This document provides information on history taking and examination for nose and paranasal sinus issues. It discusses evaluating the chief complaints, symptoms, duration of symptoms, and risk factors. Key parts of history include characterizing the nasal symptoms, eliciting secondary symptoms, and considering age, sex, occupation, and place of residence as these may provide clues to etiology. Causes of various nasal symptoms like obstruction, discharge, headache/facial pain, smell disturbances, and voice changes are explored. Syndromes associated with nasal/sinus issues are also mentioned.

1. HISTORY TAKING AND
EXAMINATION OF NOSE AND
PNS
DR SAHEENA N

2. 'THE AIM OF AN OUTPATIENT ASSESSMENT IS TO REACH A
DIAGNOSIS IN ORDER TO GUIDE MANAGEMENT. IN MANY
PATIENTS THIS BE CLEAR FROM THE HISTORY ALONE'

3. HISTORY TAKING
• BEST INITIATED BY CHARACTERIZING THE INDEX NASAL SYMPTOM(S),
NOTING DURATION, PERIODICITY, NOCTURNAL VARIATION, SEASONAL EFFECTS,
LATERALITY AND
ASSOCIATION WITH TRAUMA OR PRIOR SURGERY, AND WHETHER THERE ARE ANY
ALLEVIATING OR
PROVOKING FACTORS.
THE ENQUIRY SHOULD COVER THE PRESENCE OF
• NASAL OBSTRUCTION OR CONGESTION ,FACIAL PAIN, HYPOSMIA,
• ANOSMIA, RHINORRHOEA AND POST-NASAL DISCHARGE.
• SECONDARY SYMPTOMS SUCH AS SNEEZING, ITCH, EPIPHORA, TASTE DISTURBANCE
AND DRY MOUTH SHOULD BE ELICITED WHERE APPROPRIATE.

4. HISTORY TAKING
AGE
• PEDIATRIC AGE GROUP
-FORIGN BODY NOSE
-CHOANA ATRESIA
-MENINGOCELE

5. • ADOLESCENTS
- JNA
-HORMONAL RHINITIS

6. • YOUNG ADULTS
-TRAUMA
-SEPTAL HAEMATOMA
• ELDERLY
-SINONASAL MALIGNANCIES
• BIMODAL DISTRIBUTION
-NASOPHARYNGEAL CANCER
-2ND TO 3RD DECADES AND 5TH TO 7TH DECADES

7. • SEX
MALE PREDOMINANCE
-SINONASAL MALIGNANCY
- NASOPHARYNGEAL CARCINOMA
-JNA
FEMALE PREDOMINANCE
- ATROPHIC RHINITIS
-HORMONAL RHINITIS

8. • OCCUPATION
WOOD WORKERS – SINONASAL MALIGNANCY
HARD WOOD-ADENOCARCINOMA
SOFT WOOD - SQUAMOUS CELL CARCINOMA
EXPOSURE TO DUST – ALLERGIC RHINITIS
OCCUPATIONAL RHINITIS
-DEF:-RHINITIS CAUSED BY EXPOSURE TO AIRBORNE AGENTS PRESENT IN THE
WORK PLACE
-SYMPTOMS MANIFEST ON WEEK DAYS AND ABATE DURING WEEKENDS AND
HOLIDAYS
-IMMUNOGENIC OR NON IMMUNOGENIC (IRRITANT)

9. • PLACE
RHINOSPORIDIOSIS- SOUTHERN STATES OF INDIA
NPC- SOUTHERN CHINA AND TAIWAN

10. CHIEF COMPLAINTS
• PRIMARY NASAL SYMPTOMS
BLOCKAGE/CONGESTION
DISCHARGE- ANTERIOR OR POSTERIOR
FACIAL PAIN /PRESSURE
REDUCTION/LOSS OF SMELL
• OTHER SYMPTOMS
SNEEZING
BLEEDING FROM NOSE
HEADACHE
VOICE CHANGE
SNORING/ MOUTH BREATHING
SWELLING OR DEFORMITY
EPIPHORA

11. DURATION OF SYMPTOMS
• DURATION
ACUTE<12WKS OR CHRONIC>12WKS
• FOR A DIAGNOSIS OF RECURRENT ACUTE RHINOSINUSITIS,
THERE MUST BE SYMPTOM-FREE EPISODES BETWEEN THE
CLINICAL EVENTS.
• CHRONOLOGICAL ORDER

12. ..DURATION
• COMMON COLD(ACUTE VIRAL
RHINOSINUSITIS) WILL LAST
FOR LESS THAN 10 DAYS
• ACUTE POST-VIRAL
RHINOSINUSITIS WILL LAST
BETWEEN 100 DAYS AND 12
WEEKS IN DURATION.
• ARS IS CONSIDERED TO BE
BACTERIAL (ABRS) IF AT LEAST
THREE OF THE SYMPTOMS +

13. RHINITIS
• RHINITIS IS DEFINED CLINICALLY AS HAVING TWO OR MORE SYMPTOMS OF
ANTERIOR OR POSTERIOR RHINORRHOEA, SNEEZING, NASAL BLOCKAGE
AND/OR ITCHING OF THE NOSE DURING TWO OR MORE CONSECUTIVE DAYS
FOR MORE THAN ONE HOUR ON MOST DAYS.
• 2TYPES
• 1.ALLERGIC RHINITIS
• 2.NARES
• ALLERGIC RHINITIS IS SUBDIVIDED INTO INTERMITTENT (IAR) OR
PERSISTENT (PER) DISEASE AND THE SEVERITY INTO MILD OR
MODERATE/SEVERE
allergic rhinitis -aria classification

