Diseases » Nose conditions » Diagnosis

Diagnosis of Nose conditions

Nose conditions Diagnosis: Book Excerpts

• Ask the Following Questions - NASAL DISCHARGE
• Ask the Following Questions - NASAL OBSTRUCTION
• Ask the Following Questions - NOSE, REGURGITATION OF FOOD THROUGH
• Differential Diagnosis - Nasal Congestion
• Differential Diagnosis - Nasal Obstruction & Rhinorrhea
• Differential Diagnosis - Epistaxis (Nosebleed)
• Approach to the Diagnosis - NASAL MASS OR SWELLING
• Approach to the Diagnosis - NASAL DISCHARGE
• History and physical examination - Butterfly rash
• History and physical examination - Nasal flaring
• Diagnosis
  - Fractured nose
• Diagnosis - Nasal papillomas
• Diagnosis - Nasal polyps
• History and physical examination - Butterfly rash
• History and physical examination - Nasal flaring
• History and physical examination - Nasal obstruction
• History - Nosebleed
• Differential Overview - Nasal Congestion/Discharge
• Diagnosis - Nose, fractured
• Diagnosis - Nasal papillomas
• Diagnosis - Nasal polyps
• History - Epistaxis [Nosebleed]
• History - Butterfly rash
• History - Nasal obstruction
• Clinical Features and Diagnosis - Nasal Discharge
• History and physical examination - Butterfly rash
• History and physical examination - Nasal flaring
• Approach to the Diagnosis - NASAL DISCHARGE
• Approach to the Diagnosis - NASAL MASS OR SWELLING

Diagnostic Tests for Nose conditions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Nose conditions.

NASAL DISCHARGE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it unilateral or bilateral? Unilateral nasal discharge, especially if it is purulent, suggests acute sinusitis, Wegener's granulomatosis, neoplasm, foreign body, and syphilis. If the discharge is clear or mucoid, it could be just simply chronic sinusitis. Bilateral nasal discharge suggests an URI, especially if it is an acute onset. If it is a chronic condition and it is mucoid or clear, allergic rhinitis, chronic sinusitis, or vasomotor rhinitis should be suspected. Rarely, cerebral spinal fluid rhinorrhea is the problem.
2. Is there fever? The presence of fever makes acute sinusitis most likely if the discharge is unilateral, but if it is bilateral, one should suspect an acute viral URI. However, if there is significant pain associated with the fever, one should consider the possibility that there is an acute sinusitis.
3. Is it purulent, mucoid, or clear? The presence of a purulent discharge suggests acute sinusitis, chronic bacterial sinusitis, mucormycosis, Wegener's granulomatosis, neoplasm, foreign body, and syphilis. The presence of a mucoid discharge suggests allergic rhinitis or a chronic sinusitis. The presence of a clear discharge suggests cerebral spinal fluid rhinorrhea and senile rhinorrhea, especially if the patient is older. If there is unilateral face pain, one should consider cluster headache or migraine.
4. Is there pain? The presence of pain with fever or purulent discharge certainly suggests acute sinusitis. However, when there is pain with a clear discharge, one should think of cluster headache or migraine.
5. Is there sneezing or an allergy history? The presence of sneezing or an allergic history should suggest allergic rhinitis and sinusitis. However, allergic rhinitis and sinusitis may also occur without sneezing or an allergic history.

DIAGNOSTIC WORKUP

Routine orders for the workup of a nasal discharge include a CBC, sedimentation rate, chemistry panel, VDRL test, smear and culture of the nasal discharge, and x-rays of the sinuses. If the discharge is chronic and mucoid or clear, one should do a nasal smear for eosinophils and serum IgE level to look for allergic rhinitis. A trial of therapy may be indicated in these cases also. If Wegener's granulomatosis is suspected, serum for ANCA should be done.

If there is still diagnostic confusion after the above tests have been done, referral to an ear, nose, and throat specialist or an allergist is indicated. The specialist will perform nasopharyngoscopy and is in a better position to evaluate whether CT scans or bone scans are needed. Also, the specialist can better evaluate when the patient should undergo allergy skin testing, inhalation testing, or radioallergosorbent tests (RASTs).

