DR MANPREET SINGH NANDA PROFESSOR ENT

2.  Mental state
 Consciousness
 Built and nutrition
 Attitude and Gait
 Facies
 Pallor – palmar creases, mm lips cheeks, conjuctiva,
nail beds
 Cyanosis – tongue (central), nail bed , tip of nose,
palmar skin
 Jaundice – sclera, nail bed , ear lobule, tip of nose
 Skin eruptions – macules ( change in skin colour),
papules , vesicles, pustules (solid projections)
 Neck nodes

3.  Pulse – pulse rate, rhythm (regular, irregular)
 Respiratory rate – fast, slow
 Temperature – continous ( fluctuates less
than 1 deg), remittent ( fluctuates more than
2 deg), intermittent
 Blood Pressure

4.  External Nose
 Nares and Columella
 Vestibule
 Anterior Rhinoscopy
 Posterior Rhinoscopy
 PNS

5.  INSPECTION
 External deformity – deviation, crooked
/saddle /hump
 Scar/sinus
 Skin colour change – rash
 Widening of nasal bridge – polyps
 Swellings – cysts, rhinophyma, tumours

6.  PALPATION
 Superficial and deep (pressure applied)
 With thumb and index finger
 Temperature
 Fixity of skin/mobility
 Tenderness
 Bony framework/shape change
 Crepitus - #

7.  Symmetry
 Caudal dislocation
 FACE
 Dark circles around eyes – allergy
 Vestibule – lifting tip of nose (Not on
rhinoscopy)
 Erythema
 Ulcer
 Perforation
 Crusting
 Furuncle

9.  Vienna/Thudicum/Killians Nasal Speculum
 Topical decogestants/ Xylocaine
 Left hand
 Widen the vestibule/ Never touch septum
 Otoscope (children)
 Speculum close introducing/partial open removal
 Inferior turbinate- ant end/middle turbinate -
hyp
 Inf/middle meatus – discharge/polyp
 Nasal septum – spur/deviation
 Floor of nasl cavity

10.  Size of nasal speculum – age/ nose size
 Colour of nasal mucosa – normal pink,
common cold, rhinitis medicamentosa –
generalised congested, acute sinusitis –
localised congestion, allergic – pale, atrophic
– dry with crust
 Secretions
 Sup turbinate – extension
 Cant – post end of turbinates and septum,
roof

11.  PROBE TEST
 Blunt probe
 To examine nasal mass
 Consistency
 Mobility or fixed
 Sensation to touch
 Bleed on touch
 Origin/attachment – pass probe all around

13.  Post rhinoscopy mirror
 Warm on mirror side
 Breathe through nose – relax soft palate
 Tongue depressor
 Don’t touch oropharynx – gag reflex
 Choana/ post end of septum and turbinates
 E.T orifices/ fossa of rosenmuller/ adenoids
 Look for polyp/ mass/ epistaxis/ pus

15.  INSPECTION
 Look for swelling over PNS
 Skin changes
 Orbit – lid oedema, conjuctival congestion,
proptosis
 PALPATION
 Palpate both sides simultaneous for compare
 Use index finger and thumb
 Look at facial expression while palpating

16.  Maxillary – canine fossa/ ant wall of cheek
lateral to nose
 Frontal – floor of frontal above medial
canthus / ant wall
 Ethmoidal – medial wall of orbit just behind
root of nose
 Tenderness in acute sinusitis

17.  TRANSILLUMINATION TEST
 Rarely done
 Dark room
 Maxillary – bright light applied on hard palate
with lips closed – crescentric glow observed
B/L in region of eye lids and over maxillary
sinus
 Frontal – light applied at floor of frontal
sinus – light glow observed on ant wall –
result compared with other side
 Absent/poor glow – pus/mass/thickening of
mucosa

18.  POSTURAL TEST
 Rarely done
 Middle meatus is observed for appearance of
discharge in various head positions
 Maxillary – head bent such that affected
sinus upright position
 Frontal – pus appears immediately with head
forwards chin down
 Ethmoidal – pus appears in 10-15 min in same
position

