Clinical Examination of the Oral Cavity, Tongue, and Salivary Glands (Surgery)

A. ORAL CAVITY - CLINICAL EXAMINATION

Instruments Required

• Good light source (headlamp or torch)
• Two tongue depressors (one in each gloved hand)
• Gloves for palpation

Subsites to Examine Systematically

• Lips (including commissures)
• Buccal mucosa (bilateral)
• Upper and lower gingivobuccal sulci
• Hard and soft palate
• Oral tongue (anterior 2/3)
• Floor of mouth
• Retromolar trigone

Inspection

1. Lips - Look for leukoplakia, ulcers, carcinoma (lower lip >90%), angular cheilitis, chancre
2. Buccal mucosa - Erythema, white/red patches, ulcers, Stensen's duct orifice (opposite upper 2nd molar)
3. Gums and teeth - Mobility (suggests mandibular invasion by tumour), gingivitis
4. Palate - Cleft, swellings (minor salivary gland tumours common here), ulcers
5. Floor of mouth - Wharton's duct orifices flanking frenulum linguae; ranula (translucent bluish cystic swelling)
6. Tongue - Dorsum, ventral surface, lateral borders (most common site for carcinoma), protrusion

"The oral cavity may be best visualized with a well-directed headlamp and a tongue depressor in each gloved hand. A systematic approach to examination ensures that no mucosal surface is missed."

• Cummings Otolaryngology

Palpation

• Bimanual palpation is mandatory - one finger inside the mouth, one hand outside
• Palpate floor of mouth, cheeks, tongue, and retromolar region for induration
• Any induration in a white/red patch is strongly suspicious of malignancy

Red Flag Signs of Oral Neoplasm (Bailey & Love)

B. TONGUE - CLINICAL EXAMINATION

Inspection

1. Open the mouth wide
2. Protrude the tongue fully
3. Move the tongue to each side
4. Lift the tongue to the roof of the mouth (to see the ventral surface and floor of mouth)

• Protrusion: Normally midline. Deviation to one side = ipsilateral hypoglossal nerve palsy (XII) or tongue infiltration by carcinoma (ankyloglossia)
• Dorsum: Colour, coating, papillae; leukoplakia (white patches), median rhomboid glossitis, syphilitic lesions
• Lateral borders: Most common site for carcinoma - look for ulcer, fungating or nodular growth
• Ventral surface and floor: Ranula, sublingual dermoid, varicosities
• Atrophy/fasciculations: Suggest LMN lesion of CN XII

Palpation of the Tongue

• Wrap the tongue in a gauze swab, hold and pull it gently to one side
• Palpate the tongue bimanually - index finger inside the mouth on the tongue; thumb/fingers outside under the chin
• Feel for induration - the single most important sign of malignancy
• Palpate the posterior 1/3 which is not visible (finger palpation essential here)

"Carcinoma of the tongue should be diagnosed whenever an elderly man presents a fungating growth or an ulcer with raised, everted margin and indurated base at the lateral border of the anterior 2/3rd of the tongue." - S. Das

Key Tongue Conditions in Surgical Practice

Lymph Node Drainage of the Tongue

• Anterior 2/3: submental and submandibular LN
• Posterior 1/3: jugulo-digastric LN (bilateral drainage)
• Jugulo-omohyoid LN (secondary/level III)
• Carcinoma of posterior tongue: bilateral neck LN involvement is common

C. SALIVARY GLANDS - CLINICAL EXAMINATION

1. PAROTID GLAND (S. Das)

Position to Know

• Below, behind and slightly in front of the lobule of the ear
• Normal parotid fills the hollow below the ear lobule; swelling obliterates this hollow

History

• Duration and rate of growth (slow = benign; sudden rapid increase = malignant transformation)
• Pain: acute parotitis, abscess; colicky pain at meals = calculus in duct
• Watery discharge during meals = parotid fistula
• Facial nerve palsy = malignant parotid tumour
• Bilateral symmetric enlargement + lacrimal gland = Mikulicz's syndrome; if + dry eyes + arthritis = Sjogren's syndrome

Inspection

• Site: swelling below/behind ear lobule; obliteration of the pre-auricular hollow
• Skin: overlying skin colour, fixity, sinuses
• Stensen's duct orifice: inspect inside mouth opposite upper 2nd molar - look for saliva flow, pus, or dryness

Palpation

1. External palpation - note size, shape, consistency, surface, margins, fixity to skin and masseter muscle
2. Test fixity to masseter: ask patient to clench teeth - if swelling moves with masseter = muscle/deep lobe involvement
3. Bidigital palpation of Stensen's duct: index finger inside mouth along the duct toward the orifice; thumb outside the cheek (Fig. 25.7, S. Das) - feel for calculus in the duct
4. Facial nerve assessment (MANDATORY):
   • Ask patient to show teeth, whistle, close eyes, raise eyebrows
   • Facial nerve NOT involved in benign parotid tumour
   • Facial nerve involvement = malignant parotid tumour (this is a key distinguishing sign)
5. Regional lymph nodes: preauricular, parotid, and submandibular nodes
6. Jaw movement: trismus = malignant involvement of temporomandibular joint periarticular tissue