14. RHINOSINUSITIS

15. HISTORY OF PRESENT ILLNESS
NASAL OBSTRUCTION
U/L OR B/L OR ALTERNATING
INTERMITTENED ,CONTINUOUS OR PROGRESSIVE
AGGRAVATING /RELIEVING FACTORS
ACUTE/CHRONIC/RECURRENT

16. NASAL OBSTRUCTION MAY BE
• STRUCTURAL- DUE TO AN OBSTRUCTING LESION EG: ADENOIDS
/DNS/ TUMOURS
• MUCOSAL-DUE TO MUCOSAL SWELLING AND CONGESTION EG:
ACUTE RHINITIS/ ALLERGY
• MIXED- DUE TO A MUCOSAL DISEASE THAT CAUSED AN
OBSTRUCTING LESION EG: RHINITIS WITH POLYP OR TURBINATE
HYPERTROPHY

17. U/L NASAL OBSTRUCTION -CAUSES
• -DNS
• FOREIGN BODY IN NOSE
• UNILATERAL RHINO SINUSITIS
• ANTROCHOANAL POLYP
• UNILATERAL SINONASAL
POLYPOSIS
• RHINOLITH
• FURUNCULOSIS OF THE NASAL
VESTIBULE
• ATRESIA OF THE NASAL VESTIBULE
• UNILATERAL NASOPHARYNGEAL
MASS
• COCHA BULLOSA
• SYNECHIA
• UNILATERAL ATROPHIC RHINITIS
• RHINITIS CASEOSA
• RHINOSPORIDIOSIS
• INVERTED PAPILLOMA
• UNILATERAL CHOANAL ATRESIA
• SINONASAL MALIGNANCY

18. B/L NASAL OBSTRUCTION-CAUSES
NASAL CAUSES
• DNS WITH COMPENSATORY
INFERIOR TURBINATE
HYPERTROPHY
• BILATERAL ETHMOIDAL POLYPOSIS
• ANTROCHOANAL POLYP FILLING
THE ENTIRE NASOPHARYNX
• SPHENOCHOANAL POLYP
• ALLERGIC RHINITIS
• BILATERAL RHINOSINUSITIS
• ATROPHIC RHINITIS
• SEPTAL HAEMATOMA
• SEPTAL ABSCESS
• RHINITIS MEDICAMENTOSA
• RHINITIS SICCA
• B/L CHOANAL ATRESIA

19. ..B/L NASAL OBSTRUCTION
NASOPHARYNGEAL CAUSES
• ADENOID HYPERTROPHY
• JNA
• ADVANCED SINONASAL MALIGNANCY

20. NASAL DISCHARGE
TYPES OF NASAL DISCHARGE
• WATERY - COMMON COLD
- VASOMOTOR RHINITIS
- CSF RHINORRHOEA(U/L OR B/L)
• MUCOID – ALLERGIC RHINITIS
• MUCOPURULENT – INFECTIVE RHINITIS, SINUSITIS
• PURULENT – FURUNCULOSIS, FOREIGN BODY, ATROPHIC RHINITIS
• BLOOD STAINED – FOREIGN BODY, NON-HEALING GRANULOMA,
MALIGNANCY
• ODOUR-FOUL SMELLING, UNILATERAL NASAL DISCHARGE – THINK OF
FOREIGN BODY (CHILDREN)
OROANTRAL FISTULA/ FUNGAL SINUSITIS/ MALIGNANCY WITH ULCERATION

21. NASAL DISCHARGE -CAUSES
UNILATERAL NASAL DISCHARGE CAUSES:
• 1. FOREIGN BODY NOSE
• 2. RHINOLITH
• 3. ANTROCHOANAL POLYP.
• 4. UNILATERAL CHOANAL ATRESIA
• 5. UNILATERAL SINONASAL POLYPOSIS
• 6. UNILATERAL RHINOSINUSITIS
• 7. CSF RHINORRHOEA

22. BILATERAL NASAL DISCHARGE CAUSES
• 1. ALLERGIC RHINITIS
• 2. VASOMOTOR RHINITIS
• 3. AC POLYP COMPLETELY OBSTRUCTING THE NASOPHARYNX
• 4. ETHMOIDAL POLYP
• 5. DIPTHERITIC RHINITIS
• 6. ADENOID HYPERTROPHY
• 7. BILATERAL CHONAL ATRESIA
• 8. JNA
• 9. NASOPHARYNGEAL MALIGNANCY

23. HEADACHE/FACIAL PAIN
.MAXILLARY SINUSITIS
• PAIN PRESENT IN THE CANINE FOSSA OR MALAR EMINENCE AND
DENTAL PAIN.
• HEADACHE INCREASES WITH THE PROGRESSION OF THE DAY.
.ETHMOIDAL SINUSITIS
• PAIN PRESENT IN THE BRIDGE OF THE NOSE OR MEDIAL TO
INNER CANTHUS OF THE EYE.

