Oropharyngeal Examination - Legit Question

[Apollyon]

Aloha all,

You guys (oto in specific, and surgical in general) have been great in indulging those of us that do a few things occasionally that you guys do often.

My question is real, and I am looking for some pointers. When I have to look at the patient's oropharynx, what can I do to get the best look? I have adults lean their heads back sometimes, but the adults seem unable or unwilling to open their mouths adequately (ironic for how wide some of them have opened their mouths to get as fat as they are), or won't protrude the tongue. I press down on the tongue with the blade, until I can hear the wood cracking. With the kids, I know that contacting the tonsillar pillar will cause a reflex opening the mouth, and that brief window gives me what I need sometimes.

But what am I doing wrong? I have a Fenix light, so, when I do get the chance, I know that I can see what I have to. I recall a resident that had this holder that held the tongue blade, and had two fiberoptic lights on it, so it was all there.

Should I be pushing down harder on the tongue? Sweeping it to the side? Or what?

Seriously, I am looking for professional tips here!

(And I don't have access to a fiberoptic scope!)

Thank you.

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[Fah-Q]

Tell them to relax their tongue and breathe through their mouth. Having them pant like a dog will raise the palate and relax the tongue. Don't just push the tongue down with the blade but also push it posteriorly to get a better view. Some people are just difficult to get a good view. If all else fails just gag 'em and get a quick look. Another option is to palpate the oropharynx if you really can't get a view. Admittedly, this is a very "oto" move and patients like it about as much as a rectal exam.

 

[Pir8DeacDoc]

Tell them to relax their tongue and breathe through their mouth. Having them pant like a dog will raise the palate and relax the tongue. Don't just push the tongue down with the blade but also push it posteriorly to get a better view. Some people are just difficult to get a good view. If all else fails just gag 'em and get a quick look. Another option is to palpate the oropharynx if you really can't get a view. Admittedly, this is a very "oto" move and patients like it about as much as a rectal exam.

Agree with this.

What exactly is it you want to see? A mirror can work nicely too if you are trying to see the base of tongue. The sweetheart retractor might work too..Some people just have small mouth/big tongue and not much can change that.

 

[Apollyon]

Mahalo for the quick replies. Of course, I hadn't thought of those things.

I am just trying for a good view of the oropharynx, along with the tonsils, usually for the pharyngitis and possible abscess cases, along with the uvula.

"If you always do what you've always done..." &c.

I'll keep at it!

Thanks again!

 

[OtoHNS]

I'd say the biggest single thing you can do is to tell the patient to relax their tongue and keep it in their mouth. Patients will always stick their tongue out, but doing this frequently causes the tongue to elevate so that you can't see anything and makes the tongue tense so you can't push it down easily.

 

[Apollyon]

So just have them open wide? I can even say it in Spanish - "Abra la boca, y soca la lingua".

I hadn't really thought about that. I even tell the patients that, when they say "ahh", it elevated the palate so I can see more.

Common sense is an uncommon virtue. Thank you again!!

 

[resxn]

I'd say the biggest single thing you can do is to tell the patient to relax their tongue and keep it in their mouth. Patients will always stick their tongue out, but doing this frequently causes the tongue to elevate so that you can't see anything and makes the tongue tense so you can't push it down easily.

This is the one single thing that I think students and residents don't have patients do.

The gag reflex is strongest in the midline so when you are evaluating the oropharynx, use the depressor on the sides of the tongue and look at one side at a time rather than in the middle trying to see both at the same time.

Even then, sometimes it's hard. When I am doing an I&D on a PTA, pt's have serious trismus most of the time. I use two tongue blades side by side on the side of the tongue to get good exposure for them.

You'll get it with the tips on this page with 20 or so practice attempts. Usually it will click and you'll be good from then on. But there are still those patients where I can't see what I want using any trick I've got. That's when you go buy that scope or refer to the ENT who has one.

 

[Apollyon]

That is money. Thank you!

 

[DrBodacious]

This Indian guy I work with describes some patients as having a tongue like a "magic carpet" - that when they open their mouth and you put your tongue blade in - it just wiggles around reflexively. Those patient's are tough.