Examination of Nose
Dr. T. Balasubramanian M.S. D.L.O
In addition to the illuminating instruments described
under the heading examination of patient in otolaryngology, certain
other unique instruments are necessary in the examination of the nose.
1. Thudichum's nasal speculum
2. Lac's tongue depressor
3. St. Claire Thompson post nasal mirror
4. Tilley's nasal dressing forceps
5. Spirit lamp to warm the post nasal mirror
Tilleys nasal dressing forceps and Thudichum's
The steps that must be followed while examining a nose
1. Examination of external nose
2. Anterior rhinoscopy
3. Posterior rhinoscopy
Examination of external nose:
On inspection the following things should be looked for
In this step the following aspects must be diligently looked for
1. Change in shape / contour of the nose
2. Deformities congenital / acquired if any
3. Presence of clefts and sinuses
4. Presence of swelling : inflammatory, cysts, or tumors
5. Presence of ulceration : trauma / infective / neoplastic
On palpation the following must be sought after
1. Tenderness - If it is present over the nasal bone area then # nasal
bone must be suspected. If it is present over the tip of the
nose, it could be due to vestibulitis, if tenderness is present over
the dorsum of the nose the septal hematoma, of septal abscess must be
2. Crepitus - when present over the nasal bone area then # nasal bone
is a surity.
3. Deformity - The presence of deformity is one of the features of
trauma to the nose. Nose being the most prominent area of the
face, it is susceptible to various injuries. Any blow to the
dorsum of the nose can cause buckling of the cartilagenous nasal
septum. This buckling may lead to bleeding under the
perichondrium of the nasal septum. This bleeding infact lifts the
perichondrium away from the nasal septum. If this happens on both
sides of the nasal septum the nutrition to the nasal septum which is
dependent on the intact perichondrium suffers. The cartilage
infact under goes liquefaction necrosis within 48 hours, depriving
dorsal support to the nose causing pig snout deformity.
4. The nasal septal area must be palpated to ascertain the presence or
absence of septal cartilage.
Figure showing external deformity
In anterior rhinosopy the following steps must be performed
in the given order.
1. Examination of the vestibule (i.e. the skin lined cavity of the
2. Examination of nasal cavity using thudichum's nasal speculum.
3. Patency test.
4. Probe test if examination of nasal cavity reveals a mass. This
test is done to ascertain the site of origin of the mass.
5. Examination of the nasal cavity after vasoconstriction. This
is done after packing the nasal cavity with cotton plegets dipped in
oxymetazoline or xylometazoline nasal drops.
Examination of vestibule:
This is carried out by tilting the tip of the
nose. The vestibule is lined with skin and has all the dermal
appendages. All the diseases which affect the adnexia of the skin
can occur in the vestibule. Boils i.e. vestibulitis can cause
swelling of the roof and lateral wall. Ulcerations in this area
can be infective or neoplastic. Excoriation of skin lining the
vestibule can also occur due to persistent nasal discharge.
Method of examination of nasal vestibule
Examination of nasal cavity using a nasal speculum:
A Thudichum's nasal speculum is utilised for this purpose. The
speculum is held in the non dominant hand. The speculum is hooked
with the index finger, while the middle and ring fingers are
utilised to press and release the speculum blade.
The axis of the anterior nares is upwards and backwards, while that of
posterior nares is backwards. The tip of the nose is lifted and
the blades of thudichum's speeculum is introduced getting these two
axis in a straight line. The speculum is always introduced with
the blade closed. The speculum is always introduced in a upwards
and backwards direction. Once inside the nose the blades are
gradually opened to avoid discomfort to the patient. The roof,
floor, lateral and medial walls of the nasal cavity are systematically
Nasal septum is visualised with a special eye for the presence of
spurs, deviations, or perforations. The lateral wall displays the
inferior and middle turbinates. Their color, size and the quality
of the mucosal lining is assessed. Discharge if any from the
middle meatus is also looked for.
Since the middle meatus is situated backwards the head is tilted
upwards and backwards up to an angle of 45 degrees. This manouver
brings the middle meatus into clear vision. If polyp or neoplasm
is visualised within the nasal cavity a probe test is done to confirm
Probe test: Is done using Jobson's Horne probe. The
nose is anaesthetised with 4% xylocaine. Cotton is wound tightly
over the probe end of Jobson's Horne probe. The probe is used to
assess the site of attachement of the nasal mass, its consistency,
Nasal patency test:
Is performed using a cold tongue depressor just under the nose of the
patient and comparing the amount of mist formation between both
sides. A wisp of cotton can also be used to ascertain the patency
of the nose. Patency is compared with both sides.
It can be done using
1. Post nasal mirror
2. Flexible nasopharyngoscope
3. 30 degrees nasal endoscope
4. Examination under general anaesthesia after retracting the soft
palate. Digital palpation is possible only in this method.
Examination using post nasal mirror:
The post nasal mirror is warmed using a sprit lamp.
The throat of the patient is anesthetised using 4% xylocaine spray.
The tongue depressor is held in the non dominent hand, and the tongue
is depressed. The already warmed post nasal mirror is gently is
passed under the uvula visualising the post nasal space. The
mirror is tilted to visualise the various portions of the naso
Examination of nasopharynx using post nasal mirror is a difficult
procedure to master. It may be difficult to perform in all
individuals. If it cannot be performed then a flexible
nasopharyngoscope, or a nasal endoscope must be used. If a
suspected lesion needs to be palpated it can be done after retracting
the soft palate under general anaesthesia.
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