How to Perform a Comprehensive Nose Examination: A Guide for Medical Students

A thorough nose examination is a critical skill for medical students and healthcare professionals. It allows for the accurate diagnosis of various conditions, from common colds to more complex nasal pathologies. This guide will walk you through the steps of conducting a nose examination, covering anatomy, technique, common findings, and the importance of patient communication. Written with the authenticity of a practicing physician, this comprehensive article aims to equip you with the necessary knowledge and skills to excel in clinical practice.

1. Understanding Nasal Anatomy

• External Nose: The external nose is composed of a bony upper part and a cartilaginous lower part. Understanding the anatomy of the nasal bones, cartilage, nostrils (nares), and nasal septum is essential for both inspection and palpation.
• Nasal Cavity: The nasal cavity extends from the nostrils to the nasopharynx. It includes the nasal septum, which divides the cavity into two, the turbinates (superior, middle, and inferior), and the meatuses beneath each turbinate.
• Vascular Supply: The nose has a rich blood supply, primarily from the branches of the internal and external carotid arteries. Kiesselbach's plexus, located on the anterior part of the septum, is a common site for epistaxis (nosebleeds).
• Nerve Supply: The nasal cavity receives sensory innervation from the trigeminal nerve, with the olfactory nerve providing the sense of smell.

2. Preparation and Patient Communication

• Informed Consent: Before beginning the examination, explain the procedure to the patient, including the use of instruments like the otoscope or nasal speculum. Ensure they are comfortable and obtain verbal consent.
• Patient Positioning: The patient should be seated comfortably with their head slightly tilted back. Adequate lighting is crucial, so ensure a good light source or headlamp is available.

3. Inspection

• External Inspection: Begin with a visual inspection of the external nose, noting any asymmetry, deformities, swelling, or skin lesions. Look for signs of trauma, such as bruising or abrasions.
• Internal Inspection: Using a nasal speculum or otoscope, gently spread the nares and inspect the internal structures. Pay attention to the nasal septum for deviations, perforations, or signs of inflammation. Check the turbinates for hypertrophy, which could indicate chronic inflammation or allergic rhinitis.
• Nasal Discharge: Note the presence of any discharge. Clear discharge may suggest allergies or viral infections, while purulent (yellow or green) discharge may indicate a bacterial infection. Bloody discharge could be a sign of trauma, a foreign body, or a neoplasm.

4. Palpation

• External Nose Palpation: Gently palpate the external nose for tenderness, which may indicate trauma or infection. Palpate the nasal bones and cartilages to assess for any irregularities.
• Sinus Palpation: Palpate the frontal and maxillary sinuses for tenderness. Sinus tenderness may suggest sinusitis, especially if accompanied by other symptoms like facial pain or headache.

5. Testing Nasal Patency

• Occlusion Test: Ask the patient to close one nostril and breathe in through the other. Repeat on the opposite side. Reduced airflow may indicate nasal obstruction, which could be due to a deviated septum, nasal polyps, or hypertrophic turbinates.
• Cottle’s Test: This test helps assess nasal valve function. With the patient inhaling, gently pull the cheek lateral to the nostril to see if the airflow improves. Improvement suggests nasal valve collapse.

6. Assessing Olfactory Function

• Olfactory Testing: To test the sense of smell, use a familiar, non-irritating scent (such as coffee or vanilla). Avoid irritants like alcohol or ammonia, which stimulate the trigeminal nerve instead. Ask the patient to close their eyes, occlude one nostril, and identify the scent placed under the other nostril.

7. Common Findings and Their Significance

• Deviated Septum: A common finding, which may be congenital or due to trauma. It can cause nasal obstruction and may require surgical correction if symptomatic.
• Nasal Polyps: These are soft, painless growths on the lining of the nasal passages or sinuses. They are associated with chronic inflammation and conditions like asthma or aspirin sensitivity.
• Turbinates Hypertrophy: Enlarged turbinates can cause nasal obstruction and are often seen in chronic rhinitis or allergic conditions.
• Epistaxis: Nosebleeds, often from Kiesselbach's plexus, may be due to trauma, dry air, or underlying bleeding disorders.
• Foreign Bodies: Common in pediatric patients, foreign bodies in the nose can cause unilateral discharge, often foul-smelling, and require prompt removal.
• Sinusitis: Inflammation of the sinuses may present with facial pain, tenderness, and purulent nasal discharge. Chronic sinusitis may require imaging studies for further evaluation.

8. Advanced Techniques and Tools

• Nasal Endoscopy: For a more detailed examination, especially in cases of chronic sinusitis or suspected neoplasms, a nasal endoscopy can be performed. This involves using a flexible or rigid endoscope to visualize deeper structures of the nasal cavity and sinuses.
• Imaging Studies: If a structural abnormality is suspected, such as a sinus mass or severe septal deviation, imaging studies like CT or MRI can provide detailed views.

9. Documentation and Reporting

• Recording Findings: Document the findings of the nose examination clearly in the patient's medical records. Include details about any abnormalities, the patient’s symptoms, and any recommendations for further tests or referrals.
• Communication with Patients: After completing the examination, discuss your findings with the patient. Explain any conditions you’ve identified, the significance of these findings, and the next steps in management. Provide reassurance where appropriate and answer any questions they may have.

10. Conclusion

• Mastering Nose Examination: Proficiency in nose examination is essential for identifying a wide range of conditions, from the common cold to more serious nasal pathologies. Practice and familiarity with normal and abnormal findings will enhance diagnostic accuracy and improve patient care.