Mohamed
Zaki Helal, M.D.
Professor of ORL,
Cairo,
Email: mzhelal@mzhelal.com
Web
Page:
www.mzhelal.com
This depends on the following:
· History taking.
· Physical examination.
· Investigations.
Click the rectangle below to play Diagnosis of Sinonasal Disorders Flash Movie
History Taking
Symptoms of sino-nasal disease include: nasal obstruction, nasal discharge i.e. rhinorrhea, nose bleeds i.e. epistaxis, smell disturbances, nasal tone of voice, headache and facial pain, irritation and sneezing, external deformity, or eye symptoms.
(1) Nasal Obstruction:
It is the sense of increased nasal resistance to air flow, i.e. nasal blockage.
Nasal obstruction may be:
· Unilateral or bilateral.
· Complete or partial.
· Continuous due to structural causes (deviated septum, polyps and tumors), or intermittent due to vaso-active conditions (e.g. inflammations, allergy and vasomotor disorders).
· Alternating i.e. changing from one side to the other due to awareness of nasal cycle in inflammatory and vasomotor diseases.
(2) Nasal Discharge:
Nasal sero-mucinous secretions (1-1.5L/day) are naturally driven by the cilia towards the nasopharynx, then down to the oropharynx to be swallowed. They can cause symptoms if they increase in their amount or are changed in characters, so, one becomes aware of them.
Nasal discharge varies as follows:
· Direction: anterior (nasal) or posterior (postnasal). Small increment in amount of secretions can be delt with by ciliary movement to present as postnasal discharge. Larger amounts beyond the capacity of cilia will flow forwards.
· Side: unilateral or bilateral.
· Composition:
i. Watery in allergy or CSF rhinorrhea
ii. Mucoid, mucopurulent or purulent in inflammatory conditions
iii. Sanguineous in inflammations or tumors
iv. Crusts due to stasis and dryness as in atrophic rhinitis
v. Food in nasal regurge.
· Odour: may be offensive in sinusitis of dental origin, neglected foreign bodies or tumors.
· Relation to position or straining in CSF rhinorrhea.
(3) Nose Bleeds (Epistaxis):
Epistaxis may be:
· Unilateral or bilateral.
· Anterior or postnasal bleeding.
· Mild, moderate or severe.
It may be related to:
· Trauma.
· Blood diseases in young-aged patients.
· Hypertension and atherosclerosis in elderly patients.
(4) Smell Disorders:
Abnormalities in smell sensation may be caused by:
· Nasal diseases causing obstruction
· Disorders of the olfactory nerve as inflammations and invasion by tumors, or
· Disorders of central pathways of olfaction as tumors and epilepsy.
Smell disturbances may be:
· Quantitative: varies from decreased smell sensation (hyposmia) to total loss of smell (anosmia). Anosmia or hyposmia is accompanied by affection of the taste sensation as flavour is percieved via both taste and smell sensations.
· Qualitative:
i. Cacosmia i.e. perceiving bad odour
ii. Parosmia i.e. perceiving altered smell, or
iii. Hallucination of smell perceiving a non-existing smell.
(5) Nasal Tone of Voice:
As the nose and PNS act as resonators for voice, a change in the nasal resonance of voice is called nasality or nasal tone of voice. Two types of nasality can be recognized:
· Closed nasality (rhinolalia oclusa): due to bilateral nasal obstruction leading to diminished resonation of voice (affects mainly the letters M and N).
· Open nasality (rhinolalia aperta): due to defective closure of the velo-pharyngeal valve leading to resonation of non-resonationg consonants (especially K, Sh, S …).
(6) Headache and Facial Pain:
May be primary (with no definite cause) as migraine or neuralgias, or secondary (that has a cause) as traumatic, inflammatory and neoplastic conditions of the nose and sinuses.
(7) Itching and Sneezing:
Sneezing is a reflex to expel irritating particles in inspired air. It may be initiated by exposure to an allergen in allergic rhinitis. Sneezing is a symptom in the prodromal stage of colds and in vasomotor rhinitis.
(8) Extarnal Nasal Deformity:
This is a complaint from the esthetic (cosmetic) point of view i.e. the patient complains of disfigurment. However, deformed nose is usually accompanied by nasal obstruction.
(9) Eye Symptoms:
Due to the intimate proximity of the orbit to the nose and PNS, an eye disorder may be the presenting symptom of a sinonasal disease. Eye symptoms include proptosis, limited mobility, dimished vision or field deficits.
Nasal Examination
Examination of the nose includes both external examination and examination of nasal interior. This can be aided by endoscopic examination.
I. External Examination:
A. Inspection:
The nose is checked for:
· Swellings or masses.
· Deformity.
· Skin lesions as scars, ulcers, vesicles…
· Ala nasi may be working in respiratory distress, or may be atrophic and collapsed in long term nasal obstruction in early childhood (adenoid face).
· Patency by cold mirror test: A cold mirror or a metalic tongue depressor is hold below the nostrils during resting breathing, an area of fogging will be formed. This gives an idea about the patency of the nose. Each side may be checked separately.
B- Palpation:
The nose is examined for:
· Tendeness.
· Deformity to differentiate bony from cartilaginous deformities.
II. Examination of Nasal Cavity:
This is done through both anterior and posterior naris i.e. anterior and posterior rhinoscopy. Endoscopes expand and refine nasal examination.
Anterior Rhinoscopy:
It is the examination of the nasal cavity through the anterior nares using the nasal speculum and head light. This visualizes:
i. Nasal vestibule,
ii. Anterior part of the septum
iii. Anterior ends of the inferior and middle turbinates, and
iv. Anterior portions of inferior and middle meati.
Posterior Rhinoscopy:
Examination of the nasal interior through the choana is done by depressing the tongue with a tongue depressor and passing a warmed postnasal mirror behind the soft palate to get the image of the nasopharynx, the choanae and the posterior part of the nasal cavity. Posterior rhinoscopy visualizes the posterior parts of the turbinates and meati. This maneuvre may be difficult due to gagging reflex and might be intolerable to the patient.
Endoscopic Examination:
After applying a topical anesthetic and a decongestant agent to the nasal mucosa, a rigid nasal endoscope is passed through the anterior nares to examine the nasal cavity. It allows visualization of inaccessible areas and helps detection of small lesions that may be missed during anterior and posterior rhinoscopy.
Investigations
By the end of the physical examination a provisional diagnosis might be reached. In order to verify the clinical diagnosis the ENT surgeon may request certain investigations. These include the following:
1.
Imaging:
This gives an idea about the stucture of the nose and PNS.
CT scanning:
It is the best to visualize bony boundaries of the nose and PNS and related structures.
Click here to play CT Nasal Anatomy Flash Movie
MRI:
It helps delineating soft tissue structures specially neighbouring structures as the brain and orbital contents.
Plain X-rays:
They are no longer used as they have high rates of false results.
2.
Investigations
of Nasal Functions:
For nasal patency and smell one can use:
· Rhinomanometry: to measure the nasal resistance for air flow.
· Acoustic rhinometry: to measure the cross sectional area of the nasal cavity at different points using a pulsed sound and measuring the reflected sound.
· Olfactometry: to assess the sense of smell.
3.
Auxilary
investigations:
These include biopsy taking for histopathological examination, swabs from discharge for culture and sensitivity, Blood tests……