This document provides guidance on clinically evaluating the nose. It outlines the key steps including taking a thorough patient history, performing a general examination, and conducting a local examination of the nose. The local examination involves anterior and posterior rhinoscopy to inspect the nasal cavities and paranasal sinuses. Potential abnormalities are described. Recommended blood investigations and radiological imaging include a CBC, sinus CT, and tests for underlying conditions. The goal is to arrive at an accurate diagnosis by combining the clinical findings with investigation results.

1. CLINICAL EVALUATION
OF NOSE
Moderator: Prof .Dr.N.Dhinakaran MS
Presenter: Dr.s.vinitha PG

2.  History taking
 General Examination
 Systemic Examination
 Local Examination
 Investigation
 Conclusion
C O N T E N T S

3. History taking:
Name,age,sex,occupation, address
Chief complaints:
1.Nasal obstruction
2.Nasal discharge
3.Epistaxis
4.Loss of smell
5.sneezing
6.Hawking sensation
7.cough
8.Headache
9.Facial pain
10.voice change
11.External nasal deformity
12.snoring

4. Nasal obstruction:
 Side: right/left/bilateral
 Duration:
 Severity: persistent/intermittent
 Progressive or non-progressive
 Associated with climatic changes (allergic rhinitis)
 Relieved with medication
 Association with purulent nasal discharge

5. Unilateral
 C shaped DNS
 FB
 AC polyp
 U/L atrophic rhinitis
 Rhinosporidiosis
 Stewart's granuloma
 Benign & malignant lesion
Bilateral
 S shaped DNS
 Rhinitis
 Ethmoidal polyp
 Atrophic rhinitis
 AR
 VMR
 Growth in nasopharynx
Intermittent
 VMR
 AR
 Early stage of ethmoidal polyposis
Progressive
 Malignancy
 Final stage of polyp

6. Relieved with medication
 Inflammatory-
AllergicRhinitis,Chronic Rhinitis
 VMR
 Ethmoidal polyposis
Drug induced obstruction
 Antihypertensive- methyl
dopa,hydralazine,prazosin
 Anti depressants-alprax
 Betablocker_propranolol,nadol
ol
 OCP
 ergot
 Iodides & alcohol
Obstruction after washing face with water: VMR
Obstruction more during expiration:AC polyp(ball valve
phenomenon

7. Nasal discharge:
 Side
 Duration
 Nature:
watery/mucoid/purulent/muco
purulent
 color
 Blood stained
 Foul smell +/-
 Crust+/-

8. Unilateral Nasal discharge Bilateral nasal discharge
 Foreign body
 u/l sinusitis
 Rhinitis caseosa
 Fungal sinusitis
 malignancy
 Chronic sinusitis
 polyp with 2' infection
 atrophic rhinitis with sinusitis
Watery nasal discharge
 Common cold
 AR
 VMR
 CSF leak
Purulent nasal discharge
 Chronic sinusitis
 atrophic sinusitis with 2' infection
 Rhinitis caseosa
 Malignancy with 2' sinusitis

9. Bloody nasal discharge
 Chronic sinusitis
 fungal sinusitis
 chronic granulomatous condition
 benign & malignant disease
Thick nasal discharge
 Cystic fibrosis
 karatagners syndrome
 AFS

10. EPISTAXIS
Commonest cause
1.children- nose picking 3.adult: hypertension
2.adolescent-JNA(recurrent) 4.Elder: HT f/b malignancy
Other causes
LOCAL:
1.Trauma,sx
2.infection
3.Granulomatous condition
4.Physiological:
puberty,extremes of temp,high altitude
5.vicarious menstruation
6.congenital: telangiectasia
7.Tumors
SYSTEMIC:
1.Bleeding diathesis
2.leukemia/Anemia
3.Hodgkin
4.liver disease/Vit k defn
5.RHD (ms)
DRUG INDUCED
IDIOPATHIC

11. Smell disturbances
ANOSMIA:total loss of smell
HYPOSMIA:reduced
PAROSMIA: altered sense of smell
CACOSMIA: any smell experienced as foul
Causes:
 Rhinitis
 Trauma to cribriform plate
 P' effect - intracranial
abscess,tumors, meningitis
 Olfactory Neuroblastoma
 Psychogenic
 Organic :temporal lobe
epilepsy
 Tumors: frontal/temporal

