Examination of nose and pns

DR MANPREET SINGH NANDA
PROFESSOR ENT

1. Examination of Nose and PNS

2. General Physical Examination 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. Vitals 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. Local Examination External Nose Nares and Columella Vestibule Anterior Rhinoscopy Posterior Rhinoscopy PNS

5. Examination of External Nose 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. Anterior nares and Columella Symmetry Caudal dislocation FACE Dark circles around eyes – allergy Vestibule – lifting tip of nose (Not on rhinoscopy ) Erythema Ulcer Perforation Crusting Furuncle

8. Anterior Rhinoscopy 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

9. 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

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

11. Posterior Rhinoscopy 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

12. Examination of PNS 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

13. 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

14. 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

15. 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

16. FUNCTIONAL TESTS OF NOSE 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

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

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

19. 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

20. 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

21. 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

22. 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

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

24. Radiological investigations 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

25. 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

26. 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

27. Examination of infant 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