Examination of nose

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. 1 st year Shalakya Tantra Dept. ITRA Jamnagar

2. BULL’s EYE LAMP

3. Vienna Nasal S peculum

4. Thudicum Nasal S peculum

5. Flexible Endoscope

6. Rigid Endoscope

7. Lack’s tongue depressor

8. Hartman’s F orcep

9. Jobson Probe Aural Speculum

10. Aural Speculum

11. Laryngeal Mirror

12. Post- rhinoscopic Mirror

13. Tuning fork

14. 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)

15. 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.

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

17. 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 : 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

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. Herpes zoster: Skin lesions are restricted to the area of maxillary nerve (CN V2) distribution. 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.

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 . 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

20. 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.

21. 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

22. 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 .

23. 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.

24. 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.

25. 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.

26. 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

27. 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 .

28. 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

29. 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

30. 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.

31. 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.

32. 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

33. 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).

34. 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”.

35. 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

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

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

38. 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

39. 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

40. HANDKERCHIEF TEST