How do I perform a nasal examination?

How to Perform a Nasal Examination

Begin with anterior rhinoscopy using a nasal speculum or handheld otoscope to visualize the anterior nasal cavity, removing any blood clots first if present, and consider applying topical decongestants (such as oxymetazoline) to improve visualization. 1

Anterior Rhinoscopy Technique

Anterior rhinoscopy is the foundational examination method and should be performed systematically:

• Use a nasal speculum or handheld otoscope to examine the anterior nasal cavity 1
• In young children, an otoscope is particularly useful for visualization 1
• Remove blood clots (if present) either by suction or gentle nose blowing before examination to allow complete visualization 1
• Apply topical decongestants (such as oxymetazoline) after initial inspection to improve visualization, particularly when assessing for nasal polyps or turbinate hypertrophy 2

What to Look For During Anterior Rhinoscopy:

• Nasal septal deviation or perforation 1
• Large nasal polyps obstructing the nasal cavity (visible without endoscopy) 2
• Turbinate hypertrophy (best assessed after decongestant application) 2
• Bleeding sites in the anterior nasal cavity, particularly Kiesselbach's plexus 1
• Mucosal abnormalities or masses 1

When to Advance to Nasal Endoscopy

Nasal endoscopy should be performed or the patient referred for endoscopy in specific clinical scenarios where anterior rhinoscopy is insufficient:

Mandatory Indications for Endoscopy:

• Recurrent epistaxis despite prior treatment with packing or cautery 1
• Recurrent unilateral nasal bleeding 1
• Suspected nasal polyps not visible on anterior rhinoscopy, particularly with comorbid asthma, atopy, or waxing/waning smell 2
• Unilateral polyps (to rule out carcinoma, inverting papilloma, antrochoanal polyp, or allergic fungal sinusitis) 2
• Adolescent males with unilateral, profuse epistaxis (to exclude juvenile nasopharyngeal angiofibroma) 1

Optional Indications for Endoscopy:

• Difficult-to-control epistaxis 1
• Concern for unrecognized pathology contributing to symptoms 1
• Suspected nasal foreign body not visible on anterior rhinoscopy (particularly in children with unilateral symptoms) 1
• Evaluation of posterior nasal cavity and nasopharynx when malignancy is suspected 1

Diagnostic Accuracy Considerations

Important caveat: Traditional examination tools (nasal speculum and otoscope) have excellent specificity (85-88%) but only moderate sensitivity (55-68%) for detecting nasal pathology 3. This means:

• If you see pathology with anterior rhinoscopy, it's likely real (high specificity)
• If you don't see pathology, you may still be missing it (moderate sensitivity)
• Smaller polyps in the middle meatus or posterior nasal cavity may only be detected by endoscopy 2
• Nasal endoscopy can localize bleeding sites in 87-93% of cases, compared to much lower rates with anterior rhinoscopy alone 1

Common Pitfalls to Avoid

• Don't rely solely on anterior rhinoscopy when clinical suspicion is high for pathology (asthma + smell changes suggests polyps; unilateral symptoms suggest tumor or foreign body)
• Don't skip clot removal before examination—it obscures visualization 1
• Don't dismiss unilateral findings—they require more thorough evaluation with endoscopy and often imaging 2, 1
• Posterior rhinoscopy mirror has very poor sensitivity (12.5%) and is not recommended for ruling out posterior pathology 3
• Don't routinely use topical anesthesia/decongestants for screening—they don't significantly improve diagnostic accuracy for routine anterior rhinoscopy 3, but do use decongestants when specifically assessing for polyps or turbinate hypertrophy 2