, note whether sensation is intact over the skin of the nose.
Apply pressure to the face over the paranasal sinuses and assess for tenderness.

Anterior Rhinoscopy:

Anterior rhinoscopy is performed using a head lamp and a nasal speculum. The patient should be positioned facing the examiner, with the head held vertically. The examiner holds the nasal speculum in the left hand to examine the right nasal cavity and the right hand to examine the left nasal cavity. This allows the examiner to use the index finger of the hand holding the speculum to apply upward pressure on the nasal tip, increasing visualization. The nasal speculum is inserted into the nasal cavity with the blades closed. Once inserted, the blades of the speculum can be opened and the inferior turbinate examined. The patient is then instructed to tilt the head backward to allow for examination of the superior nasal cavity. The nasal speculum should be withdrawn with the blades slightly open to prevent discomfort to the patient from traction on the nasal hairs.
Note the overall patency of each nasal cavity. Look for any intranasal masses or lesions. The misting pattern on a dental mirror placed under the nares can assist in determining the relative degree of nasal air flow (i.e., an obstructed nasal passage would result in decreased misting of the mirror).
In the setting of epistaxis, examine Kiesselbach’s area for prominent vessels.
Note the color and consistency of any secretions in the nasal cavities.
Examine the septum on both sides. Note any deviation or bony spurs.
Examine the inferior turbinate on both sides. Note any hypertrophy, mucosal erythema or edema, or whether a pale, boggy appearance is present (suggestive of allergy).
Note whether the choanae are visible posteriorly. In some cases, adenoidal tissue can be visualized obstructing the choana.

Inspection and Bimanual Examination of the Oral Cavity:

The oral cavity examination should be performed using a head lamp and tongue depressors to assist in visualization.
Examine the lips for lesions, fissures, cracking, and abnormal pigmentation.
Examine the general condition of the teeth and gums. Note any dental caries, periodontal disease, or missing teeth.
Note the patient’s occlusion class.
Examine the tongue for lesions. The tongue may be grasped with gauze and directed to one side or the other to enable visualization of the lateral surface.
Evaluate tongue mobility by asking the patient to protrude the tongue and move it from side to side.
Examine the floor of mouth by having the patient lift the tongue/touch the tip of the tongue to the roof of the mouth.
Perform a bimanual examination of the floor of mouth by palpating with one gloved hand in the mouth and the other pressing upward on the submental region. Note any masses or nodules.
Examine the buccal mucosa for lesions or discoloration. Tongue depressors may be used to push the buccal wall laterally away from the teeth to aid in visualization.
Examine the hard palate. Note any growths or lesions, particularly non-midline masses. (A torus palatinus is a midline bony outgrowth of the hard palate that is benign and does not require further evaluation.)
Depress the tongue and visualize the soft palate and oropharynx. Note the size and length of the uvula and whether it is bifid (which may indicate a submucous cleft palate).
Note the size and symmetry of the palatine tonsils. Tonsillar size may be graded from 0 to 4+ based on how far medially they extend. Also note whether tonsillar exudate is present, if the tonsils appear cryptic or scarred, or if tonsilliths are present.
With a gloved finger, palpate the tongue base and the palatine tonsils for presence of any masses. Prepare the patient for the likelihood of gagging and discomfort during this process.