- Clean your hands
- Introduce yourself (full name and job) and confirm the patient’s identity
- Explain that you would like to perform an examination of the nose, to include use of a Thudichum's nasal speculum and flexible nasendoscope
- Check whether there is any pain in the head or neck
- Obtain verbal consent
- Prepare your equipment
- Position the patient: sitting upright or partly-upright with the head tilted upwards and resting against the headrest
- Check the patient's allergy status and spray local anaesthetic/decongestant into the nose
Face: Note any nasal deformity, facial rashes, swelling, bruising, mouth breathing and the intercanthal distance
Inspect the nose from the front and both sides for: scars, erythema, skin lesions, deviated dorsum or tip, dorsal hump, saddle deformity, tip projection, scars, collumellar retraction. Aesthetic evaluation is beyond the scope of this page.
Place a metal tongue depressor under the patient's nose and ask them to gently exhale. If there is unilateral blockage, only one mist spot will be seen instead of two.
Assess for alar collapse as the patient sniffs. If there is nasal blockage, apply lateral pressure to the patient's cheek adjacent to nose to see if this improves the airway. This is called Cottle's test, which implies nasal valve weakness/collapse. A more specific test is to very slightly lateralise the upper lateral cartilage with a Jobson Horne probe and test for reduced airway collapse on inspiration.
Anterior rhinoscopy using a Thudichum speculum helps examine the anterior portion of the nose for:
- The septum (Little’s area for any exposed blood vessels, cartilaginous and bony deviation, perforation, haematoma, mucosal damage)
- Nasal mucosal pathology (e.g. rhinitis)
- Nasal discharge/mucopus
- Turbinates (hypertrophic?)
Flexible or rigid nasendoscopy completes the examination of the nasal cavity. The classic "three-pass technique" is performed with a rigid endoscope.
Systematically examine the Eustachian tube orifices, fossae of Rosenmüller and adenoid tissue in the postnasal space, the sphenoethmoidal recesses (above the choanae), the middle meatus and the anterior skull base.
- Oropharynx and oral cavity
- Eyes (especially if there is associated nasal trauma or frontal disease)
- Neck exam for any lymphadenopathy
- Upper cranial nerves
- Ears for effusions
- Olfactory testing: Sniffin' Sticks, UPSIT or other odour identification tests.
- Patient reported outcome measures: SNOT-22 and other questionnaires
- Biochemistry: consider sending clear watery rhinorrhoea for beta-2 transferrin to exclude CSF leak
- Immunology: inflammatory markers, c-ANCA, ACE, ANA if vasculitis is suspected
- Microbiology: send any discharge for culture and sensitivities (controversial - low yield)
- Radiology: CT paranasal sinuses/skull base, not primarily for diagnostic reasons, but essential if you are planning endoscopic sinus surgery (for bony anatomy). Radiology is not required for simple nasal fractures. Plain X-rays have no role in either case.
Page last reviewed: 24 September 2017