The following document was written by Mr Vik Veer MBBS(lond) MRCS(eng) DoHNS(eng) in Dec 2007. You may use the information here for personal use but if you intend to publish or present it, you must clearly credit the author and www.clinicaljunior.com
This site is not intended to be used by people who are not medically trained. Anyone using this site does so at their own risk and he/she assumes any and all liability. ALWAYS ASK YOUR SENIOR IF YOU ARE UNSURE ABOUT A PROCEDURE. NEVER CONDUCT A PROCEDURE YOU ARE UNSURE ABOUT.
The following document is one way of examining the nose. There are obviously many ways and techniques to do this which aren't mentioned here. I suspect you will only use this as a guide to your own examining technique which you should evolve to suit your own approach and style. I have also assumed that you have some knowledge of ENT throughout this examination. If you are uncertain to the reasons why i have mentioned things in my examination or need clarification there are some excellent books you can refer to. I would suggest using 'Key Topics in Otolaryngology' or 'ENT Secrets', both are adequate for SHO / ST level ENT.
I have written this with the idea that this will be used in an exam setting - so you will be presenting your findings as opposed to a clinic setting. i would try and talk constantly whilst examining the patient. It keeps the examiner interested and shows off what you know.
Examination of the Nose
Ask for consent and then continue with inspection
“Is there any pain at all? (response) and would it be alright if, while i am examining you, that i speak to the examiner about you?"
(remember to wait for response - too often we rehearse these examinations so often that we forget to wait for the answers to these questions in the panic of an exam)
“On inspection there is no obvious structural abnormality including saddle nose or tip ptosis (looking from the side)”
“There are no obvious masses, rashes, or scars”
Get the patient to sniff whilst occluding each of the nostrils in turn, and then place a Lack tongue depressor beneath the nose to see the shiny surface cloud with exhalation.
“the airflow in both nostrils appears equal and normal” - comment on alar collapse or decreased airflow if noted
At this point ask again if there would be any pain if you touched his/her nose
Feel for sinus facial pain - tip support and then lift the tip to assess the vestibule. Use the Thudichums speculum to inspect the nasal cavity.
“Firstly examining the anterior septal area there are no abnormalities in little’s bleeding area and the remaining septal mucosa appears healthy with no obvious perforation.
There is a mild deviation of the septum to the left/right with no spurs or maxillary crest dislocation seen.
Now looking at the lateral wall - The middle and inferior turbinates are normal* (*or congested / have features of rhinitis - boggy / inflamed / clear watery mucus).
There is no crusting or signs of any other abnormality on examination with a nasal speculum”
Commonly in exams you will see patients with benign nasal polyps
“There are multiple fleshy translucent polyps which appear to be originating mainly from middle meatus“
“At this point I move on to examining the nasal cavity and post nasal space with a flexible nasendoscope. – say the same things as before looking at each area one by one.
In addition you should also say – “examining the post nasal space shows a normal / obliterated adenoid pad with normal Eustachian tube openings on both sides with no masses seen particularly in the fossae of Rosenmuller”
Oral examination
“the hard and soft palate appears normal with no signs of structural abnormalities including bifid uvula and cleft palate – say ah – and moves normally with vocalisation. The tonsils are not grossly enlarged."
Is there any pain in your mouth or teeth?” - palate and percuss the teeth – “there isn’t any movement or tenderness of the teeth below the maxillary sinus.”
You can now attempt to wrap up the examination with some final examination that they may or may not ask you to do.
"I would complete my examination by palating the neck for any lymphadenopathy – paying particular attention to the submandibular and jugulo-omohyoid groups."