98 THE PHARYNX AND NASOPHARYNX

noted, but size is not an indication of sepsis. The surface of the tonsils is
examined to see whether the mouths of the crypts contain pus. In the adult the
tonsil may be squeezed by the pressure of a spatula on the anterior pillar to see
if pus or food particles are extruded from the crypts. Pus is fluid, but particles
of food appear as solid yellowish pellets which have an unpleasant smell and
taste, of which the patient often complains. The free edge of the anterior
pillar is examined for a band of congestion in this area. The neck is then
palpated for enlarged cervical lymph nodes. There are no absolute criteria of
tonsillar sepsis on inspection, but the combination of palpable cervical
glands, flushing along the free edge of the anterior pillar, and the presence of
pus hi the tonsillar crypts is generally agreed to denote sepsis in the tonsil.

Attention is then turned to the condition of the mucosa of the posterior
pharyngeal wall. Dryness and glazing of the epithelium suggests an atrophic
condition in the nose. Mucopus may be seen coming down from the naso-
pharynx to suggest sinus infection. Dilated blood vessels may be seen on the
pharyngeal wall or on the surface of the tonsil. In some cases there is a
roughness of the mucosa, or small submucosal swellings due to discrete
lymphoid nodules. An appearance suggesting an abnormal gland may be
suspected in thin, long-necked people if they are examined with the head
slightly rotated to one side. This swelling is due to the prominence of a cervical
vertebra.

EXAMINATION IN CHILDREN

Most children can be coaxed to open their mouths sufficiently to allow an
adequate examination of the pharynx without the use of a depressor. Indeed,
most children resent having a spatula inserted into their mouths, and it is
wise not to use one except in the case of the child who clamps his mouth
tightly. The young child will be sat on his mother's knee, and she should hold
his hands. Mothers should not be encouraged to hold their child's head,
because they usually over-restrain the child who becomes fractious. Children
over the age of 4 years will usually sit by themselves provided that the mother
is close by. The child will open his mouth, and the older one will say ""aK
which is sufficient to depress the tongue and expose the tonsils and pharynx.
The younger child can generally be persuaded to put his tongue out, and this
protrudes the anterior pillars so that the tonsils are swung into view. Difficulty
is usually only experienced with frightened children. Those who howl will
open their mouths sufficiently to allow an inspection. The child who clamps
his jaws tightly must be examined with a tongue depressor which is of a
suitably small size. It is inserted between the cheek and the teeth and the tip is
turned medially behind the back teeth, and as this makes the child gag the
pharynx is exposed, even if momentarily.

Examination of the nasopharynx (posterior rhinoscopy) has been described
on p. 13.