Physical Exam: The Nose

September 25, 2007

Poor Nose.

It really gets largely ignored by doctors. On a typical exam of the body, the nose is only examined if: a) an allergist/ENT is seeing the patient; or b) the problem is specific to the nose (like a child putting peas in it).

My typical physical of the nose looks like this: Nose: no discharge.

That’s it. No discharge. It just sits there in the middle of your face and minds its own business and does not cause enough trouble to merit specific examination. Sure, between upper respiratory infections and allergies, the nose is the offending organ for a lot of misery, but the exam is just uninteresting for most physicians.

Cyrano

It would be a complete faux pas for me to talk about the nose without mentioning the play Cyrano De Bergerac. In the play, Cyrano is a very witty man with a very large nose. He falls in love with the beautiful Roxanne, but feels he cannot follow-through due to his proboscis. Instead, he composes love poems for Christian, a man with very good looks but a very dull wit. It is a wonderful story, and I highly recommend it to anyone.

One of my favorite scenes from the play is where you first encounter Cyrano and he defends his generous facial adornment while showing his incredible wit:

CYRANO:
What are you staring at, sir?

PLAYGOER 5
Nothing.

CYRANO:
Does my nose offend you, sir?

PLAYGOER5:
Not at all, sir.

CYRANO:
Is it the wrong color? Does it dangle?

PLAYGOER 5:
Not at all, sir. It’s small, very small.

CYRANO:
Idiot!

It’s enormous! You insult me by selling it short when it is long! A
man should proud of such a nose, sir, a nose that displays its
owner as well-endowed with courage, wit, and daring, unlike
your stubby snout so lacking in personality, spark, and grace!
So lacking in nose is your grotesque mug,
That it would rival the face of a pug!
(Addressing all:)
For those of you who find my nose an object of ridicule, my
answer is altogether different if you are noble, for then I
attack with steel instead of speech!

DE GUICHE:
Will no one stand to challenge him?

VISCOUNT:
Leave it to me! (Approaches CYRANO) Your nose, sir, is big. Very big.

CYRANO:
Yes, very. Is that all?

VISCOUNT:
Yes.

CYRANO:
You’ve nothing more?

VISCOUNT:
No.

CYRANO:
A challenge as weak as that is not worth a reply. If you wish to offend, do
it properly. There are fifty, no, more types of criticism you could supply,
were you more clever. Allow me to demonstrate:

Economic: Why buy a table with that on which to set your plate?

Whimsical: How many lies did you tell?

Concerned: It’s swollen! Are you not well?

Mythical: The Norse giants would not dare compare!

Amazed: A coat hanger with a moustache? How rare!

Musical: Every ear can hear that horn blow!

Venetian: Such a fine mask for Capitano!

Resourceful: My bloodhound’s lost. Can I use you?

Touristic: Such a monument! What cost to view?

Aquatic: You could duel the swordfish and win!

Relieved: Finally, something for Cyrano to contain all is fury in!

The Nose Exam

To examine the nose you do two things: you look at it, and look in it. Looking at it involves looking on the outside for any obvious deformities and asymmetry. For people with repeated sinus infections, you may find that they have a deviated nasal septum which blocks the drainage of the sinus cavities. This can be fixed through nasal septum surgery (septoplasty).

Examining the inside of the nose is generally done only when specific nasal problems are suspected. The most common reason for doing so is to look for causes of recurrent nosebleeds (epistaxis). In general, nosebleeds occur when the inside front portion of the nose becomes inflamed or irritated. The most common cause of this in this region is allergies. Another cause of epistaxis is self-nose exam (see below). When you look into the nose for epistaxis, you are looking for the source of recurrent bleeding - which hopefully can be fixed by an ENT. I find, however, that regular use of saline nasal spray, along with nasal steroids (mild ones, like Nasacort AQ), are the best treatment for this problem.

As a medical student, I was taught by allergists and ENT’s that you can tell a lot by looking into the nose. In truth, it generally looks about the same to me. Usually it is red and there is a lot of mucous in it (what did you expect?). Occasionally in pediatrics you are rewarded by finding objects that have been stored away for future use that have caused chronic nasal problems. Peas are probably the most common item for me to find in the nose, although I think breakfast cereals are common as well (Cheerios, not Shredded Wheat).

