Oral (mouth) and oropharyngeal (throat) examination

Introduction

Introduce yourself, confirm the patient's name and date of birth, obtain consent and proceed to wash hands.

Ask the patient to remove any dentures and to sit on a chair and face you. Check if they are in any pain or discomfort and offer analgesia if necessary.

Patients with severe odynophagia (pain on swallowing) are more likely to suffer from trismus (reduced opening of the jaw, also known as “lockjaw”). This can greatly hinder your ability to examine and therefore it may be appropriate to offer analgesia and examine the patient after this has taken effect.

Equipment

Collect the following equipment:

Inspection

General inspection

Start by facing the patient and observing for any obvious swelling around the cheek or mandible, which may be due to swollen parotid or submandibular glands.

In addition to multiple small salivary glands littered around the mucosa of the oral cavity there are three large salivary glands which open into it on each side:



General causes of salivary gland enlargement include:

Unique causes of parotid enlargement include:



Lips and gums

Ask the patient to open their mouth and use your torch to inspect the patients lips for any colour changes, such as “brown freckles” found in Peutz-Jegher’s syndrome, or signs of inflammation (stomatitis/cheilitis). Look for any ulcers (sores) which may be sequelae of erythema multiforme or infections, such as syphilis or herpes simplex virus. Very rarely, a lip ulcer with a hard edge may be due to cancer.

Briefly observe for inflammatory dental disease in the gums (gingivitis) and teeth (periodontitis).

Hereditary intestinal polyposis syndrome, or “Peutz-Jegher's syndrome,” is an autosomal dominant disease characterised by the development of benign hamartomatous polyps in the gastrointestinal tract and hyperpigmented macules (brown freckles) on the lips and oral mucosa.



Inflammation of the mouth and lips (stomatitis) or the lips only (cheilitis), is most commonly caused by irritation at the corners of the mouth (called angular cheilitis). This can be precipitated by vitamin (B2) and mineral (iron) deficiencies or candida infection.

Tongue

Ask the patient to stick out their tongue and move it from side to side to observe for any obstruction, which may be due to swellings.

Inspect the tongue for:

If there is any abnormal tongue movement, perform a cranial nerve examination.

Glossitis refers of inflammation of the tongue. This can be infective or nutritional in origin. The tongue will be sore, the dorsal surface will usually be smooth and erythematous, and there will be absence of some of the lingual papillae. Two important types of glossitis are as follows:


Buccal mucosa, cavity floor and hard palate

Use your tongue depressors to manipulate the tongue and have a good look at the buccal mucosa. Ask the patient to lift their tongue to view the floor of the oral cavity and then to tilt their head back so you can observe the hard palate.

Identify any:

Oropharynx

Ask the patient to centre their tongue. Using your tongue depressors, gently press the tongue so that you can get a good view of the oropharynx. Identify the soft palate and uvula. Mucosal changes described above may also be present here. Position your torch to get good views of the anterior palatoglossal and posterior palatopharyngeal arches. The pharyngeal tonsils will be sat in the tonsillar depressions in between the pharyngeal folds (pillars) which form the arches.

Palpation

A labelled image of the oropharynx.

Identify the various structures in the oropharynx.

Inflammation of the pharyngeal folds and uvula will be present in pharyngitis. Pharyngitis may also present with uvular swelling. Other causes of swelling include injury (for example, during intubation) or acid reflux.

Identify the position of the uvula. Deviation with the absence of any other signs or symptoms may be normal, but otherwise may be due to a contralateral glossopharyngeal nerve lesion (the uvula is deviated “away” from the lesion). If there is nearby palatine swelling, such the presence of a peritonsillar abscess (quinsy), then this will push the uvula to the contralateral side.

In most healthy individuals, the tonsils can be difficult to identify. Chronic, bilaterally enlarged tonsils are usually benign. Causes of a unilateral tonsillar enlargement however include papilloma and carcinoma. Pharyngitis may spread to the tonsils causing tonsillar inflammation (tonsillitis). Swelling is often bilateral, usually with one tonsil swelling more than the other. White exudate may be present if the cause is bacterial in nature.

Tonsils will be absent in a tonsillectomy; white granulation tissue is often present in the weeks immediately following one.

Asking the patient to say “aaah” will cause them to naturally depress the base of the tongue and aid you in your examination.

Inflammation of the pharynx is known as pharyngitis. The patient will present with odynophagia and fever. This is typically caused by “common-cold” viruses such as adenovirus and are self-limiting. More aggressive viruses include Epstein-Barr virus and measles virus. Bacterial infections are much less common but are almost always due to Group A streptococcal species such as Streptococcus pyogenes.



Tonsillitis is a subtype of pharyngitis, and hence has the same aetiology and presentation. Both viral and bacterial tonsillitis can cause swelling, but only the latter presents with exudate. Numerous infections of tonsillitis requiring antibiotics (>7 in the span of a year) may warrant consideration of a tonsillectomy.



One of the complications of bacterial tonsillitis is infection spreading to the peritonsillar space forming a peritonsillar abscess, also known as a “quinsy.” An untreated peritonsillar abscess can lead to oropharyngeal obstruction and trismus (due to odynophagia). The size of the tonsils has no bearing on the presence or absence of a peritonsillar abscess; often the complication occurs when the tonsils are barely enlarged.

Palpation

Put on the non-sterile gloves. Ask the patient if they mind if you palpate around the oral cavity.

Bimanually palpate the floor of the oral cavity, identifying any sialoliths or swelling of the submandibular or sublingual glands. Next palpate the lateral wall for swelling of the parotid gland. Characterise any such swellings assessing for size, tenderness, texture and consistency.

Use your index or middle finger to palpate on the inside of the oral cavity, and your thumb or a finger of the opposing hand to palpate externally. You may choose to do this with one or two hands depending on their size.

Completion

Complete the examination by thanking the patient, disposing of equipment and washing your hands. If appropriate, offer to examine the ears, nose, neck and cranial nerves. Further investigations would warrant referral to any of the following teams, depending on the pathology identified:

Present and/or document your findings.

Interactive markscheme


When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end. We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:

  1. Introduction: "Hello, I'm SimpleOSCE and I am a medical student. I've been asked to examine your mouth and throat today. Can I confirm your name and DOB? Thank you."
  2. Explain examination and obtain consent: “This will involve me using a torch to look inside the mouth. I will be using some tongue depressors to which may be a little uncomfortable, so let me know if you are in any pain.”
  3. Wash your hands.
  4. Check if the patient is in pain or discomfort. Use analgesia if necessary.
  5. Assemble the correct equipment including a torch, 2 tongue depressors and a pair of non-sterile gloves.
  6. Inspect for any obvious parotid or submandibular swelling.
  7. Ask the patient to open their mouth and inspect the lips for colour changes (such as brown freckles), inflammation (cheilitis) and ulcers.
  8. Inspect the gums and teeth for dental disease.
  9. Ask the patient to stick out their tongue and move it from side to side.
  10. Inspect the tongue for macroglossia, glossitis and white patches (candidiasis).
  11. Inspect the buccal mucosa, cavity floor and hard palate for aphthous ulcers, white patches, submandibular duct stones and sublingual/submandibular gland swelling.
  12. Throughout the examination, use your tongue depressor to obtain a better view.
  13. Identify the pharyngeal folds and uvula for inflammation and swelling and the tonsils if they are enlarged.
  14. Put on non-sterile gloves.
  15. Palpate the floor and wall of the oral cavity looking for any sialoliths or salivary gland swelling.
  16. Dispose of equipment in a clinical waste bin.
  17. Wash your hands and thank the patient.
  18. Present/document your findings.
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