Assessing the Nose and Sinuses

• The nose is the first segment of the respiratory system and is multifunctional.
• As inspired air passes through the nasal mucosa, nasal turbinates, and nasal hairs, it is heated, humidified, and filtered.
• The nose is also the sensory organ for smell.
• The sinuses lighten the skull, serve as resonators for sound, and provide mucus, which drains into the nasal cavity.
• Assessment of these areas offers insight to respiratory complaints as well as problems involving the ears, throat, and even headaches.

• Review related history that would give the examiner information past and present) regarding patient's sense of smell and general information regarding the nose and sinuses, including allergies, epistaxis, nasal discharge, frequent colds, trauma or surgery, and sinus pain.
• Ask about the use of nasal sprays and intranasal use of cocaine or amphetamines.
• Cranial nerve I is usually not tested in a routine examination. If the sense of smell is tested, it can be performed while assessing the nose or while assessing the neurologic system.

Special Considerations

Pediatric Patient

• Most newborns are obligate nose breathers, and, therefore, special attention must be given to the patency of the nares. Often, nasal flaring is a sign of respiratory distress.
• Avoid the nasal speculum in infants and young children; simply push the tip of the nose up and shine the light into the nares.
• Only palpate the sinuses in children 8 and older; in younger children the sinuses are too small for palpation.
• In toddlers, pay special attention to the possibility of foreign bodies lodged in the nasal cavity.

Pregnant Patient

• Nasal stuffiness and epistaxis may occur during pregnancy because of the increased vascularity in the upper respiratory tract.

Elderly Patient

• In older patients, the nose may appear larger, with the growth of especially coarse nasal hairs. The sense of smell may be diminished, and the nasal mucosa may become drier, making these patients more prone to nosebleeds.

Relevant Nursing Diagnoses

• Possible disturbed sensory perception: olfactory
• Possible ineffective airway clearance

• Completion of the examination while maintaining the patient's comfort
• Examination performed appropriately for age, and developmental and educational level

• Otoscope with short, wide nasal tip or nasal speculum and penlight
• Small samples of familiar odors

• Inspect the external aspect of the nose.
• Exposes any asymmetry, deformity, inflammation, or skin lesions.
• Palpate the nose gently.
• Uncovers pain, any breaks in the contour of the nose, or minute masses.
• Test the patency of each nostril by having the patient close the mouth, then occlude one nostril and sniff inward through the other naris.
• Reveals any obstruction of the nares, such as nasal polyps or rhinitis.
• Inspect the nasal cavity using either the otoscope with the nasal tip or a nasal speculum and penlight.

  See Fig. 4.3A Inspect Nasal Cavity

• This allows a more thorough examination of the nasal cavity.
• Tilt the patient's head back, stabilize the instrument, and gently insert the speculum approximately 1 cm while avoiding the nasal septum.
• Provides maximum exposure while maintaining patient safety and comfort; the nasal septum is highly vascular and may bleed if irritated by the speculum.
• Note the color and characteristics of the mucosa.
• Exposes any swelling, discharge, or bogginess, which are indicative of rhinitis, sinusitis, or chronic allergies.
• Note the inferior and middle turbinates (the superior will not be in your view).
• Exposes nasal polyps or foreign bodies.
• Note any deviation of the nasal septum.
• A deviated septum is common and does not present a problem unless airflow is obstructed (if found in a hospitalized patient, document the findings in case the person requires a nasogastric tube or nasal suctioning).
• Palpate the sinuses.

  See Fig. 4.3B Palpate Sinuses

• Tenderness is elicited by palpation of sinuses in persons with chronic allergies and sinusitis.
• Frontal sinuses by pressing with your thumbs up from under the medial aspect of the eyebrows.
• Pressure but not pain should be felt; be careful not to press on the eyeballs.
• Maxillary sinuses by pressing up and in from under the cheekbones.
• Pressure but not pain should be felt.
• Test cranial nerve I: olfactory.
• Evaluates the patient's sense of smell; abnormalities can indicate a neurologic or a local problem.
• Direct the patient to close eyes and occlude one naris.
• Ensures that the patient is not identifying the substance by sight and that he or she is not compensating by using the other naris.
• Hold a substance with a familiar odor under the other naris and have the patient identify the odor.
• Allows easy detection if the sense of smell is intact.
• Repeat for the other side.
• Tests the sense of smell in each naris.

Evaluation and Follow-Up Activities

• Inspect and ensure that if any bleeding occurred during the examination, it has stopped
• Compare assessment findings to normal
• Refer patient to an ear, nose, and throat specialist for further testing and evaluation of abnormal findings, if necessary

Key Points for Reporting and Recording

• Abnormal findings noted in the assessment.
• Deformities or tenderness noted as well as location and description.
• Patency of nares.
• Color, character of mucosa, including any lesions and their location.
• Position of septum (midline or side of deviation).
• Results of palpation of sinuses (note tenderness/no tenderness and which sinus).
• Sinus tenderness.