Key Takeaways for Nasal Examination from Bates Guide Principles
1. Systematic External and Internal Assessment Using Anterior Rhinoscopy as Foundation
The nasal examination must systematically evaluate external nasal anatomy, nasal valve patency, and internal structures via anterior rhinoscopy using a nasal speculum with appropriate lighting or otoscope with nasal adapter. 1
- Inspect external nasal contour for deformities, asymmetry, or saddle nose deformity, which may indicate previous trauma, surgery, cocaine abuse, or inflammatory processes 2, 1
- Assess nasal valve patency by observing for alar collapse during inspiration 2, 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 2, 1
- Document septal position including any caudal septal deformity or deviation; note that if significant caudal septal deflection exists, the inferior turbinate on the opposite side is often compensatorily enlarged 2, 1
- Apply topical decongestant to distinguish mucosal edema from bony turbinate hypertrophy—reduction after decongestant suggests mucosal rather than structural hypertrophy 2, 1
2. Mucosal Characteristics and Secretions Provide Critical Diagnostic Clues
Document mucosal color, appearance, and quality of nasal secretions, recognizing that specific patterns correlate with distinct pathologies despite some overlap between conditions. 2, 1
- Red, swollen nasal tissue indicates infectious rhinitis and sinusitis 2
- Pale, boggy turbinates suggest allergic rhinitis 2
- Purulent secretions (yellow-green, green, or gray) persisting beyond 10 days in the middle meatus area are characteristic of sinusitis 2
- Clear, watery secretions are typical of allergic rhinitis; with extreme inflammation, a pale yellow color might be observed 2
- Mucosal appearance alone cannot definitively distinguish allergic from nonallergic rhinitis, as both may present with pallor, edema, or hyperemia 2, 1
- Purulent exudates in the middle meatus are highly predictive of bacterial sinusitis 2
3. Comprehensive Examination Must Include Associated Upper Airway Structures and Pediatric-Specific Findings
The nasal examination should extend beyond the nose to evaluate ears, eyes, throat, and lungs for complications and comorbid conditions, with special attention to pediatric findings that indicate chronic disease. 2, 1
- Examine tympanic membranes for signs of otitis media, eustachian tube dysfunction, or middle ear effusions, which frequently accompany sinusitis 2, 1
- Inspect the oropharynx for pharyngeal erythema, lymphoid hyperplasia, and purulent material in the posterior pharynx 2, 1
- Look for allergic shiners (dark infraorbital swollen semicircles or blue-grey periorbital discoloration from venous stasis) 2, 1
- Assess for Dennie-Morgan lines (prominent folds extending from medial lower lid, present in 60-80% of atopic children) 1
- In children, document dental malocclusion, high-arched palate, or upper lip elevation, which suggest early-onset or longstanding nasal disease 2, 1
- Note transverse nasal crease from constant nose itching in allergic children 2, 1
- Perform chest auscultation in patients with possible sinusitis and cough, as acute or chronic sinusitis might initiate or worsen asthma and bronchial hyperresponsiveness 2
- Recognize that asymptomatic patients may have minimal or no findings on examination despite a suggestive history 2, 1