This document outlines examination techniques and tests for evaluating the nose and sinuses. It describes how to inspect and palpate the nose, perform anterior and posterior rhinoscopy, and examine surrounding structures. It also lists various tests that can be used to diagnose conditions, such as rhinomanometry to measure nasal airflow, imaging tests like x-rays and CT scans, allergy tests, and smell identification tests. The goal of the examination and testing is to evaluate the nose, sinuses and related structures for any abnormalities, infections, masses, or other issues.

2.  Mental state
 Consciousness
 Built and nutrition
 Attitude and Gait
 Facies
 Pallor – palmar creases, mm lips cheeks, conjuctiva,
nail beds
 Cyanosis – tongue (central), nail bed , tip of nose,
palmar skin
 Jaundice – sclera, nail bed , ear lobule, tip of nose
 Skin eruptions – macules ( change in skin colour),
papules , vesicles, pustules (solid projections)
 Neck nodes

3.  Pulse – pulse rate, rhythm (regular, irregular)
 Respiratory rate – fast, slow
 Temperature – continous ( fluctuates less
than 1 deg), remittent ( fluctuates more than
2 deg), intermittent
 Blood Pressure

4.  External Nose
 Nares and Columella
 Vestibule
 Anterior Rhinoscopy
 Posterior Rhinoscopy
 PNS

5.  INSPECTION
 External deformity – deviation, crooked
/saddle /hump
 Scar/sinus
 Skin colour change – rash
 Widening of nasal bridge – polyps
 Swellings – cysts, rhinophyma, tumours

6.  PALPATION
 Superficial and deep (pressure applied)
 With thumb and index finger
 Temperature
 Fixity of skin/mobility
 Tenderness
 Bony framework/shape change
 Crepitus - #

7.  Symmetry
 Caudal dislocation
 FACE
 Dark circles around eyes – allergy
 Vestibule – lifting tip of nose (Not on
rhinoscopy)
 Erythema
 Ulcer
 Perforation
 Crusting
 Furuncle

9.  Vienna/Thudicum/Killians Nasal Speculum
 Topical decogestants/ Xylocaine
 Left hand
 Widen the vestibule/ Never touch septum
 Otoscope (children)
 Speculum close introducing/partial open removal
 Inferior turbinate- ant end/middle turbinate -
hyp
 Inf/middle meatus – discharge/polyp
 Nasal septum – spur/deviation
 Floor of nasl cavity

10.  Size of nasal speculum – age/ nose size
 Colour of nasal mucosa – normal pink,
common cold, rhinitis medicamentosa –
generalised congested, acute sinusitis –
localised congestion, allergic – pale, atrophic
– dry with crust
 Secretions
 Sup turbinate – extension
 Cant – post end of turbinates and septum,
roof

11.  PROBE TEST
 Blunt probe
 To examine nasal mass
 Consistency
 Mobility or fixed
 Sensation to touch
 Bleed on touch
 Origin/attachment – pass probe all around

13.  Post rhinoscopy mirror
 Warm on mirror side
 Breathe through nose – relax soft palate
 Tongue depressor
 Don’t touch oropharynx – gag reflex
 Choana/ post end of septum and turbinates
 E.T orifices/ fossa of rosenmuller/ adenoids
 Look for polyp/ mass/ epistaxis/ pus

15.  INSPECTION
 Look for swelling over PNS
 Skin changes
 Orbit – lid oedema, conjuctival congestion,
proptosis
 PALPATION
 Palpate both sides simultaneous for compare
 Use index finger and thumb
 Look at facial expression while palpating

16.  Maxillary – canine fossa/ ant wall of cheek
lateral to nose
 Frontal – floor of frontal above medial
canthus / ant wall
 Ethmoidal – medial wall of orbit just behind
root of nose
 Tenderness in acute sinusitis

17.  TRANSILLUMINATION TEST
 Rarely done
 Dark room
 Maxillary – bright light applied on hard palate
with lips closed – crescentric glow observed
B/L in region of eye lids and over maxillary
sinus
 Frontal – light applied at floor of frontal
sinus – light glow observed on ant wall –
result compared with other side
 Absent/poor glow – pus/mass/thickening of
mucosa

18.  POSTURAL TEST
 Rarely done
 Middle meatus is observed for appearance of
discharge in various head positions
 Maxillary – head bent such that affected
sinus upright position
 Frontal – pus appears immediately with head
forwards chin down
 Ethmoidal – pus appears in 10-15 min in same
position