24. FRONTAL SINUSITIS
• HEADACHE PRESENT IN THE FOREHEAD REGION (OFFICE HEADACHE OR
VACUUM HEADACHE). PAIN STARTS IN THE MORNING, PEAKS IN THE MID-DAY,
• THEREAFTER DECREASES TOWARDS THE EVENING.
SPHENOIDAL SINUSITIS
• PAIN IN THE VERTEX OR OCCIPITAL REGION

25. POST NASAL DRIP/DISCHARGE
CAUSES
• O COMMON COLD
• O RHINOSINUSITIS
• O DNS
• O ADENOID HYPERTROPHY
SNEEZING
CAUSES
O ALLERGY
O COMMON COLD

26. EPISTAXIS
• TYPES
ANTERIOR-FROM LITTLE'S AREA
POSTERIOR-WOODRUFF'S PLEXUS (COMMON IN HYPERTENSIVE
PATIENTS)
• COMMON CAUSES
• IDIOPATHIC IS THE COMMONEST
• CHILDREN – DIGITAL TRAUMA(NOSE PICKING)
• ADOLESCENTS – RTA AND SPORTS INJURY(FOOTBALL, RUGBY AND
KARATE)
• OLD AGE – HYPERTENSION

27. EPISTAXIS-CAUSES
• I. IDIOPATHIC- MOST COMMON CAUSE.
• MORE THAN 50% CASES OF EPISTAXIS ARE OF UNKNOWN
ETIOLOGY
• II. TRAUMATIC-
1.NOSE PICKING(DIGITAL TRAUMA)
2. ACCIDENTAL (SPORTS INJURY, RTA)
• III. CONGENITAL - TELANGIECTASIA, STURGE-WEBER SYNDROME
• IV. FOREIGN BODY, RHINOLITH

28. • V. INFECTIVE
• O FUNGAL RHINOSINUSITIS
• O RHINOSPORIDIOSIS
• O TB
• O LEPROSY
• O SYPHILIS
• O RHINOSCLEROMA
• O MIDLINE GRANULOMA
• O SARCOIDOSIS
• O WEGENERS GRANULOMATOSIS
• O T-CELL LYMPHOMA

29. • VI. NEOPLASTIC
• O BENIGN – BLEEDING POLYPUS, JNA, INVERTED PAPILLOMA
• O MALIGNANT – CARCINOMA OF NOSE AND PARANASAL SINUSES
• VII. MISCELLANEOUS
• O MAGGOTS IN THE NOSE(NASAL MYIASIS)

30. SYSTEMIC CAUSES
• O INCREASED TENSION IN SYSTEMIC ARTERIES-HT,DM
• O INCREASED TENSION ON VENOUS PRESSURE-CHRONIC LIVER
FAILURE ,CHRONIC RENAL FAILURE(ERYTHROPOETIN
DEFICIENCY)
• O ACUTE EXANTHEMATOUS FEVER
• O BLOOD DYSCRASIAS-ITP, TTP, FACTOR -II,VII,IX,X DEFICIENCY,
HEMOPHILIA, CHRISTMAS DISEASE, VON WILLIBRAND DISESASE,
GLANZMANN DISEASE, BERNAUD SOULLIER SYNDROME,
THROMBASTHENIA
• O DRUG INDUCED-HEPARIN, WARFARIN, COUMARIN

31. SMELL DISTURBANCES
• CONDUCTIVE IMPAIRMENT -FROM OBSTRUCTION OF NASAL
PASSAGES( POLYP/SEPTAL DEFORMITIES/TUMOURS)
•
SENSORYNEURAL- FROM DAMAGE TO OLFACTORY
NEUROEPITHELIUM,CENTRAL TRACT AND CONNECTION (TUMORS,
NEURODEGENERATIVE DISEASES , EPILEPSY ETC)

32. SMELL DISTURBANCES
• 1. HYPOSMIA - DIMINISHED SENSE OF SMELL
CAUSES - AGING, TOBACCO SMOKER, RADIATION THERAPY,
REPEATED SURGERY WITH REMOVAL OF
MUCOSA,NEURODEGENERATIVE DISORDERS, TUMOURS IN AND
AROUND OLFACTORY BULB AND TRACTS
• 2 ANOSMIA - ABSENCE OF SMELL
CAUSES - COMPLETE DESTRUCTION OF OLFACTORY PATHWAY BY
- TRAUMA (SKULL BASE FRACTURE-TRANSECTION OF
OLFACTORY NERVE)
-ATROPHY OF MUCOSA(ATROPHIC RHINITIS)

33. ..SMELL DISTURBANCE
• 3. PAROSMIA - ALTERED SENSE OF SMELL
• 4. CACOSMIA - PERCEPTION OF BAD ODOUR
CAUSE- DUE TO TEMPORAL LOBE EPILEPSY
• 5. HYPEROSMIA – INCREASED SENSATION OF SMELL(ASS WITH
CHANGE IN HORMONAL BALANCE EG:PRGNANCY, ADDISONS
DISEASE ; MIGRAINE , EPILEPSY)

34. • 6.PHANTOSMIA-DYSOSMIC SENSATION PERCEIVED IN THE
ABSENCE OF AN ODOUR STIMULUS
( AKA OLFACTORY HALLUCINATION)
OLFACTORY AGNOSIA - INABILITY TO RECOGNISE AN ODOUR
SENSATION ( STROKE )
7. PRESBYOSMIA- DECLINE IN SMELL SENSE WITH AGE

35. FOSTER KENNEDY SYNDROME
• OLFACTORY GROOVE MENINGIOMA
OR PLASMACYTOMA)
• IPSILATERAL OPTIC ATROPHY
• DISC OEDEMA OF CONTRALATERAL
EYE
• IPSILATERAL ANOSMIA

36. KALLMANN SYNDROME
• INHERITED DISORDER
• HYPOGONADOTROPHIC
HYPOGONADISM
• ANOSMIA OR HYPOSMIA

37. VOICE CHANGE
RHINOLALIA CLAUSA-DECRESED NASAL TWANG OF VOICE OR HYPONASALITY
OF VOICE
NASAL CAUSES
• INFLAMMATORY CAUSES
• ACUTE VIRAL RHINITIS
• ACUTE DIPHTHERIC RHINITIS
• CHRONIC SPECIFIC RHINITIS(TB, SYPHILIS)
• CHRONIC NON-SPECIFIC RHINITIS(RHINITIS SICCA, RHINITIS
MEDICAMENTOSA)
• NASAL POLYPOSIS

