Approach To ENT Nose & Sinus History Taking

General Principles

History must be structured, symptom-directed, and anatomically correlated.
Each symptom should be explored with:
- Duration
- Mode of onset
- Progression
- Aggravating/relieving factors
- Laterality
- Associated symptoms
ENT history often reveals the diagnosis before examination.

Chief Nasal Symptoms

These are the five pillars of nasal history-taking:

Nasal Obstruction
Nasal Discharge
Epistaxis
Smell Disturbances
Facial Pain / Headache

Each one indicates different anatomical and pathological processes.

1. Nasal Obstruction

Key Questions

Unilateral or bilateral?
Intermittent or continuous?
Alternating (suggests nasal cycle exaggeration)?
Sudden or gradual?
Associated with position (lying down, side-lying)?
Worse during certain seasons (allergic rhinitis)?
Triggered by cold air, perfumes (vasomotor rhinitis)?
Does obstruction change with decongestants?

Differential Clues

Unilateral obstruction → DNS, foreign body (children), choanal atresia, polyp, tumor.
Bilateral obstruction → allergic rhinitis, viral infections, turbinate hypertrophy, massive polyposis.
Intermittent obstruction → hypertrophied turbinates or deviated septum + nasal cycle.
Progressive obstruction → polyps, tumors.

Associated Symptoms To Ask

Mouth breathing
Snoring
Sleep disturbance
Hyponasal speech

2. Nasal Discharge (Rhinorrhea)

Always ask:

Nature

Watery
Mucoid
Purulent
Bloody
Foul-smelling
Unilateral vs bilateral

Diagnostic Clues

Watery → allergy, viral infection, CSF rhinorrhea (especially unilateral, positional).
Mucoid → allergic or chronic inflammatory.
Purulent → bacterial sinusitis.
Foul-smelling unilateral discharge → foreign body, rhinolith.
Blood-stained mucus → tumors, trauma, granulomatous disease.

Postnasal Drip

Ask about:

Frequent throat clearing
Morning cough
Sleeping with 2 pillows
Bad taste on waking

These strongly suggest sinus involvement (especially maxillary and ethmoidal).

3. Epistaxis (Nosebleed)

Important History Points

Side of onset
Frequency
Duration
Volume
Trigger (heat, trauma, sneezing)
Hypertension history
Anticoagulant use
Bleeding disorders

Age-related Clues

Children → Little’s area bleeding (trauma, nose picking).
Elderly → posterior epistaxis (Woodruff’s plexus).

Associated Symptoms

Nasal obstruction
Facial pain
Systemic symptoms → anemia, clotting disorder

4. Smell Disturbances

Includes:

Anosmia
Hyposmia
Parosmia
Phantosmia

Key Questions

Onset after viral infection (e.g., COVID-19)?
After head trauma?
Associated with polyps or allergies?
Progressive loss (suggests tumor compressing olfactory groove)?

5. Facial Pain And Headache

Location-Based Interpretation

Frontal headache → frontal sinus disease.
Cheek heaviness → maxillary sinusitis.
Pain between eyes → ethmoid disease.
Deep, retro-orbital pain → sphenoid sinusitis.

Important Features To Ask

Worse on bending forward?
Morning heaviness?
Pain with eye movement?
Intermittent vs continuous?

Additional Symptoms To Explore

Sneezing

Paroxysmal → allergies.

Itching

Suggestive of allergic rhinitis.

Nasal Voice / Speech Change

Hyponasal speech → obstruction.
Hypernasality → palatal defect.

Snoring & Sleep Disturbance

Turbinate hypertrophy
Nasal blockage
Adenoid hypertrophy (children)

Systemic Symptoms

Fever → acute sinusitis
Weight loss → tumor
Diplopia → orbital complications

Past Medical & ENT-Specific History

Allergic history
Asthma (atopy link)
Migraines
Previous nasal trauma
Nasal surgeries (septoplasty, turbinectomy, FESS)
Immunocompromised states → fungal sinusitis risk

Drug History

Antihistamine use
Steroid sprays
Decongestant overuse (rhinitis medicamentosa)
Anticoagulants

Family History

Atopy
Nasal polyps
Cystic fibrosis (children with chronic sinusitis)

Occupational History

Exposure to fumes, dust, chemicals
Bakers → occupational rhinitis
Woodworkers → nasal adenocarcinoma (hardwood dust)

Red Flag Symptoms (“Alarm Features” To Ask)

Unilateral persistent obstruction
Unilateral blood-stained discharge
Foul-smelling unilateral discharge
Diplopia
Facial numbness
Recurrent epistaxis
Proptosis
Severe headache not responding to medication
Nasal deformity
Weight loss

These suggest aggressive sinusitis, fungal disease, or neoplasm.