19.  COLD SPATULA TEST
 Tongue depressor cold – in front of ant nares
– fogging – compared for nasal obstruction
 COTTON WOOL TEST
 Fluff of cotton held against each nostril and
movement seen
 COTTLE TEST
 Elevation of naso labial fold relieves nasal
obstruction in case nasal valve involved
 EXAMINATION OF LYMPH NODES – level II/RP

20.  DIAGNOSTIC NASAL ENDOSCOPY
 Excellent magnification/ good light/ detailed
examination
 Rigid using angled nasal endoscopes
(0,30,45,70,90)/ Flexible
 Anaesthesia – Lignocaine
 1st pass – inf meatus, NLD, nasopharynx
 2nd pass – sup meatus, 3rd pass – middle
meatus
 Biopsy
 Cauterisation of bleeder

21.  NASOPHARYNGEAL EXAM UNDER GA
 Rose position
 Boyle’s davis mouth gag and rubber catheter
in each nostril
 Digitally palpate
 With angled mirror
 Rarely done

22.  TESTS FOR SMELL
 Time consuming and cumbersome
 Patient to close eyes
 Lemon/coffee powder/rose/garlic
 Ammonia – irritates V CN –
psychogenic/hysterical
 For both nostrils separate
 Avoid spirit – irritant
 Electro Olfacto Gram (EOG) using electrodes
 UPSIT – University of Pennsylvania Smell
Identification Test – cumbersome/not practical

23.  TESTS FOR ALLERGY
 Nasal smear under microscope – eosinophilia
 In Vivo tests
 Allergic skin tests –
 Subcuticular/prick/scratch test – most
accurate/quick/practical/easy/safe
 Emergency kit should be available
 Dust mite/pollen/grass/cat and dog hair
 Control – positive is histamine, saline – negative
 Intradermal test
 Nasal challenge test – allergen introduced to
nose – reaction - cumbersome

24.  In Vitro tests (serological tests)
 Using patient’s blood sample
 RAST – Radio allergen sorbent test
 PRIST – Paper radio immuno sorbent test
 RIST – Radio immuno sorbent test
 Here specific Serum Ig E is measured
 Specific tests
 Costly

25.  RHINOMANOMETRY
 Done by calculating nasal resistance to
airflow
 Resistance of nasal airway and nasal flow
pressure at external nares is measured
 Types
 Active – generation of nasal airflow and nasal
pressure with normal breathing
 Passive – generation from external source –
fan, pump

26.  BLOOD INVESTIGATIONS
 LFT – if nasal bleed
 Bacterial culture – little value as normal nose
has bacteria
 Complete haemogram
 Complete urine
 PHOTOGRAPHY – for rhinoplasty

27.  PLAIN X RAY
 Water’s view – occipito mental view with mouth
open – tip of nose and chin touch the plate – for
maxillary, frontal, sphenoid sinus
 Not for ethmoids as two superimpose
 Best for maxillary
 Caldwell’s view – occipito frontal view – tip of
nose and forehead touch the film – for frontal
sinus, nasal cavity, orbit
 Best for frontal
 Lateral view – for ethmoid, sphenoid and
adenoids
 Best for ethmoid and adenoids

30.  Base skull view/sub mento vertical view –
sphenoid, ethmoid
 Best for sphenoid
 Normally air filled sinus – translucent/same as
orbit
 Radio opaque – if opacity greater than orbit
 Totally opaque – large cyst/polyp
 Wall destruction – malignancy
 Partially opaque – AC polyp, cyst
 Pus with air fluid level – acute sinusitis
 Mucosal thickening – chronic sinusitis
 Expansion of sinus/ haziness/ cloudiness

31.  X Ray Nasal bones lateral view - #
 X Ray Nasopharynx lateral view – adenoids
 CT SCAN
 Coronal section – best
 Extent of disease/OMC/ cribriform plate/ lamina
papyracea/ optic nerve/ carotid artery
 Bony destruction
 MRI
 Tumour extension into cranial cavity/ orbit/
congenital malformations/ glioma/
encephalocele

32.  Nasal discharge – minimal – normal in first
few days of life
 B/L choanal atresia – life threatening
 Diagnosis – by passing blunted small rubber
or plastic catheter through nose and taken
out from oral cavity
 Contrast X Ray under GA
 Otoscope