What are the key components to assess during a nasal examination?

Nasal Examination: Key Components to Document

A comprehensive nasal examination should systematically assess external nasal anatomy, nasal valve patency, internal nasal structures via anterior rhinoscopy, mucosal characteristics, secretions, and associated upper airway findings, with documentation of septal position, turbinate size, presence of polyps or masses, and any signs of related conditions such as otitis media or sinusitis. 1

External Nasal Assessment

• Inspect the external nasal contour for deformities, asymmetry, or saddle nose deformity, which may indicate previous trauma, surgery, cocaine abuse, or inflammatory processes 1
• Assess nasal valve patency by observing for alar collapse during inspiration 1
• Perform the Cottle maneuver by pulling the patient's cheek laterally to open the nasal valve angle—improvement in breathing suggests nasal valve pathology 1

Anterior Rhinoscopy Findings

Use a nasal speculum with appropriate lighting or an otoscope with nasal adapter to perform anterior rhinoscopy, which is the foundation of the nasal examination 1, 2

Septal Assessment

• Document any caudal septal deformity or deviation 1
• Note that if significant caudal septal deflection exists, the inferior turbinate on the opposite side is often compensatorily enlarged 1

Turbinate Evaluation

• Assess inferior turbinate size and appearance for hypertrophy 1
• Consider applying topical decongestant to distinguish mucosal edema from bony hypertrophy—reduction after decongestant suggests mucosal rather than structural hypertrophy 1
• Evaluate middle turbinate for hypertrophy 1

Mucosal Characteristics

• Document mucosal color and appearance: pale/edematous mucosa, erythema, or hyperemia 1
• Note that mucosal appearance alone cannot definitively distinguish allergic from nonallergic rhinitis, as both may present with pallor, edema, or hyperemia 1
• Reddened mucosa typically indicates acute infection or overuse of topical decongestant sprays 1

Secretions and Discharge

• Note the quantity, quality, and character of nasal secretions 1
• Presence of mucopurulent material suggests sinusitis 1

Masses and Polyps

• Identify any nasal polyps or masses visible on anterior rhinoscopy 1

Advanced Visualization (When Available)

Nasopharyngoscopy (rigid or flexible) provides superior visualization of structures not adequately seen with anterior rhinoscopy alone 1, 3:

• Middle meatus and ostiomeatal complex 1, 3
• Posterior septum 1
• Sinus ostia 1
• Posterior choanae 1
• Nasopharynx 1, 4
• Presence and extent of nasal polyps 1

Nasal endoscopy is superior to anterior rhinoscopy alone for detecting pathology in the ostiomeatal complex and posterior nasal cavity, with substantial agreement for detecting septal deviation, turbinate hypertrophy, and polyps 3

Associated Findings in Related Structures

Examine for signs of conditions commonly associated with nasal pathology 1, 4:

Otologic Examination

• Assess tympanic membrane appearance and mobility using pneumatic otoscopy 1, 4, 5
• Look for signs of otitis media, eustachian tube dysfunction, or middle ear effusion 1, 4
• Document any air-fluid levels or bubbles behind the tympanic membrane 4

Oropharyngeal Examination

• Inspect for tonsillopharyngeal findings, postnasal drainage, or cobblestoning 1, 6

Facial and Periorbital Signs

• Look for allergic shiners (blue-grey periorbital discoloration from venous stasis, present in up to 60% of atopic patients) 1
• Assess for Dennie-Morgan lines (prominent folds extending from medial lower lid, present in 60-80% of atopic children) 1
• Note any nasal crease from chronic nasal rubbing 1

Pediatric-Specific Findings

• In children, document dental malocclusion, high-arched palate, or upper lip elevation, which suggest early-onset or longstanding nasal disease 1

Common Pitfalls to Avoid

• Do not rely solely on mucosal appearance to distinguish allergic from nonallergic rhinitis, as both can present similarly 1
• Recognize that asymptomatic patients may have minimal or no findings on examination despite a suggestive history 1
• Traditional examination tools (speculum, otoscope, posterior rhinoscopy mirror) have excellent specificity but only moderate sensitivity, meaning they may miss pathology that would be detected by endoscopy 7
• Posterior rhinoscopy mirror has particularly low sensitivity (12.5%) and is not recommended for ruling out posterior nasal pathology 7
• Application of topical anesthesia and decongestants does not significantly improve diagnostic accuracy of traditional tools and is not routinely necessary 7

Objective Measurements (When Indicated)

Peak nasal inspiratory flowmetry (PNIF) is the simplest objective measure of nasal patency and correlates well with subjective sensation 1

• PNIF is useful for documenting baseline function and response to treatment 1
• Rhinomanometry and acoustic rhinometry provide more detailed assessment but are typically reserved for research or specialized evaluation 1