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

Examination Of The Nose And Paranasal Sinuses

(Starts Here — Full Detailed Clinical Method)

General Principles

Ensure good lighting.
Examine the nose both externally and internally.
Examine sinuses by inspection, palpation, and transillumination.
Use:
- Head mirror or headlight
- Nasal speculum
- Thudicum speculum
- Otoscope (if speculum unavailable)

1. Inspection Of External Nose

Look For

Shape
Symmetry
Deformities
Saddle nose (septal necrosis)
Deviations
Scar marks (previous surgery or trauma)
Skin changes
- Erythema
- Ulceration (basal cell carcinoma)
- Crusting (vestibulitis)

Look During Respiration

Flaring of alae (respiratory distress)
Valve collapse during inspiration (external valve collapse)

2. Palpation Of External Nose

Gently palpate nasal bones → tenderness suggests fracture
Check for step deformity
Palpate upper lateral cartilages → mobility
Palpate tip → structural support assessment

3. Assessment Of Patency (Nasal Airflow)

Cold Mirror Test

Place mirror under nostrils
Observe condensation
Asymmetry suggests obstruction

Cotton Wisp Test

Movement indicates airflow quality

Alternate Nostril Occlusion

Patient breathes through one nostril at a time
Helps identify unilateral obstruction

Cottle’s Maneuver

Lateral retraction of cheek improves airflow → suggests nasal valve collapse

4. Internal Inspection (Anterior Rhinoscopy)

Equipment

Head mirror / headlight
Nasal speculum (Thudicum)

Technique

Seat patient at eye level
Hold speculum with the left hand for both nostrils to avoid injuring the patient
Open blades vertically (never laterally)

Structures To Observe

Vestibule → hair follicles, furuncles
Septum → deviation, spur, perforation, crusting
Inferior turbinate → hypertrophy, pallor (allergy), congestion
Middle turbinate → polyps, concha bullosa
Meatuses → discharge
Polyps → glistening, pale, insensitive
Foreign bodies

Discharge Evaluation

Color
Quantity
Origin site

5. Posterior Rhinoscopy

Not easy in uncooperative patients, but essential for nasopharyngeal assessment.

Structures Visualized

Posterior border of septum
Choanae
Nasopharynx
Adenoids (children)
Posterior end of turbinates
Postnasal drip

Clinical Uses

Adenoid hypertrophy diagnosis
Nasopharyngeal carcinoma suspicion
Polyps extending posteriorly

6. Examination Of Paranasal Sinuses

Inspection

Look for:

Swelling around orbit
Edema
Erythema
Tenderness
Facial asymmetry

Palpation

Frontal Sinus

Palpate above eyebrows → tenderness in frontal sinusitis.

Maxillary Sinus

Palpate over cheeks
Tap with finger for percussion tenderness

Ethmoid Sinus

Medial orbital tenderness → ethmoiditis

Sphenoid Sinus

Cannot be palpated externally → relies on symptoms (deep headache)

Transillumination Test

Although less used clinically due to CT availability, still tested in exams.

Frontal Sinus

Darkened room
Light placed under eyebrow
Observe glow above orbit

Maxillary Sinus

Light placed in mouth against palate
Observe infraorbital region for illumination

Dullness suggests sinus opacity.

7. Cranial Nerve Examination (Related To Nose & Sinuses)

CN I → olfaction testing
CN II → visual acuity if orbital complications suspected
CN III, IV, VI → eye movement (ethmoid infection → orbital cellulitis)
CN V1/V2 → sensation loss in tumors or invasive fungal sinusitis

8. Diagnostic Nasal Endoscopy (Rigid/Flexible Endoscopy)

A core ENT skill that provides magnified visualization of the nasal cavity, turbinates, septum, meatuses, osteomeatal complex, nasopharynx, and sinus drainage pathways.

Indications

Chronic rhinosinusitis
Recurrent sinus infections
Nasal polyps
Epistaxis source identification
CSF rhinorrhea localization
Tumor evaluation
Fungal sinusitis
Foreign body diagnosis
Pre-operative mapping for FESS
Post-operative monitoring (synechiae, crusting)

Types of Endoscopes

Rigid Endoscopes

0°, 30°, and 70° Hopkins rod-lens systems
High-definition visualization
Used in adults and cooperative older children

Flexible Nasopharyngoscope

Used when rigid scope is difficult
Ideal for children, gagging or anxious patients
Allows assessment of dynamic airway and soft tissue lesions

Preparation

Explain procedure to patient
Use topical decongestant (xylometazoline)
Apply topical anesthetic (lignocaine spray)
Patient seated, head slightly forward
Ensure proper suction devices ready

Systematic Endoscopic Examination Sequence

Step 1: Nasal Vestibule

Crusting
Vestibulitis
Folliculitis
External valve collapse
Synechiae
Skin lesions (BCC, SCC)

Step 2: Inferior Meatus

Check for nasolacrimal duct abnormalities
Evaluate inferior turbinate hypertrophy
Look for impacted foreign bodies

Step 3: Middle Meatus (Most Important Area)

The middle meatus reveals most sinus pathologies because it houses the osteomeatal complex (OMC).

