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4.2 Examination ofNose andParanasal Sinuses
179
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Fig. 4.4 Types of noses in various ethnic groups (a) Greek, (b) Roman, (c) Nordic, (d) Semitic, (e) North American
Indian, (f) Mongolian, (g) Negro
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Fig. 4.5 Shape of nose, (a) Nubian nose, (b) Greek nose, (c) Hook nose, (d) Arched nose, (e) Button nose, (f) Straight
nose, (g) Concave nose, (h) Crooked nose
29mm - 32mm
Small
Fig. 4.6 Size of nose
35mm - 38mm
Medium
41mm - 44mm
Large
180
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Fig. 4.7 (a) Telangiectasia, (b) Rhinophyma
4 History andExamination ofNose andPara Nasal Sinuses
– Types of lesions over skin
Ulcer—BCC, SCC
Growth—SCC, BCC,
granuloma
Mass—Rhinophyma
Swelling—Inflammatory,
traumatic
– Rashes over nose—Buttery or
malar rashes
Buttery rash over the nasal
bridge
Malar rash in systemic lupus
erythematosus
– Thickening and coarseness—
Hypothyroidism
– A large bulbous nose with a coarse
‘orange skin’ like appearance suggests a rhinophyma (Fig.4.7a)
– Check for any telangiectasia on the
nose, face or hands (Fig.4.7b)
• Scars or abnormal creases
– Allergic (horizontal) nasal
creases—Allergic rhinitis
– Allergic shiners—Dark circles
under eyes
– Denny—Morgan folds—Skin folds
or eye bags under eyes
– Allergic salute—Itchy nose and
sneezing with the child constantly
rubbing the nose upwards
• Swelling over the nose—The differen-
tial diagnoses of a midline nasal mass
include inammatory lesions, trau-
matic deformity, benign neoplasms,
malignant neoplasms and congenital
masses. Congenital midline nasal
masses include nasal dermoids, gliomas and encephaloceles.
• Deformities of nose—Congenital
nasal deformities were classied into
the following four categories:
– Type I—Hypoplasia and atrophy
(represents paucity, atrophy or underdevelopment of skin, subcutaneous
tissue, muscle, cartilage and/or bone)
– Type II—Hyperplasia and duplica-
tions (represents anomalies of
excess tissue, ranging from duplications of parts to complete
multiples)
– Type III—Clefts (the comprehen-
sive and widely used Tessier classication of craniofacial clefts is
applied)
– Type IV—Neoplasms and vascular
anomalies (both benign and malignant neoplasms are found in this
category)
• Type of tip of nose
Bullous tip/bullous tip—A bullous tip
is rounded with an enlarged appearance of nose. It is caused by
rhinophyma.
Celestial tip/upturned tip—The tip of
nose is projected upward, and the size
of nose is small.
4.2 Examination ofNose andParanasal Sinuses
181
Deviated tip—The tip of nose deviated
from midline is usually present in
deviated nose and crooked nose.
Down-turned tip—The tip is directed
downward and is usually present in
long nose and Nubian nose.
(b) Palpation of external nose: The palpa-
tion of the nose starts from nasion to tip;
the examiner presses along the bridge of
the nose with both index ngers to feel
the bony skeleton and skin thickness. The
palpation of the nose is done to assess
nasal bone, frontal process of maxilla,
upper lateral cartilage, lower lateral cartilage, dorsum of nose and side of nose for
crepitation, tenderness, step ladder deformity, etc. The external nose is assessed on
various parameters.
• Tenderness
– Dorsum of nose—Tenderness on
dorsum is suggestive of fractured
nasal bone.
– Side of nose—Fractured nasal
bone, furunculosis, concha bullosa,
septal spur
– Tip of nose—Furunculosis, septal
abscess
• Abnormal movements—Examiner
holds the dorsum of nose with the
index nger and thumb of the right
hand and moves. It is indicative of
bilateral nasal bone fracture.
• Crepitation over nose—Examiner
holds the dorsum of nose with the
index nger and thumb of the right
hand and moves it side by side for any
crackling sound. It is suggestive of
fractured nasal bone.
• Irregularity—The irregularity of nasal
dorsum or side of nose is suggestive of
fractured nasal bone, hump, supratip
deformity, wavy dorsum, saddle nose
and crooked nose.
• Depression—Supratip depression or
saddle nose.
• Convexity of dorsum—Hump on
dorsum.
• Alignment—Misalignment fractured
nasal bone.
• Abnormal movement of nose—
Fractured nasal bone.
• Swelling over nose (from nasion to
tip)—Meningioma, glioma, meningocele, dermoid.