38. ...RHINOLALIA CLAUSA
INFECTIVE CAUSES
• BACTERIAL RHINITIS
• SINUSITIS
• FURUNCULOSIS
TRAUMATIC CAUSES
• SEPTAL ABSCESS
• SEPTAL HEMATOMA
• SYNECHIA

39. NEOPLASTIC CAUSES
• SQUAMOUS PAPILLOMA
• INVERTED PAPILLOMA
• JNA
• HEMANGIOMA
• ADENOCARCINOMA
• NASAL GLIOMA
OTHERS
• CHOANAL ATRESIA
• DNS

40. NASOPHARYNGEAL CAUSE
• ADENOIDS
• NASOPHARYNGEAL CARCINOMA
OTHERS
• HABITUAL SPEECH PATTERN
• FAMILIAL SPEECH PATTERN

41. RHINOLALIA APERTA-INCREASED NASAL TWANG OF THE VOICE OR HYPERNASALITY OF
VOICE
CONGENITAL CAUSES
• CLEFT PALATE
• CONGENITAL SHORT PALATE
• LARGE NASOPHARYNX
ACQUIRED CAUSES
• PALATAL PALSY
• VELOPHARYNGEAL INSUFFICIENCY
• OTHERS
• HABITUAL SPEECH PATTERN
• FAMILIAL SPEECH PATTERN

42. SNORING
• ABNORMAL SOUND PRODUCED DURING SLEEP
• DUE TO VIBRATION OF THE LAX TISSUE OF THE UPPER AIRWAY
TRACT
DUE TO PARTIAL OBSTRUCTION
• CAUSES – DNS, ADENOID HYPERTROPHY, NASAL POLYPOSIS,
TUMOURS
OF THE NOSE, HYPERTROPHIED TURBINATES.

43. OSAS
• MORE THAN 5 EPISODES OF APNOEA OR 10 OR MORE EPISODES OF
HYPOAPNOEA DURING NORMAL 1 HOUR OF SLEEP WITH EXCESSIVE DAY
TIME SLEEPINESS AND INTEREFERENCE OF DAY TO DAY ACTIVITIES.
• APNOEA-COMPLETE CESSATION OF BREATHING FOR 10 SECONDS.
• HYPOAPNOEA-50% REDUCTION IN THE THORACO-ABDOMINAL
MOVEMENTS AND LASTING FOR 10 SECONDS IN THE PRESENCE OF
CONTINUED AIR FLOW.
• APNOEIC INDEX- NO. OF APNOEA PER HOUR OF SLEEP

44. • TYPES OF OSA
• CENTRAL
• ABSENCE OF AIR FLOW WITH NO RESPIRATORY EFFORTS.
• OCCURS IN HEART FAILURE, FRONTAL LOBE LESION AND BRAIN STEM LESION
• OBSTRUCTIVE
• ABSENCE OF AIR FLOW WITH CONTINUED RESPIRATORY EFFORT
• MIXED

45. GRADES OF OSA
• MILD - 5 TO 20 APNOEA PER HOUR.
• MODERATE- 20 TO 40 APNOEA PER HOUR.
• SEVERE - MORE THAN 40 APONEA PER HOUR.
• PICKWICKIAN SYNDROME/HYPOVENTILATION SYNDROME
OBESITY, HYPERTENSION AND DIABETES. OSA IS COMMONLY
ASSOCIATED WITH
THIS SYNDROME

46. CLINICAL FEATURES
• MALE PREDOMINANCE
• OBESITY
• SNORING
• OBSTRUCTION TO BREATHING
• EXCESSIVE DAY TIME SLEEPINESS
• MEMORY LOSS
• INTELLECTUAL DETERIORATION
• PERSONALITY CHANGES

47. HISTORY S/O COMPLICATIONS OF
RHINOSINUSITIS

48. PAST HISTORY
• HISTORY OF SIMILAR ILLNESS
• TRAUMA OR SURGERY
• CHRONIC DISEASES LIKE DM, HTN, B.ASTHMA,BLEEDING DISORDRERS, TB,
LEPROSY ,SYPHILIS,
• EPILEPSY,MALIGNANCIES ETC
• DRUG HISTORY
• ALLERGY HISTORY- DRUG OR DIET OR ALLEGENS

49. DRUG INDUCED RHINITIS
• SEVERAL COMMONLY EMPLOYED MEDICATIONS, SUCH AS
ASPIRIN,
OTHER NON-STEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS),
BETA-BLOCKERS, ANGIOTENSIN-CONVERTING ENZYME (ACE)
INHIBITORS, METHYLDOPA, ORAL CONTRACEPTIVES,
PSYCHOTROPIC AGENTS AND NASAL TOPICAL DECONGESTANTS
(OXYMETAZOLINE, NAPHAZOLINE ,XYLOMETAZOLINE) MAY INDUCE
SYMPTOMS OF RHINITIS WHEN THEY ARE ADMINISTERED EITHER
TOPICALLY OR SYSTEMICALLY

50. SAMTER'S TRIAD
ASPIRIN EXACERBATED RESPIRATORY
DISEASE(AERD)
THE COMBINATION OF
• BRONCHIAL ASTHMA
• NASAL POLYPOSIS AND
• ASPIRIN SENSITIVITY

51. RHINITIS MEDICAMENTOSA
• PERSISTENT OVERUSE OF THE TOPICAL NASAL
VASOCONSTRICTORS ALSO LEADS TO NASAL DECONGESTION BY
A MECHANISM INVOLVING A REBOUND EFFECT FOLLOWING
WITHDRAWAL OF THESE
• DRUGS, EXCESSIVE USE OF THESE AGENTS MAY ALSO LEAD TO
NASAL HYPER-REACTIVITY AND HYPERTROPHY OF THE NASAL
MUCOSA, A CONDITION KNOWN AS ‘RHINITIS MEDICAMENTOSA.

