26 Examination of the Nose
A working diagnosis of nasal disease may be possible after an accurate history has been taken. The essential symptoms are nasal obstruction, sneezing, rhinorrhoea, postnasal drip, headache and facial pain, abnormal sense of smell, epistaxis, snoring and cosmetic deformity. A previous history of trauma or allergy may also be relevant. Nasal disease is common, signs can be elicited quickly, and management of the common diseases makes for good discussion.
Common findings are septal deviation, hypertrophied turbinates, septal perforation and nasal polyps. It is therefore essential that you are familiar with the aetiology, relevant investigations and treatments of these conditions. There may be a combination of signs (e.g., a deviated septum and nasal polyps), so be thorough with your examination.
26.1 Position of the Patient
Be bare below the elbows and make sure that you are seen to wash/clean your hands before seeing each patient. Be polite with the patient, make sure that you clearly introduce yourself before starting the examination and explain what you have been asked to do. Sit opposite the patient, with your knees together and to the right side of the patient’s legs. This is more elegant than sitting with your legs astride the patient’s.
26.2 External Nose
Examine the nose in relation to the rest of the patient’s face. Pay particular attention to the size and shape; the curve or deviation of the bony and cartilaginous dorsum, the width or projection of the tip, the shape of the columella and nares. The thickness of the skin may be relevant if cosmetic surgery is contemplated. Look for swelling, bruising, erythema or for ulceration of the skin. An old examination favourite is a patient with the lupus pernio rash of sarcoid on the nasal or facial skin, with a septal perforation. Turn the patient’s head to the left and right to check the profile. Be especially vigilant to look for a fading lateral rhinotomy scar or hidden bicoronal incision wound behind the hairline.
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