• Palpation of specic area of external
nose
– Palpate the nasal bones (upper 1/3
of nose) (Fig.4.8a, b)
Alignment—Fracture, deviated
nose, crooked nose
Tenderness—Fracture, furunculosis
Irregularity of dorsum—
Suggestive of fracture
Crepitation—This is suggestive
of fracture
– Palpate the upper lateral cartilage
(middle 1/3 of nose)
Alignment—Deviated nose,
crooked nose
Tenderness—Furunculosis,
fractured nose
– Palpate the alar cartilage (lower 1/3
of nose)
Alignment—Collapsed ala
Tenderness—Vestibulitis, furunculosis
• Palpation of the tip of nose
– Alar recoil—This is done by press-
ing the ala medially and watching
for the ala to bounce back into normal position.
– Tip recoil—It is dened as the
inherent strength and support of the
nasal tip. It is evaluated by depressing the tip towards the upper lip and
watching for the tip-supportive
structures to bounce back
(Fig.4.8c).
2. Examination of Internal Nose: The examination of the internal nose has been divided
into examination of the vestibule and examination of nasal cavity proper. To examine the
vestibule, the tip of the nose is to be elevated
182
a
bc
4 History andExamination ofNose andPara Nasal Sinuses
Palpation of nose for
abnormal movement
Fig. 4.8 Shows palpation of external nose, (a, b) Shows movement of nasal dorsum (bony structure of nose), (c) Tip
recoil
with thumb so that the vestibule becomes visible. First examine the nasal vestibule, caudal
septum location and nasal valve, then nasal
cavity proper to be examined with nasal
speculum.
(a) Examination of vestibule: This part of
the examination is done without speculum to examine the vestibule by carefully
elevating the tip of the nose with thumb,
so that the vestibule can be inspected for
• Inspect the position of the caudal septum: Midline/dislocation (deviation)
to one side
• Inspect the external nasal valve
• Swelling
– Over septum—Septal haematoma,
(b) Examination of nasal cavity proper
septal abscess
– Over oor—Nasolabial cyst
– Lateral wall—Dentigerous cyst
• Mass/growth
– Septum—Rhinosporidiosis, hae-
mangioma
– Floor—Rhinosporidiosis
– Lateral wall—Rhinosporidiosis
furunculosis
• Collapse of ala or aring of ala is
noted
• Stenosis, adhesions
• Deviated nasal septum—Caudal dislocation of septum
• Mass in vestibule—Rhinosporidiosis,
nasal polyp
(anterior rhinoscopy): This examina-
4.2 Examination ofNose andParanasal Sinuses
183
a
b c
d
Fig. 4.9 Anterior rhinoscopy, (a) How to use Thudicum nasal speculum, (b, c) How to do anterior rhinoscopy (ARS)
and structures visualized, (d) Shows examination of nasal vestibule
tion of nasal cavity is done with the
help of Thudicum or Killian nasal speculum. This is termed as anterior
rhinoscopy.
(c) Anterior rhinoscopy: This is an exami-
nation of nasal cavity with the help of
nasal speculum and light to visualize the
interior of the nose; if required the nasal
decongestion is done with xylometazoline nasal drop (Fig.4.9).
How to use Thudicum nasal speculum—
Insert your index nger into the bend of the
speculum and support it above with the
thumb. The middle and ring ngers are
used to manipulate the prongs of the speculum. You will be aiming to look at the gap
between these two ngers. 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 (Fig.4.9).
• Procedure—Patient is seated in front
of the examiner, and a headlight or
head mirror is used for illumination.
Now a nasal speculum, either
Thudicum or Killian held in the right
hand and left hand, is used to stabilize
the head. Now a closed nasal speculum is inserted in the nose in the vestibular area and opened to visualize the
nose. At the end of examination, the
speculum is half closed and removed
from nose to avoid entrapping of hair
(Fig.4.7b).
184
4 History andExamination ofNose andPara Nasal Sinuses
a
Fig. 4.10 Inferior turbinate, (a) Normal, (b) Mild HIT (c) Moderate HIT
b c
• Structure visualized—In ARS examination, various anatomical sites, like
inferior meatus, inferior turbinate,
middle meatus, middle turbinate,
superior meatus, septum, oor of nose,
are examined. A few common diseases
present in nasal cavity like septal deviation, septal perforation, hypertro-
Unilateral—Iatrogenic (Denker’s opera-
tion, radical turbinectomy)
Bilateral—Atrophic rhinitis, rhinitis sicca,
tuberculosis, syphilis, leprosy,
post-radiotherapy
phied turbinate, polyps, papilloma,
granulomas, tumours, ulcers, crusting,
Little’s area prominent vessels, telangiectasia can be diagnosed (Fig.4.9).