Key Parotid Conditions

2. SUBMANDIBULAR SALIVARY GLAND (S. Das)

History

• Swelling in submandibular region that is tense and painful at mealtimes = calculus in Wharton's duct (pathognomonic history)
• Distinguish from lymph node enlargement (more common in this region)

Inspection

1. Give patient lemon/lime juice to suck - swelling of obstructed gland will appear at once (provocation test for calculus)
2. Wharton's duct orifice inspection: use torch to inspect floor of mouth; orifices are on either side of frenulum linguae
   • Look for: inflammation/swelling at orifice (impacted stone), pus (on pressing gland = infected gland), dryness on one side vs normal flow the other
   • Dry swab test: place dry swabs on both orifices, give lemon juice on dorsum of tongue; remove swabs after 1 minute - the swab on the obstructed side remains dry

Palpation (bimanual - key technique)

• One index finger inside the mouth in the floor of the mouth (along the duct)
• Other hand underneath the chin/submandibular region
• Feel for calculus in the duct (palpable bidigitally if in the duct)
• Assess: discrete nodular vs single swelling (nodes vs gland), consistency, fixity
• Differentiating gland from lymph nodes: the gland is one swelling; lymph nodes are multiple, discrete or matted

"This examination also differentiates an enlarged salivary gland from enlarged submandibular lymph nodes. The finger inside the mouth can feel the deep part of the salivary gland but not the lymph nodes." - S. Das

Investigations

• Plain X-ray: 80% of submandibular calculi are radio-opaque (vs 20% for parotid)
• Ultrasound: non-invasive; effective for stone detection in gland/duct
• Sialography: lipiodol (Neohydril) injected into duct orifice; demonstrates calculus, duct stricture, sialectasis, or fistula site

3. SUBLINGUAL GLAND AND MINOR SALIVARY GLANDS

• Ranula: cystic swelling of sublingual gland or Blandin-Nuhn glands; translucent, bluish, floor of mouth
• Plunging ranula: extends through mylohyoid into neck; bimanual cross-fluctuation test positive
• Minor salivary gland tumours: most common in hard palate (2nd most common: upper lip); mixed tumours and adenoid cystic carcinoma
• Sublingual dermoid: opaque, non-translucent; midline; above mylohyoid = floor of mouth swelling; below = submental/submandibular cystic swelling

D. GENERAL APPROACH - EXAMINATION FRAMEWORK

Work-up Once a Suspicious Oral/Salivary Lesion is Found (Bailey & Love, Current Surgical Therapy)

1. History and clinical examination (as above)
2. Incisional biopsy - gold standard; avoid necrotic areas; narrow deep biopsy preferred over shallow broad
3. CT + MRI - mandatory for staging oral cancers; MRI superior for soft tissue and perineural spread
4. Neck examination - palpate all levels (I-VI); clinical exam alone has ~74% sensitivity; cross-sectional imaging is complementary
5. EUA (Examination Under Anaesthesia) - for tumours that cannot be fully assessed or biopsied in the awake patient
6. Sentinel Lymph Node Biopsy (SLNB) - for early oral cancers (cT1/T2 N0); positive SLNB → completion neck dissection
7. MDT/Tumour board discussion before treatment

Synchronous Tumours

• Incidence of synchronous primary tumours of the upper digestive tract: 2.4-4.5% (Bailey & Love)
• Full upper aerodigestive tract assessment is important in all oral cavity malignancies

E. HUTCHINSON'S CLINICAL SIGNS (S. Das reference)

• Hutchinson's Wart (condyloma): seen on middle of dorsum of tongue in secondary syphilis
• In examining the tongue for syphilis: primary chancre on tongue, secondary mucous patches/snail-track ulcers/Hutchinson's wart, tertiary gumma (midline dorsum)

SUMMARY MNEMONIC for Salivary Gland Examination

• Swelling - site, size, shape, duration
• Hardness/consistency - variable in pleomorphic adenoma; rock hard in malignancy
• Integrity of facial nerve (parotid) - most important sign
• Palpation bimanual - for duct, stone, deep part of gland

• S. Das - A Manual on Clinical Surgery, 13th Ed., pp. 353-368
• Bailey & Love's Short Practice of Surgery, 28th Ed., pp. 840-841 (Oral Cavity) and pp. 1969-1980
• Sabiston Textbook of Surgery, pp. 1341-1342 (Salivary Gland anatomy and examination)
• Current Surgical Therapy 14e, p. 969 (Oral cavity and neck examination)
• Cummings Otolaryngology Head & Neck Surgery (Oral cavity and salivary gland physical examination)