Nose Examination

PREPARATION

  • Clean your hands 
  • Prepare your equipment
  • 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 nasolaryngoscope
  • Check whether there is any pain in the head or neck
  • Obtain verbal consent
  • 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 into the nose, with an explanation and tissues 

 

EXTERNAL INSPECTION

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, dorsal hump, saddle deformity, scars, nasal tip (depression), collumellar retraction

 

NASAL FUNCTION

Place a metal tongue depressor under the patient's nose and ask them to 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 there is nasal valve stenosis. This is called Cottle's test.

 

INTERNAL EXAMINATION

Thudicum inspection helps examine the anterior portion of the nose for:

  • The septum (Little’s area for any exposed blood vessels, cartilaginous and bony deviation, perforation, mucosal damage)
  • Colour of the general nasal mucosa
  • Nasal discharge/mucopus
  • Polyps
  • Turbinates (swollen/ hypertrophic)

The flexible or rigid nasendoscope helps complete the examination of the nose further back. Remember to examine the sinus ostia using a flexible scope; using a rigid scope, this is the 'three-pass' technique of passing the scope straight back (horizontal or zero degrees) and then two further passes at thirty and seventy degree angles. Note the Eustachian tube orifices, Fossae of Rosenmueller and adenoid tissue in the postnasal space.

 

OTHER EXAMINATIONS

  • Oropharynx and mouth 
  • Eyes (especially if there is associated nasal trauma or frontal disease)
  • Neck exam for any lymphadenopathy

 

INVESTIGATIONS

  • Bedisde/clinic: U Penn (University of Pennsylvania) smelling salts to assess for anosmia; SNOT-22 and other questionnaires
  • Biochemistry: consider sending clear rhinorrhoea for beta-2 transferrin 
  • Microbiology: send any discharge for culture and sensitivities
  • Radiology: a good starting point is to request a CT nasal sinuses/skull base, especially if you are planning operative intervention (for bony anatomy); CT sinuses has superceded plain radiographs in developed nations 
  • NB Plain radiographs of the nasal bones do not add much to the diagnosis of nasal fractures and are not recommended

 

 

Page last reviewed: 23 September 2016