• Findings on ARS
– Inferior turbinate
Size—It may be normal, atrophied or hypertrophied inferior
turbinate (Fig.4.10).
• Normal
• Hypertrophy—It may be
mild to severe (Fig.4.8)
• Unilateral associated with DNS
– Towards the concave side—
Compensatory HIT
– Towards the convex side—
Paradoxical HIT
• Unilateral not associated with DNS
– Haemangioma, allergic rhinitis,
NARES, idiopathic
• Bilateral
– Allergic rhinitis, hypothyroidism,
idiopathic, intrinsic rhinitis
• Atrophied
• Congestion (Fig.4.11)
– Normal
– Mild congestion
– Moderate congestion
• Colour (Fig.4.12)
– Pinkish—Normal
– Red—Haemangioma,
congestion (normal to
moderate) (Fig.4.9)
– Blue—Allergic rhinitis
– Pale—Intrinsic rhinitis
(mild and moderate)
– Inferior meatus
Mass—Nasal polyp,
rhinosporidiosis
Swelling—Nasolabial cyst
Growth—Squamous cell carcinoma, adenocarcinoma
Opening on the lateral wall—
Inferior meatal antrostomy
– Middle meatus
Mass—AC polyp, ethmoidal
polyp, inverted papilloma, angiomatous polyp
bc
4.2 Examination ofNose andParanasal Sinuses
a b c
Fig. 4.11 Congested turbinate (a) Normal, (b) Mild congestion, (c) Moderate congestion
a
185
Fig. 4.12 The colour of nasal mucosa (a) Normal, (b) Mild pale, (c) Moderate pale
Growth—SCC, adenocarcinoma
Swelling—Agar nasi cell
Pus/discharge—Maxillary
sinusitis, frontal sinusitis, anterior ethmoidal sinusitis
– Middle turbinate
Size
Normal
Large—Concha bullosa, hypertrophied middle turbinate
Small—Atrophic rhinitis,
iatrogenic
Shape
Normal—IF MT is concave laterally and convex medially.
Paradoxical—It is inferiomedially curved middle turbinate with concave surface faces
medially.
Ballooning (concha bullosa)—It
is pneumatized middle turbinate
convex on both sides; it is of
three types lamellar, bulbous
and extensive type.
L-shaped middle turbinate
Medially displaced middle
turbinate
Types
Type 1—Where the anterior border of the middle turbinate runs
directly posteroinferiorly from
its attachment to the conchal
plate, as seen in 38% of the
cases.
Type 2—Where the anterior border of the middle turbinate initially coursed f—inferiorly from
the conchal plate and then turned
186
4 History andExamination ofNose andPara Nasal Sinuses
in a posteroinferior direction, as
seen in 42% of the cases.
Type 3—Where the anterior
borders bulge anteriorly before
coursing posteroinferiorly, as
seen in 20% of the cases.
– Septum
Midline—(normal position)—
Nasal septum lies straight in
midline.
Deviated—This may be deviated to one side (C shaped) or
both sides (S shaped).
Shape of DNS—C shaped (anterior to posterior, superior to inferior), S shaped (anterior to
posterior, superior to inferior)
Severity of DNS—Mild, moderate and severe
Component involved—Bony,
cartilaginous or both
Types of acute angulation—
Septal spur, caudal dislocation
and inferior dislocation
Swelling—Septal haematoma,
septal abscess
Perforation—Septal perforation
(mostly involves cartilaginous
part)
Mass—Rhinosporidiosis,
microaneurysm, haemangioma,
paraganglioma, pyogenic granuloma
Growth—Tumours (benign or
malignant)
Ulcer—Carcinoma, histoplasmosis, trauma, vestibulitis,
tuberculosis, SLE, vasculitis
Thickening of septum—Septal
haematoma, idiopathic
– Nasal cavity
Mass/growth—Inverted papilloma, angiomatous polyp, JNA,
SCC, adeno carotid artery (CA)
FB or rhinolith—Its size and site
noted
Secretion/discharge
Watery (serous) (Fig. 4.13a)—
CSF rhinorrhea, acute rhinitis,
allergic rhinitis
Yellow (purulent) (Fig.4.13b)—
Bacterial sinusitis, pyocele
Black (Fig. 4.13c)—Mucormy-
cosis, aspergillosis
White—Candidiasis, aspergillus
Brown—Atrophic rhinitis
Crusting
Black colour—Mucormycosis
(Fig.4.14a)
Brown colour—Atrophic rhinitis (Fig.4.14b)
Size
Wide or roomy (Fig. 4.15a)—
Atrophic rhinitis, opposite to
DNS, post-inferior turbinectomy, post-endoscopic Denker
operation
Narrow (Fig.4.15b)—DNS, B/L
HIT, septal haematoma, septal
a b c
Fig. 4.13 Different colours of nasal discharge (a) watery, (b) yellow, (c) black
4.2 Examination ofNose andParanasal Sinuses
187
Fig. 4.14 Crusting in
the nasal cavity, (a)
Mucormycosis, (b)
Atrophic rhinitis
