Examination of the Nose

The following guide presents one structured approach to examining the nose. There are many valid techniques, and you should adapt this framework to develop your own style as you gain clinical experience. This guide assumes a basic working knowledge of nasal anatomy and common rhinological conditions. For further reading, Key Topics in Otolaryngology or ENT Secrets are both appropriate for SHO or ST-level ENT.

This guide is written primarily for the examination setting, where you present your findings aloud to an examiner as you go. Talking continuously demonstrates both clinical competence and systematic thinking.

This page is maintained by Professor Vik Veer, Consultant ENT and Sleep Surgeon at the Royal National ENT Hospital, London.

Equipment

Have the following available before you begin:

• Thudichum's nasal speculum — a short, two-bladed speculum used to gently open the nostril and allow inspection of the nasal vestibule and anterior nasal cavity. It is held between the index finger and thumb, with the blades opening horizontally.
• Light source — a head mirror with a reflected light, or a modern fibreoptic headlight, to illuminate the nasal cavity.
• Lack tongue depressor — used to assess nasal patency by holding the cold metal surface beneath both nostrils simultaneously and comparing the two patches of condensation from exhaled air.
• Flexible fibreoptic nasendoscope — a thin, flexible camera passed through the nose under topical anaesthesia and decongestant to visualise the full nasal cavity, middle meatus, nasopharynx, and post-nasal space. This is standard practice in an ENT clinic and should be offered at the end of the examination.
• Rigid 0-degree and 30-degree nasal endoscopes — used in clinic or in theatre; the 30-degree scope provides better views into the middle meatus and around corners.

Step 1: Consent and Introduction

Introduce yourself, confirm the patient's identity, and gain verbal consent before beginning.

"Is there any pain at all? And would it be all right if, while I am examining you, I speak to the examiner about my findings?"

Always wait for the patient's response. In an exam setting, the habit of forgetting to wait — because the examination has been rehearsed so many times — is a common and easily avoidable error.

Step 2: External Inspection

Ask the patient to sit upright. Inspect the external nose from the front, from each side (lateral profile), and from below (looking up at the nostrils — the "basal view").

"On inspection from the front, there is no obvious structural abnormality. The nasal dorsum is straight with no deviation. Looking from the side, there is no saddle nose deformity (a depression of the dorsum, seen after trauma, previous surgery, or septal perforation) and no tip ptosis (drooping of the nasal tip)."

"There are no obvious masses, rashes, telangiectasia, or scars on the external nose."

Specific external findings to note:

• Saddle nose deformity — a concave nasal dorsum caused by loss of cartilaginous or bony support, seen after septal haematoma, cocaine use, granulomatosis with polyangiitis (GPA, formerly Wegener's), or trauma.
• Rhinophyma — bulbous, thickened, reddened skin of the nasal tip, associated with rosacea.
• Nasal skin lesions — basal cell carcinoma (BCC), squamous cell carcinoma (SCC), or sebaceous cysts on the nasal skin are important not to miss.
• Tip ptosis — a drooping nasal tip, which can cause functional obstruction at the internal nasal valve as well as a cosmetic concern.

Step 3: Assessing Nasal Airflow

Assess nasal airflow clinically before introducing any instruments.

Ask the patient to breathe in and out through each nostril in turn, while you occlude the other side with gentle finger pressure on the ala. Listen for any restriction, and watch for alar collapse (the ala being sucked inwards on inspiration — this indicates weakness of the external nasal valve).

Then hold a Lack tongue depressor (or a small metal mirror) horizontally just beneath the nostrils. Ask the patient to breathe out normally through both nostrils simultaneously and observe the two patches of condensation.

"Airflow in both nostrils appears approximately equal and within normal limits. There is no evidence of alar collapse or significant asymmetry of airflow."

If airflow is reduced on one side, note this and consider causes: deviated nasal septum, inferior turbinate hypertrophy, nasal polyps, or a foreign body.

Step 4: Palpation of the External Nose and Sinuses

Before touching the nose, ask again whether there would be any pain on palpation.

Gently palpate:

• Nasal tip support — assess tip firmness by gentle upward pressure. A weak tip is relevant to surgical planning.
• Nasal bones — palpate along the dorsum for any step deformity, crepitus, or tenderness following trauma.
• Sinus facial pain — press firmly over the maxillary sinuses (below the orbital rims, overlying the cheeks), over the ethmoid sinuses (beside the bridge of the nose), and over the frontal sinuses (the supraorbital ridges). Tenderness may indicate sinusitis.

"Palpation of the nasal bones reveals no tenderness, step deformity, or crepitus. There is no sinus tenderness over the maxillary or frontal regions."

Step 5: Anterior Rhinoscopy with Thudichum's Speculum

Hold the Thudichum's speculum between the thumb and index finger of your non-dominant hand. Insert the closed blades gently into the nostril and open them horizontally to a comfortable degree — do not force them open. Use your dominant hand to direct the light source and tilt the patient's head to different angles to improve the view. Examine each nostril in turn.

Tilt the patient's head back slightly to see further into the nasal cavity. Inspect each area systematically:

Nasal Septum

"Examining the anterior septal area: Little's area (the Kiesselbach plexus) — the anterior inferior part of the septum where the blood supply is richest and where the vast majority of nosebleeds arise — appears normal with healthy mucosa and no evidence of bleeding, crusting, or ulceration. The remaining septal mucosa appears healthy."

