The oral examination begins anteriorly with a systematic evaluation of structures from anterior to posterior, from left to right.
The floor of the mouth is evaluated by having the patient elevate the tongue. In small children the tongue will often need to be elevated mechanically. The retromolar trigone (the area among the inferior aspect of the anterior tonsillar pillar, medial aspect of the mandible, and lateral aspect of the tongue) needs to be evaluated by pushing the lateral tongue medially to expose this region. The faucial arches need to be closely evaluated for signs of abnormality.
The tonsils should be evaluated for signs of inflammatory changes as well as debris collecting within the crypts of the tonsil. Tonsillar size should be graded on a 1 to 4 scale: 4+ tonsils touch in the midline. Tonsils that are 1+ in size are contained within the tonsillar fossa; 2+ tonsils extend to the medial extent of the tonsillar pillars; 3+ tonsils extend beyond the tonsillar pillars. The oropharyngeal inlet should also be evaluated for adequacy. The tonsils may be of relatively small size but, when combined with a small oropharyngeal inlet, may be obstructing. The posterior pharyngeal wall should be evaluated for symmetry. Granular tissue may often be seen on the posterior pharyngeal wall and represent small areas of lymphoid tissue. Lateral pharyngeal bands are frequently present and represent mild inflammatory changes on the posterior pharyngeal wall secondary to nasopharyngeal drainage or other irritation of this lymphoid tissue.
The soft palate should be evaluated both at rest and in motion. The uvula deserves close attention. A bifid uvula may be a sign of a submucosal cleft of the soft palate. On phonation the soft palate should elevate. Motion of the soft palate should be symmetric. Intraoral palpation is also warranted.
The floor of the mouth should be palpated for any sign of stone development within salivary ducts or a mass developing within the floor of the mouth. The hard palate should always be palpated, paying particular attention to the posterior aspect of the hard palate. A posterior projection should be apparent, signifying a normal condition. A notching of the posterior aspect of the hard palate may represent a submucous cleft palate. The buccal area should also be palpated, feeling for stones and also to express saliva from the parotid glands.
The tongue should be palpated looking for abnormalities within the substance of the tongue.
Endoscopic and Radiologic Evaluation of Pharynx
Flexible endoscopy can be performed easily and safely in an office setting without sedation using a topical anesthetic on the nasopharynx. The nasopharynx is examined for adequacy of velopharyngeal closure, the soft palate for the presence of a submucosal cleft, the tongue base and the lingual tonsils are assessed for size and inflammatory changes, and the hypopharynx and larynx are visualized for signs of cysts, masses, or inflammation.
Radiologic evaluation often begins with a lateral neck x-ray, which provides good visualization of the nasopharynx and assesses the overall size of the adenoid pad. Retropharyngeal and inflammatory processes on the posterior pharyngeal wall may also be identified. Computed tomography and magnetic resonance imaging provide fine detail of specific abnormalities in the oral cavity and oropharynx and the relationship to surrounding structures. Sialograms are rarely performed. Sialograms require the cannulation of either the parotid duct or the submandibular duct and the installation of contrast material to visualize the ductal system within these glands. Abnormalities within the ducts (sialectasia or stones) can be identified. Infectious complications of this procedure increase in the face of active sialadenitis.