Fig. 4.15 (a) Roomy
nasal cavity, (b) narrow
nasal cavity
abscess, synechia, alar collapse,
fractured septum
– Floor of nose (Nasal oor)
Swelling—Nasolabial cyst,
growth over palate, dentigerous
cyst
Mass/growth
Discharge—Sinusitis, rhinitis
Gap—Cleft palate, trauma to
palate
Foreign body—The most common site is between the nasal
septum and inferior turbinate
Unerupted tooth
– Nasal valve area—The nasal valve
area is the narrowest portion of the
nasal passage. It is bounded: medially by the septum; superiorly and
laterally by the caudal margin of
the upper lateral cartilage and its
bro-adipose attachment to the
pyriform aperture (‘empty triangle’); inferiorly by the oor of the
pyriform aperture. The internal
nasal valve (INV) is the narrowest
area of the nose where turbulence
of the inspiratory and expiratory
a
a
b
b
current takes place. The angle
between the septum and the upper
lateral cartilage is 10°–15°. The
nasal valve is usually located less
than 2 cm distal in the nasal passageway, approximately 1.3 cm
from the naris.
Diameter
Normal
Reduced—Trauma, surgery,
HIT, septal deviation, septal
spur, nasal mass, septal
haematoma
Increased—Atrophic rhinitis,
post-endoscopic medial
maxillectomy
• Probe test—The blunt probe is used
to assess the origin, sensation on
touch, bleed on touch, painful on
touch, consistency of nasal mass, origin of mass.
– Insensitive—Nasal polyp
– Sensitive—Hypertrophied inferior
turbinate, hypertrophied middle
turbinate
– Bleed on touch—Rhinosporidiosis,
carcinoma
188
– Site of attachment
Inferior meatus—Rhinosporodisis
Middle meatus—AC polyp,
Inverted papilloma, rhinosporodisis
Roof—Aesthesioneuroblastoma
Septum—Rhinosporodisis
Floor—Nasolabial cyst
(d) Posterior rhinoscopy: This is done either
with a posterior rhinoscopy mirror or
with a 90° endoscope.
Findings of posterior rhinoscopy
• Mass/growth
– Site of mass in nasopharynx—
Midline, lateral, lling nasophar-
ynx, nasal extension, bleed on touch
– Surface of mass—Ulceration, smooth
– Colour of mass—White, yellow,
reddish
– Movement with respiration
– Sessile or pedunculated
• Lateral wall of nasopharynx
– Eustachian tube
– Fossa of Rosenmuller
• Anterior wall—Choana
• Roof of nasopharynx—It houses the
adenoid
• Posterior wall of the nasopharynx
4.2.1.2 Special Examination
oftheNose
• Clinical tests for assessment of nasal air-
ow/nasal patency or functional tests of
nose: Nasal airow can be assessed using sev-
eral clinical methods.
– Nostril occlusion test—Place your thumb
over the nostril not being assessed to
occlude airow. Ask the patient to breathe
in and out through their nose and note the
degree of airow. Repeat assessment on the
other nostril, noting any difference in
apparent airow. Reduced airow indicates
obstruction (Fig.4.16).
– Cold spatula test (Misting test)—Place a
cold shiny surface, such as a metal tongue
depressor under the nose. Observe for misting of the metal surface as the patient
breathes and compare the misting pattern
of the two nostrils (Fig.4.17).
4 History andExamination ofNose andPara Nasal Sinuses
Fig. 4.16 The nostril occlusion test
Fig. 4.17 Cold spatula test
– Cotton wool wisp tests—A uff of cotton
to be held against each nostril and movement noticed while the patient breathes
through the nose.
– Cottle test (Cottle’s manoeuvre)—Place
one or two ngers tip on the patient’s cheek on
either side of nose, gently press and pull outward. This temporarily opens the nasal valve.
If doing this helps the patient to inhale more
easily through the nose, the nasal obstruction
is likely to be in the nasal valve area (Fig.4.18).
• Clinical tests for ciliary function (test for
ciliary dyskinesia):
– Saccharine transit time—This can be
done by placing a small fragment of saccharine on the anterior end of the inferior turbinate and timing how long it takes the patient
to taste it. If the patient tastes the sweetness,
this is useful to rule out ciliary dyskinesia,
though a negative result is of little value.
– Other tests—Other tests for ciliary dyski-
nesia are high-speed video microscopy