Common presentations for the nose/nasoethmoid region:
• Blocked nose
• Crusty nose
• Loss of smell (anosmia)
• Offensive smell (cacosmia)
• Runny nose
Common problems and their causes
Useful questions and what to look for
Examination of the nose
The structure of the nose is related to its function: the large surface area of mucosa over the turbinates humidifies, warms, and filters particles from the air. The roof of the nose contains specialized neuroepithelium to provide the sense of smell. Normal air flow fluctuates slightly through each nostril (nasal cycle).
Thorough examination of the nose requires special equipment:
• Nasal mirror and tongue spatula: it may be necessary to anaesthetize the oropharynx with topical anaesthesia prior to examining the postnasal space.
• Thudichum’s speculum: this is useful to view the anterior–inferior nasal septum including Little’s area.
Position the patient in a chair slightly higher than your own. Ask the patient to remove any glasses.
• Examine the skin for lesions or scarring.
• Note any redness, discharge, crusting, or offensive smell.
• Palpate the nasal bones and lateral cartilages, looking for asymmetry, mobility, or other abnormality.
• Have the patient tilt their head back to allow you to inspect the columella and alar cartilages.
• Examine the appearance of the nasal mucosa, including colour, texture, and hydration.
• Check for inflammation, position of the septum, and presence of polyps (insensitive to touch).
• A foreign body, usually accompanied by an offensive unilateral discharge, may be seen inside the nose of a child. Infestation is rare.
• Inspect the postnasal space using a nasal mirror. Try to visualize posterior choanae, inferior turbinates, and any adenoidal tissue
This is performed to assess the patency of the nasal valve. Place your thumb in the nasolabial furrow and push the cheek outward. If the airway improves, the test is positive. The valve will need mechanical support (a graft).
Some swellings around the base of the nose may be secondary to dental pathology. Often there is bony swelling in the labial sulcus. If the teeth are not managed correctly the cyst will recur. Request an OPT and refer to maxillofacial surgeons for advice.
Examination of the nasoethmoid region
• Examine nose as detailed earlier in this section; note displacement
• Check intercanthal distance
• Check for CSF leaks/signs of head/neck injury
• Check for ocular injury.
These are potentially serious injuries.
• FBC and coagulation screen to rule out bleeding disorder as the cause of epistaxis.
• Beta-2-transferrin in rhinorrhoea fluid. This is a high specificity test for CSF which has superseded other diagnostic techniques including glucose and tau-protein testing.
• Electron microscopy of nasal brushings can be used to test for ciliary disease.
Occipitomental views may be of use if sinus disease or nasal/sinus fractures are suspected. Opacity of the sinuses may be secondary to infection, a fluid level or polyposis. Also look for bony expansion or erosion, suggestive of neoplasm. Generally speaking, plain films of the nose are no longer taken to diagnose a fracture. This is made on clinical grounds.
CT is indicated for patients with complex nasal/facial trauma, skull base trauma, CSF rhinorrhoea, or suspected malignancy. It is not always indicated for soft tissue pathology (e.g. polyps), but it can demonstrate intrasinus mucosal thickening which would be missed on plain radiographs. MRI is useful in the assessment of possible tumours.
Nearly all patients with seasonal allergic rhinitis show positive skin prick tests. However, these tests can be used to help isolate specific allergens in cases of perennial allergic rhinitis. RAST (radio-allergo-absorbent test) blood tests are also used to detect the presence of circulating immunoglobulins.
Patients should have their pulse and BP checked and if bleeding has been severe, should be investigated for bleeding disorders. Elderly patients in particular are affected more by blood loss and may develop postural hypotension or syncope. Occasionally IV fluids may be required. Patients who have had major nose bleeds should be admitted for observation, bed rest, and IV fluids. Following trauma, although these are technically open (compound) fractures, nasal fractures associated with epistaxis generally do not require antibiotic cover.
This usually settles on its own, or requires only simple first-aid measures (sitting forward and pinching the cartilaginous part of the nose for at least 20 minutes). If the bleeding stops advise the patient against picking, blowing, or sniffing for 24 hours.