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

NASAL OBSTRUCTION: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it acute or chronic? The presence of acute nasal obstruction should suggest acute sinusitis, acute rhinitis, a viral URI, allergic rhinitis, nasal diphtheria, cluster headache, migraine, foreign body, and trauma. The presence of chronic nasal obstruction, particularly if it is unilateral, would suggest sinusitis, foreign bodies, neoplasm, deviated septum, polyps, Wegener's granulomatosis, mucormycosis, and nasal gumma. If it is bilateral, it would suggest allergic rhinitis, vasomotor rhinitis, adenoid enlargement, rhinitis medicamentosa, and ingestion of drugs such as reserpine.
2. Is it unilateral or bilateral? The presence of unilateral nasal obstruction suggests acute purulent sinusitis, foreign body, neoplasm, mucormycosis, Wegener's granulomatosis, polyps, and neoplasms. It also suggests a deviated septum. The presence of bilateral nasal obstruction suggests allergic rhinitis, acute viral URI, nasal diphtheria, rhinitis medicamentosa, adenoids, and vasomotor rhinitis.
3. Is there fever? The presence of fever with unilateral nasal obstruction would suggest acute sinusitis. The presence of fever with bilateral nasal obstruction would suggest acute rhinitis and acute viral URI. Nasal diphtheria may occasionally present with this picture, even in modern times.

DIAGNOSTIC WORKUP

Routine diagnostic studies include a CBC, sedimentation rate, chemistry panel, VDRL test, ANA, a nasal smear and culture for bacteria and fungi, and x-rays of the sinuses. A nasal smear for eosinophils and serum IgE antibodies should be done if allergy is suspected. A trial of antibiotics or antihistamines may assist in the diagnosis. If Wegener's granulomatosis is suspected, serum for ANCA should be done.

If there is still confusion regarding the diagnosis at this point, a referral to an ear, nose, and throat specialist or allergist would be indicated. The ear, nose, and throat specialist may do a nasopharyngoscopy and is in a better position to determine when CT scans or bone scans are indicated. The allergist can best determine whether allergy skin testing, inhalation testing, or RAST studies would be indicated.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

NOSE, REGURGITATION OF FOOD THROUGH: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Are there structural abnormalities on examination of the nasopharynx? Structural abnormalities of the palate indicate cleft palate, congenital short soft palate, trauma, tuberculosis, syphilis, carcinoma, leprosy, and post-tonsillectomy scarring.
2. Are the abnormalities congenital or acquired? Congenital abnormalities of the palate include cleft palate and congenital short soft palate. Acquired abnormalities of the palate include trauma, syphilis, tuberculosis, carcinoma, leprosy, and post-tonsillectomy scarring.
3. Is there paralysis of the soft palate? The finding of paralysis of the soft palate may suggest myasthenia gravis, poliomyelitis, Guillain-Barré syndrome, pseudobulbar palsy, brain tumor, basilar artery insufficiency, and syphilitic meningitis.
4. Is the paralysis of the soft palate intermittent or constant? Intermittent paralysis of the soft palate should suggest myasthenia gravis.
5. Are there associated hypoactive or hyperactive reflexes? The presence of hypoactive reflexes would suggest poliomyelitis or Guillain-Barré syndrome. The presence of hyperactive reflexes or sensory findings would suggest pseudobulbar palsy, a brain tumor, basilar artery insufficiency, and syphilitic meningitis, among other conditions.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, smear and culture from the lesions in the nasopharynx, and a tuberculin test. A chest x-ray also should be done if tuberculosis is suspected. A neurologic workup consists of MRI of the brain, EMG and nerve conduction velocity studies, spinal fluid analysis, acetylcholine receptor antibody titers, and Tensilon tests. It is best to consult an ear, nose, and throat specialist or a neurologic specialist before ordering expensive diagnostic tests.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Nasal Congestion: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Upper respiratory infection
  –Most common cause of nasal congestion
  –Respiratory droplet spread, 1–2 day incubation, duration 7–14 days
  –Cough, rhinorrhea, fever, malaise
  –Viral etiology (adenovirus, rhinovirus)
• Perennial allergic rhinitis
  –Family history of allergy
  –Onset <20 years
  –Persistent watery nasal discharge
  –No variation with season
  –Pale, bluish, watery, nasal mucosa
• Seasonal allergic rhinitis
  –Itchy, teary eyes
  –Sneezing
  –Watery nasal discharge
  –Varies with season
  –Exposure to allergen (dust, mold, pollen)
  –Pale, bluish, watery, nasal mucosa
• Perennial nonallergic rhinitis
  –No variation with season
  –Obstruction may alternate nares
  –Swollen nasal mucosa
• Sinusitis (acute or chronic)
  –Patients often have a history of sinusitis
  –Craniofacial discomfort
  –Sinus headaches
  –Pain with percussion of teeth in maxillary sinusitis
  –Retro-orbital pain upon coughing or sneezing in cases of ethmoid sinusitis
  –Mucopurulent nasal drainage
• Rhinitis medicamentosa (rebound rhinitis)
  –Prolonged use of intranasal decongestants
• NARES
• Nasal polyps
• Vasomotor rhinitis
• Foreign body in nose
• Intranasal cocaine use
  –May see nasal septum perforation
• Medication side effects (e.g. aspirin, β-blockers, NSAIDs, oral contraceptives, reserpine, and thioridazine)
• Idiopathic rhinitis
• Less common etiologies include cystic fibrosis, Wegener's granulomatosis, folliculitis of nasal hair, congenital abnormality, sarcoidosis