12. HEAD ACHE
1.site: frontal, temporal, vertex,occipital
OFFICE headache/ morning headache-frontal sinusitis
Spectacle headache- Ethmoiditis
occipital- sphenoiditis,tension,HT,cervical causes
2.side: U/L(migraine ) or B/L
3.Duration
4.Dull/ throbbing(vascular)
5.periodicity: Migraine
6.agg/ relieving factor
7.associated with vomit/ophthalmic changes/ aura

13. Facial pain
Side,severity,continuous/intermittent, agg&relieving factor
Causes
 Neuralgia- 1)Primary -trigeminal,glossopharyngeal
2)secondary-dental,cervical
3)central-herpetic,brain stem lesion,thalamus lesion
 Glossodynia
 Ocular
 TMJ Dysfn
 Vascular:migraine/temporal arteritis
 atypical facial pain

14. Voice change
Rhinolalia clausa:
Nasal /nasopharyngeal obstruction
Rhinolalia aperta:
Cleft palate,following adenoidectomy

16. FAMILY HISTORY:
Allergy(drugs,dust)
Dm,SHT,CAD,PTB
MENSTRUAL HISTORY:
Menarche/menopause
Cycles: regular/ duration
LMP

17. GENERAL EXAMINATION:
• Conscious, oriented,
• Build and nourishment
• VITALS: BP,PR,RR,Temp
"PICCLE""
Pallor
Icterus
Cyanosis.
Clubbing
Lymph node& thyroid gland enlargement
Pedal edema
Systemic Examination
Cvs,RS,GIT

18. LOCAL EXAMINATION:
 Face
 External nose
 Columella
 Vestibule
 Anterior rhinoscopy
 Posterior rhinoscopy
 Paranasal sinuses
 Cold.spatula test

19. Examination of face:
Dark circles- Allergic & chronic rhinitis
Redness- erysipelas
Furunculosis
Septal abscess
Osteomyelitis
Of nasal bone

20. Facial cellulitis
Ethmoiditis
Agressive bact,fungal rhinosinusitis
Furunculosis
Angioneurotic edema
Post trauma

21. • Vesicles
• Fissures

22. • Crusts • Ulceration

23. Examination of external nose
Skin
Signs of inflammation
Scars
Sinus
Skin discoloration
Swelling
Fistula
Vesicles
Osteocartilagenous framework

24.  Signs of inflammation--Furunculosis
 Scar-- sx/trauma
 Sinus- (congenital)
 Skin discoloration-Red. Erysipelas

25. Generalised swelling , yellowish nodule
surrounded by hyperemic boggy
mucosa__ sarcoidosis
Diffuse bulbous affliction of nasal tip-
lupus pernio/mortimer's malady
(cutaneous sarcoid)

26. Swelling--dermoid,glioma.
Mucocele,encepahlocele
osteoma,fibrous dysplasia,
osteomyelitis & malignancy of maxillarysinus
Frustenberg test
(+) Meningocele

27.  Vesicles- herpes simplex,zoster
 Crease-allergic salute,VMR, chronic
rhinitis
 Thickened skin in nasal tip-Acne
rosacea
 Fistula-osteomyelitis

28. Osteocartilagenous framework
Congenital

29. Congenital
Also look for fissured nose,columellar retraction, supratip
depression

30. Acquired:
Saddle nose: leprosy, Syphilis
Rhinoscleroma.
Trauma,surgery
Parrot nose: crouzen
Tapir nose: rhinoscleroma,
Leishmaniasis
Crooked nose: trauma

31. Increased intercanthal distance:
advanced ethmoidal polyposis
Malignancy of nasal & pns
Down's syndrome
Skin mobility:
Decreased in scar frmn , malignancy
Increased thickness:
Abscess,cyst,rhinophyma
Fluctuation:
Abscess,cyst

32. EXAMINATION OF COLUMELLA
 Scar
 Fissures- AR,VMR,CRS
 Ulceration-AR,VMR,CR
 Crusting
 Destruction- granulomatous
disease

