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  1. 1. EXAMINATION OF THE NOSE Physical examination: Most physicians use a head-mounted light. However, because the light cannot be precisely aligned on the axis of vision, it is difficult to avoid shadowing in narrow areas (eg, nasal cavity). Better illumination results with a head-mounted convex mirror; the physician looks through a hole in the center of the mirror, so the illumination is always on-axis. The head mirror reflects light from a source (any incandescent light) placed behind the patient and slightly to one side and requires practice to use effectively. The nose is examined using a nasal speculum, which is held so that the 2 blades open in an anteroposterior (or slightly oblique) direction and do not press against the septum. The physician notes crusting, discharge, septal deviation or perforation; whether mucosa is erythematous, boggy, or swollen; and presence of polyps. The skin over the frontal and maxillary sinuses is examined for erythema and tenderness, suggesting sinus inflammation.
  2. 2. <ul><li>The cyclic congestion and decongestion in both nasal cavities systematically accompany the nose respiratory function. The turbulent behavior of the nasal airflow seems to be a prerequisite of the adequate contact of inspired air particles with a nasal mucosa. The aim of the present study was to gain further information regarding the turbulent airflow behavior just during the nasal cycle dynamics. The nasal cycles in 10 healthy human subjects were investigated applying endoscopic imaging, rhinoresistometry, and acoustic rhinometry methods. The nasal function has been estimated at the regular intervals of 20 minutes over a time period of 15 hours. The following parameters were calculated in each case: airflow resistance, hydraulic diameter, friction coefficient , transition from the laminar flow to the turbulent one, and minimal cross-sectional areas. In addition to the previously known cyclic changes of the flow resistance and of the nasal width, periodic alterations in the turbulence function were noted. Under the resting phase, the laminar flow was usually demonstrated. Under the working phase, the turbulences arouse already at low flow velocities. The increases of turbulences that supplemented the working phase were caused by the enlargement of the cross-sectional area in the anterior nasal cavum. The latter followed to the decongestion of the mucosa of the head of the inferior turbinate as well as of the septal tuberculum. Rhinoresistometry and acoustic rhinometry predominantly complement each other. Application of both methods provides therefore valuable information on the functional nasal cycle changes. A combination of these two methods is recommended thus for the proper evaluation of the nasal cavity behavior </li></ul>
  3. 3. <ul><li>Check patency by asking patient to occlude one nostril, and then breath through opposite nostril. Repeat for opposite nostril. </li></ul><ul><li>External nose- - possible findings Deformity        trauma </li></ul><ul><li>Discharge         infection, trauma, foreign body </li></ul><ul><li>Flaring              respiratory distress </li></ul><ul><li>Transverse crease- from &quot;allergic salute&quot; </li></ul>
  4. 4. <ul><li>Nasal cavity </li></ul><ul><li>Technique </li></ul><ul><li>Use nasal speculum, or larger ear speculum on an otoscope </li></ul><ul><li>Ask patient to tilt head back </li></ul><ul><li>Gently introduce the speculum into the vestibule, while visualizing the mucosa, and gently advancing the speculum until you can visualize the lower nasal cavity. </li></ul><ul><li>If using a nasal speculum, open it in anterior-posterior direction, NOT pressing on sensitive septum </li></ul><ul><li>Findings: </li></ul><ul><li>Bluish, swollen mucosa-          allergies </li></ul><ul><li>Generalized redness-                infection </li></ul><ul><li>Bleeding-                                  often from Kiesselbach plexus, on anterior septum </li></ul>
  5. 5. EXAMINATION of the SINUSES <ul><li>Frontal and maxillary sinuses are the most accessible to examination </li></ul><ul><li>Palpation and percussion may or may not be helpful - while physicians frequently percuss or palpate the facial bones overlying sinuses in order to assess for tenderness, different examiners will frequently have different findings when examining the same patient (sinus palpation or percussion is not reliable) . </li></ul>
  6. 6. <ul><li>Transillumination of maxillary sinuses: Darken room completely </li></ul><ul><li>Patient seated with head back, mouth open and eyes closed </li></ul><ul><li>Light source just lateral to nose and inferior and medial to eye </li></ul><ul><li>Look for light transmitted through sinuses to hard palate </li></ul><ul><li>Lack of transillumination suggests that sinus is filled with secretions </li></ul>
  7. 7. <ul><li>Findings suggesting diagnosis of sinsusitis: </li></ul><ul><li>&quot;Does This Patient Have Sinusitis?&quot; </li></ul><ul><li>               The following increase the likelihood that your patient has sinusitis: </li></ul><ul><li>   History of colored nasal discharge </li></ul><ul><li>  Poor response to decongestants </li></ul><ul><li>   Maxillary tooth pain </li></ul><ul><li>    Physical exam showing purulent nasal discharge and abnormal </li></ul><ul><li>  maxillary sinus transillumination </li></ul>