Workup and Diagnosis

• History and physical examination with attention to head and neck
  –Onset, duration, recurrence pattern, associated symptoms (e.g., cough, fever, itchy palate or eyes), medication/illicit drug use, and family history
  –Examine the eyes, ears, sinuses, nares, oral mucosa, tongue, posterior pharynx, neck, chest, and heart in all cases
• Allergy (skin prick) testing to common inhaled antigens will be positive in patients with perennial and seasonal allergic rhinitis (perform only if chronic or recurrent)
• Nasal lavage with identification of cell type
  –Increased eosinophils in NARES and perennial and seasonal allergic rhinitis
  –Increased PMNs in infectious etiologies
• Rhinoscopic exam/flexible nasopharyngolaryngoscopy may reveal polyps, deformity, mucosal inflammation, or discharge draining from sinus meatus
• CT scan of the sinuses is usually reserved for patients who are resistant to medical therapy for 6–8 weeks
  –May see opacification and air fluid levels in sinusitis
• Nasal cultures have low specificity and are of little clinical value

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Source: In a Page: Signs and Symptoms, 2004

Nasal Obstruction & Rhinorrhea: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Physiologic
  –Nasal cycle
  –Nasopulmonary reflex
  –Puberty
  –Menstruation and pregnancy
• Congenital
  –Choanal atresia or stenosis
  –Cleft palate
  –Craniofacial syndromes such as Treacher Collins, Crouzon
• Cyst
  –Dermoid, meningocele, or encephalocele
  –Thornwaldt

• Infectious
  –Bacterial rhinosinusitis with Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, staph
  –Viral rhinosinusitis with rhinovirus, adenovirus, coxsackie

• Viral prodrome
  –Measles, mumps, mono, polio
• Fungal (if immunocompromised)
  –Aspergillosis, mucormycosis
• Inflammatory
  –Allergic rhinitis
  –Nasal polyps
  –Adenoid hypertrophy
  –Nasopharyngeal GERD
• Granulomatous
  –Sarcoidosis
  –Wegener syndrome
  –SLE
  –Churg-Strauss syndrome
• Traumatic
  –Foreign body
  –Septal hematoma
  –Septal abscess
• Neoplastic
  –Chordoma
  –Craniopharyngioma
  –Juvenile angiofibroma
  –Olfactory neuroblastoma
• Cystic fibrosis
• Thyroid disease (hypo- or hyper-)
• Ciliary dyskinesia
  –Kartagener, immotile cilia syndrome, etc.
• Chronic rhinitis

Workup and Diagnosis

• History
  –Onset, duration, severity, exacerbating and relieving factors, work of breathing
  –Family history
  –Environmental history: Pets, smoke exposure
• Physical exam
  –Passage of suction catheter to rule out atresia/stenosis
  –Direct rhinoscopy with otoscope, or with nasal speculum and headlight or head mirror
  –Fiberoptic rhinoscopy: Flexible well tolerated, rigid (better optics) only for older children
  –Examine nose before and after decongestion
• Allergy testing
  –In vitro (RAST) better tolerated in young children than in vivo (intradermal, prick skin testing)
  –Nasal cytology
  • Studies
    –Lateral neck X-ray: Useful for adenoid hypertrophy or nasopharyngeal cysts
    –Sinus X-ray: Limited utility, essentially replaced by CT
    –CT scan: Contrast only required if tumor suspected; if sinus surgery anticipated, need coronal views
    –MRI: Excellent for tumors, necessary for congenital cysts (differentiate meningocele from encephalocele); much too sensitive for sinusitis
    –Angiography: Useful for juvenile nasopharyngeal angiofibromas and other tumors requiring preoperative embolization

