The document summarizes the examination of the nose and paranasal sinuses. It describes various instruments used in the examination like speculums, mirrors, and probes. It details the different parts of the examination including inspection of the external nose, anterior and posterior rhinoscopy, and tests to evaluate nasal patency and smell. Common complaints, nasal obstructions, and findings related to the sinuses are also outlined. The examination aims to thoroughly evaluate the nose and related structures.

1. “EXAMINATION OF NOSE
AND PARANASAL SINUS”
Dr. Hemant Nagar
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 examination usually includes
physical examination of external nose,
vestibule, anterior rhinoscopy, posterior
rhinoscopy and functional examination
of nose.

17. Inspection and palpation
Injuries with or without nasal/skull fracture.
Acne rosacea: It has typical butterfly rash over nose and cheeks.
Swelling and cysts:
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

18. 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.

19. 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.
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

20. 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: straight / deviations /perforations / granulations
• Inferior and middle turbinates: Compensatory hypertrophy/
hypertrophy
ANTERIOR RHINOSCOPY EXAMINATION

21. 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.

22.  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.

24.  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.

25.  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

26.  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

27. 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.

28.  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.

29. 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

30. 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

31.  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.

32. HANDKERCHIEF TEST