9.1 Visual Inspection

Visual inspection of the patient is done to evaluate the face and external nose. Questions of overall assessment are paramount: Are there gnathic abnormalities? Is there significant facial asymmetry or facial scoliosis? Is the nose over- or underprojected? In making these determinations, the surgeon relies not just on classic facial geometry formulas but also on his or her aesthetic sense ( Fig. 9.1 ). ¹

Does the nose look too long, too short, too broad, or too narrow? Does it distract from the attractiveness of the eyes? In previously operated cases, does the current nose fit the patient′s face or personality? Once these determinations have been made, attention is directed toward local findings in the external nose. We have had good experience with photographing rhinoplasty candidates on their initial visit, then using modern graphic software to jointly analyze the photo on the computer screen and simulate possible changes ( Fig. 9.2 ). This process generates sketches, diagrams, and interview notes that document both the findings and the consultation and will ultimately direct surgical planning.

9.2 Palpation

Visual inspection is followed by palpation. But before touching the nose, the surgeon should tell the patient that only palpation can supply essential information on the tension and elasticity of the various structural components of the nose. ^{2 , 3} Some problems are easier to palpate than to see ( Fig. 9.3 ). There are five areas in which palpable findings are particularly important:

1. 
   

   The nasal dorsum. The junction of the bony and cartilaginous nasal dorsum is palpated to detect any roughness, irregularities, appositional bone growth after previous surgery, or an open roof.

   
   
2. 
   

   Protection. Finger pressure is applied to the nasal tip and anterior septal angle to assess tip and supratip recoil, which will indicate the quality of protection in both areas. The height and tension of the anterior septal cartilage can be assessed over the anterior septal angle.

   
   
3. 
   

   Length of the nasal bones. The relationship of the bony and cartilaginous portions of the nasal pyramid will influence surgical planning. Short nasal bones, or a short nasal pyramid, are a frequent indication for the use of spreader grafts.

   
   
4. 
   

   The nasal vestibule. The shape and tension of the anterior septum and the size of the nasal spine and premaxilla can be assessed by palpation.

   
   
5. 
   

   The alar cartilages. The shape, size, and elasticity of the alar cartilages can be assessed by bimanual palpation.

9.3 Nasal Endoscopy

Nasal endoscopy is useful for detecting any intranasal pathology. ^{4 , 5} A logical, consistent routine should be followed to ensure complete and systematic coverage ( Fig. 9.4 ). With endoscopy, the examiner can explore the internal anatomy of the nose and evaluate the lateral nasal wall, the “sluice” leading to the para-nasal sinuses, and the general appearance of the nasal mucosa. ⁶ The mucosa is scrutinized for mucous or pus tracks, edema, and polyps. The function of the internal and external nasal valves during inspiration and expiration can also be assessed endoscopically ( Fig. 9.4 ).

Algorithm for nasal endoscopy ( Fig. 9.5 ):

1. 
   

   Start with a 0° scope 3 or 4 mm in diameter. Advance the endoscope over the nasal floor to the choana. The inferior turbinate, caudal nasal septum, choana, and pharyngeal tubal orifice can be visualized in the same sagittal plane as the posterior extension of the inferior turbinate ( Fig. 9.5 ).

   
   
2. 
   

   Retract the endoscope to inspect the nasal vestibule and valve area during normal and forced inspiration and expiration. The middle meatus is visualized.

   
   
3. 
   

   Switch to a 30° or 45° scope with a 3- or 4-mm diameter. Advance the endoscope with the field of view directed upward, passing beneath the middle meatus. Inspect the sphenoethmoid recess and the sphenoid sinus ostium. Look into the olfactory rim. Angle laterally after passing the choana. Tell the patient to swallow, and evaluate the opening mechanism of the eustachian tube.

   
   
4. 
   

   Withdraw the endoscope and evaluate the inferior meatus with the orifice of the nasolacrimal duct several millimeters behind the head of the inferior turbinate.

9.4 Function Testing

9.4.1 Computed Rhinomanometry

Computer-assisted rhinomanometry can provide objective evidence for the subjective feeling of obstructed nasal breathing. The principle involves the synchronous recording of the pressure differential (D∆) between the nasal vestibule and choana (measured in pascal, Pa) and the airflow (V) measured in cubic centimeters per second ( Fig. 9.6 ). ⁷ – ¹⁰ An improved technique called four-phase rhinomanometry determines not only intranasal pressure and flow at 150 Pa but also the log peak resistance (log VR) and log effective resistance (log R_eff) for the quantitative analysis of nasal obstruction. ¹¹ In practice, active anterior rhinomanometry with a decongestion test (using decongestant nose drops) is most commonly used in selecting patients for nasal surgery. The test aids in differentiating stenosis with an anatomical cause from dynamic stenosis (mucosal disease, hyperreactivity) and pseudostenosis (e.g., in rhinitis sicca) ( Fig. 9.6 ).

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