19.  COLD SPATULA TEST
 Tongue depressor cold – in front of ant nares
– fogging – compared for nasal obstruction
 COTTON WOOL TEST
 Fluff of cotton held against each nostril and
movement seen
 COTTLE TEST
 Elevation of naso labial fold relieves nasal
obstruction in case nasal valve involved
 EXAMINATION OF LYMPH NODES – level II/RP

20.  DIAGNOSTIC NASAL ENDOSCOPY
 Excellent magnification/ good light/ detailed
examination
 Rigid using angled nasal endoscopes
(0,30,45,70,90)/ Flexible
 Anaesthesia – Lignocaine
 1st pass – inf meatus, NLD, nasopharynx
 2nd pass – sup meatus, 3rd pass – middle
meatus
 Biopsy
 Cauterisation of bleeder

21.  NASOPHARYNGEAL EXAM UNDER GA
 Rose position
 Boyle’s davis mouth gag and rubber catheter
in each nostril
 Digitally palpate
 With angled mirror
 Rarely done

22.  TESTS FOR SMELL
 Time consuming and cumbersome
 Patient to close eyes
 Lemon/coffee powder/rose/garlic
 Ammonia – irritates V CN –
psychogenic/hysterical
 For both nostrils separate
 Avoid spirit – irritant
 Electro Olfacto Gram (EOG) using electrodes
 UPSIT – University of Pennsylvania Smell
Identification Test – cumbersome/not practical

23.  TESTS FOR ALLERGY
 Nasal smear under microscope – eosinophilia
 In Vivo tests
 Allergic skin tests –
 Subcuticular/prick/scratch test – most
accurate/quick/practical/easy/safe
 Emergency kit should be available
 Dust mite/pollen/grass/cat and dog hair
 Control – positive is histamine, saline – negative
 Intradermal test
 Nasal challenge test – allergen introduced to
nose – reaction - cumbersome

24.  In Vitro tests (serological tests)
 Using patient’s blood sample
 RAST – Radio allergen sorbent test
 PRIST – Paper radio immuno sorbent test
 RIST – Radio immuno sorbent test
 Here specific Serum Ig E is measured
 Specific tests
 Costly

25.  RHINOMANOMETRY
 Done by calculating nasal resistance to
airflow
 Resistance of nasal airway and nasal flow
pressure at external nares is measured
 Types
 Active – generation of nasal airflow and nasal
pressure with normal breathing
 Passive – generation from external source –
fan, pump

26.  BLOOD INVESTIGATIONS
 LFT – if nasal bleed
 Bacterial culture – little value as normal nose
has bacteria
 Complete haemogram
 Complete urine
 PHOTOGRAPHY – for rhinoplasty

27.  PLAIN X RAY
 Water’s view – occipito mental view with mouth
open – tip of nose and chin touch the plate – for
maxillary, frontal, sphenoid sinus
 Not for ethmoids as two superimpose
 Best for maxillary
 Caldwell’s view – occipito frontal view – tip of
nose and forehead touch the film – for frontal
sinus, nasal cavity, orbit
 Best for frontal
 Lateral view – for ethmoid, sphenoid and
adenoids
 Best for ethmoid and adenoids

30.  Base skull view/sub mento vertical view –
sphenoid, ethmoid
 Best for sphenoid
 Normally air filled sinus – translucent/same as
orbit
 Radio opaque – if opacity greater than orbit
 Totally opaque – large cyst/polyp
 Wall destruction – malignancy
 Partially opaque – AC polyp, cyst
 Pus with air fluid level – acute sinusitis
 Mucosal thickening – chronic sinusitis
 Expansion of sinus/ haziness/ cloudiness

31.  X Ray Nasal bones lateral view - #
 X Ray Nasopharynx lateral view – adenoids
 CT SCAN
 Coronal section – best
 Extent of disease/OMC/ cribriform plate/ lamina
papyracea/ optic nerve/ carotid artery
 Bony destruction
 MRI
 Tumour extension into cranial cavity/ orbit/
congenital malformations/ glioma/
encephalocele

32.  Nasal discharge – minimal – normal in first
few days of life
 B/L choanal atresia – life threatening
 Diagnosis – by passing blunted small rubber
or plastic catheter through nose and taken
out from oral cavity
 Contrast X Ray under GA
 Otoscope