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Epistaxis (Nosebleed): Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Trauma
  –Dry air, especially in winter months
  –Digital trauma (nose-picking)
  –Nasogastric or nasotracheal tube
  –Blunt trauma, with or without fracture
  –Foreign body: Usually accompanied by unilateral foul-smelling rhinorrhea
  –Air pollution (indoor or outdoor)
  –Barotrauma: Diving or airplane descent in patient with upper respiratory infection
  –Chemical or caustic burn

• Inflammation
  –Upper respiratory infection (viral or bacterial)
  –Rhinitis (allergic, nonallergic with eosinophilia, atrophic, chronic): Results in increased mucosal vascularity and increased trauma from sneezing, rubbing, and nose blowing
  –Vestibulitis

• Anatomic
  –Nasal septal deviation
  –Postoperative, following sinus surgery, adenoidectomy, septoplasty, etc.
• Platelet dysfunction
  –NSAID use, especially aspirin
  –Idiopathic thrombocytopenic purpura
  –Leukemia
• Coagulopathy
  –Von Willebrand disease
  –Hemophilia
  –Liver disease
  –Anticoagulants (coumadin, heparin)
• Benign masses
  –Nasopharyngeal angiofibroma: Presents only in adolescent males
  –Pyogenic granuloma
  –Papilloma
• Malignant neoplasms
  –Rhabdomyosarcoma
  –Lymphoma

• Vascular abnormalities
  –Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease): Autosomal dominant, 90% with recurrent epistaxis
  –Hemangioma
  –Internal carotid pseudoaneurysm (suspect with massive bleed after head trauma)

Workup and Diagnosis

• History
  –Frequency, duration, precipitating factors, maneuvers required to make it stop
  –Medications, including over-the-counter and herbals
  –Family history of nosebleeds, easy bleeding, or bruising
  –Environmental history, including types of heating and cooling systems, allergies, etc.

• Physical exam
  –Assess general condition, with vital signs, to estimate acute degree of blood loss
  –Suction, or have child blow out all blood clots and fresh blood
  –Decongest (topical oxymetazoline) nose; may anesthetize with topical lidocaine or ponticaine as well
  –Anterior rhinoscopy (using otoscope is often easier and more accessible than headlight and nasal speculum)
• Labs
  –Hemoglobin and hematocrit
  –Platelet levels, coagulation studies (PT, aPTT)
  –For refractory cases, closure time (an in vitro bleeding time) and von Willebrand profile
• Hematology consultation
• Studies (for exceptional cases only)
  –CT scan with contrast
  –MRI/MRA
  –Angiography

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Source: In A Page: Pediatric Signs and Symptoms, 2007

NASAL MASS OR SWELLING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis is not difficult except in the case of granulomas and carcinomas, when skillful biopsy and culture are necessary. In Wegener midline granuloma, a search for alveolitis and glomerulonephritis will help determine the diagnosis. Serum for ANCA antibodies is often diagnostic.

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Source: Differential Diagnosis in Primary Care, 2007

NASAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis of nonbloody rhinorrhea is not usually difficult in the acute cases because it is frequently due to the common cold or allergic rhinitis (in which case the history will be helpful). When the rhinorrhea persists, a smear for eosinophils and appropriate skin testing are useful if the discharge is nonpurulent; a Gram stain, culture for bacteria and fungi, and x-rays of the sinuses will be valuable if the discharge is purulent. Cerebrospinal rhinorrhea is a possibility.

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Source: Differential Diagnosis in Primary Care, 2007

Butterfly rash: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus [LE])?

Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Nasal flaring: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient’s condition is stabilized, obtain a pertinent history. Ask about cardiac and pulmonary disorders such as asthma. Does the patient have allergies? Has he experienced a recent illness, such as a respiratory tract infection, or trauma? Does the patient smoke or have a history of smoking? Obtain a drug history.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Fractured nose: Diagnosis

(Professional Guide to Diseases (Eighth Edition))

CONFIRMING DIAGNOSIS Palpation, X-rays, and clinical findings such as a deviated septum confirm a nasal fracture.

Diagnosis also requires a complete patient history, including the injury’s cause and the amount of nasal bleeding. Watch for clear fluid drainage, which may suggest a cerebrospinal fluid (CSF) leak and a basilar skull fracture. If the patient is pregnant, a computed tomography (CT) scan is necessary.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Nasal papillomas: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

On examination of the nasal mucosa, inverted papillomas usually appear large, bulky, highly vascular, and edematous; color varies from dark red to gray; and consistency, from firm to friable. Exophytic papillomas are usually raised, firm, and rubbery; pink to gray; and securely attached by a broad or pedunculated base to the mucous membrane.

PEDIATRIC TIP Juvenile angiofibroma is a benign vascular tumor that arises in the nasopharynx and occurs most commonly in adolescent males. Nasal obstruction and hemorrhage may occur as with nasal papillomas. Any adolescent male who continues to have recurrent episodes of epistaxis should be assessed for juvenile angiofibroma. Medical management involves surgical excision, with preoperative embolization to reduce bleeding.

CONFIRMING DIAGNOSIS Tissue biopsy followed by histologic examination of excised tissue confirms the diagnosis.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Nasal polyps: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis of nasal polyps is aided by the following tests:

❑ Examination with a nasal speculum shows a dry, red surface, with clear or gray growths. Large growths may resemble tumors.

❑ X-rays of sinuses and nasal passages reveal soft tissue shadows over the affected areas.

Nasal polyps occurring in children require further testing to rule out cystic fibrosis and Peutz-Jeghers syndrome.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Butterfly rash: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body. (See Butterfly rash: Causes and associated findings.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Nasal flaring: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Once the patient’s condition is stabilized, obtain a pertinent history. Ask about cardiac and pulmonary disorders such as asthma. Does the patient have allergies? Has he experienced a recent illness, such as a respiratory tract infection, or trauma? Does the patient smoke or have a history of smoking? Obtain a drug history.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Nasal obstruction: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin the history by asking the patient about the duration and frequency of the obstruction. Did it begin suddenly or gradually? Is it intermittent or persistent? Unilateral or bilateral? Inquire about the presence and character of drainage. Is it watery, purulent, or bloody? Does the patient have nasal or sinus pain or headaches? Ask about recent travel, the use of drugs or alcohol, and previous trauma or surgery.

Examine the patient’s nose; assess airflow and the condition of the turbinates and nasal septum. Evaluate the orbits for any evidence of dystopia, decreased vision, excess tearing, or abnormal appearance of the eye. Palpate over the frontal and maxillary sinuses for tenderness. Examine the ears for signs of middle ear effusions. Inspect the oral cavity, pharynx, nasopharynx, and larynx to detect inflammation, ulceration, excessive mucosal dryness, and neurologic deficits. Lastly, palpate the neck for adenopathy.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Nosebleed: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

An assessment of the amount of blood lost is made from the history, including the onset of the bleeding, precipitating factors (including any acute or subacute injury to the nares or cranium), duration and quantity (i.e., number of soaked towels), past history of epistaxis and treatment, and history of blood dyscrasias. In adults, a history of medication use (including NSAIDs, anticoagulants), allergic rhinitis, hypertension, liver disease, ischemic heart disease, diabetes mellitus, and alcohol abuse may influence management. A family history of problems with epistaxis should be obtained. Be alert to the possibility of an intranasal foreign body in children with epistaxis with unilateral nasal discharge or foul odor.

Physical examination

The blood supply to the nose arises from the internal maxillary and facial arteries via the external carotid artery and the anterior and posterior ethmoid arteries via the internal carotid. The anteroinferior septum (Little’s area) is supplied by a confluence of both systems known as “Kiesselbach’s plexus.” Little’s area is a common site of epistaxis because it is ideally placed to receive environmental irritation (cold, dry air, cigarette smoke) and is easily accessible to digital trauma. Fortunately, this area is easy to access and treat. However, approximately 5% of nosebleeds originate from a posterior nasal source (5); it can be much more difficult to identify a source of epistaxis in this area. Providing effective treatment for obstinate bleeding in this area may also be more uncomfortable for the patient and much more formidable for the health provider.

