In this PPT description of various basic instruments, anterior rhinoscopy, Posterior rhinoscopy, septum examination, nasal valve patency examination, paranasal sinus examination, etc.

1. “EXAMINATION OF NOSE
AND PARANASAL SINUS”
Dr. Shraddha Joshi
Ph.D. 1st year
Shalakya Tantra
Dept.
ITRA
Jamnagar

2. BULL’s EYE
LAMP

3. Vienna Nasal
Speculum

4. Thudicum
Nasal
Speculum

5. Flexible
Endoscope

6. Rigid
Endoscope

7. Lack’s tongue
depressor

9. Hartman’s
Forcep

10. Jobson Probe
Aural
Speculum

11. Aural
Speculum

12. Laryngeal
Mirror

13. Post-
rhinoscopic
Mirror

14. Tuning fork

15. Main complaints
• Nasal stuffiness/ obstruction
• Nasal discharge: anterior/
postnasal drip
• Sneezing
• Itching
• Nose bleed (epistaxis)
• Nasal crusting
• Disturb smell
• Emitting foul smell to others
• Swelling nose and paranasal
sinuses
• Nose deformities: congenital or
acquired
• Injury/foreign body (FB)
Associated complaints
• Headache
• Vomiting
• Fever
• Facial fullness/pain
• Exophthalmos
• Change in voice
(hypernasal/hyponasal)
• Snoring/obstructive
sleep apnea (OSA)
• Cough
• Epiphora
• Deafness(conductive)

16. Nasal obstruction: Unilateral/ Bilateral.
Nasal Discharge: Watery/Purulent
Epistaxis: Bouts of profuse bleeding in cases of anemic young,
adolescent males indicate nasopharyngeal angio-fibroma.
Headache
Disturbed smell:
• Cacosmia (perception of putrid odor) is common in cases of
empyema of maxillary sinus.
• Hyposmia (partial loss of smell sensation) is common in cases of
nasal obstruction.
• Anosmia (total loss of smell sensation) indicates neural
pathology.
• Parosmia (perversion of sense of smell) & hyperosmia is
common in hysterical ladies.

17. Nasal examination usually includes
physical examination of external nose,
vestibule, anterior rhinoscopy, posterior
rhinoscopy and functional examination
of nose.

18. The skin and osteocartilaginous framework of nose needs proper
inspection as well as palpation for the skin lesions and the
osteocartilaginous framework deformities.
Injuries with or without nasal/skull fracture.
Acne rosacea: It has typical butterfly rash over nose and cheeks.
Healed lupus: Patient has loss of tissue around the edges of
nares. It can be due to trauma.
Swelling and cysts:
a. Dermoids: They occur over nasal bones and columella.
b. Dermoid cyst: It can present as a discharging sinus over the
osteocartilaginous junction of nasal bridge.
c. Furuncle: It presents as a tender red swelling near the tip of nose.
EXTERNAL NOSE EXAMINATION

19. d. Dental cysts/abscess: They present as swelling near the nasal
alae.
e. Rhinophyma: It presents as enlargement of the lower part of
nose.
 Superficial ulcers and inflammation: It can be secondary to
nasal discharge or due to herpes simplex.
a. Herpes zoster: Skin lesions are restricted to the area of
maxillary nerve (CN V2) distribution.
b. Rodent ulcer: Basal cell carcinoma Palpation of external nose
differentiates between bony, cartilaginous and soft tissue
swelling and diagnose deformity, fracture (crepitus) and other
lesions.

20. Vestibule is an anterior skin lined part of nasal cavity having
vibrissae (hairs in nasal vestibule).
It can be easily evaluated by lifting the tip of nose. For further
details, refer to chapter Diseases of External Nose.
Examine for the following components:
 Metaplasia: Frequent picking of nose produces metaplasia that
stands out as whitish dry areas.
 Ulcerations and perforation: Septal perforations can be due to
frequent picking and industrial dusts and fumes especially nickel
and chrome.
VESTIBULE EXAMINATION

21.  Caudal deflection of septum: Dislocation of septal cartilage from
its groove in the maxillary crest.
 Furuncle or fissures: Vestibular examination becomes painful.
 Papilloma: It is usually pedunculated.
 Cyst: Nasolabial cyst presents as a smooth bulge in the floor and
lateral wall of left nasal vestibule and upper part of upper lip.
Cyst obliterates the alar facial fold.