52. KARTAGENER'S SYNDROME
TRIAD OF
• CHRONIC SINUSITIS,
• BRONCHIECTASIS AND
• SITUS INVERSUS.
• TWENTY-SEVEN PER CENT OF
PATIENTS WITH KARTAGENER’S
SYNDROME HAVE NASAL POLYPS

53. YOUNG'S SYNDROME
YOUNG’S SYNDROME IS A RARE DISEASE CONSISTING OF THREE COMPONENTS:
• OBSTRUCTIVE AZOOSPERMIA,
• BRONCHIECTASIS AND
• SINUS DISEASE.
IT IS A RECOGNIZED CAUSE OF MALE INFERTILITY AND IS WELL KNOWN IN THE
FIELD OF INFERTILITY

54. CHURG STRAUSS SYNDROME/ EOSINOPHILIC
GRANULOMATOSIS
WITH POLYANGITIS (EGPA)
• • ASTHMA
• • EOSINOPHILIA OF >10% IN PERIPHERAL BLOOD
• • PARANASAL SINUSITIS
• • PULMONARY INFILTRATES, SOMETIMES TRANSIENT
• HISTOLOGIC EVIDENCE OF VASCULITIS WITH EXTRAVASCULAR EOSINOPHILS
• • MONONEURITIS MULTIPLEX OR POLYNEUROPATHY
• • IF ≥4 CRITERIA ARE PRESENT, SENSITIVITY IS 85%, AND SPECIFICITY IS 99.7%.
• THE TYPICAL CASE THAT SHOULD RAISE SUSPICION OF EGPA IS THAT OF A PATIENT WITH
ADULT-ONSET ASTHMA AND A HISTORY OF RHINOSINUSITIS, WHO DEVELOPS
PRONOUNCED EOSINOPHILIA AND LUNG INFILTRATES

56. PERSONAL HISTORY
• A HISTORY OF CIGARETTE SMOKING IS RELEVANT AS IT MAY POTENTIATE
ALLERGIC RHINITIS, AND VASOMOTOR RHINITIS IS SOMETIMES SEEN AS A CAUSE
OF NASAL OBSTRUCTION DURING SMOKING CESSATION.
• COCAINE ABUSE AND HABITUAL NOSE PICKING CAN CAUSE SEPTAL CRUSTING,
SEPTAL PERFORATION, AND SADDLE DEFORMITY
• THE PSYCHOLOGICAL ASPECTS OF THE HISTORY ARE IMPORTANT TO ADDRESS.
• MANY RHINOLOGIC SYMPTOMS RELATE TO STRESS, ANXIETY, AND
PSYCHOSOMATIC MANIFESTATIONS .
• DIRECTED ENQUIRY INTO WORK AND HOME SITUATIONS WILL OFTEN ELICIT A
PATIENT’S OWN CONCERNS TO THIS END.

57. FAMILY HISTORY
• H/O SIMILAR ILLNESS
• HEREDITORY DISEASES
• INFECTIOUS DISEASES EG: TB, LEPROSY,SYPHILIS ETC
SOCIOECONOMIC STATUS

58. EXAMINATION OF NOSE AND
PNS

59. 1. THE PATIENT SITTING ON THE STOOL MUST BE AT THE SAME LEVEL AS THE
DOCTOR.
2. THE PATIENT’S LEGS MUST BE PLACED TO ONE SIDE OF THE EXAMINER.
3. THE DISTANCE BETWEEN THE DOCTOR AND THE PATIENT MUST NOT BE MORE
THAN 8 INCHES (I.E.
THE FOCAL LENGTH OF THE HEAD MIRROR).
4. THE MIRROR IS FIXED OVER THE RIGHT EYE IN SUCH A WAY PART OF THE
MIRROR TOUCHES THE NOSE.
ILLUMINATION IS THE MOST IMPORTANT ASPECT WHICH SHOULD
BE CONSIDERED FIRST
•

62. GENERAL PHYSICAL EXAMINATION
• BUILT
• NOURISHMENT
• ORIENTATION TO TIME, PLACE & PERSON
• VITALS
• PULSE
• RESPIRATORY RATE
• BLOOD PRESSURE
• TEMPERATURE
• PALLOR/ICTERUS/CYANOSIS/CLUBBING/PEDAL OEDEMA/ GENERALISED
LYMPHADENOPATHY

63. SYSTEMIC EXAMINATION
• CVS – S1, S2 HEARD, NO AUDIBLE MURMURS.
• RS – NORMAL VESICULAR BREATH SOUNDS HEARD
NO CREPTS, NO WHEEZING.
• CNS - HIGHER MENTAL FUNCTIONS, MOTOR FUNCTIONS,
SENSORY FUNCTIONS
• CRANIAL NERVES – OLFACTORY, OPTIC, OCCULOMOTOR, TROCHLEAR,
TRIGEMINAL, ABDUCENS, FACIAL NERVE, VESTIBULOCOCHLEAR NERVE,
GLOSSOPHARYNGEAL, VAGUS, SINALACCESSORY,HYPOGLOSSAL
• PER ABDOMEN- SOFT, NON TENDER, NO ORGANOMEGALY.