 A. Focused physical examination (PE). When examining the epistaxis patient, first assess vital signs for hypotension, orthostasis, and hemodynamic instability. After examining the face for any obvious signs of recent injury, it is important to visualize as much of the nasal vestibule as possible. It is imperative to keep the patient’s head upright, for if he or she tilts backward, then only the roof of the nasal cavity will be seen. The nasal speculum should be held in a horizontal position to allow an optimal view of the nasal septum, which is the site of most bleeding.

Visualization of the bleeding can be done by direct illumination of the area, or sometimes more easily by indirect illumination using a head mirror. Suction may be needed to remove clots, fresh blood, or mucous to visualize the bleeding. Direct nasopharyngoscopy with endoscopy (using a topical anesthetic such as Cetacaine or lidocaine gel) may be necessary, especially if the source of the bleeding is extremely posterior. Topical vasoconstrictors such as phenylephrine or oxymetazoline can be useful in decreasing the rate of bleeding in order to visualize the area (and may sometimes help achieve long-term cessation of the bleeding).

 B. General PE. Depending on the patient’s history, it may be important to proceed to a more general PE with a special focus on the skin to look for petechiae, telangectasias, hemangiomas, and ecchymoses (Chapter 15.3).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Nasal Congestion/Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Common cold

❑ Allergic rhinitis

❑ Vasomotor rhinitis

❑ Nasal polyp

❑ Sinusitis

❑ Drugs

❑ Deviated septum

❑ Intranasal foreign body

❑ Sarcoidosis

❑ Cerebrospinal fluid leak

❑ Wegener granulomatosis

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Source: Field Guide to Bedside Diagnosis, 2007

Nose, fractured: Diagnosis
(Handbook of Diseases)

Palpation, X-rays, and signs and symptoms, such as a deviated septum, confirm a nasal fracture. The diagnosis also requires a full patient history, including the cause of the injury and the amount of nasal bleeding. Watch for clear fluid drainage, which may suggest a cerebrospinal fluid (CSF) leak and a basilar skull fracture. A computed tomography (CT) scan may be necessary.

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Source: Handbook of Diseases, 2003

Nasal papillomas: Diagnosis
(Handbook of Diseases)

On examination of the nasal mucosa, inverted papillomas usually appear large, bulky, highly vascular, and edematous. Color varies from dark red to gray; consistency, from firm to friable. Exophytic papillomas are commonly raised, firm, and rubbery pink to gray and securely attached by a broad or pedunculated base to the mucous membrane. Histologic examination of excised tissue confirms the diagnosis.

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Source: Handbook of Diseases, 2003

Nasal polyps: Diagnosis
(Handbook of Diseases)

The following tests are used to diagnose nasal polyps:

❑ X-rays of sinuses and nasal passages reveal soft-tissue shadows over the affected areas.

❑ Examination with a nasal speculum shows a dry, red surface, with clear or gray growths. Large growths may resemble tumors.

Nasal polyps occurring in children require further testing to rule out cystic fibrosis and Peutz-Jeghers syndrome.

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Source: Handbook of Diseases, 2003

Epistaxis [Nosebleed]: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If your patient isn’t in distress, take a history. Does he have a history of recent trauma? How often has he had nosebleeds in the past? Have the nosebleeds been long or unusually severe? Has the patient recently had surgery in the sinus area? Ask about a history of hypertension, bleeding, or liver disorders, and other recent illnesses. Ask if the patient bruises easily. Find out what drugs he uses, especially anti-inflammatories, such as aspirin, and anticoagulants such as warfarin.

Physical examination

Begin the physical examination by inspecting the patient’s skin for other signs of bleeding, such as ecchymoses and petechiae, and noting any jaundice, pallor, or other abnormalities. When examining a trauma patient, look for associated injuries, such as eye trauma or facial fractures. Determine if the epistaxis is unilateral or bilateral. Inspect for blood seeping behind the nasal septum, in the middle ear, and in the corners of the eyes.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Butterfly rash: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Nasal obstruction: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin the history by asking the patient about the duration and frequency of the obstruction. Did it begin suddenly or gradually? Is it intermittent or persistent? Unilateral or bilateral? Inquire about the presence and character of drainage. Is it watery, purulent, or bloody? Does the patient have nasal or sinus pain or headaches? Ask about recent travel, the use of drugs or alcohol, and previous trauma or surgery.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Nasal Discharge: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Anatomic

Choanal Atresia/Stenosis

Unilateralchoanal atresia may produce persistent mucous discharge from thenose, as may unilateral or bilateral choanal stenosis.

