What is the recommended approach for a thorough nose examination in a patient presenting with nasal symptoms, considering their medical history and potential underlying conditions such as sinusitis or nasal polyps?

Nasal Examination Approach

A comprehensive nasal examination requires systematic assessment using anterior rhinoscopy with a nasal speculum or otoscope as the foundation, supplemented by nasopharyngoscopy when available, to evaluate septal position, turbinate size, mucosal characteristics, secretions, and presence of polyps or masses, while simultaneously examining for associated conditions including otitis media, sinusitis, and asthma. 1

External Nasal Assessment

Begin by inspecting the external nose for:

• Structural deformities: Look for asymmetry, deviated/deformed nose suggesting previous trauma, or saddle nose deformity indicating trauma, surgery, cocaine abuse, or inflammatory processes 2
• Nasal valve function: Observe for alar collapse during inspiration 2
• Cottle maneuver: Pull the patient's cheek laterally to open the nasal valve angle—improvement in breathing indicates nasal valve pathology 2, 1

Anterior Rhinoscopy (Essential Component)

Use a nasal speculum with appropriate lighting or an otoscope with nasal adapter—this is the foundation of examination and has 88% specificity for detecting pathology 2, 3:

Septal Evaluation

• Document any caudal septal deformity or deviation 2, 1
• Note that significant caudal septal deflection typically causes compensatory enlargement of the contralateral inferior turbinate 2, 1

Turbinate Assessment

• Inferior turbinate: Assess size, color, and degree of hypertrophy 2, 1
• Middle turbinate: Evaluate for hypertrophy or deformity that may obstruct the ostiomeatal complex 2
• Decongestant test: Apply topical decongestant to distinguish mucosal edema (will shrink) from bony hypertrophy (will not shrink) 2, 1

Mucosal Characteristics

• Color and appearance: Document whether mucosa appears pale/edematous, erythematous, or hyperemic 2
• Critical caveat: Mucosal appearance alone cannot distinguish allergic from nonallergic rhinitis, as both may present with pallor, edema, or hyperemia 2, 1
• Erythematous mucosa suggests acute infection or rhinitis medicamentosa from overuse of topical decongestants 2

Secretions

• Character: Note whether secretions are clear, purulent, or mucopurulent 2
• Mucopurulent material in the middle meatus strongly suggests sinusitis 2, 1

Masses and Polyps

• Identify any polyps or masses: Nasal polyps appear as semitranslucent, pale gray growths contrasting with pink adjacent mucosa 4
• Unilateral polyps are a red flag: They mandate immediate tissue biopsy to exclude inverted papilloma (>95% unilateral) or malignancy before any medical therapy 5
• Bilateral polyps: Typically arise from the middle meatus and ethmoid region, presenting with nasal congestion, obstruction, and anosmia 6, 4
• Pediatric consideration: Nasal polyps in children should prompt evaluation for cystic fibrosis 2, 4

Nasopharyngoscopy (When Available)

Rigid or flexible nasopharyngoscopy provides superior visualization compared to anterior rhinoscopy alone (sensitivity 54-58% for speculum/otoscope vs. comprehensive view with endoscopy) 2, 3:

• Middle meatus: Assess for mucopurulent drainage suggesting sinusitis 2
• Posterior septum and choanae: Evaluate for obstruction 2
• Sinus ostia: Look for patency and drainage 2
• Nasopharynx: Examine for adenoid hypertrophy (especially in children), masses, or postnasal drainage 2

Associated Findings in Related Structures

Otologic Examination

• Tympanic membrane: Use pneumatic otoscopy to assess mobility 2
• Look for middle ear effusions, eustachian tube dysfunction, or otitis media—frequently present with acute sinusitis 2, 1

Oropharyngeal Examination

• Posterior pharynx: Assess for pharyngeal erythema, lymphoid hyperplasia, or purulent material suggesting postnasal drainage from sinusitis 2

Facial and Periorbital Signs

• Sinus tenderness: Palpate over frontal and maxillary sinuses 2
• Periorbital findings: Dark circles beneath eyes or periorbital edema suggest chronic sinusitis 2
• Warning signs requiring urgent evaluation: Orbital swelling or pain, forehead swelling, diplopia, proptosis, or periorbital inflammation suggest complications requiring immediate referral 2

Pulmonary Assessment

• Chest auscultation: Sinusitis may trigger or worsen asthma and bronchial hyperresponsiveness 2
• Consider office spirometry in patients with sinusitis and cough 2

Pediatric-Specific Findings

In children, document:

• Dental malocclusion, high-arched palate, or upper lip elevation: These suggest early-onset or longstanding nasal disease 2, 1
• Structural problems: Cleft palate, adenoidal hypertrophy, or laryngopharyngeal reflux may cause nasal obstruction 2

Critical Pitfalls to Avoid

• Never assume asymptomatic examination rules out disease: Patients may have minimal or no findings even with a suggestive history if examined when asymptomatic 2, 1
• Never rely solely on mucosal appearance: Both allergic and nonallergic rhinitis can present identically on examination 2, 1
• Never start corticosteroids for unilateral masses before biopsy: This delays appropriate treatment for malignancy or invasive fungal disease 5
• Do not routinely use posterior rhinoscopy mirror: It has only 12.5% sensitivity and is inadequate for ruling out posterior pathology 3

When to Refer

Consultation with an allergist-immunologist or otolaryngologist is appropriate when 2:

• Concomitant conditions complicate assessment: chronic otitis media, asthma, nasal polyps, recurrent pneumonia, immunodeficiencies, aspirin sensitivity, allergic fungal disease, or granulomas
• Structural abnormalities require surgical evaluation: significant septal deviation compressing the middle turbinate, middle turbinate deformity obstructing sinus outflow, or obstructing nasal polyps after failed medical therapy
• Recurrent or chronic symptoms persist despite aggressive medical management with radiographic evidence of ostiomeatal obstruction