Examination of the Nose

Straightness – if the tip of the nose or the bridge of the nose is significantly deviated then it is likely that the septal cartilage will also be bent, if a patient is complaining of asymmetrical nasal obstruction in this instance it is possible that surgery may help.

Tip/Profile

A dorsal hump does not always mean that the nose has been broken in the past. A lot of patients, especially men, will naturally have a dorsal hump.

A dip in the nose just above the tip is usually abnormal (supra-tip depression) and might result from cartilage loss secondary to infection, trauma or previous surgery (particularly aggressive sub mucous resection of the septum).

Anterior Nares

In children, lifting the tip of the nose with the thumb allows quite a good view of the nasal cavity with a torch or otoscope. In adults, the view is not as good but it is worth doing this anyway as anterior septal deviations, vestibulitis, alar collapse and other conditions may be seen and can be missed by passing an otoscope too far into the nose.

Vestibular stenosis from previous surgery demonstrated by lifting nasal tip

Palpation

Palpation of the lower third of the nose (squeezing gently between finger and thumb) can give you an idea whether the anterior septum is in the midline or is significantly deviated to one side. Anterior septal deviation are generally more symptomatic than posterior ones so an asymmetry picked up this way is usually a significant cause of obstruction.

Assessment of Airflow

The sensation of nasal airflow is very subjective. Scientific methods of measuring nasal resistance have found little use in clinical practice:

Objective and subjective nasal airflow Eitan Yaniv, Tuvia Hadar, Jacob Shvero, Eyal Raveh. American journal of otolaryngology 1 January 1997 (volume 18 issue 1 Pages 29-32)

Sniff: obstruct each side at a time with a finger or thumb and ask the patient to sniff or inhale, significant nasal obstruction can be picked up fairly easily.

Mirror – ‘sniff testing’ may not be practical in babies and small children. A cold mirror held underneath the nose will mist in the presence of exhaled air, however, this test is only really useful when identifying complete obstruction (e.g choanal atresia.

Rhinoscopy

Outside the ENT clinic, an otoscope with a large (4mm or larger) speculum is the best instrument to use to examine the nose. In most cases it should be possible to see the nasal septum and inferior turbinate, and in some cases the middle turbinate. Most of the images on this page are taken with an endoscope – this view is not going to be practically possible with an otoscope. Using a decongestant spray will allow you a better view of the nasal cavity when the mucosa is very swollen.

Rhinitis

The definition of rhinitis in clinical practice is based on the presence of symptoms such as obstruction, discharge, sneezing and facial pain rather than the actual appearance of the nasal mucosa.

A variety of descriptions of the appearance of rhinitis exist. In general the mucosa will be swollen with enlargement of the inferior turbinates, the mucosa may be haemorrhagic or irregular and there may be associated discharge.

A common finding in the examination of rhinitis is the presence of thin strands of mucous between the septum and turbinates, these are not generally seen in the healthy nose.

Sinusitis

As well as oedma of the nasal mucosa, the presence of mucopus in the nose is indicative of sinusitis, especially arising from the middle meatus. If endoscopy of the nose reveals no active mucopus then sinus infection is unlikely

	Infected rhinorrhoea in a child, underlying rhinosinusitis.
	Pus in the middle meatus indicative of paranasal sinusutis.

Septum

The septum is not flat, rather varying in thickness.

Coronal CT of sinuses and nose. Note the significant variation in septal thickness that may be misinterpreted as a septal deviation,

To assess a deviated septum it is important to look in both sides of the nose and see if there is a significant difference between the two.

Comparison between the two sides makes the diagnosis of deviated septum more obvious

Palpation of the external nose is also helpful.

Septal Haematoma occurs after surgery or trauma. The diagnosis is usually fairly obvious, the nasal mucosa is grossly engorged and is fluctuant and tends to fill one or both nasal airways.

Turbinates

(inferior turbinate 640)The inferior turbinated should be easily visible with an otoscope. Occasionally, especially if the nose has been decongested the middle turbinate ay also be visible. Enlarged inferior turbinates are often mistaken for polyps. Polyps are insensate whereas the inferior turbinate is very sensitive to touch, for example with a blunt probe

Polyps

	Polyps are inflammatory lesion consisting of a thin layer of respiratory epithelium and a largely avascular central stroma containing some white blood cells, classically eospinophil but also lymphocytes and other cell lines. Single and multiple benign nasal polyps.
	The classical appearance is a glistening grey translucent appearance like a peeled grape, However, very large polyps can develop epithelial change anteriorly and can look pink a bit like normal nasal mucosa.
	Left untreated for a long time, polyps can lead to broadening of the nasal bridge.
	One way of distinguishing polyps from normal mucosa (particularly the inferior turbinates, is to touch the lesion with a blunt probe. Polyps are insensitive.
	Occasionally a polyp will arise in the maxillary antrum rather than the more usual ethmoid sinuses and grow backwards into the nasopharynx. These are called antro-choanal polyps and can reach an impressive size, becoming visible in the mouth behind the soft palate.
	Antro-choanal polyp, plain x ray demonstrating opaque antrum and polyp just visible in open moth.
	Coronal CT of same lesion, opaque maxillary antrum and intranasal soft tissue in keeping with antro-choanal polyp.

More Sinister Lesions

The presence of a unilateral lesions and symptoms such as bleeding and pain have to be treated as suspicious. Although a lot of unilateral lesions are simple benign polyps, the differential includes inverted papilloma and frank malignancy. Pleas refer suspicious lesions for ENT assessment urgently.

	Transitional cell carcinoma of the nose presenting as a bleeding unilateral polypoid lesion.
	Nasopharyngeal angiofibroma. Classically these lesions present with severe epitasis in adolescent boys.

Septal Perforations

Perforations are caused by trauma (injury, surgery or chemical trauma such as cocaine abuse), by infections (septal abscess very rarely syphilis) and rarely by tumours.

	Small perforations are easier to see.
/td>	However, when the perforation is large it can be quite confusing and there is often a lot of crusting present obscuring the view. If it is possible to see turbinates on both lateral walls at the same time there must, by definition, be a perforation present.

Further Investigations

Nasal Endoscopy

In ENT clinic, nasal endoscopy can provide a lot more information: the presence of smaller polyps and lesions further back in the nose, the middle meatus and the opening of the nasal sinuses can also be directly seen. Examination of the back of the nasal cavity reveals a view of the adenoid pad, the Eustachian openings and the sphenoid recess

Skin Tests

Skin tests are an inexpensive and quick way of trying to identify type 1 (IgE mediated) allergy in outpatients. Multiply allergic patient after skin prick testing - note very strong reaction with ‘pseudopodia’ to horse antigen.

Blood tests

Measuring total circulating IgE gives some idea of whether an allergic tendency is present although this is not in practice a particularly useful test. Measuring IgE to specific antigens (e.g. dust mite, grass pollen) is a more scientific but more expensive way of testing for allergies (RAST test).

Miscellaneous images

	Fluorescein dye emanating from a DCR (opening in the lachrymal sac) to relieve epiphora (watery eye).
	Light transmitted from a fibre optic light source placed inside the lachrymal sac after previous DCR
	Patent opening into the ethmoid sinuses created at endoscopic sinus surgery (FESS).
	Adhesions in the middle meatus arising from trauma such as surgery or naso-tracheal intubation.
	Scabbing in the middle meatus a few weeks after endoscopic sinus surgery.