Nose Station Approach

– History –

  • CC: most likely will present as nasal obstruction:
    • Site: uni\bi-lateral? Alternates?
    • Onset: first time? When? Gradual\sudden? Continuous\intermittent? Getting better\worse?
    • Duration: how long does each episode last?
    • Timing: specific time year\season? How frequent?
    • Relieving\aggravating factors: posture? Temperature? Activity? Cigarette smoking\pets?
    • Severity: Interfering w\ ADL? Affecting your sleep (sleep apnea)?
  • Associated sx:
    • Constitutional: fever, fatigue, wt loss, loss of appetite, night sweats, chills?
    • Ear: ear pain, discharge, tinnitus, ringing, popping sensation?
    • Inner ear: vertigo, dizziness, balance problems, N\V?
    • Eye: eye pain, blurred\double vision, lacrimation?
    • Nose: obstruction\breathing difficulty, stuffed nose, snoring, epistaxis, discharge, loss of smell?
      • If presenting w\ epistaxis: Amount? Color? Clots? bleeding from other sites\easy bruising? How does it usually stop?
    • Sinusitis: headache, facial pain\numbness, pressure, recent flu\ear infection?
    • Throat: difficulty swallowing, speech problems, loss of taste?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM, DLP)
      • Atopy (asthma, eczema)
      • URTI
      • Bleeding disorders
    • Medications: anticoagulants, steroids, intranasal sprays (decongestants)
    • Surgery, hospitalization, trauma
    • Blood transfusions, IV drug use, tattoos
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Travel Hx
    • Diet, exercise

 


– Nose Physical Exam –

  • WIPE, blah blah 🙂
  • “Take vital signs”
  • Proper position and exposure of the nose
  • General inspection of the pt and surroundings
  • Mention that you should do a full head and neck exam, but for now, you’ll focus on the ears

1. External Inspection:

  • Symmetry, alignment
  • Septal deviation, deformities (bony or cartilaginous)
  • Prior trauma, scars
  • Swellings, discharge

2. Palpation:

  • Swellings
  • Tenderness
  • Temperature

3. Anterior Rhinoscopy:

  • Tell the pt that they might feel some discomfort, but they should let you know if the feel any pain!
  • Using a nasal speculum + light (headlight, torch, or the otoscope)
  • Pt’s head in normal position -> elevate the nasal tip w\ your thumb
  • Comment on:
    • Mucosa
    • Discharge, blood
    • Septum
    • Turbinate
    • Polyps
    • Foreign bodies
    • “Normal pink mucosa, no discharge or blood, the septum is in a satisfactory position not deviated, turbinate is not hypertrophied, no nasal polyps, and no foreign bodies”

4. To complete:

  • Full exam of: head and neck, ENT, eyes, CN, and LN

 


– Differential Diagnosis –

  • Deviated septum
  • Rhinitis (allergic, perennial, vasomotor)
  • Chronic sinusitis w\ or w\ polyps
  • Acute sinusitis
  • Foreign bodies
  • Malignancy (nasopharyngeal ca, SCC, adenocarcinoma)
  • Trauma, septal hematoma, abscess

 

– Investigations –

  • Nasal endoscopy, fiberoptic
  • Imaging: paranasal sinuses CT, MRI

 

– Management –

  • Conservative -> medical -> surgical
  • Sinusitis: saline irrigation, intranasal steroid spray -> systemic steroids, abx -> FESS

 


Download the PDF version: here

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