Diseases Of The Nose Throat And Ear

CHAPTER 19
CLINICAL EXAMINATION

A good light is essential for a proper examination of the pharynx and naso-
pharynx. In hospital this is achieved by reflecting the light from a bull's eye
lamp by a forehead mirror, or by the use of an electric headlamp worked off
the mains. A similar headlamp powered by batteries may be used in the
patient's home, but this has the same disadvantages as an electric torch—when
the battery begins to fail the light is poor and an appreciation of colour
changes diminishes. A constant source of light is important in examination
when much depends on the recognition of changes in colour in the buccal and
pharyngeal mucosa.

The patient should be encouraged to relax and breathe easily through his
mouth. An angled metal tongue depressor is more useful than a wooden
spatula because the view with this is obstructed by the examiner's fingers
holding the spatula. The blade of the depressor is introduced centrally so that
the tip reaches just beyond the highest part of the dorsum of the tongue.
Gentle pressure downwards and forwards should depress the tongue to
expose the pharynx (Fig. 47). If the instrument is placed too far forward the
tongue arches posteriorly to obstruct the view, while if it is placed too far back
the patient will gag. In some patients with irritable throats the depressor may
be placed to one side of the midline and then the other, pressing the tongue
towards the midline to expose each side of the pharynx in turn. Some patients
will reject this, and many of these can display their throats adequately without
any assistance. Should a thorough examination be essential in a patient who
resents the depressor, the throat may first be sprayed with a 10 per cent
solution of cocaine hydrochloride.

Examination should be systematic and thorough. The buccal mucosa, teeth
and tongue should be inspected before examining the pharynx. Dentures
should be removed because if they are loose the patient will not relax during
the examination. The soft palate is next inspected for mobility and adequate
closure of the nasopharynx during phonation. Any evidence of a midline
cleft should be noted, whether it be a bifid uvula, a submucous cleft or a frank
cleft palate.

The function of the soft palate is highly important, especially in children.
The only speech sounds pronounced with an open nasopharynx are *m\ *rf
and '/#'. For all other sounds the soft palate rises to close off the nasopharynx.
Failure to do this results in hypernasality with escape of air through the nose
during phonation. The classic example of this is the patient with a cleft
palate, but it occurs to a lesser degree if the palate is insufficient, as in bifid
uvula or submucous cleft, or if it is paralysed. The action of the soft palate
may be demonstrated by a palatogram in which lateral radiographs are taken
with the patient at rest, saying V, and saying 6ee* (Fig. 48).

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