Flexible endoscopy is diagnostic.

CT is used to delineate anatomy priorto surgery.

Adenoid Hypertrophy

Common causeof upper airway obstruction and may not only cause snoring but also rhinorrhea.

Lateral radiograph of upper airwaydemonstrates adenoid enlargement.

Rhinitis

Infectious

Viral

Most commoncause of nasal discharge is viral upper respiratory infection. Normal preschool-or school-aged child has average of 6–8 of these infections/yr.Rhinoviruses are most frequent pathogens. Others include parainfluenzaviruses, respiratory syncytial virus, influenza viruses, and adenoviruses.

Nasal discharge may be clear and wateryor mucopurulent. Associated findings include fever, headache, malaise,anorexia, myalgia, cough, sore throat, and vomiting. Infants maybe irritable and restless, with difficulty in feeding and sleeping.Nasal turbinates are inflamed and edematous. Nasal wash viral culturesare confirmatory but unnecessary in most clinical situations.

Bacterial

Purulentnasal discharge may signify secondary bacterial infection. Excoriationof nares or cervical lymphadenitis suggests that pathogen is S.aureus or group A Streptococcus.

Infection with C. diphtheriae, indicatedby white or yellow membrane lining nose, is rare.

Positive bacterial culture of dischargeis diagnostic.

Allergic Rhinitis

Occurs inresponse to specific allergens. Common seasonal allergens are airborne pollensand molds, whereas common perennial allergens are dust mites andanimal allergens (dog and cat danders). Food allergens are rarecauses of isolated rhinitis.

Usual clinical manifestations are nasalcongestion, rhinorrhea, and sneezing.

Allergic conjunctivitis with itchy, tearyeyes is also commonly associated with allergic rhinitis.

Long-standing rhinitis may cause mouthbreathing, snoring during sleep, malaise, fatigue, and recurrentotitis media with middle ear effusion. Nasal mucosa is pale andturbinates are enlarged. Nasal discharge is usually clear. Purplediscoloration below eyes indicates venous nasal congestion. It isalso common to observe upward rubbing of nose (nasal salute). Enlargementof tonsils and adenoids also may occur.

Positive history of other atopic diseases(e.g., asthma and eczema) is common.

History and physical exam may be diagnosticof allergic rhinitis.

If >10% of cells seen onnasal smear are eosinophils, allergic rhinitis is likely. Definitivediagnosis rests on detection of immunoglobulin E (IgE) antibodyfor specific allergens.

Positive skin test results (prick orintradermal) are evidence of allergen-specific IgE. When skin testresult is questionably positive, radioallergosorbent test (RAST),which measures specific IgE antibody in serum, may be performed.

Elevated total serum IgE is usuallynegative in children with allergic rhinitis and is not recommendedas screening test.

Nonallergic Rhinitis with Eosinophilia

Children have perennial symptoms and nasaleosinophilia, but they lack specific IgE antibodies in serum andskin tests are negative.

Nonallergic Rhinitis without Eosinophilia

Vasomotor rhinitis describes individualswith nonallergic noninfectious rhinitis without eosinophilia. Rhinitiscan occur with exposure to cold air, high humidity, inhaled irritants,and strong odors.

Drug-Induced

Severaldrugs may produce rhinitis, including angiotensin-converting enzymeinhibitors, beta-blockers, NSAIDs, oral contraceptives, reserpine,phentolamine, methyldopa, and guanethidine.

Rhinitis medicamentosa is overuse ofnasally inhaled decongestant agents (e.g., phenylephrine or oxymetazoline),which should not be given for >5 days at a time.

Repeated use of cocaine also may causerhinitis.

Sinusitis

Inflammationof 1 or more paranasal sinuses, which include ethmoid, maxillary,frontal, and sphenoid sinuses.