33. EXAMINATION OF VESTIBULE
 Follicles- Folliculitis
 Pus points- furunculosis
 Edema- vestibulitis
 Crusts- Eczema, vestibulitis
 Scar- trauma,sx, granulomatous condition
 Vestibular stenosis-infection
TB,leprosy, syphilis,lupus
Sarcoidosis, rhinoscleroma
Post sx craniofacial resection
 Neoplasm,caudal dislocation

34. EXAMINATION OF NASAL CAVITY
ANTERIOR RHINOSCOPY:
Hold it in the left hand
Floor of nose
Inferior turbinate
Septum
Middle turbinate
Middle meatus
Roof

35. Mucosa:
1)color::Pink- normal
Hyperemic- rhinitis, sinusitis,septal abscess
Pale- Allergic rhinitis, Anemia, granulomatous
condition
2) Dryness
3)Crust

36. Floor of nose:
• Defects- cleft palate
• Swelling-osteopetrositis of palate,dental
cyst,hemangioma, neoplasm
• Granulation- foreign body

37. NASAL SEPTUM:
Bleeding points,dns,spur,,swelling,ulcers, perforation
DNS:

38. Cottle's classification of DNS:
1.Simple DNS:. Mild deflection obstructing nasal cavity
2.Obstructed DNS: severe deflection touching lateral wall
On applying vasoconstrictors ,septum & turbinates gets
separated
3.Impacted DNS:marked angulation of septum in contact with
lateral wall even after application of vasoconstrictors

39. PERFORATION:
CAUSES:
1.Trauma
2.Diseases
eg,syphillis, leprosy
3.malignancy
4.Radiation
5. irritants
6.Idiopathic
Size
Small- <1cm
Medium-
1 to 2 cm
Large
>2cm

40. NASAL PASSAGE: Patency, adhesions,
synechiae,stenosis,FB,rhinolith,growth
 Narrow: DNS,HT of turbinates,polyps,growth
 Wide: Atrophic rhinitis,rhinitis sicca

41. LATERAL WALL OF NOSE:
INFERIOR TURBINATE:.
Atrophic turbinate: Atrophic
rhinitis,post surgery
Hypertrophic : chronic hypertrophic
rhinitis
Mulberry: chronic HT
rhinitis,AR,VMR, Rhinitis medicamentosa

42. MIDDLE TURBINATE:
Hypertrophied- concha bullosa
Types1.Inferior[bulbous]
2.superior[lamellar]
3.Extensive type

43. Atrophied turbinate- Atrophic rhinitis,
Rhinitis sicca,
Atrophic stage of rhinoscleroma

44. Paradoxical middle turbinate Double turbinate
UP bends ant & in contact with MT

45. Polypoidal mucosa over turbinate
Seen in AR
Kupferberg's classification:AFS
Stage 0: no nasal edema
Stage 1: nasal edema with or without allergic mucin
Stage 2: polypoidal mucosa with or without allergic
Or fungal mucin
Stage 3: Polyps with allergic and fungal mucin

46. Crusts:
Atrophic rhinitis -greenish yellow
Rhinitis sicca- black
Invasive fungal sinusitis-black
Rhinitis caseosa
Wegners granuloma
Stewart granuloma
NODULES: TB,leprosy,Sarcoidosis
Wegners & Stewart granuloma

47. MIDDLE MEATUS
Pus(+)-sinusitis of anterior grp
Polyps(+)- Ethmoidal-multiple grape like,adult
Antral-U/L,post,children
Fungal-U/L,allergic mucin
Malignant
Mass- Benign(osteoma)
Malignant (sarcoma)

48. MASS
Size,site,color,
sessile/pedunculated,
single/multiple,
surface-smooth/irregular/surface studded with yellow spots
PROBE TEST
Sensitive to touch +/-
Bleeds on toucn+/-
Consistency,
Mobility,
margins

49. non sensitive to touch
not bleeds on touch
Pink,pedunculated
Yellow studs
Bleeds on touch

50. RHINOSCLEROMA
Indurated
Irregular
Red,rubbery
Cartilage consistency
Bleeds on touch
Probing(+) except lateral
HEMANGIOMA
Red,blanche's on pressure
sensitive to touch
Bleeds on touch

51. Olfactory Neuroblastoma
Arises from olfactory area
Single friable, red
Pedunculated
Sensitive to touch
bleeds on touch
Probe(+) expect superior