If bleeding continues, the vestibule and septum should be examined for bleeding points. These may be cauterized using silver nitrate sticks or needle diathermy under topical anaesthesia. Be careful if cauterizing the septum—extensive cautery or bilateral cautery carries a risk of septal perforation. Cocaine paste causes vasoconstriction and may also help to control bleeding. However, care is required as too much is toxic. Xylocaine with adrenaline (epinephrine) spray can be used instead. Where the bleeding source cannot be seen, the nose can be packed using ribbon gauze impregnated with petroleum jelly or bismuth iodoform paraffin paste (BIPP).
More secure packing involves using specially designed packs (such as Mercoel® or Rapid Rhino®). If these are not available a soft Foley catheter may be used. However, this can be very difficult in the awake patient. The catheter is inserted (deflated) through the nose until visible at the back of the throat. The balloon is then inflated and gentle traction applied, ‘wedging’ the balloon between the soft palate and nasopharynx. Ribbon gauze can then be packed anteriorly, being careful not to allow it to slip out of place into the nasopharynx (risk of aspiration). Packs are generally retained for around 48 hours following control of haemorrhage. Antibiotics are usually required.
In rare instances where haemorrhage cannot be controlled by packing, urgent surgical intervention or interventional radiology may be required. Call for help, secure IV access, and check the patient’s clotting status. Take blood for cross-match. Surgical ligation can be achieved endoscopically through the nose. External carotid artery and anterior ethmoidal artery ligation are now rarely undertaken. The anterior ethmoidal artery passes through the orbit and is exposed via a transorbital approaches. These are rare procedures, but may be required in those cases of continuing major bleeding resistant to all other treatments.
This usually refers to disruption of either the bony or cartilaginous skeleton of the nose (usually both) (Figure 7.1). The nose is the most commonly fractured bone in the face. Diagnosis is clinical not radiological. The type and severity of injury depends on the magnitude and direction of the force applied (lateral or frontal direction).
• Injuries involve the cartilaginous nasal skeleton only
• Injuries limited to the external nose and do not cross the orbital rims
• Injuries extend beyond the nose and involve orbit walls and possibly the cranium—these are termed nasoethmoidal fractures.
Patients present with a history of trauma to the nose, together with nasal deformity, epistaxis, and an obstructed nasal airway.
This forms as a result of bleeding between the septal cartilage and its perichondrium. It must be ruled out in every injury and appears as a dark swelling on the septum with narrowing of the nasal airway. This requires urgent incision and drainage. If missed, it can result in a septal abscess (and intracranial complications), or a delayed ‘saddle nose’ following necrosis and cartilage loss.
• Anterior nasal packing may be required if there is any nasal bleeding. For more serious bleeding, post-nasal packs may be required. For haemorrhage uncontrollable by packing, surgery or embolization may be necessary.
• Septal haematoma may be aspirated or drained under local anaesthetic.
• No treatment is indicated if there is no significant deformity, airway obstruction, or haemorrhage. Antibiotics are not required.
• Ice packs may be applied if the injury is very recent.
• Closed manipulation (manipulation under anaesthetic) is carried out to correct simple deformity. If undertaken very early (sports field), it often requires no anaesthesia. Cases must be selected carefully, as manipulation may start bleeding. Otherwise manipulation requires general anaesthesia.
• With more extensive injuries (extensive lacerations/nasoethmoidal fractures), surgical repair may be required. Refer urgently and if possible keep the patient fasted. Start antibiotics.
Beware nasal fractures with associated black eyes—these may be nasoethmoid injuries or associated with skull base fractures.
This refers to injuries which extend beyond the nose to involve the orbits and ethmoid sinuses. Fractures of this region are often complex and comminuted. The drainage pathways of the frontal sinus may also be blocked, predisposing to long-term complications (mucocoele formation). NOE fractures occur following a direct blow to the bridge of the nose. The ethmoid sinuses act as a crumple zone absorbing the impact. This results in a ‘pushed-in’ look to the bridge of the nose, sometimes referred to as a ‘Miss Piggy nose’. Clinically there can be:
• Severely comminuted nasal fractures ± soft tissue lacerations
• Separation of the medial canthi (telecanthus)
• Fracture of the anterior cranial fossa with CSF leakage
• Fracture of the frontal sinus.