Anterior ethmoid, maxillary, and frontal sinusescommunicate with nasal cavity through middle meatus, whereas posteriorethmoid and sphenoid sinuses open into nasal cavity below superiorturbinates.

Ethmoid and maxillary sinuses are presentat birth. Frontal sinus also exists but is small and does not enlargeuntil about 7 yrs of age.

Sphenoid sinus is pea sized by age4 yrs.

Sinus inflammation is often associatedwith viral URI. In many instances, it is self-limited and resolveswithout any specific treatment. Most episodes of acute sinusitisare thought to be bacterial complications of viral URIs.

Risk factors for sinusitis includeallergic rhinitis, cystic fibrosis, immotile cilia syndrome, facialtrauma, and mechanical obstruction (choanal atresia, deviated septum,nasal polyps, foreign body, tumor).

Usual pathogens causing acute sinusitisare same ones that cause acute otitis media: S. pneumoniae, nontypeableH. influenzae, and M. catarrhalis. S. aureus and anaerobic bacteriaare most common pathogens causing chronic sinusitis.

Usual clinical presentation of acutesinusitis is persistent nasal discharge and cough for >10 daysor high fever and purulent nasal discharge for >3 days.Discharge can be clear, mucoid, or purulent, and cough must be presentin daytime but can be worse at night. Sinus tenderness and headachealso may occur.

Although diagnosis is usually clinical,CT can be confirmatory by demonstrating sinus opacification or air-fluidlevel. This study is usually performed for suspected orbital abscessor intracranial complications. Sinus cultures may reveal specificpathogens.

Foreign Body

Foreign body in nasal passage can cause unilateral,purulent, foul-smelling discharge. History and physical exam includingrhinoscopy confirm diagnosis.

Cerebrospinal Fluid (CSF) Rhinorrhea

After nasaltrauma, CSF rhinorrhea usually indicates skull fracture, usuallythrough cribriform plate.

Less common cause is temporal bonefracture, where fluid enters nasopharynx via eustachian tube.

Other causes may be congenital or acquired(inflammatory bone erosion, neoplasm).

Measurement of >50 mg/dLglucose in nasal discharge indicates presence of CSF. Intrathecalinjection of radioisotope or dye with subsequent nuclear scintigraphyor CT, respectively, often demonstrates site of leak.

Diagnostic Approach

Cause ofnasal discharge often can be determined by history and physicalexam. Most common causes are viral upper respiratory infection andallergic rhinitis.

Nasal smear that shows many eosinophilssuggests allergic rhinitis, either seasonal or perennial, althoughthis same finding may occur with subgroup of nonallergic rhinitis.

Skin testing remains principal methodof diagnosis with allergic disease. When skin test is definitelypositive, there is little need for other tests. When skin test isquestionably positive, RAST, which measures specific IgE antibodyin serum, may be performed.

Nasal foreign body and sinusitis areother common causes of nasal discharge. Foul-smelling unilateraldischarge usually occurs with foreign body. Diagnosis of sinusitisis usually clinical.

CT of sinuses should usually be reservedfor children with orbital or CNS complications or when sinus surgeryis contemplated.

CSF rhinorrhea is rare occurrence butcan be associated with recurrent meningitis. Special imaging studiescan be used to locate site of leak.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Butterfly rash: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Nasal flaring: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When the patient's condition is stabilized, obtain a pertinent history. Ask about cardiac and pulmonary disorders such as asthma. Does the patient have allergies? Has he experienced a recent illness, such as a respiratory tract infection, or trauma? Does the patient smoke or have a history of smoking? Obtain a drug history.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

NASAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis of nonbloody rhinorrhea is not usually difficult in acute cases because it is frequently due to the common cold or allergic rhinitis (in which case the history will be helpful). When rhinorrhea persists, a smear for eosinophils and appropriate skin testing are useful if the discharge is nonpurulent; a Gram stain, culture for bacteria and fungi, and x-rays of the sinuses will be valuable if the discharge is purulent. Cerebrospinal rhinorrhea is a possibility.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

NASAL MASS OR SWELLING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis is not difficult except in the case of granulomas and carcinomas, when skillful biopsy and culture are necessary. In Wegener midline granuloma, a search for alveolitis and glomerulonephritis will help to determine the diagnosis. Serum for ANCA antibodies is often diagnostic.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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