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4.2 Examination ofNose andParanasal Sinuses
209
a b c
d e
Fig. 4.31 Deformities of base of nose, (a) Nasal outline asymmetry, (b) Alar base positioning asymmetry, (c) Nostril
outline asymmetry, (d) Nostril axis asymmetry, (e) Columellar angle asymmetry
• Nostril shape asymmetry (Fig.4.31)
– Nasal outline asymmetry
– Alar base position asymmetry
– Nostril outline asymmetry
– Nostril axis asymmetry
– Columellar angle asymmetry
Deformities of base of nose
4.2.2 Examination ofParanasal
Sinus Examination
(a) Inspection: Inspection of the paranasal sinus
is done to look for swelling, skin changes, scar
marks, redness, elevation, depression, etc.
(b) Palpation (Fig. 4.32):
• Tenderness
– Maxillary sinus tenderness—The
examiner has to apply gentle pressure
over the canine fossa, which lies above
the canine tooth, on the anterior wall of
the maxillary sinus to elicit pain. This
is present in acute maxillary sinusitis,
acute pan sinusitis.
– Ethmoid sinus tenderness—The exam-
iner has to apply gentle pressure medial
to medial canthus and tenderness is
present in acute ethmoiditis and acute
pan sinusitis.
– Frontal sinus tenderness—The exam-
iner has to apply gentle pressure on the
oor of the frontal sinus that lies above
the medial canthus of the eye and is
present in acute frontal sinusitis and
acute pan sinusitis.
• Step ladder deformity—It is a sign of
displaced fracture and is elicited by palpating the margins of the paranasal sinus.
• Crepitation—A crackling sound is heard
while examining a displaced fracture. It is
a sign of fracture.
• Abnormal movement—It is a sign of
displaced fracture of the paranasal sinus
or mandible.
• Swelling
– Site
The infraorbital area or anterior
wall of the maxillary sinus
Hard palate or inferior wall of the
maxillary sinus
Medial canthus of the eye
– Size—This is measured in two direc-
tions only.
– Consistency—The swelling can be
Soft—Haematoma, cyst
Firm—Fibroma
Hard—Hard swelling suggests
either bony swelling or malignant
210
Fig. 4.32 How to elicit paranasal sinus tenderness
– Movement
Fixed—Swelling arising from
underlying bony structures is xed.
Mobile—Benign swelling of the
cheek
– Overlying skin or mucosa
Mobile—Skin over benign swelling
is mobile.
Fixed/not mobile—Skin over
inammatory swelling or malignant
swelling is xed.
• Transillumination test
– Maxillary sinus (Fig.4.34)
A bright light applied on the hard
palate with the lip closed produced
a crescentic glow observed in the
region of the eyelids and over the
maxillary sinus.
In dim room light, place the light
directly on the infraorbital rim and
ask the patient to open their mouth
to look at the illumination on the
hard palate. It is absent or poor in
pus, mass or thickening in the sinus.
– Frontal sinus—A light is applied at the
oor of the frontal sinus. A light glow
is observed on the anterior wall of the
4 History andExamination ofNose andPara Nasal Sinuses
Fig. 4.33 Transillumination test for maxillary sinus
frontal sinus in normal. It is absent or
poor in case of pus, thickening of the
mucosa or mass (Figs.4.33 and 4.34).
• Postural tests—It is rarely done nowadays. In this test, the middle meatus is
observed for the appearance of discharge/
pus in various head positions.
4.2 Examination ofNose andParanasal Sinuses
Fig. 4.34 Transillumination test for frontal sinus
211
– Maxillary sinus—Head is bent to one
side so the affected sinus comes in an
upright position.
– Frontal sinus—In the head forward
and chin down position, pus appears
immediately in the middle meatus.
– Ethmoidal sinus—If pus takes
10–15 min to appear in the middle
meatus in the head forward and chin
down position (Figs.4.35 and 4.36).