An upturned nose and/or separation of the canthi are highly suggestive of NOE fractures. The ‘bow-string’ test assesses for canthal detachment. The lateral canthus is pulled laterally, if there is detachment medially the medial canthus will also move laterally. Consider also possible injuries to the:
• Nasolacrimal apparatus.
Severity of the injury may vary considerably in this region. The degree of bone displacement and comminution is difficult to visualize on plain radiographs and CT is necessary. This also facilitates assessment for skull base fractures. Usually there is extensive comminution of the involved bones with associated soft tissue injuries.
Anterior nasal packing may be required. For more serious bleeding, post-nasal packs may be required. Care is required (be aware of the potential for skull base fractures). Any septal haematoma may be aspirated but may require open drainage under local or general anaesthesia.
Surgical repair is indicated in the majority of cases. Non-operative treatment may be appropriate where the fracture is undisplaced or the general condition of the patient prevents surgery. Simple closed reduction of the nasal bones may be undertaken with minimal displacement. More complex fractures may require open reduction and internal fixation. Accurate repositioning of the canthal ligaments is required for a good cosmetic result. Correct management of the frontal sinus is also essential. An open approach (usually via a bicoronal flap) is indicated for complex fractures or when frontal sinus treatment is required. In general, the best cosmetic result is obtained when repair is carried out early.
Foreign bodies and infestation
This is a common problem in children. Patients present with a unilateral foul-smelling discharge, obstruction, and vestibulitis, as well as epistaxis in some cases. If cooperative, the foreign body can be removed by asking the patient to blow their nose and attempting retrieval. Hard items can be removed by passing a wax hook or Jobson–Horne probe past the foreign body and gently pulling it outwards. Alternatively, a small drop of ‘superglue’ on the end of a narrow wooden or plastic applicator lightly held against the foreign body will hopefully stick enough to provide traction. It is not advisable to use tweezers as this may push the item back. Soft foreign bodies (such as chips) may be retrieved with suction.
This technique may work if there is total obstruction of the nostril. The child is positioned on the parent’s lap (usually the mother) with the ‘intention’ of receiving a ‘big kiss’. The parent then places their own lips over the mouth of the child, ensuring an air tight seal. The opposite patent nostril is occluded by the parent and a forceful exhalation given to deliver a short puff of air into the child’s mouth. This positive pressure may be enough to blow out the foreign body. In theory, such positive pressure techniques carry a risk of causing barotrauma to the airway, lungs, or tympanic membranes. However, these complications have not been reported and are minimized with small volumes of exhaled air.
If the patient is uncooperative or if retrieval otherwise fails, a referral should be made to ENT. A foreign body which is not removed can accumulate a calcareous deposit over time and present years later as a rhinolith—a foetid, stony mass. If large these can be difficult to remove and can cause erosion of the lateral wall and floor of the nose.
Nasal myiasis is a parasitic infestation of the nose by fly larvae (maggots), commonly from the botfly. It is rare and therefore easily overlooked. Consider this in anyone who has travelled abroad/works with animals and where no foreign body is obvious. Infestation usually occurs in countries where livestock (particularly sheep, cattle, and goats), are kept under hot, wet conditions. It is therefore commonly seen in Africa, Australia, and New Zealand but it can occur worldwide. Patients present with symptoms similar to a foreign body, i.e. nasal obstruction and discharge. They also complain of severe irritation in the nose. In some cases facial oedema and fever can develop. Death has also been reported. Larvae can usually be removed with forceps. Discuss the need for antibiotics with microbiology. Larvae can also grow in other sites, so enquire about other sites of swelling/irritation anywhere on the body.