64. EXAMINATION OF NOSE

65. INSPECTION
FIRST LOOK AT THE EXTERNAL NOSE. ASK THE PATIENT TO REMOVE ANY
GLASSES.
LOOK AT THE NOSE FROM THE FRONT AND SIDE FOR
EXTERNAL DEFORMITY- DEVIATION/ CROOKED/SADDLE/HUMP
SCAR OR SINUS EG: PREVIOUS SURGERY OR TRAUMA
SKIN CHANGES- INFLAMMATION/RASH EG: VESTIBULITIS
WIDENING OF NASAL BRIDGE
SWELLING –CYST/RHINOPHYMA/ TUMOURS

66. PALPATION

67. VESTIBULE OF NOSE

68. ANTERIOR RHINOSCOPY
• THUDICUM SPECULUM
• LIGHT IS FOCUSED AT DIFFERENT SITES IN NOSE TO EXAMINE NASAL SEPTUM,
ROOF, FLOOR AND LATERAL WALL BY TILTING PATIENT’S HEAD IN DIFFERENT
DIRECTIONS.

69. ..ANTERIOR RHINOSCOPY
EXPLAIN THE PROCEDURE TO THE PATIENT. PATIENT IS SEATED ERECT IN FRONT
AND 30CM AWAY FROM THE EXAMINER. USING THETHUDICUM’S NASAL SPECULUM
WITH THE DOMINANT HAND OF THE EXAMINER, THE BLADES OF SPECULUM
INTRODUCED INTO THE VESTIBULE OF THE NOSE AND EXAMINE THE INTERIOR OF
EACH
NASAL CAVITY SEPARATELY WHILE THE NON-DOMINANT HAND SUPPORTS THE HEAD
OF
THE PATIENT.

70. ..ANTERIOR RHINOSCOPY
• NASAL PASSAGE
-NARROW (SEPTAL DEVIATION OR HYPERTROPHY OF TURBINATES)
-WIDE (ATROPHIC RHINITIS, POST SURGICAL EG: TURBINECTOMY)

71. ..ANTERIOR RHINOSCOPY
MEDIAL WALL
SEPTUM –DEVIATION,
PERFORATION,ULCERS,CRUSTING
MUCOSA OVER SEPTUM-
PINK/CONGESTED/PALE/BLUISH

72. ..ANTERIOR RHINOSCOPY

73. ..ANTERIOR RHINOSCOPY
Lateral wall
Inferior turbinate- look for turbinate hypertrophy
Inferior meatus- secretion/mass
Middle turbinate-hypertrophy( concha bullosa)
Middle meatus- any secretion/polyp/mass
Mucosa over the turbinates- normal/congested/pale/bluish

74. RHINOSPORIDIOSIS
• FRIABLE POLYPOID LESION
• MAY RESEMBLE A
STRAWBERRY BECAUSE THE
SURFACE IS STUDDED WITH
WHITE FLECKS, WHICH ARE
MATURE SPORANGIA.

75. PROBE TEST- TO ASSESS ATTATCHMENT, CONSISTENCY, MOBILITY AND
SENSITIVITY OF MASS
WHETHER THE MASS BLEEDS ON TOUCH
..ANTERIOR RHINOSCOPY

76. FLOOR
• ANY SECRETIONS
• CRUST-GREENISH CRUST IN ATROPHIC RHINITIS
COLOR OF NASAL MUCOSA
NORMAL –PINK
CONGESTED- RHINITIS
PALE OR BLUISH –ALLERGIC RHINITIS
..ANTERIOR RHINOSCOPY

77. ANTROCHOANAL VS ETHMOIDAL POLYP

78. • TECHNIQUE:
• PATIENT SITS FACING EXAMINER OPENS HIS MOUTH BREATHES QUIETLY FROM
MOUTH.
• EXAMINER DEPRESSES TONGUE WITH TONGUE DEPRESSOR AND INTRODUCES
POSTERIOR RHINOSCOPIC MIRROR WARMED AND TESTED ON BACK OF HAND.
• MIRROR IS HELD LIKE A PEN AND CARRIED BEHIND SOFT PALATE.WITHOUT TOUCHING
POSTERIOR THIRD OF TONGUE TO AVOID GAG REFLEX .
• LIGHT FROM HEAD MIRROR IS FOCUSED ON RHINOSCOPIC MIRROR WHICH FURTHER
ILLUMINATES PART TO BE EXAMINED.
..POSTERIOR RHINOSCOPY

79. ..POSTERIOR RHINOSCOPY

80. ..POSTERIOR RHINOSCOPY

81. POSTERIOR RHINOSCOPY-STRUCTURES VISUALISED
ROOF AND POSTERIOR WALL
-ADENOID HYPERTROPHY
ANTERIOR WALL
-POSTERIOR PART OF NASAL SEPTUM AND TURBINATES
CHOANAE
-ANY SECRETIONS
-ANY POLYP / MASS
LATERAL WALL
1. TORUS TUBARIS
2. FOSSA OF ROSENMULLER
3. EUSTACHIAN TUBE ORIFICE
4. MASS

82. EPISTAXIS
• IN A CASE OF EPISTAXIS IT IS IMPORTANT TO THOROUGHLY EXAMINE
THE NOSE.
• SUCH A NASAL EXAMINATION LOCATES THE SOURCE OF BLEEDING
• HELPS EXCLUDE SINISTER CAUSES SUCH AS BENIGN OR MALIGNANT
TUMOURS AND GRANULOMATOUS CONDITIONS.
• JUVENILE ANGIOFIBROMA OF THE POSTNASAL SPACE SHOULD BE
CONSIDERED IN CASES OF UNILATERAL EPISTAXIS IN THE
YOUNG/ADOLESCENT MALE POPULATION.

