Undertaking a history of the nose should include questions aiming to establish whether any of its functions – smelling, conditioning, warming, humidification of inhaled air and voice resonance – is impaired or not. Change of airway resistance and sense of smell are key indicators of nasal pathology. Also common presentations seen in primary care are rhinorrhoea, epistaxis, facial pain or sense of pressure, and a nasal voice. Rhinorrhoea is perhaps the most frequent sign reported and observed by the clinician when dealing with nasal problems. Like otorrhoea, the clinician should ascertain whether the discharge is watery, purulent, mucousy or blood stained as this will help determine the cause. Rhinorrhoea can be chronic, acute or recurrent; so gaining an understanding of the duration may be pertinent. The patient should be asked if it is linked to any allergies or whether it is seasonal. Associated symptoms that the patient may describe include watering eyes, itchy eyes, sore throat and facial pain or pressure.

Many patients complain of nasal obstruction. This can be unilateral or bilateral. The clinician should determine the duration it has been occurring for, whether it is constant, intermittent or related to seasons or allergies. Any associated symptoms should also be explored including facial pain, sneezing, headache, post-nasal drip, sore throat, otalgia and asthma. If a patient presents with epistaxis, the clinician must prioritise significant bleeding over undertaking a history. However, once the bleeding is controlled, then the clinician should enquire as to whether the epistaxis was unilateral or bilateral, anterior or posterior. Foreign bodies can lead to epistaxis and should be ruled out, especially in children. It is important to ask the patient if the bleed was spontaneous or post trauma. The onset, duration and recurrence are also of significance.

Associated symptoms should be reviewed along with medications prescribed and past medical history. For example, the patient may be prescribed anti-coagulants or suffer from hypertension or renal disease. Symptoms that may direct the clinician to suspect sinusitis include pressure or pain in the patient’s cheeks or forehead, nasal congestion, a sense of heaviness in the head heaviness and sometimes facial pain.

Determining the severity of the pain and the length of time a patient has experienced the symptoms will establish appropriate management. If the sinusitis has lasted up to 10 days it is likely to be viral. For symptoms lasting longer than 10 days it is more likely to be a bacterial sinusitis. Symptoms lasting for more than 12 weeks are suggestive of chronic sinusitis, and lasted >12 weeks is chronic sinusitis. Patients may describe fever, purulent discharge, nasal obstruction, post-nasal drip, chronic unproductive cough, malaise and facial pain.

Nasal voice may be distinguished in hyponasal and hypernasal speech, otherwise respectively known as rhinolalia clausa and rhinolalia aperta. The first is typical of nasal congestion, the latter of cleft palate and velopharyngeal insufficiency. The doctor should be informed about the presence of defects of smell, such as loss of smell (anosmia), its reduction (hyposmia), and unpleasant odours, particularly putrefactive odours (cacosmia). A thorough patient history is essential in determining any olfactory disorders such as sense of smell and sense of taste can often be confused by patients. Patients may also present with hyposmia, which is partial loss of smell. The clinician should ascertain the time the loss occurred and if there were any other contributing factors, such as trauma or illness. Intra-nasal obstruction, allergic rhinitis, head trauma and also type II diabetes and Alzheimer’s have been linked to anosmia. Drug and alcohol history should be taken as long term alcohol misuse can lead to anosmia. Certain medications such as metronidazole can also cause it (Fig. 3.1).

An otoscope can be used to make a rhinoscope with a wide speculum. The patient should be asked to breathe with his mouth during the examination to prevent the otoscope lens fogging during the procedure. The otoscope gives a good view of the anterior nasal cavity (Fig. 3.2).

Patients do often experience recurring spontaneous nasal bleeding, from one or both nostrils. Sometimes, the GP is called to deal with epistaxis at the surgery, but much more frequently this pathology is handled in the Emergency Room.

Children tend to bleed from the nose more easily than adults and from the front of the septum, otherwise known as Little or Valsalva area. Establishing the severity of bleeding should take precedence over the history taking.