Nasal exam: external nose, anterior rhinoscopy and nasal endoscopy
- Examination
Looking at the outside of the nose, then inside with a speculum and, when needed, an endoscope finds deviations, polyps, bleeding points and danger signs.
What it is
The nasal exam moves from outside to inside. The external nose is inspected and palpated; the vestibule is seen by lifting the tip; anterior rhinoscopy with a head light and a nasal speculum shows the front of the septum, the inferior turbinate and the floor of the nose. After a topical decongestant and anaesthetic, a flexible or rigid endoscope reaches the back of the nose and the nasopharynx. The exam looks for structural problems (septal deviation or perforation), mucosal disease (swollen turbinates, polyps), bleeding points and the few findings that cannot wait: septal haematoma, a one-sided mass and cerebrospinal fluid leak.
Findings and interpretation
- Swollen, boggy turbinates are common in rhinitis; a large inferior turbinate is pink and attached to the side wall, a polyp is pale and translucent.
- Polyps are linked to chronic rhinosinusitis, asthma, aspirin sensitivity, allergic rhinitis and cystic fibrosis.
- One-sided polyps may accompany or be a benign or malignant tumour: tissue diagnosis and imaging are needed.
- A septal haematoma can cause cartilage necrosis, abscess and a saddle nose if not drained.
- Clear watery discharge after head trauma may be cerebrospinal fluid; beta-2-transferrin confirms it, bedside glucose strips are not reliable.
- With an existing septal perforation, examine gently: instruments can enlarge the damage.
How it is done
- Inspect the external nose from the front, the side and above: deviation, saddle shape, swelling and skin lesions.
- Palpate the nasal bones and cartilage gently, and the skin over the frontal and maxillary sinuses for tenderness and redness.
- Assess airflow from each side by closing the other nostril, and ask about smell.
- Lift the nasal tip with the thumb to see the vestibule and the front of the septum.
- Anterior rhinoscopy: with a head light, insert the speculum and open the blades vertically, supported by a finger, without touching the septum.
- Look at the septum (deviation, perforation, haematoma, bleeding point), the inferior turbinate and the floor; note colour, crusts and discharge.
- If needed, apply a topical decongestant and anaesthetic, wait several minutes and look again.
- Nasal endoscopy: follow the floor of the nose to the choanae and nasopharynx; note adenoids and eustachian tube openings.
Findings that change management
| Finding | Think of | Action |
|---|---|---|
| Purplish septal bulge after trauma | Septal haematoma | Same-day drainage by ENT |
| Pale grape-like masses on both sides | Nasal polyps | Endoscopy and routine ENT referral |
| One-sided polyp or mass, bleeding | Sinonasal tumour | Priority ENT referral, imaging and biopsy |
| Bleeding point on the anterior septum | Anterior epistaxis | Pressure, vasoconstrictor, cautery if the site is visible |
| Clear fluid after head trauma | Cerebrospinal fluid leak | Beta-2-transferrin and urgent referral |
Common mistakes
- Opening the speculum sideways or pressing on the septum causes pain and bleeding.
- Missing a septal haematoma after a blow to the nose.
- Calling a large inferior turbinate a polyp, or a one-sided «polyp» benign without tissue diagnosis.
- Treating months of one-sided obstruction with sprays without ever looking inside the nose.
Next step / Initial management
- The first workup is clinical; sinus CT is for suspected complications, tumour or planning surgery.
- Septal haematoma: refer the same day for incision and drainage.
- One-sided mass, polyp or blood-stained discharge in an adult: priority (urgent) ENT referral for endoscopy and biopsy.
- Bilateral polyps: routine ENT referral for endoscopy and treatment; ask about asthma and aspirin sensitivity.
- Nasal fracture with deformity: reassess once swelling settles (3 to 5 days) and refer for reduction within 2 weeks.
Test yourself
Think of the answer, then tap the question to see it.
After a punch to the nose, a purplish bulge is seen on the septum. What is needed?
Immediate incision and drainage of a septal haematoma to prevent cartilage necrosis and saddle nose.
A 60-year-old smoker has a one-sided nasal polyp and blood-stained discharge. What is the next step?
Priority ENT referral for endoscopy, imaging and biopsy: a one-sided polyp may be a tumour.
How is the nasal speculum opened during anterior rhinoscopy?
With the blades opening vertically (up and down), supported by a finger, without pressing on the septum.
Clear nasal discharge appears after a head injury. Which test confirms cerebrospinal fluid?
Beta-2-transferrin in the fluid; bedside glucose strips are not reliable.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Evaluation of the Patient With Nasal and Pharyngeal Symptoms (MSD Manual Professional Edition, 2026); Nasal Polyps (MSD Manual Professional Edition, 2025); Nasal Fractures (MSD Manual Professional Edition, 2026); How To Treat Anterior Epistaxis With Cautery (MSD Manual Professional Edition, 2025); Smell Disorders (NIDCD, National Institutes of Health, 2023).
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Representative model, for educational purposes only.