Look for:

Edema
Purulent discharge
Polypoid changes
Fungal debris
Anatomical variants:
- Concha bullosa
- Paradoxical turbinate
- Septal spur touching turbinate (contact point headache)
- Agger nasi cells
- Haller cells

Step 4: Sphenoethmoidal Recess

Essential when evaluating sphenoid sinus disease
May show mucopus in sphenoidal sinusitis
Polyps may extend posteriorly

Step 5: Nasopharynx

Adenoid hypertrophy
Fossa of Rosenmüller masses (NPC suspicion)
Tubal openings
Post-nasal drip pooling

Endoscopic Findings and Their Clinical Meaning

Purulent discharge from middle meatus

→ Maxillary, anterior ethmoid, or frontal sinusitis.

Purulent discharge from sphenoethmoidal recess

→ Sphenoid sinusitis.

Polyps

Multiple bilateral polyps → chronic sinusitis / allergy.
Unilateral antrochoanal polyp → arises from maxillary sinus.
Fungal polyps → yellowish-brown “allergic mucin”.

Crusting

Atrophic rhinitis
Post-operative cavities
Wegener granulomatosis (now GPA)

Bleeding point identification

After suction, small telangiectatic vessels may be visible
Important for recurrent epistaxis

Septal deviations & spurs

Critical when planning septoplasty
Spurs contacting turbinates → pain, headache

9. Radiological Examination of Nose and Sinuses

CT Scan (Gold Standard)

Provides detailed visualization of bone and air spaces.

Indications

Chronic sinusitis
Recurrent sinusitis
Surgical planning (FESS)
Suspected complications:
- Orbital
- Intracranial
- Osteomyelitis

CT Findings

Mucosal thickening
Air-fluid levels
Osteomeatal complex blockage
Polyps
Fungal infection:
- Hyperdense areas (calcification)
- Heterogeneous opacities
Deviated septum
Concha bullosa
Onodi cells near optic nerve
Haller cells narrowing infundibulum

MRI

Used for:

Tumors
CSF leak
Soft tissue evaluation
Differentiating fungal sinusitis
Intracranial extension

X-Ray (Rarely Used Now But Asked In Exams)

Views:

Water’s view (maxillary sinuses)
Caldwell view (frontal/ethmoid)
Lateral view (nasopharynx, adenoids)

10. Special Investigations

Smell Testing (Olfactory Assessment)

Bedside Testing

Coffee
Vanilla
Orange peel
Peppermint

Formal Testing

UPSIT (University of Pennsylvania Smell Identification Test)
Sniffin’ Sticks test

Interpretation

Conductive anosmia:
- Polyps
- DNS
- Rhinitis
Sensorineural anosmia:
- Viral infections
- Head trauma
- Neurodegenerative diseases

Ciliary Function Tests

Useful in:

Primary ciliary dyskinesia
Chronic sinusitis refractory to treatment

Tests Include

Nasal nitric oxide measurement
Saccharin test
Electron microscopy of cilia

Microbiological Tests

Nasal swab cultures
Fungal cultures
KOH prep for fungal elements
TB PCR for granulomatous disease

Allergy Testing

Skin prick test
Serum IgE levels
RAST panel

11. Anatomical Variations – Clinical Impact

Understanding variations is essential because they influence symptoms and dictate surgical approaches.

Concha Bullosa

Pneumatized middle turbinate
Can narrow middle meatus
Causes:
- Headache
- Blockage
- Chronic sinusitis

Deviated Nasal Septum Variants

C-deviation
S-deviation
Spur formation
High vs low deviation

Clinical Issues

Obstruction
Snoring
Headaches
Recurrent sinusitis due to OMC blockage

Haller Cells

Infraorbital ethmoid cells
Compress infundibulum → obstruction

Agger Nasi Cells

Anterior ethmoid cells
Block frontal recess → frontal sinusitis

Onodi Cells

Posterior ethmoid cells
Close to optic nerve → dangerous during surgery

12. Red Flag Findings During Examination

These findings demand urgent referral, imaging, or intervention.