83. FUNCTIONAL EXAMINATION OF NOSE
(A)PATENCY OF NOSE
• COLD SPATULA TEST
• COTTON WOOL TEST
• COTTLE’S TEST
(B) SENSE OF SMELL

84. ..COLD SPATULA TEST/ VAPOUR
CONDENSATION TEST
EXPLAIN THE PROCEDURE TO THE PATIENT, THE PATIENT IS ASKED
TO SIT
ERECT 30CM AWAY FROM THE EXAMINER, THE NON-DOMINANT HAND
(LEFT HAND) OF THE EXAMINER SUPPORTING THE HEAD OF THE
PATIENT. THE
DOMINANT HAND (RIGHT HAND) USING LACK’S TONGUE DEPRESSOR
AND ITS
PLACED 2CM AWAY FROM THE ANTERIOR NARES OF THE PATIENT
NOSE AND ASK
THE PATIENT TO GENTLY BREATH OUT AND COMPARE THE FOGGING

85. • INFERENCE
EQUAL FOGGING ON BOTH SIDES –NORMAL
REDUCED FOGGING ON ONE SIDE-U/L NASAL OBSTRUCTION
REDUCED FOGGING ON BOTH SIDES- B/L NASAL OBSTRUCTION
..COLD SPATULA TEST

86. COTTON WOOL TEST
TAKING A WISP OF COTTON ON THE RIGHT HAND OF THE EXAMINER AND IS
PLACED 2CM AWAY FROM THE EXTERNAL NARE OF ONE SIDE, THE INDEX FINGER
OF THE EXAMINER LEFT HAND USED TO BLOCK THE OPPOSITE NARE AND ASK
THE PATIENT TO GENTLY BREATH OUT AFTER TAKING A DEEP BREATH. AND
OBSERVE THE VIBRATION OF THE COTTON WISP.
THE SAME PROCEDURE IS REPEATED ON THE OPPOSITE SIDE.
COMPARE THE VIBRATION OF COTTON WISK ON BOTH SIDES
INFERENCE
EQUAL MOVEMENT ON BOTH SIDES- NORMAL
REDUCED/ABSENT MOVEMENT ON ONE SIDE-U/L NASAL OBSTRUCTION
REDUCED MOVEMENT ON BOTH SIDES- B/L NASAL OBSTRUCTION

87. COTTLE’S TEST
• THE PATIENT’S CHEEK OF THE EXAMINING SIDE IS LIFTED
UPWARDS AND LATERALLY BY THE EXAMINER’S INDEX
FINGER OF ONE HAND, APPLYING TRACTION TO THE ALAR
CARTILAGE TO INCREASE THE INTERNAL NASAL VALVE
ANGLE.
• ASK THE PATIENT WHETHER THE NASAL OBSTRUCTION
HAS IMPROVED OR NO CHANGE
• AND THE SAME PROCEDURE IS REPEATED ON OPPOSITE
SIDE

88. COTTLE’S TEST POSITIVE-
• NASAL OBSTRUCTION IMPROVED-
• OBSTRUCTION IS AT THE LEVEL OF NASAL VALVE REGION
• EG:NASAL VALVE COLLAPSE , DNS IN THE NASAL VALVE AREA
• COTTLE’S TEST NEGATIVE-
• NO CHANGE
• OBSTRUCTION IS NOT IN THE VALVE REGION
..COTTLE’S TEST

89. SENSE OF SMELL

90. OLFACTORY TESTING
• THREE CRITERIA HAVE BEEN DESCRIBED AS NECESSARY TO MAXIMIZE ODOUR
RECOGNITION
IN OLFACTORY TESTING.
• 1. ODOURS MUST BE FAMILIAR TO THE PATIENT.
• 2. THERE SHOULD BE A LONG-STANDING ASSOCIATION BETWEEN THE ODOUR
AND ITS NAME.
• 3. HELP SHOULD BE GIVEN TO RECALL THE NAME.
• RELIABILITY IS IMPROVED BY USING BOTH THRESHOLD TESTING AND ODOUR
DISCRIMINATION ASSESSMENT.
• THRESHOLD TESTING IDENTIFIES THE CONCENTRATION AT WHICH AN ODORANT IS
RELIABLY PERCEIVED.

91. • A SIMPLE THRESHOLD TEST CAN BE PERFORMED USING
BUTANOL OR PHENYLETHYLALCOHOL, WHICH ARE USED
BECAUSE OF THEIR MINIMAL TRIGEMINAL STIMULATION EFFECTS.
• VARYING DILUTIONS OF THE OLFACTORY STIMULANT (4 PERCENT
BEING THE LOWEST DILUTION) ARE PRESENTED TO THE PATIENT
IN A RANDOM ORDER.
• PATIENTS HAVE TO MAKE A CHOICE BETWEEN THE ODORANT AND
TWO CONTROL SAMPLES AS TO WHICH THEY CAN SMELL, AND
THE LOWEST CONCENTRATION THAT CAN BE PERCEIVED IS
DOCUMENTED.

