Describe the clinical examination and investigation of the nose and paranasal sinuses.

History and Clinical Examination

• The history should establish six symptoms, and each points in a different direction:
• Nasal obstruction — is it unilateral or bilateral, constant or alternating, and is it progressive? Alternating obstruction is reassuring (the nasal cycle on a mild deviation); persistent unilateral obstruction in an adult is the pattern that demands a tumour be excluded
• Discharge (rhinorrhoea) — watery (allergic, vasomotor, CSF); mucoid; purulent (infective); unilateral foul discharge in a child is a foreign body until proved otherwise; and blood-stained unilateral discharge in an adult is a malignancy until proved otherwise
• Epistaxis — side, frequency, severity, and precipitants
• Sneezing and itching — which point strongly to allergy, particularly with itching of the eyes and palate

Investigation

• Nasal endoscopy — rigid (0 and 30 degree) or flexible, after decongestion and topical anaesthesia; performed in three passes along the floor, the middle meatus, and the sphenoethmoidal recess
• Imaging — plain radiographs are now obsolete for sinus disease, being insensitive and non-specific, and should not be requested
• CT is the imaging of choice, in the coronal plane, showing the osteomeatal complex, the extent of disease, anatomical variants and the relations to the orbit and skull base
• The essential caveat about CT: incidental mucosal thickening is present in a large proportion of asymptomatic people, so CT must be interpreted with the symptoms and the endoscopy, never alone. Treating a scan rather than a patient is a common error
• CT is best performed after a course of medical treatment, so that it shows persistent rather than reversible disease
• MRI is superior for soft tissue, and is used to distinguish tumour from retained secretion, and to assess orbital, dural and intracranial extension and perineural spread. CT and MRI are complementary in malignancy, not alternatives
• Allergy testing — skin prick tests, which are quick and cheap but require antihistamines to be stopped; and specific IgE (RAST), which is unaffected by drugs and is used where skin testing is impractical or there is dermographism
• Nasal smear for eosinophils, supporting an allergic or eosinophilic cause
• Objective airway measurement — peak nasal inspiratory flow.
• Smell testing — the UPSIT and Sniffin’ Sticks
• Mucociliary function — the saccharin test as a screen, with nasal nitric oxide (characteristically very low in primary ciliary dyskinesia) and ciliary biopsy with electron microscopy where it is suspected
• Biopsy of any mass — but never biopsy a nasal mass in a child, or any pulsatile or highly vascular mass, before imaging.
• Blood tests where relevant — ANCA for granulomatosis with polyangiitis; ACE for sarcoidosis; immunoglobulins where there is recurrent infection; and clotting studies in recurrent epistaxis
• Sweat chloride and genetic testing for cystic fibrosis in a child with nasal polyps, which is the rule that must not be forgotten
• Persistent unilateral obstruction in an adult demands that a tumour be excluded, whatever else is found
• Unilateral foul discharge in a child is a foreign body until proved otherwise, and the smell is the giveaway
• Blood-stained unilateral discharge in an adult is malignancy until proved otherwise and needs endoscopy
• Alternating obstruction is reassuring, indicating the nasal cycle acting on a mild deviation
• Facial pain alone is rarely sinusitis, and is far more often midfacial segment pain or migraine
• Ask about aspirin sensitivity and asthma; the Samter triad with polyps changes both prognosis and management
• Ask about hardwood dust and nickel, which are occupational causes of sinonasal adenocarcinoma
• Pale boggy mucosa suggests allergy and red mucosa suggests infection.
• Always examine again after decongestion; it separates fixed from mucosal obstruction and is routinely skipped
• The Cottle test suggests valve compromise, and identifies patients whose obstruction will not be relieved by septal surgery alone
• Look for the allergic salute and nasal crease in a child, which make the diagnosis across the room