Unilateral Polyp

→ Rule out antrochoanal polyp or malignancy.

Friable, Bleeding Mass

→ Suspect inverted papilloma or carcinoma.

Proptosis

→ Orbital complications of sinusitis or tumors.

Severe Orbital Pain with Reduced Eye Movement

→ Orbital cellulitis or abscess.

CSF Leak

Clear watery rhinorrhea
Worse on bending forward
Halo sign on filter paper
Beta-2 transferrin positive

Black Necrotic Tissue

→ Mucormycosis (fungal emergency)

Cranial Nerve Deficits

→ Tumor invasion or advanced infection.

Facial Numbness

→ V2 involvement, maxillary sinus tumor.

Widespread Crusting and Saddle Nose Deformity

→ Wegener granulomatosis (Granulomatosis with Polyangiitis)

13. Examination-Based Differential Diagnosis Approach

Blocked Nose (Unilateral)

DNS
Polyp
Antrochoanal polyp
Foreign body (children)
Tumor
Rhinolith

Blocked Nose (Bilateral)

Allergic rhinitis
Viral URTI
Turbinate hypertrophy
Polyposis
Choanal atresia (infants)

Blood-Stained Discharge

Tumor
Trauma
Inverted papilloma
Fungal infection
Foreign body

Foul-Smelling Discharge

Foreign body
Rhinolith
Chronic sinusitis
Atrophic rhinitis

14. Sinus-Specific Physical Clues

Frontal Sinusitis

Supraorbital tenderness
Pain when bending forward
Congested frontal recess

Maxillary Sinusitis

Cheek tenderness
Postnasal drip
Pain radiating to teeth

Ethmoid Sinusitis

Medial canthal tenderness
Eye pain
Orbital complications more common

Sphenoid Sinusitis

Deep retro-orbital headache
Occipital headache
Pain worsens with lateral gaze

15. Full OSCE-Style Examination Script (Step-by-Step)

A high-yield ENT practical format that examiners love. This section teaches you how to speak during OSCEs while performing the exam.

Step 1: General Approach

Wash hands.
Introduce yourself and confirm the patient’s name.
Ask for permission to examine the nose.
Ensure adequate lighting.
Patient seated, head supported.

Phrase to say in exam:
“I will begin with an external inspection of the nose, followed by anterior rhinoscopy, assessment of sinus tenderness, patency tests, transillumination as required, and proceed to posterior nasal examination if indicated.”

16. External Nose Examination (OSCE Language + Findings)

Inspection

Say:
“I am inspecting the external nose for deformity, asymmetry, swelling, scars, discharge, or signs of trauma.”

Look for:

Saddle nose deformity (trauma, GPA, syphilis)
Rhinophyma (rosacea)
Deviated nasal dorsum
Scars from previous surgery
External valve collapse
Skin lesions (BCC, SCC)
Flaring of alae (air hunger)

Palpation

Say:
“I am palpating the nasal bones and upper lateral cartilages for tenderness or crepitus.”

Findings:

Crepitus → fracture
Warmth/swelling → cellulitis
Clicking → osteochondral instability

17. Patency Tests (OSCE Technique)

Cold Metal Test

Hold metal spatula under nostrils.
Check for symmetrical misting.
Reduces with:
DNS
Polyps
Turbinate hypertrophy
Tumors

Cottle’s Test (Internal Valve Assessment)

Lift cheek laterally → improvement in breathing suggests internal nasal valve collapse.

Fogging of Glass

Used similarly to assess airflow difference.

18. Anterior Rhinoscopy (OSCE-Level Detail)

Phrase:
“Using a nasal speculum and headlight, I will examine the vestibule, septum, turbinates and meatuses systematically.”

Technique

Avoid touching septum (painful).
Gently lift tip of nose.
Insert speculum vertically.

Examine in This Order

Vestibule
Septum
Inferior turbinate
Middle turbinate
Meatuses

Key Findings & Their Interpretation

DNS → one narrow passage, one spacious.
Crusting → atrophic rhinitis.
Purulent discharge → sinusitis.
Polyps → pale, insensitive, mobile.
Hypertrophied turbinates → allergic rhinitis (pale blue), infectious rhinitis (red).
Septal perforation → whistling sound; causes include cocaine, trauma, previous surgery.

19. Posterior Rhinoscopy (Classic ENT Exam Skill)

OSCE phrase:
“I will now examine the posterior nasal cavity using a postnasal mirror if available.”

