Examination of the Nose — Anterior Rhinoscopy and Nasal Endoscopy

A systematic approach to examining the nose — external inspection, assessing the nasal airway, anterior rhinoscopy with a Thudichum speculum, and the three-pass diagnostic nasal endoscopy — with the structures to inspect and the findings that matter at each step.

Examining the nose is a short, systematic sequence that moves from the outside in: look at the external nose, test how well air moves through it, inspect the anterior cavity with a speculum, and — where available — pass an endoscope for the structures the naked eye cannot reach. Each step answers a different question, and doing them in order means nothing is missed. This article sets out that sequence, the instruments each step needs, and the findings that change management.

Equipment

A headlight or head mirror to free both hands, a Thudichum nasal speculum (a small sprung speculum that opens the nostril) for anterior rhinoscopy, and — for the posterior and lateral wall — a rigid nasal endoscope (0° for a straight view; 30° or 45° to look up into the meatus). A topical decongestant (and often a topical local anaesthetic) sprayed before endoscopy shrinks the mucosa, opens the passages, and makes the examination more comfortable and more complete.

Step 1 — External Inspection

Before any instrument, look at the nose and face:

Skin and soft tissue: scars (previous surgery or trauma), erythema, lesions, swelling, or bruising.
Shape and axis: a deviated bony or cartilaginous dorsum, a deviated tip, a dorsal hump, or a saddle-nose deformity (loss of dorsal height, seen after septal haematoma, trauma, granulomatous disease, or cocaine use).
The vestibule and columella: widen the nostrils gently with a thumb to see the anterior septum and vestibular skin — a common site of furunculosis and anterior septal deviation.

Step 2 — Assess the Nasal Airway

Patency is functional information the speculum alone will not give you:

Misting test: hold a cold metal tongue depressor or laryngeal mirror under the nose and ask the patient to breathe out. Two symmetrical patches of condensation mean both sides are moving air; one absent or smaller patch localises obstruction to that side.
Cottle’s test: draw the cheek laterally on one side to pull open the nasal valve. If breathing improves, the internal nasal valve is a contributor to the obstruction — important, because valve collapse is not fixed by turbinate or septal surgery alone.
Alar collapse: watch the nostrils on brisk sniffing; visible in-drawing of the ala indicates a weak external valve.

Step 3 — Anterior Rhinoscopy

Seat the patient upright with the head supported, at your eye level, and aim the headlight into the nostril. Hold the Thudichum speculum so it opens the nostril without touching the septum (the septum is exquisitely sensitive and touching it causes pain and reflex tearing). Inspect in the first (head-neutral) and second (head-extended) positions:

Nasal septum: its position (deviation, spur, or dislocation into the vestibule) and Little’s area / Kiesselbach’s plexus on the anterior septum — the source of most anterior epistaxis. Look for perforation, ulceration, or crusting.
Inferior turbinate: size and mucosal state. A congested, boggy inferior turbinate suggests rhinitis; a pale, swollen mucosa suggests allergy. Distinguish a hypertrophied turbinate from a polyp — a turbinate is sensate and does not move freely; a polyp is insensate, pale, mobile, and does not blanch with decongestion.
Middle turbinate and middle meatus: the anterior part is visible; the middle meatus is where the maxillary, frontal, and anterior ethmoid sinuses drain (the ostiomeatal complex), so pus or polyps here point to sinus disease.
Mucosa and discharge: colour, swelling, and the character of any discharge (watery, mucoid, mucopurulent, blood-stained, or crusted).

Step 4 — Diagnostic Nasal Endoscopy

Anterior rhinoscopy sees only the front third of the cavity; the endoscope reaches the rest. After decongestion, a rigid endoscope is passed in a systematic three-pass technique, each pass following a different route:

First pass — along the floor: the scope is advanced along the floor of the nose, beneath the inferior turbinate, to the nasopharynx — inspecting the inferior meatus, the Eustachian tube orifice, the fossa of Rosenmüller (the site of nasopharyngeal carcinoma), and the adenoid.
Second pass — sphenoethmoidal recess: angled up between the middle turbinate and the septum to the sphenoethmoidal recess, where the sphenoid sinus and posterior ethmoids drain.
Third pass — middle meatus: into the middle meatus to inspect the uncinate process, the bulla ethmoidalis, the hiatus semilunaris, and the drainage of the ostiomeatal complex — the key area in chronic rhinosinusitis and functional endoscopic sinus surgery.

An angled scope (30° or 45°) is used to look up into the meatus and recesses that a 0° scope passes straight by.

Step 5 — Document the Findings

Record the examination in a structured way so it can be compared over time:

External: normal / deformity / scar / skin lesion
Airway: patent / obstructed (side), Cottle positive or negative
Septum: midline / deviated (side) / spur / perforation / Little’s area
Turbinates: normal / hypertrophied / pale / congested
Meatus and mucosa: clear / discharge (character) / polyps / pus in the middle meatus
Endoscopy: nasopharynx, Eustachian orifices, fossae of Rosenmüller, sphenoethmoidal recess, middle meatus
Impression: a one-line summary (e.g., “Left septal deviation with contact spur; bilateral pale inferior turbinates; no polyps; nasopharynx clear”)

Frequently Asked Questions

Why should the speculum not touch the nasal septum? The septal mucosa is highly sensitive. Touching it with the speculum causes pain, reflex lacrimation, and a poorly tolerated examination. The Thudichum speculum is opened to lift the ala and widen the nostril, keeping its blades off the septum.

What is the difference between a hypertrophied turbinate and a nasal polyp? A turbinate is a normal, sensate structure covered in mucosa; it does not move freely and its mucosa blanches and shrinks with a decongestant. A polyp is insensate, pale or grey, mobile on palpation, and does not shrink with decongestion. Mistaking one for the other changes management entirely.

Why decongest the nose before endoscopy? Topical decongestant shrinks the turbinate and mucosal swelling, opening the passages so the endoscope can reach the meatus, recesses, and nasopharynx with less discomfort and a fuller view. A topical anaesthetic is often combined with it.

What is the fossa of Rosenmüller and why does it matter? It is a recess in the lateral wall of the nasopharynx, behind the Eustachian tube orifice, and the commonest site of origin of nasopharyngeal carcinoma. It is inspected on the first endoscopic pass, which is why unexplained unilateral middle-ear effusion in an adult warrants nasendoscopy.

Can the whole nasal cavity be seen with anterior rhinoscopy alone? No. Anterior rhinoscopy shows the anterior septum, the inferior turbinate, and part of the middle turbinate — roughly the front third. The posterior cavity, the sphenoethmoidal recess, the depth of the middle meatus, and the nasopharynx require nasal endoscopy (or, historically, posterior rhinoscopy with a mirror).