Fig. 4.35 Common causes of orofacial pain
212
Fig. 4.36 Flowchart for the diagnosis of the patient with orofacial pain
4 History andExamination ofNose andPara Nasal Sinuses
4.3 Colour Atlas ofNasal Cavity Disorders
4.3 Colour Atlas ofNasal Cavity
Disorders (Fig.4.37)
213
a
c
b
d
e f
Fig. 4.37 A clinical picture of the nasal disease, (a, b)
Caudal dislocation of septum, (c, d) Cyst in the vestibule,
(e) Antrochoanal polyp, (f) Rhinosporidiosis, (g, h) Septal
spur, (i) Meningoencephalocele, (j) Skull base tumour, (k)
Atrophic rhinitis, (l) Crusting due to bleeding, (m)
Inverted papilloma, (n, o) Concha bullosa, (p, q) Septal
spur impinging on turbinate, (r, s) Polyp in middle
meatus, (t) Floor of nose, (u) Pus in middle meatus, (v)
Sphenochoanal polyp, (w) Polyp in nose
214
4 History andExamination ofNose andPara Nasal Sinuses
g h
i
k l
m
j
Fig. 4.37 (continued)
4.3 Colour Atlas ofNasal Cavity Disorders
215
n
p
o
q
r s
Fig. 4.37 (continued)
216
4 History andExamination ofNose andPara Nasal Sinuses
t
v w
u
Fig. 4.37 (continued)
4.4 Clinical Atlas ofCommon External Nasal Deformities
4.4 Clinical Atlas ofCommon
External Nasal Deformities
(Fig.4.38)
a b c
217
d
Fig. 4.38 Common disorders of the external nose, (a) Crooked nose, (b) Hump of the nose, (c) Deviated tip of nose,
(d) Trauma to the nasal tip, (e) Lacrimal abscess, (f) Dermoid cyst
e
f
History andExamination
ofNasopharynx
5
5.1 Symptoms/Chief
Complaints/History
ofNasopharyngeal Disease
andTumour
1. History/clinical presentation of nasopharyn-
geal disorders
(a) Main symptoms of nasopharyngeal disor-
ders and tumours—They can be presented
with various
• Nasal obstruction—This is also termed
as difculty in breathing through the
nose. It can be unilateral or bilateral
– Unilateral—carcinoma, JNA, NPC
– Bilateral—adenoid, Thornwaldt
cyst
– Alternate—it may be a cyclical
change
• Epistaxis—This is common symptom
of JNA, bleeding disorders, NPC
– Mild—NPC
– Moderate—angiomatous polyp
– Severe—juvenile nasopharyngeal
angiobroma
• A lump in the neck (swollen lymph
node)—An enlarge lymph node in the
posterior triangle of the neck is a cardinal symptom of NPC
• Blood mixed saliva—NPC
• Sore throat—NPC, adenoid
• Headaches—NPC
• Face pain or numbness—NPC
• Difculty opening mouth (Trismus) is
caused by the involvement of pterygoid muscle in NPC
• Halitosis—NPC
• Snoring—adenoid, JNA, NPC
• Lower cranial nerve syndrome—NPC
(b) Other symptoms of nasopharyngeal
tumours and diseases
• Ear symptoms—aur fullness, serous
otitis media, hearing loss caused by
adenoid, NPC, JNA
• Ophthalmologic symptoms—diplopia,
ophthalmoplegia (CN III, IV, VI),
blindness (CN II)
• Personal history—diet rich in saltcured meats and sh, EBV infection
• Neurological symptoms—headache,
facial pain (V nerve), xeropthalmia,
Jugular foramen syndrome
• Other symptoms—weight loss,
anorexia
(c) Duration of symptoms
• Short duration—nasopharyngeal
carcinoma
• Long duration—juvenile nasopharyngeal angiobroma, adenoid
(d) Mode of onset
• Sudden—trauma
• Gradual—juvenile nasopharyngeal
angiofibroma, adenoid, Thornwaldt
cyst
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck
Surgery, https://doi.org/10.1007/978-981-96-1765-4_5
219