  8. 8. EARS, NOSE and THROAT EXAMINATION CHECKLIST <ul><li>A = Attempted Satisfactory   </li></ul><ul><li>B = Attempted Below Satisfactory& </li></ul><ul><li>C = Did Not Attempt </li></ul>
  9. 9. <ul><li>1. OTOSCOPY:   Ex gently pulls the auricle up and back.   While holding the otoscope the Ex slowly inserts the speculum with a downward and forward movement into the ear canal.   Repeats with opposite ear. </li></ul>
  10. 10. <ul><li>2. HEARING ACUITY:   Ex asks Pt to block one ear with finger while Ex checks the auditory acuity in the opposite ear.   Ex then rubs fingers together 3 ft. from the unobstructed ear and then moves fingers in until Pt can hear the rubbing. </li></ul><ul><li>                                    AND / OR </li></ul><ul><li>The Ex whispers a word or number while standing approximately 3 feet from Pt's side and asks him/her to repeat word. </li></ul>
  11. 11. <ul><li>3. WEBER TEST: The Ex sets the tuning fork in vibration and places the base of the fork on the midline of the Pt's head. Ex asks Pt whether the sound is heard equally in both ears or better in one ear. </li></ul>
  12. 12. <ul><li>4. RINNE TEST: The Ex sets the tuning fork in vibration and places the base against Pt's mastoid bone. Ex asks Pt to specify when the sound is no longer heard. The Ex then places tuning fork in front of Pt's ear while Ex asks Pt if he can now hear the sound from tuning fork. Repeats with opposite ear. </li></ul>
  13. 13. <ul><li>5. PATENCY:   Ex asks Pt to inhale through each nostril separately while the opposite nostril is held shut. </li></ul><ul><li>6. SPECULUM:   Ex is positioned in front of Pt while gently inserting the short wide-tipped speculum into Pt's nostril.   Ex examines the lower portions of the nose and then asks Pt to tilt head slightly backwards. </li></ul>
  14. 14. 7-9.   INSPECTION: <ul><li>7. Ex uses a light to inspect the buccal mucosa and the BACK of the mouth and throat.   Using a tongue depressor Ex depresses more than halfway back on the tongue.   Ex may have Pt phonate while inspecting the throat. </li></ul>
  15. 15. <ul><li>8. Ex asks Pt to bite down.   Ex inspects the TEETH and GUMS at the same time using a tongue depressor or gloved finger to move the lips out of the way. </li></ul>
  16. 16. <ul><li>9. Ex asks Pt to extend TONGUE and move it from side to side.   Ex uses a cotton gauze or gloved finger when touching tongue.   (May inspect tongue at the same time Ex is inspecting the floor of mouth). Ex is not required to palpate the tongue. </li></ul>
  17. 17. PALTATION <ul><li>Check for </li></ul><ul><li>1. Firmness, nodules, pain. </li></ul><ul><li>2. Patency of nares (Have pt close mouth and occlude one nare) </li></ul>
  18. 18. INSPECTION <ul><li>Check </li></ul><ul><li>1. Skin appearance – color same as face </li></ul><ul><li>2. symmetrical </li></ul><ul><li>3.Nares – septum, midline, symmetrical </li></ul>
  19. 19. OTOSCOPE <ul><li>1) Tilt the patients head back slightly. Ask them to hold their breath for the next few seconds. </li></ul><ul><li>2) Insert the otoscope into the nostril, avoiding contact with the septum. </li></ul><ul><li>3) Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity. </li></ul><ul><li>4) Repeat for the other side. </li></ul>
  20. 20. OLFACTORY <ul><li>1) Close patient's eyes and occlude one naris. </li></ul><ul><li>2) Have available 2 or 3 vials of familiar aromatic odors. </li></ul><ul><li>3) Have the patient take a deep breath for the odor to reach the upper nose. </li></ul><ul><li>4) Repeat the process with the other naris. </li></ul>
  21. 21. SINUSES <ul><li>1) Frontal sinuses - use your thumbs to press up under the bony brow on each side of the nose. </li></ul><ul><li>2) Maxillary sinuses - press up under the zygomatic processes using your thumbs or index and middle fingers. Percussion: 1) Tap lightly directly over each sinus with your index finger. Findings : No tenderness or swelling </li></ul>
  22. 22. Speculum examination A nasal speculum, a transilluminator on a battery handle, and a sterile swab for culture material are needed for the examination. Some clinics have fiberoptic nasopharyngoscopes for examination of the sinus ostia and nasopharynx, and it may be necessary to send the patient for screening sinus x-rays. Sinus examinations should always be done in a darkened area, and the use of a decongestant spray such as oxymetazolin or 0.5% neosynephrine is encouraged. . Use of nasal speculum to visualize nasal cavity and septum. Exudate or disorders of the septum should be noted. During examination of the nose, a careful external inspection should be carried out with notation made of any previous injury, trauma, or congenital deformity. Frontal and maxillary sinuses should be transilluminated, and the speculum should be used to evaluate the intranasal cavity. A fiberoptic examination can be carried out along with percussion and palpation over the maxillary and frontal sinuses to denote tenderness.
  23. 23. <ul><li>Transillumination of frontal sinus. Light is placed under supraorbital rim and transillumination observed through frontal bone. </li></ul>
  24. 24. <ul><li>Transillumination of maxillary sinus. The light is placed against the cheek and transillumination observed through the open mouth. </li></ul>
  25. 25. <ul><li>Use of nasal speculum to visualize nasal cavity and septum. Exudate or disorders of the septum should be noted. </li></ul>