Rhinitis is a common condition in which there is inflammation of the nasal lining. It can occur in isolation or in association with sinusitis (rhinosinusitis). Symptoms include a blocked nose, runny nose, postnasal drip, chronic or nocturnal coughing, sneezing, and lacrimation. A patient can be diagnosed with rhinitis if they suffer two or more of these symptoms for over an hour every day for 2 weeks.
Rhinitis is commonly allergic or infective in nature. However, there are other, rarer causes, and it can be part of a systemic disease (see Table 7.1). It is therefore important to take a good history. This includes asking about any past history of atopy or asthma and any seasonal or diurnal variation. The patient’s main symptom will help direct choice of treatment. Document what medications are being used and the effectiveness of any previous treatment. Smoking is also a common contributor.
Table 7.1 Classification and causes of rhinitis
Simple acute infective rhinitis
This is a self-limiting condition usually caused by the common cold, it is of viral origin and spread by droplet transmission.
Sensitization of the nasal lining to allergens causes a hypersensitivity reaction, resulting in congestion, oedema, rhinorrhoea, and irritation. Seasonal allergic rhinitis such as hayfever is where allergens are present at a particular time of year (e.g. grass pollens in summer or autumnal fungal spores), and is usually accompanied by itchy or watery eyes. Perennial allergic rhinitis is where allergens are present year-round (e.g. dust mites). Such patients will often have oedematous nasal turbinates prone to hypertrophy if the allergy is long-standing.
This has similar symptoms to allergic rhinitis but without positive allergen tests. Some patients give a history of symptoms relating to positional or temperature changes. Management is as for allergic rhinitis.
This is an acquired sensitivity of the nasal lining due to prolonged use of nasal decongestants. This is caused by a cycle of nasal congestion, treatment, and rebound vasodilatation caused by cessation of the decongestants. This results in turbinate hypertrophy and nasal obstruction.
There is loss of cilia and atrophy of the nasal lining associated with abnormal patency of the nostril. This leads to the build-up of large crusts with an unpleasant odour and frequent bleeding. It usually occurs as a result of nasal surgery. Chronic atrophic rhinitis is chronic inflammation together with atrophy of the nasal mucosa, glands, turbinate bones, and the nerve supply. Chronic atrophic rhinitis may be primary and secondary.
This is tailored according to the probable cause
• Anterior rhinoscopy: look for enlarged turbinates, bluish mucosa, nasal polyps.
• Nasal endoscopy to check for mucus or polyps around the middle meatus.
• Skin prick allergy tests or RAST tests for allergies.
• Peak flow as asthma is often a contributor.
Treatment is based on the aetiology and severity of symptoms:
• Allergen avoidance and advice.
• Steroid sprays/drops.
• Oral steroids: effective but systemic effects long term.
• Antihistamines: non-sedating antihistamines are effective against sneezing, itching, and watery rhinorrhoea but not for blockage.
• Nasal decongestants: useful in the short term, but prolonged used can result in rhinitis medicaments, and turbinate hyperplasia.
• Ipratropium bromide: used as an intranasal spray, can be effective against watery/vasomotor rhinitis.
• Sodium cromoglycate: this is a mast cell stabilizer useful for allergic rhinitis.
This has a limited role in rhinitis and is considered only after medical treatments have failed. Preoperative CT of the paranasal sinuses may be required to review the need for sinus surgery. Procedures include
• Turbinate reduction: turbinate hypertrophy is common especially in allergic rhinitis.
• Septal surgery: correction of any deviated septum.
• Functional endoscopic sinus surgery: aimed at removing any blockage of the osteomeatal complex to restore functional drainage of the sinuses.
Congenital septal deviation can occur following birth trauma or from the variations in growth from the skull. Traumatic septal deviation can also occur from a broken nose. Most often a deviated septum is asymptomatic; however, impaired airflow can bother patients. Assessment includes anterior rhinoscopy to exclude other causes of obstruction, Cottle’s test to exclude valve collapse, and nasendoscopy to exclude sinusitis. Treatment is initially by intranasal steroids for 3 months. Surgery is often required. Refer to ENT/plastics or oral and maxillofacial surgery depending on local protocol.
