Examination of Oral Cavity

This is a simplified plan to examine the mouth and the tongue..

The Mouth and the tongue

Tongue

Anterior 2/3
  • Size
  • Shape
  • Papillae
  • No fissures
  • Congenital tie
  • Short ferenulum
  • Ankyloglossia
  • Congenital fissures
  • Geographical tongue
Taste

Corda tempani (facial nerve)

Sensation

Lingual nerve (trigeminal nerve)

Motor

Hypoglossal nerve

Paralyzed tongue deviate to the paralyzed side

Posterior 1/3 Not accessible except mirror or under anaesthesia
Lump (as any swelling)
Ulcer (as any ulcer)

Do not forget examination of cervical lymph nodes

TAKING HISTORY FROM A PATIENT WITH An oral cavity problem

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms Relation to the main complaint

  • Swelling
  • Ulcer
  • Pain
  • Causes of chronic superficial glossitis that predispose malignancy (six Ss)
    • Syphilis, Smoking, Sharp tooth, Spirits, Spices and Sepsis
  • Sequelae of malignancy of the tongue

Spread

Local (posterior 2/3)

Asphyxia

Lymphatic

Lymph nodes enlargement

Infiltration

Lingual artery

Haemorrhage

Lingual nerve

Pain referred to ear

Recurrent laryngeal nerve

Hoarseness of voice

Infection

Halitosis

Pain

Necrosis

Aspiration pneumonia

Ankyloglosia

Dysarthria

Dysphagia

cachexia

Causes of ulceration of the tongue

(Traumatic, Neoplastic, inflammatory, ischemic, autoimmune,..)

  • Aphthous ulcer
  • Trauma (dental)
  • Non-specific glossitis
  • Chancre
  • Gumma
  • TB
  • Carcinoma
  • Lichen planus
  • Herpetic ulcers
Causes of macroglossia
  • Multiple haemangiomata
  • Multiple lymphangiomata
  • Plexiform neurofibromatosis
  • Amyloid infiltration
  • Infiltrating carcinoma
  • Muscle hypertrophy (cretins)
Causes of swelling of the jaw
  • Infection
    • Alveolar (dental) abscess
    • Acute osteomyelitis
    • Actinomycosis
  • Cysts (odontomes)
    • Dental cyst
    • Dentigerous cyst
    • Other odontogenic cysts and cystic tumors
  • Neoplasm
    • Benign
      • Fibrous dysplasia
      • Giant cell granuloma
      • Odontogenic tumors
    • Locally invasive
      • Adamantinoma
    • Malignant
      • Osteogenic sarcoma
      • Malignant lymphoma (Burkitt’s tumor)
      • Secondary tumors (by direct invasion or blood spread)
  • Epulides
    • Fibrous epulis
    • Granulomatous epulis
    • Myeloid epulis
    • Sarcomatous epulis
    • Carcinomatous epulis
Dental Cyst vs. Dentigerous Cyst

Dental cyst

Dentigerous cyst

Adult Young age
In relation to carious tooth In relation to missing tooth
Maxilla Mandible
Incisors and canines Premolars and molars
Unilocular Tooth inside

Scalp Examination

 

Scalp examination

Inspection

Palpation

Lump

  • Number
  • Site
  • Shape
  • Size
  • Surface

Skin and color   Alopecia

  • Special signs

Pulsations Metastasis

Cirsoid aneurysm

Impulse on cough Meningiocele

Transillumination

  • Relations to the surroundings .. Mobility
  • Relation to skin
  • Relation to muscles
  • Relation to bone
  • Other swellings
  • Temperature
  • Tenderness
  • Edge
  • Reducibility
  • Solid, fluid or gas
  • Consistence
  • Fluctuation
Ulcer (as any ulcer)
Differential diagnosis of scalp disorders
  • Traumatic
    • Heamatomas
    • Cephalhaematoma
  • Sebaceous cyst
  • Neoplastic
    • Benign
      • Ivory osteoma
      • Lipoma
      • Haemangioma (capillary, cavernous and arterial)
      • Neurofibroma
    • Malignant
      • Primary
        • Basal cell carcinoma
        • Squamous cell carcinoma
        • Malignant melanoma
        • Leukaemia
        • Myeloma
      • Secondary
        • Breast
        • Bronchus
        • Thyroid
        • Prostate
        • Kidney
  • Infective
    • Cock’s peculiar tumor
    • Tinea capitis
    • Abscess
  • Others
    • Psoriasis
    • Seborrhoeic dermatitis
    • Meningiocele
    • Dermoid cyst

