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.
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).
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.