Patients with a perforation may complain of whistling, bleeding, or crusting at the site of perforation. Causes include trauma (including nose picking), previous surgery, granulomatous disease, or inhaled recreational drug use. Treatment is to keep the area moist with petroleum jelly, use of a septal obturator button (which may be intolerable for some patients), or surgical repair.
These conditions may also affect the nose:
• Wegener’s granulomatosis: a multisystem disease which causes perivascular granuloma formation usually causing renal and respiratory problems.
• Syphilis: this may also affect the nose.
Patients may present with both systemic and nasal symptoms but may also have isolated nasal symptoms, e.g. septal perforation or crusting. Investigations include blood tests (FBC, U&Es, ESR, syphilis serology, antineutrophil cytoplasmic antibodies (ANCA)), CXR, and biopsy. Treatment should involve medical specialists and may require immunosuppression.
Other anatomical abnormalities
Congenital atresia of one posterior choana may not present until adult life. A total unilateral obstruction may cause surprisingly little trouble to a patient. However, if symptoms are marked, the atresia can be treated surgically with removal of the bony obstruction.
This is a pneumatized cavity within one of the turbinates. It is a common normal anatomical variant. If large enough it may obstruct the opening of the adjacent sinus, resulting in recurrent sinusitis. In such cases the turbinate can be reduced in size (turbinectomy). The nasal septum is often deviated towards the opposite side and may require repositioning also.
Intranasal malignancy is rare and may present with:
• Nasal obstruction
• Epistaxis/nasal discharge
• Cranial nerve palsies
Maxillary tumours may encroach into the nose (as well as the orbit or oral cavity). Ethmoid tumours may cause diplopia, headache, and unilateral obstruction. Common types of malignancy affecting the nose are squamous cell carcinoma, adenoid cystic carcinoma, adenocarcinoma, malignant melanoma and olfactory neuroblastoma. Investigations include CT/MRI imaging, biopsy, and if necessary, angiography. Treatment may involve surgical resection and/or chemoradiotherapy.
This is the most common cancer originating in the nasopharynx, usually within the lateral nasopharyngeal recess (fossa of Rosenmüller). It occurs in both children and adults. Nasopharynx carcinoma differs significantly from other cancers of the head and neck in its occurrence, causes, clinical behaviour, and treatment. Viral (notably Epstein–Barr virus), dietary, and genetic factors have been implicated in its causation. Histologically this is a squamous cell carcinoma. Cervical lymphadenopathy is often the initial presentation in many patients. Other symptoms include trismus, pain, otitis media, nasal regurgitation, hearing loss, and cranial nerve palsies. Large tumours may produce nasal obstruction or bleeding. Nasopharyngeal carcinoma may be treated by surgery, chemotherapy, or by radiotherapy.
This arises from the olfactory epithelium superior to the middle turbinate. Olfactory esthesioneuroblastomas are initially unilateral and can grow into the adjacent sinuses and the contralateral nasal cavity. They can also spread into the orbit and the brain. Patients are best treated with combined-modality therapy. Surgical resection may involve either local resection or craniofacial resection with postoperative radiation therapy.
A benign polypoid swelling attached to the septum which presents in infants and children. A CT scan is needed to exclude (rare) intracranial attachment, and biopsy is required to confirm the diagnosis.
A cystic swelling often just above the medial canthus, sometimes with a sinus. As there may be extension of the cyst deep to the nasal bones or orbit, CT is often required.
This causes external flattening of the nasolabial fold and flaring of the alae nasi. In the anterior nares the cyst extends into the floor of the nose and displaces the inferior turbinate upwards. Be careful these are not dental in origin. Request an OPT. Management is surgical.
Here, the skin becomes thickened and vascular and may produce gross deformity. Shaving/lasering the excess skin without skin grafting is possible. Irregular areas of epithelium should be sent for histology since basal or squamous cell carcinoma may occur within a rhinophyma.
Eczema of the vestibular skin can result from nasal discharge and skin infection. It can affect both nostrils. This may cause crusting, irritation in the anterior nares, and nasal obstruction. Causes include nose picking, overly vigilant cleaning, and inhaled recreational drug. Treatment includes antibiotic and corticosteroid ointments.
