Nasal examination can sometimes appear in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. Technique is very important in this station. This nasal examination OSCE guide provides a step by step approach to the station. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain examination : “Today I’d like to examine your nose, this will involve me having a feel of the outside of the nose and also gently looking inside the nose” Gain consent : “Does everything I’ve said make sense?“ “Are you happy for me to go ahead?“ Inspection External : Look at the external surface of the nose noting: Skin changes – e.g. skin lesions / erythema Deformity – inspect the nose from the front, side and standing behind the patient Note any deviation in the nasal bones or cartilage Internal 1. Ask the patient to look forwards, keeping their head in the neutral position. 2. Carefully elevate the tip of the nose with your thumb, so that the nasal cavity becomes visible. Use a pen torch or otoscope as a light source to externally illuminate the cavity. 3. Inspect the nasal mucosa for any abnormalities (including the septum). 4. Inspect and compare the nasal cavities alignment (note any septal deviation). Further assessment Further inspection can be done using an otoscope with a large speculum attached (inserting only the very tip into the nose), or using Thudicum’s speculum which essentially just widens the nasal cavity to allow you to peer in using a light source. Whichever method you use, you should inspect the various elements visible: Nasal vestibule – skin changes (e.g. ulceration) / swelling / asymmetry Nasal septum – polyps / deviation Inferior turbinates – asymmetry / inflammation / polyps " The turbinates are projections of bone, covered in nasal mucosa, that control airflow through the nose, exposing it to a large surface area of mucosa which both warms and cleans the air prior to it arriving at the lungs " Palpation Nasal bones and cartilage Palpate the nasal bones assessing: Alignment Tenderness or irregularity (if suspicious of fracture in trauma) Palpate the nasal cartilage assessing: Alignment Tenderness " Palpate the infraorbital ridges and assess eye movement if there is a history of trauma to screen for an orbital blowout fracture. The classical signs are of infraorbital tenderness, epistaxis and restricted eye movement (usually on vertical gaze) " Nasal airflow There are two common methods via which to formally assess nasal airflow shown below. Method 1 1. Place your thumb over the nostril not being assessed to occlude air flow. 2. Ask the patient to breath in through their nose and note the degree of airflow. 3. Repeat assessment on the other nostril, noting any difference in apparent airflow. " Reduce airflow through a particular nostril may indicate the presence of something blocking that air passage, such as a polyp or a deviated nasal septum " Method 2 1. Place a cold shiny surface, such as a metal tongue depressor under the nose. 2. Observe for misting of the metal surface as the patient breathes, compare the misting pattern of the two nostrils. " Absence of misting, or a disparity in the amount of misting between the nostrils may suggest unequal or absent airflow through a particular nostril " To complete the examination Thank patient Wash hands Summarise findings Suggest further assessments and investigations Assessment of sense of smell Regional lymph node examination Flexible nasoendoscopy Source
