Assessment of the hard and soft palate
Examination of the oral cavity begins with assessing the state of the palate. Special attention is paid to the color of the mucous membrane and the presence of inflammatory changes. In smoking patients, characteristic zones of inflammation localized around the openings of minor salivary glands can often be found on the hard palate.
To evaluate the soft palate, a special functional test is performed. The patient is asked to pronounce a prolonged "ah-ah" sound. Normally, a symmetrical elevation of the palatal curtain is observed. However, if the patient has soft palate paresis associated with a lesion of the vagus nerve (n. vagus), the palate on the affected side does not rise. Meanwhile, the uvula (uvula) deviates toward the healthy side due to the preserved muscle tone.
Lymphoid apparatus of the pharynx
At the border of the respiratory and digestive tracts lies an accumulation of lymphoid tissue forming the Waldeyer's ring (Pirogov-Waldeyer ring). It performs vital protective and hematopoietic functions. The ring includes:
- Two palatine tonsils;
- Two tubal tonsils;
- One pharyngeal tonsil;
- One lingual tonsil.
Clinically, the palatine tonsils are the most accessible for examination, located between the anterior and posterior palatine arches. Normally, they only slightly protrude beyond the arches. During examination, the physician assesses their color, symmetry, size, as well as the presence of edema, ulceration, or exudate (deposits).
In tonsillitis, the tonsils increase in size. This enlargement is caused not only by inflammatory edema but also by hypertrophy of the lymphoid tissue itself. The degree of hypertrophy can be so pronounced that the tonsils touch each other at the midline. Chronic tonsillitis requires special attention as it is a predisposing factor for the development of a number of severe somatic diseases.
A specific picture is observed in diphtheria infection. Membranous deposits of a grayish-yellow or yellow-white color form on the tonsils. These membranes are very thick and tightly adhered to the underlying tissue; they are removed with great difficulty, exposing an eroded and bleeding surface.
Examination of the salivary glands and mucous membrane
When examining the oral mucosa, the physician notes its color, the presence of defects ( ulcers), various nodules and spots. An important step is the evaluation of the function and size of the salivary glands.
Hypofunction of the salivary glands is subjectively experienced by the patient as dryness in the mouth (xerostomia). A striking example of pathology is Sjögren's syndrome ("dry" syndrome). It is based on a disorder of lacrimal and salivary fluid secretion. The syndrome is characterized by a triad of signs:
- Xerostomia (dryness of the oral cavity);
- Xerophthalmia (dryness of the eyes);
- Dry keratoconjunctivitis.
Sjögren's syndrome is systemic in nature and may be accompanied by involvement of the joints, lungs, and pancreas.
Enlargement of the salivary glands most frequently affects the parotid glands (developing parotitis). The most common infectious cause of this condition is mumps (commonly known as epidemic parotitis). Among non-infectious and secondary causes of enlargement are sarcoidosis, various neoplastic processes, and chronic alcoholism.
Pharyngeal pathologies and swallowing disorders
The final stage is pharyngoscopy. It should be remembered that visual examination of the oral cavity only reveals the posterior pharyngeal wall. The physician assesses the presence of hyperemia (redness), the nature of possible deposits, and the presence of exudate.
Pain syndrome in the throat (odynophagia) is most commonly associated with inflammation of the pharyngeal muscles against the background of upper respiratory tract diseases. However, a more alarming symptom is dysphagia — a disorder of the swallowing act. Its pathogenesis is based on damage to the muscles of the pharynx and the upper part of the esophagus, which is frequently associated with systemic connective tissue disorders such as scleroderma or dermatomyositis.
Dysphagia has a characteristic development pattern:
- In the early stages, the patient complains of choking when swallowing solid food;
- In the late stages, severe difficulties arise even when attempting to ingest semi-liquid or liquid food.
Briefly: answers to topical questions
Which nerves provide motor and sensory innervation to the pharynx?
Motor innervation of the pharynx is related to the glossopharyngeal (IX pair) and vagus (X pair) nerves, which are mixed nerves.
- Motor innervation is carried out via the nucleus ambiguus (n. ambiguus), common to both nerves; the innervation zone includes the muscles of the pharynx, soft palate, larynx, and upper esophagus.
- Sensory innervation of the pharyngeal mucosa and tonsils is provided by the glossopharyngeal nerve.
Which regional lymph nodes receive lymphatic drainage from the palatine tonsils?
Lymphatic drainage from the palatine tonsils goes into the retropharyngeal or deep cervical lymph nodes. Lymphatic vessels pierce the pharyngeal wall at various levels (near the palatine tonsil or auditory tube) and drain into the following collectors:
- Retropharyngeal lymph nodes (nodi lymphoidei retropharyngeales) are located on the posterolateral surface of the pharynx.
- Deep cervical lymph nodes are located along the neurovascular bundle of the neck (internal jugular vein, common carotid artery).
The rule of vagus nerve lesion: the uvula "runs away" from the disease — in soft palate paresis, the uvula deviates toward the healthy side, where muscles have maintained their normal tone.
Class and exam questions
Which tonsils are part of the pharyngeal lymphoid ring?
Waldeyer's ring consists of two palatine, two tubal, one pharyngeal, and one lingual tonsil. They are located at the border of the respiratory and digestive tracts.
How to distinguish diphtheritic deposit on the tonsils?
In diphtheria, the deposits are membranous, grayish-yellow, and thick. They are tightly adhered to the tonsil tissue, and their removal leaves an erosive, bleeding surface.
What is Sjögren's syndrome and how does it manifest?
This is a systemic disease manifesting with the classic triad: dry mouth (xerostomia), dry eyes (xerophthalmia), and dry keratoconjunctivitis. It can also affect the lungs, joints, and pancreas.
How does dysphagia progress in systemic diseases?
In the early stages, dysphagia manifests as choking when swallowing solid food only. As the pathology progresses, difficulties arise even with the intake of liquid and semi-liquid food.
What else to study on this topic
- Differential diagnosis of inflammatory diseases of the hard and soft palate
- Systemic complications of chronic tonsillitis
- Etiology and pathogenesis of dysphagia in scleroderma and dermatomyositis
- Non-infectious causes of salivary gland involvement (sarcoidosis, neoplastic process)
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