Table of Contents

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External Nose
Inspection
Special Tests
Internal Nose
Inspection
With Speculum
With Otoscope
Inspection: Potential Findings
Paranasal Sinuses
Palpation
Sinus Transillumination
References

External Nose

Inspection

  1. Inspect the external aspect of the nose for any swelling, erythema, trauma, scarring, deviation or congenital abnormalities.

Always make sure to examine the nasal dorsum from both the anterior and lateral perspectives.

Special Tests

  1. Test for airway potency (nasal obstruction) by blocking one of the nostrils and asking the person to sniff.
  2. Test for anosmia: Ask the person to close their eyes and plug one nostril. With an alcohol 10 cm from their nose, the person should be able to detect the odour. More sophisticated testing can be done with specialized smell kits. Perform on both nostrils individually.

Internal Nose

Inspection (2 methods)

I) Inspection by Speculum

  1. Put on your headlamp.
  2. Slightly extend the patient's neck.
  3. Place the nasal speculum in your non dominant hand and insert it 1cm into the vestibule. Brace your index finger against the nasal ala to anchor the upper blade of the speculum. Follow the floor of the nose and open the speculum to stretch the ala.
  4. Systematically inspect the septum, the airway, and the turbinates (tap here to learn about possible findings).
  5. Repeat on the opposite side.

Do not be afraid of the nasal speculum! It has been specifically designed for the nose and will not hurt the patient if used properly. Insert it all of the way into the nose (parallel to the floor) to achieve maximal visibility.

II) Inspection by Otoscope

  1. Fit an otoscope with the largest ear speculum available.
  2. Tilt the patient's head backwards (more than you would if you were using a nasal speculum) and introduce the instrument into the vestibule. Begin by inserting it directly posteriorly. Note the inferior turbinate and the inferior portion of the nasal septum. Slowly pan the speculum upwards to visualize the middle turbinate, the nasal passage and the remaining portion of the septum.

Avoid making contact with the nasal septum as it is highly sensitive. Additionally, make sure to brace your hand against the patient's face to prevent yourself from jamming the otoscope in too deep in case of sudden movement.

  1. Systematically inspect the septum, the airway, and the turbinates (tap here to learn about possible findings).
  2. Repeat on the opposite side.

Possible Findings

Although your instrument of choice (speculum vs. otoscope) may vary depending on your location or personal preference, you must always inspect for the same things. When inspecting the nose, note any:

  • Fresh blood or crusting. These are often found in the anteroinferior nasal mucosa (an area which is reachable by the patient's finger). Remember, anterior epistaxis often stems from Kiesselbach's plexus (aka Little's area), located on the anteroinferior portion of the nasal septum.
  • Septal deviation or perforation. While some asymmetry of the tubinates on the two sides can be absolutely normal, asymmetry (deviation) of the nasal septum is not.

If you notice a deviation of the septum, make sure to describe it! Is it a mild deviation that only partially obstructs the airway, a severe deviation that completely blocks it, or somewhere in between?

  • Swelling or erythema. It is important to remember that normal nasal mucosa is generally moderately redder/darker than normal oral mucosa. Blue/grey mucosa may be a sign of allergies, while erythematous mucosa is a sign of inflammation.
  • Exudate. If present, describe it (clear, mucopurulent, purulent).
  • Polyps. Polyps are freely moveable, non-tender and semi-translucent masses that look like green grapes without the skin.
  • Other possible findings include masses, ulcers or foreign bodies. These are often associated with a bad smell.

The Paranasal Sinuses

Palpation

Although palpation of the paranasal sinuses is often taught in the classroom and medical textbooks, it has been shown to be neither a specific nor a sensitive test for acute sinusitis. As such, we will not be teaching it within this application.

Sinus Transillumination

Similar to palpation of the sinuses, sinus transillumination has also been found to be "obsolete method" for demonstrating sinus congestion. Tap here to read the reference. Accordingly, sinus transillumination will not be taught in this app.

References

Bickley, L. Bates' Guide to Physical Examination and History Taking. 10th Edition. Chapter 7.

Schwartz, M. Textbook of Physical Diagnosis. 6th Edition. Chapter 11.

Section Author

Scott Kohlert
Medical Student (MS-4)
University of Ottawa

Section Editors

Laurie McLean, MD1,2
Nita Scherer, MD1,2
Safeena Kherani, MD1,2

1The Ottawa Hospital, Deptartment of Otolaryngology

2Faculty of Medicine, University of Ottawa