11/13/24, 7\:06 PM Guide | Nasal examination

Nasal examination

Table of contents
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Gather equipment

Light source\: this can be a pen torch, otoscope or a head torch.
Nasal speculum (also known as Thudicum's speculum) or an otoscope with a large speculum.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
i n v o l v e m e l o o k i n g a n d f e e l i n g t h e o u t s i d e o f t h e n o s e a n d t h e g e n t l y l o o k i n g i n s i d e t h e n o s e .
"
Gain consent to proceed with the examination.
Ask the patient to sit on a chair.
Ask the patient if they have any pain before proceeding with the clinical examination.

External nose inspection

Inspect the external surface of the nose from the front, side and behind the patient to identify any abnormalities.
Skin changes
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Inspect for skin lesions\:
Basal cell carcinoma\: pearly lesions with telangiectasia and rolled edges.
Squamous cell carcinoma\: scaly lesions, sometimes with associated ulceration and hyperpigmentation.
Keratoacanthoma\: raised lesions with a core of scaly keratin.
Deformity
Inspect for any deviation in the nasal bones or cartilage suggestive of a fracture. This is best performed by standing behind
the patient with their head tilted slightly backwards.
Inspect the external surface of the nose from the front, side and behind (1/3)
Epistaxis
Epistaxis is bleeding from the nose caused by damage to the blood vessels of the nasal mucosa. While most epistaxis is
self-limiting, in rare cases, it can become life-threatening.
Epistaxis can be caused by bleeding from anterior or posterior nasal structures. Little's area on the anterior nasal
septum (where Kiesselbach's plexus is located) is the most common source of anterior epistaxis. This area is easy to
visualise during a clinical examination.
The bleeding points that result in posterior epistaxis are deeper within the nose and di
assessment. Posterior epistaxis is typically more profuse and has a greater risk of airway compromise.

Nasal palpation

Warn the patient that you will be applying some pressure to their nose and ask them to let you know if they experience any
pain.
1. Palpate the nasal bones assessing\:
Alignment
Tenderness
Irregularity (suggestive of fracture)
2. Palpate the nasal cartilage assessing\:
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Alignment
Tenderness
3. Palpate the infraorbital ridges and assess eye movement if there is a history of trauma to screen for an orbital blowout
fracture.
Palpate the nasal cartilage
Orbital blowout fracture
An orbital blowout fracture is a fracture of the orbital
socket (e.g. tennis ball). Typical
eye movement (usually on vertical gaze).

Nasal cavity inspection

Brief assessment

straddled.
1. Sit facing the patient with your knees together and to one side of the patient’s legs. It is not pleasant for the patient to be
2. Ask the patient to look forward, keeping their head in a neutral position.
3. Carefully elevate the tip of the nose with your thumb, so that the nasal cavity becomes visible. Use a pen torch or otoscope
as a light source to externally illuminate the cavity (elevating the tip of the nose will also assess for dislocated septal cartilage).
4. Inspect the nasal mucosa (including the septum) for any abnormalities.
5. Inspect and compare nasal cavity alignment (note any septal deviation).
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Gently elevate the tip of the patient's nose with your thumb

Further assessment

Further assessment can be performed using an otoscope with a large speculum attached (inserting only the very tip into the
nose) or using a nasal speculum (also known as Thudicum's speculum), which widens the nasal cavity to allow you to peer in
using a light source.
How to use a nasal speculum
The correct method for using a nasal speculum is slightly counter-intuitive, however, it does allow the best visualisation of the
nasal mucosa\:
1. Insert your index
2. The middle and ring
3. You will be aiming to look at the gap between these two
4. Press the prongs of the speculum together to allow them to be placed within the nostril and then reduce your grip on the
speculum to widen the prongs until an optimal view of the nasal cavity is achieved.
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Insert your index
Assessing the nasal cavities
Regardless of which method you use to visualise the nasal cavities, you should assess the following structures\:
Nasal vestibule\: inspect for in
Nasal septum\: note any polyps, deviation, perforation, haematoma, super
Inferior turbinates\: note any asymmetry, in
Nasal cavity inspection
Structures of the nasal cavity
The turbinates are projections of bone covered in nasal mucosa. They control air
large surface area of mucosa, which both warms and cleans the air before it arrives at the lungs.
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The nasal septum is the bone and cartilage in the nose that separates the nasal cavity into the two nostrils
The nasal vestibule is the most anterior part of the nasal cavity. It is enclosed by the cartilages of the nose and lined by
the same epithelium as the skin.

Nasal air

Method one

1. Place your thumb over the nostril not being assessed to occlude air
2. Ask the patient to breathe in through their nose and note the degree of air
3. Repeat assessment on the other nostril, noting any di
Interpretation
Reduced air
deviated nasal septum or foreign body.

Method two

1. Place a cold shiny surface, such as a metal tongue depressor under the nose.
2. Observe for misting of the metal surface as the patient breathes and compare the misting pattern of the two nostrils.
Interpretation
The absence of misting or a disparity in the misting between the nostrils may suggest unequal or absent air
particular nostril.
Place a cold shiny surface, such as a metal tongue depressor under the nose

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
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Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 2 5- y e a r-o l d m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t a n d
t h e r e w e r e n o a b n o r m a l i t i e s n o t e d o n i n s p e c t i o n o f t h e e x t e r n a l n o s e.
"
" I n s p e c t i o n o f t h e n a s a l c a v i t y r e v e a l e d a n o r m a l l y a l i gn e d n a s a l s e p t u m a n d u n r e m a r k a b l e n a s a l m u c o s a . w a s a l s o n o r m a l .
"
N a s a l a i r
" I n s u m m a r y, t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Olfactory assessment (UPSIT\: University of Pennsylvania Smell Identi
Regional lymph node examination
Oral cavity examination
Flexible nasendoscopy
Cranial nerve examination\: in cases of nasal trauma
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