Clinical examination of nose

DR SRAVYA M V
FIRST YEAR PG
DEPT.OF SALAKYATANTRA
GAVC,TRIPPUNITHURA
Includes,

• Examination of nose

• Examination PNS

• Examination nasopharynx
• Rhinological diseases are very common

• An array of investigative tools exist for them

• Many of them are not in common practice

• Advent of endoscopy , improvements in image capturing techniques – to see

inside the nose & beyond
• More comprehensive assessment of the nose & sinuses

• Facilitates education

• Engagement of the patients - see the effects of their disease & the response
to any treatments
Patient may present with,

• Nasal obstruction • Headache / facial pain

• Nasal discharge • Swelling / deformity

• Postnasal drip • Disturbances of smell

• Sneezing • Snoring

• Epistaxis • Change in voice (hyper / hypo nasality)

A. EXAMINATION OF NOSE
1. Examination of external nose

2. Examination of vestibule

3. Anterior rhinoscopy

4. Posterior rhinoscopy

5. Functional examination of nose

1. EXTERNAL NOSE
• Skin & osteo cartilaginous framework of nose

• Inspection & palpation

Inspection

Skin

• Signs of inflammation (furuncle, septal abscess)

• Scars (operation / trauma)

• Sinus (congenital dermoid)

• Swelling (dermoid / glioma)

• A neoplasm (basal cell / squamous cell carcinoma)

 Furunculosis Abscess Scar

Congenital dermoid sinus Dermoid Basal cell carcinoma

Osteo cartilaginous framework

• Deformity
• Deviated / twisted nose
• Hump
• Depressed bridge
• Bifid / pointed tip
Deviated nasal septum
Hump

Depressed bridge Bifid nose tip

Palpation

• Raised temperature

• Fixity of skin

• Thickening of soft tissues

• Tenderness

• Fluctuation

• Crepitation
2. VESTIBULE
By tilting the tip of nose upwards
• Furuncle
• Fissure (chronic rhinitis)
• Crusting
• Dislocated caudal end of the septum
• Tumours (cyst, papilloma or carcinoma)
Furunculosis of vestibule Nasolabial cyst
3. ANTERIOR RHINOSCOPY
Thudicum /Vienna type of speculum to open the vestibule

Examine,
Nasal septum
Roof
Floor
Lateral wall
(a) Nasal passage

• Narrow (septal deviation / hypertrophy of turbinates, growth)

• Wide (atrophic rhinitis)

(b) Septum

• Deviation / spur

• Ulcer
Septal abscess
• Perforation

• Swelling (haematoma / abscess)

• Growth (rhinosporidiosis, haemangioma)

Rhinosporidiosis
(c) Floor of nose

• Defect (cleft palate / fistula)

• Swelling (dental cyst)

• Neoplasm (haemangioma)

• Granulations (foreign body / osteitis)

(d) Roof

• Atrophic rhinitis
(e) Lateral wall

Inferior & middle turbinates & their meatuses

Examine,

Colour of mucosa

• Congested in inflammation

• Pale in allergy
Size of turbinates
• Enlarged & swollen in hypertrophic rhinitis
• Small & rudimentary in atrophic rhinitis
Discharge

• In the middle meatus - infection of maxillary, frontal/ anterior ethmoidal

sinuses

Mass
• Polyp
• Rhinosporidiosis
• Carcinoma
Probe test

Ascertains,

• Site of attachment

• Consistency

• Mobility

• Sensitiveness of the mass

• Attachment of the mass is found by passing the probe on all its surfaces

• Bleeding during probing indicates vascular nature of the mass

 4. POSTERIOR RHINOSCOPY

Look for,

(a) Choanal polyp or atresia

(b) Hypertrophy of posterior ends of inferior turbinates

(c) Discharge

• In the middle meatus in infections of maxillary, frontal / ethmoidal sinuses

• Above the middle turbinate in infection of the posterior ethmoid / the

sphenoid sinuses
5. FUNCTIONAL EXAMINATION OF NOSE

(a) Patency of nose

• Spatula test

• Cotton-wool test
(b) Sense of smell

• Clove oil

• Peppermint

• Coffee

• Essence of rose

• Ammonia stimulates the fibres of CN V

B. EXAMINATION OF PARANASAL SINUSES

1. Maxillary sinus

2. Frontal sinus

3. Ethmoid sinuses

4. Sphenoid sinus
1. MAXILLARY SINUS

Inspection, palpation & transillumination

Examine:

(a) Soft tissues of cheek, lip, lower eye lid & the molar region

(b) Orbit and its contents & the vision

(c) Vestibule of mouth by everting the lip

(d) Upper alveolus, teeth & palate

(e) Nose by anterior & posterior rhinoscopy

(f) Tenderness by pressure over the canine fossa

Transillumination

• By placing a specially made light source centrally in the mouth & closing the
lips

• Normally, a crescent of light in the inferior fornix & glow in the pupil, equally
bright on both sides

