Examination of  Nose


By

Dr. T. Balasubramanian M.S. D.L.O.

In addition to the illuminating instruments described under the heading examination of patient in otolaryngology, certain other unique instruments are necessary in the examination of the nose.
They are
1. Thudichum's nasal speculum
2. Lac's tongue depressor
3. St. Claire Thompson post nasal mirror
4. Tilley's nasal dressing forceps
5. Spirit lamp to warm the post nasal mirror












Tilley's forceps and Thudichums nasal speculum

Fig showing post nasal mirror



The steps that must be followed while examining a nose is
1. Examination of external nose
2. Anterior rhinoscopy
3. Posterior rhinoscopy

Examination of external nose:
On inspection the following things should be looked for

In this step the following aspects must be diligently looked for
1. Change in shape / contour of the nose
2. Deformities congenital / acquired if any
3. Presence of clefts and sinuses
4. Presence of swelling : inflammatory, cysts, or tumors
5. Presence of ulceration : trauma / infective / neoplastic

On palpation the following must be sought after

1. Tenderness - If it is present over the nasal bone area then # nasal bone must be suspected.  If it is present over the tip of the nose, it could be due to vestibulitis, if tenderness is present over the dorsum of the nose the septal hematoma, of septal abscess must be strongly suspected.
2. Crepitus - when present over the nasal bone area then # nasal bone is a surity.
3. Deformity - The presence of deformity is one of the features of trauma to the nose.  Nose being the most prominent area of the face, it is susceptible to various injuries.  Any blow to the dorsum of the nose can cause buckling of the cartilagenous nasal septum.  This buckling may lead to bleeding under the perichondrium of the nasal septum.  This bleeding infact lifts the perichondrium away from the nasal septum.  If this happens on both sides of the nasal septum the nutrition to the nasal septum which is dependent on the intact perichondrium suffers.  The cartilage infact under goes liquefaction necrosis within 48 hours, depriving dorsal support to the nose causing pig snout deformity.
4. The nasal septal area must be palpated to ascertain the presence or absence of septal cartilage.











Fig showing external deformity of nose




Anterior rhinoscopy:

In anterior rhinosopy the following steps must be performed in the given order.
1. Examination of the vestibule (i.e. the skin lined cavity of the nares).
2. Examination of nasal cavity using thudichum's nasal speculum.
3. Patency test.
4. Probe test if examination of nasal cavity reveals a mass.  This test is done to ascertain the site of origin of the mass.
5. Examination of the nasal cavity after vasoconstriction.  This is done after packing the nasal cavity with cotton plegets dipped in oxymetazoline or xylometazoline nasal drops.

Examination of vestibule:
     This is carried out by tilting the tip of the nose.  The vestibule is lined with skin and has all the dermal appendages.  All the diseases which affect the adnexia of the skin can occur in the vestibule.  Boils i.e. vestibulitis can cause swelling of the roof and lateral wall.  Ulcerations in this area can be infective or neoplastic.  Excoriation of skin lining the vestibule can also occur due to persistent nasal discharge.












Method of examination of nasal vestibule




Examination of nasal cavity using a nasal speculum:

A Thudichum's nasal speculum is utilised for this purpose.  The speculum is held in the non dominant hand.  The speculum is hooked with the index finger, while the middle and ring fingers are utilised to press and release the speculum blade. 
The axis of the anterior nares is upwards and backwards, while that of posterior nares is backwards.  The tip of the nose is lifted and the blades of thudichum's speeculum is introduced getting these two axis in a straight line.  The speculum is always introduced with the blade closed.  The speculum is always introduced in a upwards and backwards direction.  Once inside the nose the blades are gradually opened to avoid discomfort to the patient.  The roof, floor, lateral and medial walls of the nasal cavity are systematically examined. 

Nasal septum is visualised with a special eye for the presence of spurs, deviations, or perforations.  The lateral wall displays the inferior and middle turbinates.  Their color, size and the quality of the mucosal lining is assessed.  Discharge if any from the middle meatus is also looked for.
Since the middle meatus is situated backwards the head is tilted upwards and backwards up to an angle of 45 degrees.  This manouver brings the middle meatus into clear vision.  If polyp or neoplasm is visualised within the nasal cavity a probe test is done to confirm its attachment.




Probe test:  Is done using Jobson's  Horne probe.  The nose is anaesthetised with 4% xylocaine.  Cotton is wound tightly over the probe end of Jobson's Horne probe.  The probe is used to assess the site of attachement of the nasal mass, its consistency, mobility etc.

Nasal patency test:
Is performed using a cold tongue depressor just under the nose of the patient and comparing  the amount of mist formation between both sides.  A wisp of cotton can also be used to ascertain the patency of the nose.  Patency is compared with both sides.

Posterior Rhinoscopy:
It can be done using
1. Post nasal mirror
2. Flexible nasopharyngoscope
3. 30 degrees nasal endoscope
4. Examination under general anaesthesia after retracting the soft palate.  Digital palpation is possible only in this method.

Examination using post nasal mirror:
The post nasal mirror is warmed using a sprit lamp.
The throat of the patient is anesthetised using 4% xylocaine spray.
The tongue depressor is held in the non dominent hand, and the tongue is depressed.  The already warmed post nasal mirror is gently is passed under the uvula visualising the post nasal space.  The mirror is tilted to  visualise the various portions of the naso pharynx.
Examination of nasopharynx using post nasal mirror is a difficult procedure to master.  It may be difficult to perform in all individuals.  If it cannot be performed then a flexible nasopharyngoscope, or a nasal endoscope must be used.  If a suspected lesion needs to be palpated it can be done after retracting the soft palate under general anaesthesia.