Diagnostic Tests for Nose conditions
Nose conditions Tests: Book Excerpts
Nose conditions Diagnosis: Book Excerpts
Diagnostic Tests for Nose conditions: Online Medical Books
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NASAL DISCHARGE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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
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
Introduction: Ear, Nose, and Throat Disorders:
Assessment
(Professional Guide to Diseases (Eighth Edition))
After obtaining a thorough patient history of ear disease, inspect the auricle and surrounding tissue for deformities, lumps, and skin lesions. (See Structures of the external ear.) Ask the patient if he has ear pain. If you see inflammation, check for tenderness by moving the auricle and pressing on the tragus and the mastoid process. Check the ear canal for excessive cerumen, discharge, or foreign bodies.
Ask the patient if he has had episodes of vertigo or blurred vision. To test for vertigo, have the patient stand on one foot and close his eyes, or have him walk a straight line with his eyes closed. Ask him if he always falls to the same side and if the room seems to be spinning.
Audiometric testing
Audiometric testing evaluates hearing and determines the type and extent of hearing loss. The simplest but least reliable method for judging hearing acuity consists of covering one of the patient’s ears, standing 18" to 24" (46 to 61 cm) from the uncovered ear, and whispering a short phrase or series of numbers. (Block the patient’s vision to prevent lip reading.) Then ask the patient to repeat the phrase or series of numbers. To test hearing at both high and low frequencies, repeat the test in a normal speaking voice. (As an alternative, you can hold a ticking watch to the patient’s ear.)
If you identify a hearing loss, further testing is necessary to determine if the loss is conductive or sensorineural. A conductive loss can result from faulty bone conduction (inability of the eighth cranial nerve to respond to sound waves traveling through the skull) or faulty air conduction (impaired transmission of sound through ear structures to the auditory nerve and, ultimately, the temporal lobe of the brain).
Sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve, which can result from aging and prolonged exposure to high-frequency or loud noises.
The following tests assess bone and air conduction:
❑ Impedance audiometry detects middle ear pathology, precisely determining the degree of tympanic membrane and middle ear mobility. One end of the impedance audiometer, a probe with three small tubes, is inserted into the external canal; the other end is attached to an oscillator. One tube delivers a low tone of variable intensity, the second contains a microphone, and the third, an air pump. A mobile tympanic membrane reflects minimal sound waves and produces a low-voltage curve on the graph. A tympanic membrane with decreased mobility reflects maximal sound waves and produces a high-voltage curve.
❑ Pure tone audiometry uses an audiometer to produce a series of pure tones of calibrated decibels (dB) of loudness at different frequencies (125 to 8,000 Hz). These test tones are conveyed to the patient’s ears through headphones or a bone conduction (sound) vibrator. Speech threshold represents the loudness at which a person with normal hearing can perceive the tone. Both air conduction and bone conduction are measured for each ear, and the results are plotted on a graph. If hearing is normal, the line is plotted at 0 dB. In adults, normal hearing may range from 0 to 25 dB.
❑ Rinne test: The base of a lightly vibrating tuning fork is placed on the mastoid process (bone conduction). Then the fork is moved to the front of the meatus, where the patient should continue to hear the vibrations (air conduction). The patient must determine which sounds are louder. In a positive Rinne test, air conduction is greater than bone conduction, which may suggest sensorineural hearing loss. In a negative Rinne test, bone conduction is greater than air conduction, which may suggest a conductive loss.
❑ Speech audiometry uses the same technique as pure tone audiometry, but with speech, instead of pure tones, transmitted through the headset. (A person with normal hearing can hear and repeat 88% to 100% of transmitted words.)
❑ Tympanometry, using the impedance audiometer, measures tympanic membrane compliance with air pressure variations in the external canal and determines the degree of negative pressure in the middle ear.
❑ Weber’s test (used for testing unilateral hearing loss): The handle of a lightly vibrating tuning fork is placed on the midline of the forehead. Normally, the patient should hear sounds equally in both ears. With conductive hearing loss, sound lateralizes (localizes) to the ear with the poorest hearing. With sensorineural loss, sound lateralizes to the better functioning ear.
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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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Clinical laboratory tests. If bleeding is minor and not recurring, no testing is needed. For more vigorous bleeding or recurrent epistaxis, consider a complete blood count (CBC) with platelet count, bleeding time, prothrombin time, partial thromboplastin time, and possibly blood type and crossmatch for hypovolemic shock or severe anemia. Testing stool for occult blood may help to assess chronicity as will assessing the red cell mean corpuscular volume. The CBC can detect blood dyscrasias as well as anemia. An elevated bleeding time may imply aspirin use, von Willebrand’s disease, and many platelet-based bleeding disorders. Coagulation times can be elevated in coagulation factor diseases, but more often they implicate liver disease.
B. Imaging. Sinus radiographs or a limited CT scan of the sinuses may also be considered if concern exists for benign neoplasms or malignancy. Rarely, angiography may also be indicated for diagnosing (and treating) vascular lesions.
Diagnostic assessment
For most cases of acute epistaxis, treatment should occur simultaneously with the diagnostic assessment. However, for persistent or recurrent nosebleeds, it is important to look further for the underlying cause of the problem by performing a careful history and evaluating the problem with expedient laboratory evaluations, appropriate imaging, or further consultation when necessary to rule out more malignant causes.
References
1. Pfaff JA, Moore GP. Epistaxis. In: Rosen P, Barkin R, Danzl DF, et al, eds. Emergency medicine: concepts and clinical practice, 4th ed. St. Louis: Mosby-Year Book, Inc., 1998:2725–2727.
2. Tomkimon A, Bremmer-Smith A, Craven C, et al. Hospital epistaxis admissions and ambient temperature. Clin Otolaryngol 1995;20:239–240.
3. O’Reilly BJ, Simpson DC, Dharmeratnam R. Recurrent epistaxis and nasal septal deviation in young adults. Clin Otolaryngol 1996;21:82–84.
4. Weiss NS. Relationship of high blood pressure to headache, epistaxis and selected other symptoms. N Engl J Med 1972;287:631–633.
5. Tan LK, Calhoun KH. Epistaxis. Med Clin North Am 1999;83:43–56.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Butterfly rash:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nasal obstruction:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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. Last, palpate the neck for adenopathy.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nasal Discharge:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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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
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