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Table of Contents
Nasal examination frequently appears in OSCEs and you’ll be expected to identify relevant signs using your clinical examination skills. This guide provides a step-by-step approach to performing a nasal examination in an OSCE setting.
Light source: this can be a pen torch, otoscope or a head torch.
Nasal speculum (also known as Thudiculum’s speculum) or an otoscope with a large speculum.
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the examination will involve using patient-friendlylanguage: “Today I’d like to examine your nose, this will involve me looking and feeling the outside of the nose and the gently looking inside the nose.”
Gain consent to proceed with the examination.
Ask the patient to sitonachair.
Ask the patient if they have any pain before proceeding with the clinical examination.
External nose inspection
Inspect the external surface of the nose from the front, side and behind the patient to identify any abnormalities.
Inspect for skinlesions:
Basal cell carcinoma: pearly lesions with telangiectasia and rolled edges.
Squamous cell carcinoma: scaly lesions, sometimes with associated ulceration and hyperpigmentation.
Keratoacanthoma: raised lesions with a core of scaly keratin.
Inspect for any deviation in the nasalbones or cartilage suggestive of a fracture. This is best performed by standing behind the patient with their head tilted slightly backwards.
Basal cell carcinoma 1
Squamous cell carcinoma 2
Fractured nose 4
Epistaxis is bleeding from the nose, caused by damage to the blood vessels of the nasal mucosa. Most epistaxis is self-limiting, however, in rare cases, epistaxis can become life-threatening. Epistaxis can be caused by bleeding from anterior or posterior nasal structures. Little’s area on the anterior nasal septum (where Kiesselbach’s plexus is located) is the most common source of anteriorepistaxis. This area is easy to visualise during a clinical examination. The bleeding points that result in posteriorepistaxis are deeper within the nose and therefore difficult to visualise during clinical assessment. Posterior epistaxis is typically moreprofuse and has a greater associated risk of airway compromise.
Nasal cavity inspection
1. Sit facing the patient with your knees together and to one side of the patient’s legs. It is not pleasant for the patient to be straddled.
2. Ask the patient to look forward, keeping their head in a 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 dislocated septal cartilage).
4. Inspect the nasal mucosa (including the septum) for any abnormalities.
5. Inspect and compare nasal cavity alignment (note any septal deviation).
Further assessment can be performed using an otoscope with a largespeculum attached (inserting only the very tip into the nose) or using a nasalspeculum (also known as Thudiculum’s speculum) which widens the nasal cavity to allow you to peer in using a light source.
How to use a nasal speculum
The correct method for using a nasal speculum is slightly counter-intuitive, however, it does allow the best visualisation of the nasal mucosa:
1. Insert your index finger into the bend of the speculum and support it above with the thumb.
2. The middle and ring fingers are used to manipulate the prongs of the speculum.
3. You will be aiming to look at the gap between these two fingers.
4. Press the prongs of the speculum together to allow them to be placed within the nostril and then reduce your grip on the speculum to widen the prongs until an optimal view of the nasal cavity is achieved.
Assessing the nasal cavities
Regardless of which method you use to visualise the nasal cavities, you should assess the following structures:
Nasal vestibule: inspect for inflammation, ulceration or oedema affecting the nasal mucosa.
Nasal septum: note any polyps, deviation, perforation, haematoma, superficial vessels or areas of cautery.
Inferior turbinates: note any asymmetry, inflammation or polyps.
Thudiculum's nasal speculum
Nasal polyp 5
Deviated nasal septum 6
Structures of the nasal cavity
The turbinates are projections of bone which are covered in nasal mucosa and 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.
The nasal septum is the bone and cartilage in the nose that separates the nasal cavity into the two nostrils
The nasalvestibule is the most anterior part of the nasal cavity. It is enclosed by the cartilages of the nose and lined by the same epithelium as the skin.
Nasal bone and cartilage palpation
Warn the patient that you are going to be applying some pressure to their nose and ask them to let you know if they experience any pain.
1. Palpate the nasalbones assessing:
Irregularity (suggestive of fracture)
2. Palpate the nasalcartilage assessing:
3. Palpate the infraorbitalridges and assesseyemovement if there is a history of trauma to screen for an orbital blowout fracture.
Orbital blowout fracture
An orbital blowout fracture is a fracture of the orbitalfloor or medialwall resulting from blunttrauma to the eyesocket (e.g. tennis ball). Typical findings on clinical examination include infraorbitaltenderness, epistaxis and restrictedeyemovement (usually on vertical gaze).
Nasal airflow can be assessed using several methods, with the two most common described below.
1. Place your thumb over the nostril not being assessed to occlude airflow.
2. Ask the patient to breathe 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 and 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…
Explain to the patient that the examination is now finished.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your findings.
“Today I examined Mr Smith, a 25-year-old male. On general inspection, the patient appeared comfortable at rest and there were no abnormalities noted on inspection of the external nose.”
“Inspection of the nasal cavity revealed a normally aligned nasal septum and unremarkable nasal mucosa. Nasal airflow was also normal.”
“In summary, these findings are consistent with a normalnasal examination.”
“For completeness, I would like to perform the following further assessments and investigations.”
Further assessments and investigations
Olfactory assessment (UPSIT: University of Pennsylvania Smell Identification Test)