Structures Seen

Posterior ends of turbinates
Choanae
Adenoids
Eustachian tube openings
Nasopharyngeal masses

Findings

Adenoid hypertrophy → common in children; mouth breathing.
Nasopharyngeal carcinoma → unilateral effusion + neck mass in adults.
Choanal polyp → smooth, red polyp arising from maxillary sinus.

20. Transillumination Tests (Exam Favourite)

Though low yield clinically today, examiners love asking it.

Maxillary Sinus Transillumination

Darken the room.
Place a bright torch inside the patient’s mouth against the hard palate.
Observe infraorbital area for bilateral glow.

Absent glow suggests:

Maxillary sinusitis
Thickened mucosa
Fluid level
Tumor

Frontal Sinus Transillumination

Torch under eyebrow.
Observe forehead glow.

Absent glow:

Frontal sinusitis
Underdeveloped frontal sinus (anatomical)

21. Sinus Palpation & Percussion in OSCE Format

Frontal Sinus

Palpate above eyebrows.
Tenderness → frontal sinusitis.

Maxillary Sinus

Press over cheeks.
Tenderness → maxillary sinusitis.

Ethmoid Sinus

Press medial canthus.
Pain → ethmoiditis.

Sphenoid Sinus

Not palpable.
Symptoms guide diagnosis (deep headache).

Percussion:

Tap lightly — pain correlates with infection.

22. Functional Tests – Sense of Smell (OSCE-Ready)

Phrase:
“I will test cranial nerve I using non-irritant substances.”

Substances used:

Coffee
Soap
Chocolate
Vanilla

Interpretation:

Conductive loss: polyps, DNS, rhinitis
Sensorineural loss: viral, head trauma, Parkinsonism

23. Nasal Endoscopy – OSCE Format (Patient Communication + Steps)

Explain:
“A thin telescope will be used to visualize the nasal passages and sinus openings. You may feel mild pressure but no pain.”

Steps

Apply local anesthetic.
Apply decongestant.
Insert rigid 0° scope.
Examine systematically.
Document findings.

OSCE Findings to Mention

Polyps
Purulent discharge
OMC obstruction
Septal spur
Edema
Tumors
Fungal debris
CSF leak site

24. Clinical Scenarios in ENT Exams (High-Yield)

Scenario 1: Unilateral nasal obstruction in a 16-year-old boy

Think:

Angiofibroma
Antrochoanal polyp
Deviated septum

Scenario 2: Recurrent epistaxis + unilateral polyp in an adult male

Think:

Inverted papilloma
Malignancy

Scenario 3: Child with foul-smelling unilateral discharge

Think:

Foreign body
Rhinolith

Scenario 4: Post-COVID patient with blackish nasal crusting + facial pain

Think:

Rhino-orbital mucormycosis (emergency)

Scenario 5: Clear nasal discharge worse on bending forward

Think:

CSF rhinorrhea

25. Surgical Correlation – How Exam Findings Influence Treatment

DNS

→ Septoplasty if symptomatic.

Polyps

→ Endoscopic sinus surgery after medical therapy.

Fungal Infection

→ Requires debridement + antifungals.

CSF Leak

→ Beta-2 transferrin testing + endoscopic repair.

Tumors

→ Biopsy → imaging → surgical excision or radiotherapy depending on type.

OMC Obstruction

→ FESS (Functional Endoscopic Sinus Surgery) to restore ventilation.

26. Integrating Anatomy With Examination Findings

Inferior Turbinate Hypertrophy

Allergic = pale, bluish
Infective = red, swollen

Middle Turbinate Pathology

Polypoid = polyp origin
Lateralized = prior surgery or trauma

Septum

High deviation → blocks airflow
Low deviation → affects drainage
Spur → headache

Meatus-Mapped Pathology

Middle meatus: maxillary, anterior ethmoid, frontal sinus disease
Inferior meatus: nasolacrimal duct issues
Sphenoethmoidal recess: sphenoid sinus disease

27. Pitfalls & Mistakes Students Make in ENT Exams

Not using decongestant before rhinoscopy → poor visibility
Touching the septum with speculum → patient discomfort
Missing unilateral polyp red flag
Not documenting which side findings belong to
Not linking tenderness with likely sinus involvement
Forgetting to test smell
Ignoring crusting patterns (e.g., atrophic rhinitis)
Incomplete examination sequence

28. How Examiners Grade ENT Nose Examination

Excellent Answer Includes:

Systematic approach
Clear explanations
Anatomical reasoning
Symmetry comparison
Accurate interpretation
Mention of red flags
Clear differential diagnosis

Poor Answer Includes:

Jumping steps
No clinical correlation
Missing documentation
No mention of safety issues