– 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?
- Chronic ds (HTN, DM, DLP)
- Atopy (asthma, eczema)
- Bleeding disorders
- Medications: anticoagulants, steroids, intranasal sprays (decongestants)
- Surgery, hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- 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
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:
- Discharge, blood
- 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