One of the other main causes of nasal distress is something called rhinitis medicamentosa. This condition occurs when someone overuses decongestant nasal sprays such as Neo-Synephrine and Afrin. While these medications cause the nasal mucous membranes to open up temporarily, the body soon becomes accustomed to the presence of these chemicals, and becomes congested when they are absent. Some people mistakenly call this an “addiction” to nasal sprays. This is not technically an addiction, but instead a chemical dependency. I have never seen support groups for this, nor has someone lost their job because of time spent snorting Afrin. It is simply a rebound phenomenon that goes away over time. There are treatments for it, but I won’t spend time going over them in this post. In this condition, the nasal exam shows very pale mucous membranes (as opposed to the red ones).

When someone has trauma to their nose, you need to check them for a septal hematoma. This is a collection of blood on the nasal septum. If these are left untreated, they can weaken and even destroy the nasal septum, resulting in a saddle nose deformity.

This is not a saddle nose

This is.

The Nasal Self-Exam

While we have to continue to encourage women to perform breast self exams (yes, I do know they are controversial, so hold your comments), we don’t need to teach children to Nasal Self-Exams. They seem to come by it naturally. When you think of it, the index finger is a perfectly sized probe for the nasal cavity. While breast exams are done to look for cancer, nose self-exams are done to look for “green nuggets.”

Some children do so in search of a snack as well. My son was very proficient at finding snacks using this technique, and my wife had a perfect way to combat this disturbing habit. She simply said to him: “Oh, so you are having your dessert now. Great! Eat away.” She gave him a choice for dessert - either “green nuggets” or the regular fare. If he continued eating the former, he would forfeit the latter. He quit very quickly.

One time I was looking into a child’s nose and said to him, “Hey, there are fingerprints in here! How did they get there?” He immediately got a very guilty expression and bowed his head to the floor. You could say he was caught green-handed.

The Depths

What we cannot see on the nasal exam are the sinuses and the adenoids. The sinuses are hollow areas in the facial bones. Their main function is to fund the college education of ENT physicians’ children. Their secondary function is to add resonance to a person’s voice.

Sinuses drain into the nasal cavity and are constantly putting out fluid to keep clean. If the sinuses become plugged and cannot drain, the fluid in the cavities can become infected, resulting in Sinusitis. Contrary to popular opinion, sinusitis does not need antibiotics most of the time. It has been clearly shown that even bacterial sinus infections will eventually get better over time for the vast majority of patients.

My criteria for treatment of sinus infections are as follows:

• Symptoms lasting over a week
• Significant pain in the sinus area
• Fever
• Ear infection

Most symptoms will get better by using the following treatment:

• Saline nasal spray
• Mucous thinning medications, such as Mucinex
• Sparing use of decongestant nasal sprays (like Afrin)

Probably 75% of the people who come to my office for sinus infections are not bad enough to treat with antibiotics yet.

Oh yes, and green snot does not mean it needs antibiotics.

The adenoids are the last thing in the nasal cavity before it drains into the back of the throat. They are tonsillar tissue organs, which probably serve an immune purpose. If enlarged, however, they can cause significant airway obstruction, resulting in snoring and possibly sleep apnea. In children it is also common to see chronic recurrent sinusitis and ear infections due to enlarged adenoids that don’t allow drainage of those areas. Removal of the adenoids can result in significant reduction of these infections.

One final note should be made regarding the adenoids. People with enlarged adenoids talk in a very particular way. They have a hard time saying the letter “L”, kid of swallowing as they say it. Probably the most famous voice that clearly showed adenoidal hypertrophy (enlargement) was Tom Brokaw, of the NBC news. He was a fine anchorman, but he really swallowed those L’s.

Nose Jobs

I will leave the discussion of nasal surgery to the plastic surgeons and ENT physicians. I just want to say that Jerry Seinfeld has a very funny monologue about nose-jobs. He is very offended at the idea that they are called Rhinoplasty. He figures that people who are getting the surgery are already self-conscious about their noses, and don’t need to be associated with the rhinoceros.

I think he has a good point.

The End of the Nose

Well, that is probably more time than I have devoted to the nose for the past 5 years combined. It’s a fine organ, the nose. It kind of looks funny if you stare at it enough, but we would look far funnier without it.

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