1. EXAMINATION OF THE NOSE Physical examination: Most physicians use a head-mounted light. However, because the light cannot be precisely aligned on the axis of vision, it is difficult to avoid shadowing in narrow areas (eg, nasal cavity). Better illumination results with a head-mounted convex mirror; the physician looks through a hole in the center of the mirror, so the illumination is always on-axis. The head mirror reflects light from a source (any incandescent light) placed behind the patient and slightly to one side and requires practice to use effectively. The nose is examined using a nasal speculum, which is held so that the 2 blades open in an anteroposterior (or slightly oblique) direction and do not press against the septum. The physician notes crusting, discharge, septal deviation or perforation; whether mucosa is erythematous, boggy, or swollen; and presence of polyps. The skin over the frontal and maxillary sinuses is examined for erythema and tenderness, suggesting sinus inflammation.

22. Speculum examination A nasal speculum, a transilluminator on a battery handle, and a sterile swab for culture material are needed for the examination. Some clinics have fiberoptic nasopharyngoscopes for examination of the sinus ostia and nasopharynx, and it may be necessary to send the patient for screening sinus x-rays. Sinus examinations should always be done in a darkened area, and the use of a decongestant spray such as oxymetazolin or 0.5% neosynephrine is encouraged. . Use of nasal speculum to visualize nasal cavity and septum. Exudate or disorders of the septum should be noted. During examination of the nose, a careful external inspection should be carried out with notation made of any previous injury, trauma, or congenital deformity. Frontal and maxillary sinuses should be transilluminated, and the speculum should be used to evaluate the intranasal cavity. A fiberoptic examination can be carried out along with percussion and palpation over the maxillary and frontal sinuses to denote tenderness.