52. POSTERIOR RHINOSCOPY
 Choana- patency,polyp,growth
 posterior end of nasal septum
 Adenoids
 Posterior end of turbinates
 middle& sup.meatus-discharge
 Eustachian opening
 Tubal elevation

53. EXAMINATION OF PNS
Maxillary sinus:
Tenderness elicited by pressure over canine fossa
Ethmoidal sinus:
pressure on medialwall of orbit just behind root of nose
Frontal sinus:
pressure on the ant. wall of frontal sinus above medial eyebrow &
on floor of frontal sinus above medial canthus

54. COLD SPATULA TEST
To check the patency of nasal passage
decreased fogging / no fogging indicates obstruction

55. COTTLE'S TEST
Nasal obstruction improves in case of
nasal valve obstrn

56. BLOOD INVESTIGATION
Hb
TC DC AEC
ESR
Allergy
Total IgE
Systemic disease
Sweat chloride test
ANCA
DNE
PSG
PLATELET
BT CT
PT APTT
In vivo test
skin test
Nasal cytology for
Eosinophil
Sputum AFB
Mantoux test
Radiology
X-ray PNS,nasopharynx
CXR PA view
CT PNS
RBS/FBS/PPBS
RFT
LFT
In vitro test
Radio allergosorbent
test(RAST)
Fluoro allergosorbent
VDRL,TPI,TPHA
Nasal swab culture
Others
VCA,EA,nuclear Ag
Olfaction
CSF leak identification
INVESTIGATION

57. INVESTIGATION
1.HB- anemia (AR,malignancy, granulomatous condition)
2.TC,DC-inc(bacterial infection)
Dec(viral infection)
3.AEC:Absolute eosinophil count: Allergy
4.Nasal cytology for eosinophill
5.Total Ig E : Allergy
6.Platelet : Epistaxis,preop(N- hereditary telengiectasia)
7.BT,CT,PT,APTT-Epistaxis,anticoagulant therapy
8.ESR-inc (chronic infection, granulomatous condition, lymphoma,malignancy)
9.RBS- to r/o DM
10.RFT- preop,wegner granulomatosis,to monitor antifungal therapy in AFS

58. 11.VDRL,TPI,TPHA- septal perforation (syphilis)
12.Sweat test: >70mmol of Nacl/100g sweat
13.Nasal swabs culture:☆chronic sinusitis
☆Granulomatous
☆Atrophic rhinitis
☆vestibulitis
☆CST
14.sptum AFB
15.Mantoux test

59. SKIN TEST
Principle: To initiate allergic response( wheal and flare)
By injecting specific allergens
Which induces Sensitized mast cells in tthe skin (within 2 to20
minutes.)
Negative control: Here 0.4% phenolated saline is used
Positive control. Here 1:500 or l : 1000 w/v histamine solution is used which
excludes a false negative test due to (a) loss of potency of allergens, (b)prior
use of drugs.

60. FACTORS AFFECTING skin
test:
😀volume of antigen introduced
😀potency of antigen
😀degree of sensitization
😀reactivity of skin
FALSE POSITIVE
Improper preparation of allergen
more of glycerin
large volume

61. 1.Prick test
2.Intradermal skin test
3.scratch test - contactdermatitis
4.skin end point titration test
RAST
In vitro test
Uses enzyme to label anti IgG
Measured in spectrometry
Skin test(in vivo)

62. DIAGNOSTIC NASAL ENDOSCOPY
GRAY( GRBY)
Green 0'
Red 30'
Black 45'
Yellow 70'

63. First Pass
Floor,IT,Septum, Choana,nasopharynx, ET
opening,TT,FOR,
inferior meatus,NLD opening

64. SECOND PASS
Passed medial to middle turbinate & posteriorly
sphenoethmoidal recess
Sphenoid ostium
Superior turbinate
olfactory cleft region

65. Third pass
Middle meatus and its
structures

66. PATHOLOGY

67. X-ray
Water's view
Occipito frontal view
Pierre's view
Water+mouth open

68. Caldwell's view
Occipito frontal view
Basal view
Submento vertical view

69. Lateral view

70. CT PNS

71. THANK
YOU