Nasal examination can sometimes appear in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. The technique is very important to this station. This nasal examination OSCE guide provides a step by step approach to the station.
Confirm patient details – name / DOB
“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. Do you have any pain in your nose or face?” (proceed with care if they indicate there are tender areas)
Gain consent “Does everything I’ve said make sense?“ “Are you happy for me to go ahead?“
Look at the external surface of the nose noting:
- Skin changes – e.g. skin lesions / erythema / rash around the face / scars
- Deformity – inspect the nose from the front, side and standing behind the patient
- Note any deviation in the nasal bones or cartilage (this is best done by standing behind the patient with their head tilted slightly back)
1. Sit facing the patient with your knees together and to one side of the patient’s knees. It is not pleasant for the patient to be “straddled.”
2. Ask the patient to look forward, keeping their head in the neutral position.
3. 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 (elevating the tip of the nose will also assess for columellar dislocation).
4. Inspect the nasal mucosa for any abnormalities (including the septum).
5. Inspect and compare the nasal cavities alignment (note any septal deviation).
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.
The correct method for using the Thudicum’s speculum is slightly counter-intuitive, however, it does allow the best visualisation of the nasal mucosa. Insert your index finger into the bend of the speculum and support it above with the thumb. The middle and ring fingers are used to manipulate the prongs of the speculum. You will be aiming to look at the gap between these two fingers.
Whichever method you use, you should inspect the various elements visible:
- Nasal vestibule – skin changes (e.g. ulceration) / swelling / asymmetry
- Nasal septum – polyps / deviation / perforation / areas of cautery
- 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.
Nasal bones and cartilage
Palpate the nasal bones assessing:
- Tenderness or irregularity (if suspicious of fracture in trauma)
Palpate the nasal cartilage assessing:
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).
There are two common methods via which to formally assess nasal airflow shown below.
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.
Reduced airflow through a particular nostril may indicate the presence of something blocking that air passage, such as a polyp, deviated nasal septum or foreign body.
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.
The 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
Suggest further assessments and investigations
- Assessment of sense of smell (UPSIT – University of Pennsylvania Smell Identification Test)
- Regional lymph node examination
- Flexible nasendoscopy
- Examination of the oral cavity
Mr Krishan Ramdoo
ENT Registrar (ST6)