Physical Exam: The Fair inks

October 22, 2007

We were briefly distracted by the funny thingy hanging down in front of us (the uvula) but now we can go where the money is.  While there is not literally money in the tonsils, there is much to be made from them from a historical standpoint.

The exam of the mouth will often focus on the back of the mouth.  This part of the mouth is called the pharynx.  The pharynx is basically the area behind the front of the uvula.  It is often mispronounced as Fair-nix; but it is actually pronounced Fair-inks.

The pharynx is divided into three areas: the nasopharynx, which is above the soft palate (we have covered this when we discussed the nose - remember Tom Brocaw?), the oropharynx, which is from the soft palate down to base of the tongue, and the laryngipharynx which extends down to the vocal cords.

Often the oropharynx is the only part of the mouth physical exam noted:

OP - tons s er/ex

Which translates: oropharynx:  Tonsils without redness or gunk on the tonsils (or the back of the throat).

The Tonsils - Keepers of the Crypt

Tonsils are part of the lymphatic system - a network of tissues where white blood cells gather, serving as a line of defense against various environmental assaults.  Since the nature of the things which are put into the mouth is pretty much controlled by the decision-making ability of the owner of that mouth, the body has developed defense against poor decision-makers.  In other words: you do something dumb, your tonsils bail you out (in theory).

There are actually 3 sets of tonsils:

• The adenoids - or nasal tonsils, which are on the top surface of the soft palate
• The pharyngeal tonsils - what people think of when you say "tonsils", which are on either side of the back of the mouth.
• The lingular tonsils - which is the bumpy part of the very back of the tongue. 

The lingular tonsils are just there so that people will notice them and ask their doctor about that bumpy stuff at the back of their tongue.  They don’t really cause trouble and never get removed (that I know of).

The big players here are the pharyngeal tonsils.  They are the ones that get infected to cause tonsillitis, and they are the ones who put the children of ENT physicians through college. 

When I was a child, the only criteria for you to need a tonsillectomy (removal of the tonsils) was that you opened your mouth too often in front of an ENT doctor.  You were very lucky to make it through childhood with tonsils still intact.  An ENT would remove your tonsils for many reasons, including:

1. The tonsils were big
2. The tonsils got infected
3. The loan payment was due for their boat
4. So you could get out of a test
5. You beat up their kid in school
6. Just on a whim

All of these reasons were reimbursable by insurance companies back in the "golden age of medicine."  Now the criteria are much more strict:

1. More than 6 strep throat infections in a 12 month period (looking over the Internet, there was little agreement on this number - this is the one I was taught).
2. Signs of sleep apnea (see my previous post on this area)
3. Chronic tonsillitis (tonsils with many crypts in them with stuff that constantly gets stuck in them)
4. You beat up the insurance company guy’s kid in school

People without tonsils do just fine, and don’t seem to get as many strep throat infections, in my experience.  I have heard it repeatedly taught that this is in fact not true; that removing tonsils does not prevent strep.  But I have to say that my experience shows this to be absolutely true for most people who get their tonsils out; they rarely get strep throat again.

The (gag) Exam

If you are lucky, you have a big mouth and can open it enough for the doctor to look to the back of your throat without using the stick.  Nobody likes that stick.  They call it a tongue depressor, or a tongue blade.  Both sound nasty.  I call it a stick, and like to draw pictures on it to entertain kids.

Yet there are times when I must put that stick into peoples’ mouths to see what is there.  They used to make them with flavors (we would get them from the drug reps), but this really didn’t help stop the gagging. 

When examining young children’s throats, you need to gather all of your information in about 0.01 seconds.  The exam is performed by prying the teeth apart with the stick and then twisting it to push the teeth apart.  Then you shove the stick onto the tongue and force the child to gag.  In the split-second that the child gags, you must get all of your information as to what the exam looks like.  It is a skill that takes years to develop.

It is also sometimes dangerous to shove a stick into someone’s mouth.  First of all, they have teeth, and some are not afraid to use them.  I have never been bitten, but I have narrowly avoided it many times.  Second, the gag reflex is sometimes followed by another reflex known as "losing your lunch."  Take someone who has been vomiting for the past day and looks very ill, and then shove a stick into their mouth.  Smart move.  Just stay out of the path of flying objects.

Most sore throats are from drainage down the back of the throat.  This gives the back of the throat a "cobblestone" appearance.  Other times the throat is red, and the tonsils are covered with white stuff. 

The worst looking tonsils are from someone with mononucleosis.  They get quite large and have some grayish-colored gunk on them that resembles cheese that has been in the fridge too long.  I have actually hospitalized people with mononucleosis because their tonsils were so large that they were starting to cut off their airway.

Many people chew gum and forget to take it out before the mouth exam.  When they open their mouth, they will say something incredibly informing like: "that’s gum."  I tell them that I am aware of that fact.  They then apologize for having gum (as if that is some sort of sin), and I tell them that the only place I don’t like to see gum is on the bottom of my shoe.

Fair In Jitus

Sore throat is called pharyngitis, and it is among the most common reasons to come to the doctor’s office.  The real question people have when they have a sore throat is, do I have strep?

Strep throat is caused by streptococcus pyogenes. It generally causes a very severe throat, headache, and high fever.  It is very contagious, and spreads through airborne particles.  In August and September, when kids are just getting back in school, there is almost always a mini-epidemic of strep. 

If left untreated, most strep throat will get better on its own.  The reason strep is treated with antibiotics is because of the association of strep throat with rheumatic fever and post-streptococcal glomerulonephritis (kidney failure caused by strep).  Rheumatic fever is a condition we all had to learn about in medical school (with the Jones criteria) but practically never see anymore, as antibiotics have made this rare.  It can cause joint problems, skin problems, and most seriously, heart problems.  In the past, rheumatic disease was the most common cause of heart valve problems.  Now we rarely see many of the heart problems associated with untreated strep.

Most sore throats are caused by viruses, however, and do not require antibiotics to treat them.  It is very common for people to want medication for sore throats that are not caused by strep, but there is little justification in this.

Finally, let me address the issue of tonsil hockey.  I don’t think it is really possible for people’s tonsils to be part of the kissing process.  To call kissing tonsil hockey is irresponsible, as it motivates young children to try to reach their partner’s tonsils in a lingular fashion.  This can only end in tragedy.

On that note, I will end this discussion on the mouth.  Before we move further south on the exam, we will make a detour up north. 

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