22. Patient’s head needs to be tilted in different directions to examine
different sites in the nose: septum, inferior turbinate and meatus,
middle turbinate and meatus and floor of the nose.
• Septum: It is rarely straight and mild deviations are not
significant. In some cases, even gross looking deviations do not
cause any functional problem. Note for any perforations,
granulations, deviations.
• Inferior and middle turbinates: Compensatory hypertrophy of
middle and inferior turbinates is common on the concave side of
deviated nasal septum. In cases of chronic and allergic rhinitis,
there can occur hypertrophy of inferior margins and posterior
ends of middle and inferior turbinates.
ANTERIOR RHINOSCOPY EXAMINATION

23. Middle turbinate concha bullosa (contains air cells), paradoxical
shape (convex lateral surface) and polypoidal changes are common
findings.
• Inferior and middle meatuses: Inferior meatus is rarely visible.
Most nasal polyps first appear in middle meatus. Purulent
secretions in middle meatus can come from infections of
anterior paranasal sinuses (maxillary, anterior ethmoid and
frontal) as they all drain in it.

24. Floor of nose: A swelling in the floor of nose may extend from
hard palate and alveolar process of maxilla. A floor ulcer may
communicate with oral cavity. Foreign bodies are usually seen
between septum and inferior turbinate.
 Topical nasal decongestant: The solution of cocaine or
xylocaine with adrenaline brings about vasoconstriction
(shrinkage of mucous membrane) and local anesthesia and
facilitates the proper nasal examination.
The hypertrophied inferior turbinate does not reduce in size
much.

25.  Probe test:
• It is done under topical anesthesia.
• A probe is passed on all surfaces of mass and helps in
ascertaining the site of attachment, consistency, mobility,
vascular nature and sensitivity of the growth.
• Ulcers should be probed to know the exposed underlying bone.
• Probing of an ulcer in the floor of nose can exclude or confirm
its oral cavity communication.
• Rhinolith gives a grating sensation on probing.

27.  Posture test:
• Drainage of purulent discharge from various sinuses depends
upon the posture of patient.
• After wiping out, the purulent discharge from the middle meatus
note the timings of discharge and the posture of patient.
– Frontal sinus: Pus reappears immediately if the patient is sitting
in upright position (Head forward chin down position).
– Ethmoidal sinus: Pus reappears after some time (10–15 minutes)
if the patient is sitting in upright position.
– Maxillary sinus: Pus reappears if the head is so bent that the
affected maxillary sinus is in upward position.

28.  The infant (including its arms) should be wrapped in a cloth and
a nurse must control its head movements. „
 Nasal discharge: Slight discharge is considered normal during
the first few days of life. Persistent snuffles indicate trauma and
infection from difficult delivery and need swab for culture. „
 Nasal obstruction: Infants do not know mouth breathing and
severe or complete nasal obstruction (bilateral choanal atresia)
can be life-threatening.
 Nasal airway is adequate if baby breaths quietly with mouth
shut.
INFANTS EXAMINATION

29.  Moderate nasal obstruction may interfere with feeding and baby
becomes restless after a few sucks.
 Bubbling nasal mucus and clouding of bright surface indicate
partial patency of nasal airway.
 Testing:
• Nasal airway patency can be tested with a bluntended soft rubber
or plastic catheter.
• In cases of choanal atresia catheter will not appear in the
oropharynx.
• Diagnosis is confirmed with contrast (radiopaque solution into
each nostril) X-ray under general anesthesia.

30.  It consists of examining the nasopharynx and posterior part of
nasal cavity by the postnasal mirror.
 The patient opens his mouth and breathes quietly.
 The examiner depresses the patient’s tongue with a tongue
depressor that is held in left hand and introduces posterior
rhinoscopic mirror.
 The mirror should be held in right hand like a pen and carried
behind the soft palate, along the tongue but without touching the
posterior third of tongue (to avoid gag reflex).
 If the patient is quiet and relaxed, then usually soft palate does
not contract and hide the view.
POSTERIOR RHINOSCOPY EXAMINATION

31.  Spatula test: A clean cold tongue depressor is held below the
nose while patient exhales. Each area of mist formation on either
side is compared. „
 Cotton-wool test: A fluff of cotton is held against each nostril
and its movements indicate the nasal blow of air while the
patient inhales or exhales. „
 Alae nasi movements: In cases of inspiratory obstruction, alae
nasi collapse onto the septum. „
 Cottle test:
PATENCY OF NASAL CAVITY

32. PARANASAL SINUSES
 They are examined by inspection, palpation and
transillumination. The anterior group of sinuses (maxillary,
frontal and anterior ethmoid) drains in middle meatus. The
posterior ethmoid drains into superior meatus. The sphenoid
sinus opens into sphenoethmoidal recess.
 Tenderness of the sinuses can be elicited by pressure or
percussion with a finger on their walls. „
• Frontal sinus: Anterior and inferior walls above the medial part
of eyebrow and above the medial canthus. „
• Maxillary sinus: Anterior wall over the cheek lateral to nose.
• Anterior ethmoids: Medial wall of orbit just behind the root of
nose.

33.  Transillumination Test:
 Maxillary sinus: A specially made light source is placed in the
mouth and the mouth is closed. Normally, a crescent of light in
the inferior fornix and glow in the pupil, which are equally
bright on either side can be seen. The affected side maxillary
sinus will not transmit light if there is pus, thickened mucosa or a
neoplasm.
„
 Frontal sinus: A small light source is placed in the
superomedial angle of the orbit. The transmission of light from
the anterior wall of the both side frontal sinuses is compared.