Anatomical Significance

 SCALP Layer Content Surgical importance
S Skin Hair follicles
  • Alopecia
  • Sebaceous Cyst
  • If multiple Turban
C CT Blood vessels
  • Bleeds a lot
  • Good healing
  • Site of heamatomas
nerves Layer of local anesthesia
Fibrous tissue septa Heamatoma will be localized
A Aponeurosis
L Loose areolar tissue Loose
  • Dangerous
  • Spread of infection
  • Mobile Cutaneous swelling
  • Layer of descalping
Emissary veins
P Periosteum

Examination of an ulcer

Points to be emphasised while examining an ulcer in an OSCE station

Ulcers

Inspection

Palpation

Description

  • Number
  • Site
  • Shape
  • Size (and Depth)
  • Floor
  • Edge
  • Margin
  • Discharge
  • Temperature
  • Tenderness
  • As inspection
  • Base
    • Extent
    • Induration
    • Tenderness
    • Motility
Draining L.N.s
Neuro-Vascular Bundle

How to take a history from a patient with an ulcer

Differential Diagnosis of an Ulcer

According to the cause

Example

Character

Trauma Sloping edge
inflammation TB undermined edges

associated with pain

Venous various veins i.e. Venous Ulcer Sloping edges
Lymphatic With lymphoedema
Neurologic diabetic neuropathy Neuropathic ulcer

Without pain

Neoplastic SCC

BCC

Everted edges

Beaded edges

 

According the site
Face Leg Foot Tongue
Rodent ulcer

Epithilioma

Keratoacanthoma

Ulcerated seb. Cyst

Ulcerated M.M.

TB ulcer

Vascular Venous

Arterial

Lymphatic

neuropathic Dyspeptic

Dental

Malignant

TB

Herpes

syphilis

Traumatic Vascular Ischemia
Infection TB Traumatic
Neoplastic -1ry as MM or BCC

-Ulcerated deep malignancy

Neoplastic
Signs suggestive of malignancy in an ulcer
  • Rapid increase in size
  • Rapid increase in ulceration
  • Bleeding
  • Change in color
  • Halo of pigmentation
  • Satellite nodules
  • Irritation
  • Lymph node enlargement
  • Distant metastasis
Floor of an ulcer
  • Malignant necrotic tissue
  • Granulation tissue
    • Healing
      • Pink
      • Finley granular
      • Bleed in touch
      • Level with skin
    • Non-healing
    • Non specific
      • Pale or yellow
      • Very vascular
    • Specific
      • Like TB caseation

Principles of Examination of Lumps

 

 

Lumps

 

Inspection

Palpation

Description

  • Number
  • Site
  • Shape (sphere, hemisphere, asymmetrical, pear shaped, kidney shaped or others)
  • Size (in the 3 dimensions)
  • Surface (smooth or irregular)
  • Skin and color (smooth and shiny or thick and rough /scars or sinuses)
  • Special signs
  • Temperature
  • Tenderness
  • As inspection
  • Edge
  • Reducibility
  • Solid, fluid or gas
  • Consistence (Stony hard, firm, rubbery, spongy or soft)
  • Fluctuation by
    • Standard
    • Paget’s
    • Cross fluctuation test
    • Bipolar fluctuation test
  • Fluid thrill
  • Translucence
  • Vascular
  • Pulsation (Expansile or Transmitted)
  • Compressibility
  • Thrill

Relation to surrounding

  • Mobility

Relation to muscles:

Ask the patient to contract the muscle and reset mobility

Superficial to the muscle Swelling bulges more

Within the muscle No significant change in size

Deep to the muscle Swelling diminished in size

  • Mobility

Relation to skin:

 

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Confirm relation to the muscle

Draining L.N.s
Neuro-Vascular Bundle
Percussion
Auscultation