Relapsing polychondritis (atrophic polychondritis/systemic chondromalacia)
This is a presumed autoimmune disease characterized by inflammation and destruction of cartilage. Although the disease usually causes pain and deformity if unrecognized and untreated, it can be life-threatening when the respiratory tract, heart valves, or blood vessels are affected. It commonly presents in patients in their late 40s to early 50s although children and young adults may also be affected. Any cartilage may be affected, although in many cases the disease affects several sites, while sparing others. Common sites include the nose, ears, joints, and rib cage. Tracheomalacia and vasculitis can also occur. One sign to look for is a painful, red, and swollen ear. There is no specific test for relapsing polychondritis although inflammatory markers (such as ESR or CRP) may be high. Biopsy may help with the diagnosis. Treatment is often systemic steroids sometimes with azathioprine or cyclophosphamide.
Reduction in the sense of smell (hyposmia) is relatively common and temporary. However, total and permanent anosmia is rare and has many causes. Some people may be anosmic for one particular odour—‘specific anosmia’. Very often no cause for anosmia can be found. Nevertheless this can be an early indication of serious pathology.
• URTI (e.g. sinusitis or the common cold)
• Nasal polyps
• Head trauma, damage to the ethmoid bone
• Tumours of the frontal lobe
• Long-term alcoholism
• Cushing’s syndrome
• Radiation therapy to the head and neck
• Liver or kidney disease
• Parkinson’s disease
• Alzheimer’s disease
• Primary ciliary dyskinesia
• Olfactory esthesioneuroblastoma
• Intranasal drug use
• Pernicious anaemia
• Zinc deficiency
• Chronic atrophic rhinitis
• Paget’s disease of bone
• Wegener’s granulomatosis
• Primary amoebic meningoencephalitis.
Patients with anosmia may find food less appetising. It can also be potentially dangerous because it hinders the detection of gas leaks, fires, etc. Occasionally losing an associated sentimental smell memory has been reported to cause feelings of depression. Rarely loss of olfaction may lead to the loss of libido.
This can be confirmed using commercially available ‘smell testing kits’. Imaging studies (CT/MRI) may be required.
This is a condition in which the nasal cavity is filled with a significant amount of clear fluid. It is a common symptom seen in allergies and URTIs. It also occurs following exposure to cold air/cocaine or withdrawal from opiate drugs. Additional symptoms include sneezing, nosebleeds, anosmia, and nasal discharge.
• Exposure to cold air
• Infection (especially common cold and influenza)
• Allergies (especially pollen, dust, and animals)
• Head trauma (CSF rhinorrhoea)
• Opioid withdrawal
• Cystic fibrosis
• Whooping cough
• Nasal tumours
• Cluster headaches
• Primary ciliary dyskinesia.
This is not to be confused with the nasal cycle, which is a normal (and usually unnoticeable) cycle of alternating partial congestion and decongestion of the nasal cavity, often affecting one side and then the other. This is physiological congestion.
Pathological nasal congestion has many causes and can vary significantly. Nasal congestion in an infant can interfere with breastfeeding and cause respiratory distress. This is because they are obligate nasal breathers.
• Common cold or influenza
• Deviated septum
• Hayfever/allergic reaction
• Rhinitis medicamentosa
• Nasal polyps
• Empty nose syndrome
The treatment of nasal congestion frequently depends on the underlying cause. Antihistamines and decongestants may be used.
This usually occurs with other sinus infections (see Chapter 3 and Chapter 9). Patients complain of deep-seated throbbing pain, deep to the bridge of the nose, between the eyes. The medial orbital walls are paper thin, so orbital cellulitis can rapidly develop. Infection can also ascend into the frontal sinus. Chronic sinus disease in the ethmoid sinuses can predispose to polyps.
• Headache/facial pain.
• Sensation of dull, constant pressure over the affected sinus.
• Symptoms are usually localized over the involved sinus and are often made worse on bending, straining or lying down.
• Nasal discharge.
• Post-nasal drip.