34. SMELL
The odorous substance should be volatile and reach the olfactory
area. Any lesion anywhere in the olfactory pathway (olfactory
mucosa, olfactory nerves, olfactory bulbs and tract and the
cortical center of olfaction) will affect smelling power of the
person.
 Loss of smell: It can result from–
 Nasal obstruction due to nasal polyps, enlarged turbinates,
edema of mucous membrane as in common cold, allergic and
vasomotor rhinitis.
 Atrophic rhinitis.
 Peripheral neuritis: Toxic or influenzal.
 Injury to olfactory nerves and olfactory bulb: Fractures of
anterior cranial fossa

35.  Intracranial lesions pressing olfactory tracts: Abscess, tumor
and meningitis.
„
 Parosmia: It refers to perversion of smell. Patient interprets the
odors incorrectly, which is usually disgusting odors.
 The causes of parosmia include: Recovery phase of
postinfluenzal anosmia: Misdirected regeneration of nerve fibers.
 Anosmia: The three most common causes are sinonasal disease,
post-upper respiratory tract infection and trauma (injury to
olfactory nerves at cribriform plate or brain injury).

36. Tests for Smell:
 In routine testing, patient is asked to close eyes and smell
common odors such as lemon, peppermint, rose, garlic, coffee,
and cloves. Each side of the nose is tested separately.
 Quantitative estimation (quantitative olfactometry) needs special
equipment. „
 Electro-olfactogram: Electrode, which is placed on the
olfactory epithelium, records a slow, negative and monophasic
potential in response to odorants. Electroolfactogram (EOG)
represents a “generator potential”.

37. Indigo carmine test/saccharin sodium test:
 A drop of indigo carmine (8 mg/ml) and a drop of saccharin
sodium are put at the anterior part of the floor of inferior meatus.
 After 3 minutes, patient is asked to swallow for 30 minutes and
tell any taste of sweet (saccharin sodium).
 The examiner simultaneously inspects the posterior pharyngeal
wall at these intervals for the blue dye of indigo carmine.
 The time lag between the perception of sweet taste and
appearance of blue dye in the pharynx is noted. This time lag is
called mucous transport time (MTT).
 The normal value of MTT is 12–15 minutes (for ciliary beat
frequency of 10/sec and transit time of 6 mm/ minute).
 More than 30 minutes MTT is considered grossly abnormal.
MUCOCILIARY FLOW

38. Unilateral Nasal Obstruction
a. Infectious: Furuncle, hypertrophic turbinate, concha bullosa,
antrochoanal polyp and unilateral sinusitis.
b. Congenital: Atresia and stenosis of nares, unilateral choanal
atresia, nasoalveolar cyst.
c. Traumatic: Foreign body, rhinolith, deviated nasal septum
(DNS) and synechia
d. Neoplasms: Papilloma, bleeding polyp of septum, benign and
malignant tumors of nose and paranasal sinuses, and
nasopharynx.
NASAL OBSTRUCTION

39.  Bilateral Nasal Obstruction
a. Infectious: Bilateral vestibulitis, rhinosinusitis (infectious,
allergic and others), nasal polyps, atrophic rhinitis, septal
abscess and large choanal polyp.
b. Congenital: Congenital atresia of nares, bilateral choanal
atresia and Thornwald’s cyst.
c. Structural: Collapsing nasal alae, stenosis of nares, DNS,
adhesions between soft palate and posterior pharyngeal wall.
d. Traumatic: Septal hematoma.
e. Neoplasms: Large benign and malignant tumors.
f. Miscellaneous: Hypertrophic turbinates and adenoid
hyperplasia.

40.  Measurement of Nasal obstruction:
 Resistance to airflow is the force that impedes flow of air. The
diameter of nasal cavity is the most important variable in nasal
airflow.
 In normal cases, airflow resistance is reduced one third after
topical decongestion and further two third after wide alar
retraction.
 Acoustic rhinometry
 Rhinomanometry or rhinometry

41.  Internal nasal valve: The septal deformities and loss of ULC
support can lead to nasal obstruction. The ULC may be
thickened, twisted and concave or absent because of prior
surgery.
„
External nasal valve: The reasons of external valve compromise
includes rhinoplasty, aging and caudal septal dislocation or
trauma. „
Cottle test: In this test, which is done for the abnormality of the
nasal valve, cheek is drawn laterally while patient breathes
quietly. If there is subjective improvement in nasal airway, the
test is positive, which indicates nasal valve compromise. The test
also can be performed by lateralizing the ULC with a cotton-
tipped applicator or cerumen curette.
NASAL VALVE DISORDER

44. HANDKERCHIEF TEST