Clinical examination

Pharynx and larynx

Prior to examination of the pharynx, the oral cavity should be examined with the aid of a good light and tongue depressors (Fig. 43.8).

The ear, nose and throat (ENT) surgeon customarily uses a reflecting mirror on the head or a headband-mounted fibreoptic light source which permits use of both hands to hold instruments. Inspection should include the buccal mucosa and lips, the palate, the tongue and floor of the mouth, all surfaces of the teeth and gums, opening and closing of the mouth, and dental occlusion. Patients should be asked to elevate the tongue to the roof of the mouth and protrude the tongue to both the right and the left. Palpation may be required using one or two fingers gently intraorally to feel any swellings, and this may be combined with extra oral palpation of the submental and submandibular lymph nodes and salivary glands. Simple percussion of the teeth may reveal tenderness indicating adjacent pathology in the maxilla or mandible. Examination of the mouth without adequate illumination, the use of a tongue depressor, and gentle palpation may fail to reveal common and important pathology. Following examination of the oral cavity, the oropharynx is inspected with the light and with the tongue depressor placed firmly on to the tongue base to depress it inferiorly. The anterior and posterior faucial pillars, the tonsil, retromolar trigone and posterior pharyngeal wall should all he inspected for colour changes, ulceration, pus, foreign bodies and swellings. Even with an experienced examiner, approximately one-third of patients cannot tolerate the depression of the posterior base of tongue without gagging. Pain and trismus as a consequence of pharyngolaryngeal or neck pathology may add to the difficulty of the examination. However, if the patient is co­operative the nasopharynx may be further examined by posterior rhinoscopy using a postnasal mirror introduced along the tongue depressor and moved so that a mirror image is seen of the nasopharynx. Likewise, further examination of the infe­rior oropharynx, larynx and piriform fossae can be obtained by indirect laryngoscopy using laryngeal mirrors. Both of these mirror examination techniques require the use of a headlight and both of the examiner’s hands. Indirect laryngoscopy allows visualisation of the larynx to the level of the vocal folds, and sometimes additional views of the subglottic and tracheal airway. Vocal fold mobility may be assessed.

Fibre-optic pharyngolaryngoscopy

The fibre-optic nasendoscope is passed through the nose under topical anaesthesia, and the entire nasopharynx, oropharynx and larynx can be seen and demonstrated to others. This technique allows high-quality visualisation in over 90 per cent of patients (Fig. 43.9). Modern fibre-optic nasendoscope have produced tremendous improve­ments in examination Of the nasal cavities, pharynx and larynx. They are now widely available and should he used whenever possible.

The neck

With the patient sitting, expose the whole neck so that both clavicles are clearly seen. Inspect the neck from in front and ask the patient to swallow, preferably with the aid of a sip of water. Note the movements of the larynx and any swelling in the neck. Ask the patient to protrude the tongue if there is a midline neck swelling. A thyroglossal cyst will move upwards with the tongue protrusion. Then stand behind the seated patient who should sit with the chin flexed slightly downwards to remove any undue tension in the strap muscles, plastysma and sternocleidomastoid. Palpate the neck bilaterally using the pulps of the fingers, not the tips. It is important to palpate the groups of lymph nodes in a definite manner comparing the two sides of the neck. Begin with the superficial chain around the upper neck and carefully palpate the entire length of the deep cervical nodes around the internal jugular vein. On examining for a lump in the neck it is often helpful to ask the patient to point to the lump first. Ask them whether the lump is tender. A swelling beneath the sternomastoid muscle may be considerably larger than your evaluation on palpation. If you are suspicious that a neck node is enlarged as a result of malignancy (it may be hard, irregular or fixed to overlying skin or to deep structures) then it is mandatory to inspect the nasopharynx, tonsils, tongue base, piriform fossa and supraglottic larynx (Table 43.2).