92. UPSIT
• UPSIT (UNIVERSITY OF PENNSYLVANIA SMELL IDENTIFICATION TEST)
SYSTEM IS COMMONLY USED
• THIS IS A FORCED CHOICE SUPRA-THRESHOLD TEST WITH 40
MICROENCAPSULATED ODOURS, ACTING AS A ‘SCRATCH-AND-SNIFF’
TEST.
• THE TEST INDICATES A LEVEL OF SMELL FUNCTION, I.E. MILD TO
TOTAL ANOSMIA
THE CROSS-CULTURAL SMELL IDENTIFICATION TEST (CCSIT)
• IS A SELF-ADMINISTERED 12-ITEM TEST BASED ON UPSIT THAT CAN

93. SNIFFIN'S TEST
• SNIFFIN’ STICKS ARE A TEST
OF OLFACTORY FUNCTION
BASED ON FELT-TIP PENS
• ASSESS ODOUR THRESHOLD,
DISCRIMINATION AND
IDENTIFICATION

94. EXAMINATION OF THE PARANASAL
SINUSES
• IT INCLUDES BOTH INSPECTION AND PALPATION OF
ANTERIOR GROUP OF PNS
• LOOK FOR ANY REDNESS,SWELLING,MASS,SINUS IN
THE AREA OF PNS.
• PALPATE EACH PARANASAL SINUS SEPARATELY IN
THE MOST
DEPENDENT AND THINNEST PART.
ethmoid

95. MAXILLARY SINUS: CANINE FOSSA
–BOUNDARIES
• LATERALLY –CANINE EMINENCE
• MEDIALLY –PYRIFORM APERTURE
• SUPERIORLY –INFRAORBITAL
FORAMEN
• INFERIORLY –ALVEOLAR RIDGE
FOSSA

96. ETHMOIDAL SINUS: PRESSING ON THE MEDIAL
WALL OF THE ORBIT OR LATERAL WALL OF THE
NOSE MEDIAL TO MEDIAL CANTHUS.
FRONTAL SINUS: MEDIAL ONE THIRD OF THE
FLOOR JUST INFERIOR TO THE MEDIAL 1/3 RD
OF
THE EYEBROW OR JUST ABOVE THE MEDIAL
CANTHUS.

97. EXAMINATION OF EAR AND THROAT
EXAMINATION OF EAR
• SEROUS OTITIS MEDIA-NASOPHARYNGEAL TUMOURS
• CSOM-CRS AS FOCUS OF INFECTION
EXAMINATION OF THROAT
• OROANTRAL FISTULA
• TUMOUR EXTENSION TO ORAL CAVITY OR OROPHARYNX
• CLEFT PALATE

98. TROTTER'S TRIAD
• IN NASOPHARYNGEAL CANCER
• TRIAD OF
1. SERROUS OTTITIS MEDIA
2. PALATAL PALSY
3. DEEP SEATED UNILATERAL HEADACHE(TRIGEMINAL NERVE)

99. EXAMINATION OF NECK
• NECK EXAMINATION
• LYMPH NODES
-ANTERIOR NOSE DRAINS TO
SUBMANDIBULAR REGION
-POSTERIOR DRAINS TO MIDDLE
DEEP CERVICAL
 TRACHEOSTOMY
 THYROID SWELLING

100. CRANIAL NERVE EXAMINATION
CAVERNOUS SINUS THROMBOSIS
• AS COMPLICATION OF RHINOSINUSITIS
• 3,4,5,6 CRANIAL NERVE INVOLVEMENT
NASOPHARYNGEAL CANCER
• VAGUS AND TRIGEMINAL NERVE
OPTIC NERVE
• ORBITAL COMPLICATION OF RHINOSINUSITS
• INVASIVE FUNGAL SINUSITS

101. EXAMINATION OF A PATIENT WITH NOSE TRAUMA
Examination (with clear documentation)
●Condition of skin
● External deformity
● Bony alignment
● Septal and cartilage alignment
● Palpable fractures of the nose
● Integrity of orbital rim
● Internal
• Septal alignment
• Septal haematoma?
● Nasal function/air entry
● Eye movements
● Infraorbital nerve sensation

102. ORBITAL FLOOR FRACTURE-SIGNS
●Enophthalmos
● Subtarsal hollowing
● Infraorbital nerve paresthesia
● Palpable step in orbital rim
● Restricted vertical movement of the eye
● Subconjunctival haemorrhage
● Diplopia
● Periorbital ecchymosis
● Surgical emphysema around orbit on nose blowing

103. ORBITAL COMPLICATIONS OF
RHINOSINUSITIS
PRESEPTAL CELLULITIS
• PRESENTS WITH UNILATERAL
SWELLING OF THE EYELIDS,
ERYTHEMA, LOCAL PAIN
• AND SOMETIMES PYREXIA
• THERE SHOULD BE NO PROPTOSIS
AND NO LIMITATION OF EYE
MOVEMENT.

104. ORBITAL CELLULITIS
• CONJUNCTIVAL OEDEMA (CHEMOSIS),
• LIMITATION OF EYE MOVEMENT
(OPHTHALMOPLEGIA),
• PAINFUL EYE MOVEMENTS
• PROPTOSIS
• PUPILLARY REACTION, VISUAL ACUITY AND
COLOUR VISION IS MONITORED
• COLOUR VISION AS ASSESSED BY AN ISHIHARA
CHART IS TYPICALLY IMPAIRED FIRST, AFFECTING
PARTICULARLY RED COLOUR PERCEPTION,

105. POTT'S PUFFY TUMOUR
• FRONTAL OSTEOMYELITIS
• POTT’S PUFFY TUMOUR
• THE FRONTAL BONE THAT FORMS THE ANTERIOR
WALL OF THE FRONTAL SINUS BECOMES
OSTEOMYELITIC:
• BONE NECROSIS LEADS TO A SUBPERIOSTEAL
ABSCESS
• PRESENTS AS FLUCTUANT TENDER LUMP OF THE
FOREHEAD.
• THIS MAY BURST AND LEAD TO A FRONTO-
CUTANEOUS FISTULA.