• In the presence of pus, thickened mucosa or a neoplasm, the affected side

does not transmit light
2. FRONTAL SINUS

Inspection, palpation & transillumination

3 walls - anterior, posterior & floor

(a) External examination

• Forehead

• Root of nose

• Orbital margins

• Orbit & its contents

Look for,

• Redness

• Swelling

• Fistula

• Proptosis

• Displacement of the eye balls

Tenderness

• Elicited by pressure / percussion with a finger on its anterior wall

above the medial part of eyebrow

• By pressing upwards on its floor above the medial canthus

(b) Examination of nose

• By anterior & posterior rhinoscopy

• For evidence of discharge in the middle meatus

• For any neoplasm

Transillumination

• By placing a small light source in the superomedial angle of the orbit

• Observe the transmission of light from the anterior wall of the sinus
3. ETHMOID SINUSES

Examined by inspection & palpation

(a) External examination

Examination of

• Orbit

• Upper & lower eye lids

• Root of nose

• Eye ball & vision

Tenderness

• Elicited only in the anterior ethmoid sinuses

• Done by gentle pressure applied on the medial wall of orbit just behind
the root of nose

• In acute ethmoiditis
(b) Nasal examination

 Anterior rhinoscopy,
• Pus
• Polypi
• Growth
In the middle meatus

Between the middle turbinate and the septum

 Probe test

 Posterior rhinoscopy

• Pus

• Growth

Below / above the middle turbinate

4. SPHENOID SINUS

• Lies deep

• Anterior wall can be seen in atrophic rhinitis / in marked deviation of the

septum to the opposite side
(a) Anterior rhinoscopy

• Sphenoid sinus opens in the spheno ethmoidal recess

• Attention should therefore be paid to the findings in the olfactory

fissure near the roof of nose

• May show discharge, crusts, polyp , growth

(b) Posterior rhinoscopy

• Pus in the nasopharynx / the choana, above the middle or superior

turbinate

• Growth / polyp may also be seen

X RAY PNS WATERS VIEW
CT PNS CORONAL VIEW
CT PNS AXIAL VIEW
CT PNS SAGITTAL VIEW
 Examination of nasopharynx

1. Nasal obstruction

2. Postnasal discharge

3. Epistaxis

4. Deafness (tubal block)

5. Cranial nerve palsies

6. Enlargement of lymph nodes in the neck

Includes,

1. Anterior rhinoscopy

2. Posterior rhinoscopy

3. Other methods
(a) Digital examination

(b) Endoscopy

(c) Retraction of soft palate with catheters and mirror examination

4. Cranial nerves

5. Cervical lymph nodes

1. ANTERIOR RHINOSCOPY

• Only a small part is visible

• View can be facilitated by decongestion of nasal & turbinal mucosa with

vasoconstrictors
2. POSTERIOR RHINOSCOPY

(a) Anterior wall

Posterior border of nasal septum, choanae, posterior ends of turbinates and their
meatuses.

(b) Lateral walls

Torus tubarius, opening of eustachian tube, pharyngeal recess

(c) Floor

Upper surface of soft palate

(d) Roof of posterior wall

Abnormal findings ,

(a) Discharge

(b) Crusting

Atrophic rhinitis / nasopharyngitis

(c) Mass

(i) Smooth pale mass—antrochoanal polyp

(ii) Pink lobulated mass—angiofibroma

(iii) Irregular bleeding mass—carcinoma

(iv) Smooth swelling in the roof—Thornwaldt’s cyst / abscess

(d) Bleeding

Due to posterior nasal / nasopharyngeal pathology

3. OTHER METHODS

Digital examination

• Examine the posterior border of the nasal septum choana, lateral wall
posterior wall of nasopharynx

• For examination of adenoids, antrochoanal polyp and other masses

• Avoid this if angiofibroma is suspected

(b) Endoscopy

• After local anaesthesia & decongestion of nasal mucosa

• Gives a bright & magnified view of the nasopharyngeal structures

(c) Retraction of soft palate with catheters and mirror examination

• Requires good local or general anaesthesia

• A soft rubber catheter is passed through each nostril & recovered from the
oropharynx

• Both ends of catheter are held together & clamped

• Soft palate is retracted forwards

• Mirror can be introduced and the nasopharynx examined

4. EXAMINATION OF CRANIAL NERVES

Malignancy of nasopharynx can involve any of the CN II to XII, more often CN

IX, X and XI.
5. EXAMINATION OF CERVICAL LYMPH NODES

• Nasopharyngeal malignancy as a lymph node mass in the neck

• Commonly involved are upper internal jugular & those

along the accessory nerve in the posterior triangle of the neck

 Conclusion

• Examination of nose – external nose , vestibule, anterior &posterior

rhinoscopy , functional examination

• Examination of paranasal sinuses - inspection , palpation,

transillumination

• Examination of nasopharynx – anterior &posterior rhinoscopy , cranial

nerves, cervical lymph nodes