In infective cases it is worth checking behind the ear to see if there is any swelling of the post-auricular lymph nodes or a subperiosteal abscess (1.1; see acute mastoiditis, 4.32,4.33 and 4.34). The best view of the drum is obtained by using an auriscope which is inserted into the lateral third of the ear canal only (1.2). Avoid putting the tip of the speculum into the medial two-thirds of the canal as it is much more sensitive. The view is improved by elevating the pinna upwards and backwards in an adult or straight backwards in a child. Holding the auriscope horizontally, rather than vertically, means the patient’s shoulder is less likely to get in the way. Holding the little finger out extended towards the cheek is a useful technique in children because if the child turns towards the examiner unexpectedly it reduces the chance of twisting the speculum of the auriscope in the ear canal, which can be painful. If the drum is difficult to see it is often worth looking more superiorly by tilting the patient’s head away from the examiner (1.3).

Traditional anterior rhinoscopy using Thudicum’s speculum and a headlight or head mirror is helpful in detecting gross anatomical variations such as septal deviation, dislocation of the collumella (1.7) and hypertrophic inferior turbinates. With the help of a rigid (1.8) or flexible endoscope, the whole of the nasal cavity and the postnasal space can be examined. The middle meatus, into which most of the sinuses drain, can be thoroughly examined (1.9) and bony crests, spurs (1.10) and other abnormalities farther back in the nasal cavity can be identified. Rigid endoscopes give the clearest view but flexible endoscopes help if the nasal anatomy does not allow passage of the rigid endoscope. Decongestion of the nose, using sprays containing pseudo-ephedrine or pseudoephedrine plus lignocaine may be necessary to achieve optimum results and improve tolerance. The examination should be done to document findings systematically in the inferior and the middle meatus and the spheno-ethmoidal recess. Several anatomic variations exist in the nasal cavity that may contribute to an infection (1.11, 1.12). Possible findings include the presence of mucus or mucopus, polyps, and other mass lesions. Except for the posterior ethmoid and the sphenoid sinuses, all the sinuses drain into the middle meatus. Thus, the majority of sinus infections present with signs in the middle meatus.