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During any examination in an OSCE it is important to understand the pathology and reasoning behind each of the signs and symptoms elicited, even if the patient being examined is ‘normal’. This article explains how to perform a nasal examination and the key findings you should look for, showing you what each sign means and what conditions it may indicate.
Contents
Introduction
Wash your hands and don personal protective equipment if appropriate.
Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.
Confirm the patient’s details taking 3 points of identification; usually full name, date of birth and NHS/hospital number.
Briefly explain the examination in patient-friendly language and obtain consent, making clear that you will be looking inside the nose using a light and that this should not be painful.
Position the patient sitting upright on a chair, at roughly the same height as you so that you can comfortably look into both nostrils.
Ask the patient whether they have any pain, particularly around the nose or face, before you begin, as this examination involves palpation.
Gather your equipment: a good light source (pen torch, head torch or otoscope), a nasal speculum (Thudichum’s speculum) where available, and tissues. An otoscope fitted with a large speculum is a perfectly acceptable alternative for illuminating and magnifying the nasal cavity in most OSCEs.
General Inspection
Begin by standing back and observing the patient and their immediate surroundings, as the general appearance often gives clues before you touch the nose.
Look at the patient’s breathing and listen for mouth breathing or audible nasal obstruction, which may suggest significant blockage of the nasal airway from a deviated septum, polyps or chronic rhinosinusitis.
Note any nasal voice (rhinolalia), where speech sounds ‘blocked’, again pointing towards obstruction or nasal congestion.
Observe for an audible sniff, frequent use of tissues, or a visible nasal discharge, which may indicate rhinitis or infection.
Look around the bedside for relevant objects such as nasal sprays (steroid or decongestant), tissues, or a nasal splint/dressing following recent trauma or surgery.
Note any obvious facial swelling, skin changes or signs that the patient is systemically unwell, as facial pain with fever may suggest acute sinusitis.
Finally, glance at the eyes and periorbital region. Periorbital swelling, redness or restricted eye movements in a patient with sinus symptoms is a red flag for orbital cellulitis, a serious complication of ethmoid sinusitis that requires urgent treatment.
Inspection of the External Nose
Inspect the external nose systematically from the front, the side, and above and behind the patient. The different views help assess the bony and cartilaginous framework. With the patient’s head tilted slightly back, a view from above and behind lets you look down the line of the nose for lateral deviation. Use this as a supplementary view alongside frontal and side inspection.
Assess the overall shape and symmetry of the nose. A deviation of the bony or cartilaginous framework may follow previous trauma or fracture and can be associated with a deviated septum and nasal obstruction.
Look specifically for a saddle-nose deformity, in which the bridge of the nose is collapsed and depressed. This results from loss of support from the nasal septum and can be caused by a septal haematoma or abscess (which destroys the underlying cartilage), previous trauma or surgery, cocaine use, or systemic disease such as granulomatosis with polyangiitis (GPA) or, historically, syphilis.
Inspect the skin of the nose for lesions such as basal cell carcinoma (a common site for skin cancer due to sun exposure), and for rhinophyma — a bulbous, thickened nasal tip seen in advanced rosacea due to sebaceous gland hypertrophy.
Look for signs of recent trauma such as bruising, swelling or laceration, and for the ‘nasal crease’ (a transverse line across the lower nose), which suggests habitual rubbing from allergic rhinitis (the ‘allergic salute’).
Inspect the columella (the strip of tissue between the nostrils) and the nostrils themselves for symmetry. A widened, flattened bridge with broadening of the nose can be a further sign of underlying septal or cartilage loss, while excoriation of the nasal openings supports chronic discharge or recurrent epistaxis.
Watch the nasal alae (the soft outer walls of the nostrils) as the patient breathes in. If the alae are drawn inwards on inspiration, this indicates alar (nasal valve) collapse, a cause of obstruction that worsens with deeper breathing and is confirmed by Cottle’s test.
Palpation of the External Nose
Before palpating, check again that the patient is not in pain, as a recently injured nose can be very tender.
Using your fingers, gently palpate the nasal bones and cartilages, starting at the bony bridge and working down to the tip.
Assess for tenderness, steps or depressions in the contour, abnormal mobility, and crepitus (a crackling sensation). These findings suggest a nasal bone fracture, which is the most commonly fractured bone in the face.
Gently press over the frontal sinuses (just above the medial eyebrows) and the maxillary sinuses (over the cheeks, below the orbits) to check for tenderness. The paranasal sinuses are air-filled spaces that drain into the nasal cavity; when their drainage is obstructed by mucosal swelling, secretions accumulate and become infected. Sinus tenderness, particularly in the context of facial pain that is worse on leaning forward, purulent discharge and fever, therefore supports a diagnosis of acute sinusitis.
Quiz
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