"There is a mild deviation of the septum to the left, but no significant spurs or maxillary crest dislocation."

Note the following on septal examination:

• Septal deviation — common, but clinically significant only if causing symptomatic obstruction or obstructing the middle meatus (relevant to sinus disease). Grade and document the degree and direction.
• Septal spurs — sharp bony projections at the maxillary crest, often causing unilateral obstruction or headaches.
• Septal perforation — a hole through the cartilaginous or bony septum. Causes include previous surgery (septoplasty), cocaine use, GPA, sarcoidosis, syphilis, and trauma. Document its size and location. Anterior perforations may cause a "whistling" sound on inspiration.
• Little's area — formally known as the Kiesselbach plexus, this is the area on the anterior inferior nasal septum receiving the anastomosis of the septal branch of the superior labial artery, the anterior ethmoidal artery, the sphenopalatine artery, and the greater palatine artery. It is the site of 90% of epistaxis.

Lateral Wall (Inferior and Middle Turbinates)

"Looking at the lateral nasal wall: The inferior turbinate is visible and appears of normal size and colour with healthy-looking, moist mucosa. The middle turbinate and the middle meatus are also visible and appear normal."

Normal turbinate mucosa is pink-red and moist. Note the following:

• Inferior turbinate hypertrophy — the inferior turbinate is the most frequently enlarged nasal structure. In allergic rhinitis, the mucosa appears pale, boggy, and swollen. In vasomotor rhinitis, the mucosa may be more deeply congested. Hypertrophied inferior turbinates are a very common cause of nasal obstruction.
• Middle meatus — the space lateral to the middle turbinate, into which the maxillary, anterior ethmoid, and frontal sinuses drain. Discharge or polyps in this area strongly suggest sinusitis or chronic rhinosinusitis with nasal polyps.
• Nasal polyps — smooth, pale, semi-translucent, grape-like masses that are insensate (unlike turbinates, which are tender if probed). They most commonly arise from the middle meatus. Note their number, extent, and whether they are unilateral (more likely to require investigation for neoplasia) or bilateral (more likely to be benign, associated with allergy or chronic rhinosinusitis).

"There are multiple pale, fleshy, translucent polyps that appear to be originating mainly from the middle meatus bilaterally. There is no obvious bleeding or crusting associated with the polyps."

General Mucosal Assessment

"The nasal mucosa generally appears healthy with no areas of crusting, bleeding, ulceration, or other abnormality on examination with the nasal speculum."

Step 6: Flexible Nasendoscopy

Flexible nasendoscopy is standard practice in any ENT clinic and provides a far more complete assessment than anterior rhinoscopy alone. Under topical anaesthesia (e.g. co-phenylcaine spray — a combination of lignocaine and phenylephrine), the flexible nasendoscope is passed along the floor of the nasal cavity.

"I would now move on to examining the nasal cavity and post-nasal space with a flexible nasendoscope. I would apply co-phenylcaine spray to decongest and anaesthetise the nasal mucosa before passing the scope along the floor of each nasal cavity."

During nasendoscopy, reassess the following areas with the improved visualisation the scope provides:

• The entire nasal septum and lateral wall including the superior turbinate
• The middle meatus in detail — looking for discharge, polyps, or mucosal disease originating from the ostiomeatal complex
• The nasopharynx and post-nasal space — inspect the adenoid pad, the Eustachian tube orifices (one on each side), the fossae of Rosenmüller (the lateral recesses behind the Eustachian tube openings — a key site for nasopharyngeal carcinoma), and the posterior choanae

"Examination of the post-nasal space shows a normal (or obliterated in adults) adenoid pad with symmetrical Eustachian tube openings bilaterally. There are no masses seen, particularly within the fossae of Rosenmüller. The posterior choanae appear patent and clear."

The fossae of Rosenmüller are the lateral recesses of the nasopharynx immediately behind the Eustachian tube openings. They are the most common site of origin of nasopharyngeal carcinoma (NPC), a malignancy particularly prevalent in people of South-East Asian and North African descent. Any asymmetric mass, ulceration, or fullness here warrants urgent investigation with biopsy.

Step 7: Oral Examination

A brief oral examination complements the nasal assessment and is relevant in the context of sinus disease, nasal polyps, and midline palatal pathology.

"The hard and soft palate appear normal with no structural abnormalities, including no bifid uvula and no submucous or overt cleft palate. I will ask you to say 'Ahhh' — and I can see that the soft palate moves symmetrically with vocalisation. The tonsils are not grossly enlarged."

"Is there any pain in your mouth or teeth?"

Percuss the upper teeth beneath the maxillary sinuses. Dental pain that reproduces facial pressure or vice versa may suggest maxillary sinusitis secondary to dental disease (odontogenic sinusitis).

"There is no movement or tenderness of the upper teeth below the maxillary sinus."

Step 8: Completing the Examination

"I would complete my examination by palpating the neck for lymphadenopathy, paying particular attention to the submandibular and jugulodigastric (upper deep cervical) nodes, as well as the jugulo-omohyoid group, which is the sentinel node for the tongue base. Submental and level II nodes may be enlarged in rhinitis, sinusitis, or nasal malignancy."