Introduce yourself, confirm the patient's name and date of birth, obtain consent and proceed to wash hands.
Ask the patient to sit on a reclining chair or the end of the bed, at an angle roughly 60° from the floor. Check if they are in any pain or discomfort and offer analgesia if necessary.
Equipment
Collect the following equipment:
Head torch: If you are unable to obtain one of these, an otoscope or a pen torch is a suitable alternative. The advantage of a head torch is that you are able to manoeuvre your light source to your liking whilst keeping your hands free to examine.
Nasal speculum or rhinoscope.
Clinical waste bin.
Inspection
General inspection
Skin changes
Start by facing the patient and observing for any sequelae of dermatological disease, such as:
Black/white comedo (pimples): Comedo are found in acne vulgaris.
Yellow brown crusty lesions: These are found in actinic keratosis, usually on the scalp, nose or ear.
“Rodent” ulcer with a pearly, rolled telangiectatic edge: These are characteristic of a basal cell carcinoma.
Hyperpigmented nodules with hard, raised (everted) edges, usually with a central, deep, ulcerated base: This describes the typical appearance of a squamous cell carcinoma; however, the appearance can be variable.
A dome-shaped, symmetrical lesion surrounded by a smooth wall of inflamed skin: This suggests the presence of a keratoacanthoma, a low-grade skin tumour arising at sun-damaged areas.
Itchy, erythematous and scaly patches at the nasolabial folds: These patches are be seen in seborrheic dermatitis.
Acne vulgaris is a follicular disease in which there is blockage and inflammation of the pilosebaceous unit of the skin leading to blocked hair follicles (comedo). Early on in comedo formation, there is a combination of hyperkeratosis (excessive keratin deposition) by skin cells and overproduction of sebum, causing oily dead skin cells to clump and form a plug (a microcomedone). Bacteria such as Cutibacterium acnes and Propionobacterium acnes cause inflammation and comedo swelling forming the characteristic “pimple.”
Black comedo are those in which the comedo is open and =exposed to air; oxidation of melanin turns it black. White comedo are closed by the skin such that both pus and debris get trapped inside.
Observe the position of the nasal bones and septum. These are usually central, but mild longstanding septal deviation is not abnormal. Trauma can often lead to a fracture of the nasal bones causing them to deviate in one direction whilst the septum will point towards the other.
Epistaxis with broken nasal bones and a deviated septum.
The external nose is made up of two parts, the nasal ridge and the ala (wings). The nasal ridge is superiorly formed by two nasal bones either side of the midline, and just lateral to these, the fontal processes of the maxillary bones. Inferior to the nasal bones, the cartilages septum extends two lateral processes to form the anterior “flappy” part of the nose.
The most inferolateral parts of the nose are known as the ala. Each ala is made up of the major alar and four minor alar cartilages.
Nasal cavities
Ask the patient to tilt their head backward slightly. Collect your torch and nasal speculum. Choose one nasal vestibule (nostril) and part the ala (“wing” – the lateral, fleshy part of the nose), separating it in an anterior-posterior direction.
Inspect the interior of the cavity for any mucus or blood, the latter of which may be residual following epistaxis. If present, gently clear this using cotton wool soaked with saline. Identify the bony turbinates and look for any signs of inflammation which will be present in rhinitis. Check the lateral wall for any polyps. These may be benign papillomas, or in rare cases, could be due to a nasopharyngeal carcinoma.
As with any examination, if there are any signs or symptoms on one side, start with examination of the contralateral nasal cavity first.
Septum
Observe the septum for any haematomas. These can occur following trauma or surgery and are very important to identify; if left, they can lead to avascular necrosis of the septal cartilage. Look for any perforation which may suggest cocaine abuse.
Repeat the above process with contralateral nasal cavity.
Stand behind the patient and warn them that you are about to palpate their nose. Ask them to inform you about any pain. Palpate the nasal bones using your index and middle fingers of each hand assessing for any deviation or tenderness, both of which may follow trauma.
Next, palpate the nasal cartilages and septum, once again for position and tenderness.
Airflow
Ask the patient to apply light external pressure on their nasal vestibule using their thumb and inhale through their nose. Repeat this on the other side to note any difference in airflow, which may be present due to obstruction (polyp, turbinate inflammation, septal haematoma) or deformity (trauma and fracture of the nasal bones).
Completion
Complete the examination by thanking the patient, disposing of equipment and washing your hands. If appropriate, offer to examine the ears, throat, neck and cranial nerves. Further investigations would warrant referral to either the accident and emergency department or an ears, nose and throat specialist.
Present/document your findings.
Interactive markscheme
When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end. We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:
Introduction: "Hello, I'm SimpleOSCE and I am a medical student. I've been asked to examine your nose today. Can I confirm your name and DOB? Thank you."
Explain examination and obtain consent: “This will involve me using a torch to look inside your nose and I will be feeling for any changes.”
Wash your hands.
Check if the patient is in pain or discomfort.
Assemble the correct equipment including a torch and a nasal speculum.
Inspect for any obvious skin changes.
Observe the position of the nasal bones and septum for any deviation which may be due to trauma.
Correctly use the speculum to part the ala in an anterior-posterior direction to visualise the inside of one of the nasal cavities.
Look for any mucus, blood, signs of inflammation or polyps.
Observe the septum for any haematomas or perforation. Closely inspect Little’s area for any vessels or points of bleeding.
Repeat steps 8-10 on the contralateral side.
Stand behind the patient to palpate.
Palpate the nasal bones and cartilages for deviation and tenderness.
