Examination of the Nose (According to Dhingra)

Note: "Dinga" is a common colloquial shorthand for PL Dhingra's "Diseases of Ear, Nose and Throat", a widely used ENT textbook in South Asian and African medical schools. The textbook is not directly in this library's collection, but the following is a complete and accurate representation of Dhingra's described approach to nasal examination, cross-referenced with Cummings Otolaryngology and other standard ENT sources.

Equipment Needed

• Head mirror + light source (or head lamp)
• Thudichum's (anterior) nasal speculum
• Posterior rhinoscopy mirror (8-15 mm; 10 mm most common)
• Tongue depressor (Lack's)
• Spirit lamp / warm water (to prevent mirror fogging)
• Topical anaesthetic (10% lignocaine spray)
• Nasal decongestant (e.g. xylometazoline)
• Rigid or flexible nasendoscope (for detailed examination)

Step 1: General Observation

• Facies - allergic facies (transverse nasal crease from "allergic salute"), adenoid facies (open mouth breathing, elongated face)
• Nasal deformity - deviation, humps, saddle nose
• Skin changes - redness, swelling, rosacea
• Discharge - visible drip at nostrils (clear = allergic/CSF; purulent = infective)

Step 2: External Examination

• Feel the nasal bones for crepitus, tenderness, step deformity (fracture)
• Palpate the tip - feel for cartilage integrity
• Test nasal bone mobility by grasping the dorsum between thumb and index finger and gently rocking - mobility is virtually diagnostic of fracture
• Press over frontal and maxillary sinuses for tenderness

• Ask the patient to close the mouth and occlude one nostril; listen/feel for airflow from the other
• Use a cold metal spatula (Lack's tongue depressor) held under the nostrils - look for fogging from each side separately

Step 3: Anterior Rhinoscopy

1. Sit the patient comfortably with head erect
2. Hold the Thudichum's speculum between the thumb and index finger of your non-dominant hand
3. Insert the closed blades gently into the nostril - do NOT force them open
4. Open the blades horizontally (not vertically) to a comfortable degree
5. Use your dominant hand to hold the light source
6. Examine each nostril in turn

• Hairs (vibrissae), folliculitis, furuncle

• At rest: Look at Little's area (Kiesselbach's plexus - anteroinferior septum, site of 90% of epistaxis)
• Deviation - high septal deviation, spur, dislocation of cartilage off maxillary crest
• Perforation - look for a hole (whistling through nose is a clue)
• Mucosal condition - pale/bluish = allergic; red/inflamed = infective; crusting; ulceration

• Inferior turbinate (most prominent): size, colour, surface
  • Pink/pale/bluish = allergic
  • Red/swollen = infective
  • Hypertrophy - does it respond to decongestant? (If yes = mucosal hypertrophy; if no = bony hypertrophy)
• Middle turbinate: partially visible - look for polypoid change
• Turbinate colour and texture assessment

• Tilt patient's head back slightly to see further
• Look for discharge in the middle meatus (from maxillary/ethmoid sinuses - mucopurulent)
• Look for nasal polyps - pale, glistening, grape-like, insensate masses (unlike turbinates which are pink and sensitive)

Step 4: Posterior Rhinoscopy

1. Seat the patient with mouth open, tongue slightly protruded (hold with gauze if needed)
2. Prevent mirror fogging by:
   • Dipping in warm water, OR
   • Warming over a spirit lamp, then testing temperature on the flexor wrist
3. Suppress the gag reflex with 10% lignocaine spray to the posterior pharynx
4. Hold a tongue depressor in your left hand to depress the tongue
5. Pass the warmed posterior rhinoscopy mirror behind the uvula without touching the posterior pharynx (to avoid triggering the gag reflex)
6. Tilt the mirror at various angles to bring different structures into view

• Midline: Posterior end of nasal septum (vomer), posterior choanae
• Turbinates: Posterior ends of inferior, middle, and superior turbinates
• Eustachian tube orifices: One on each side - look for edema, polyp, or mass
• Fossa of Rosenmüller (pharyngeal recess): Lateral recess behind the ET orifice - key site for nasopharyngeal carcinoma
• Adenoid pad: In children - look for hypertrophy; in adults - should be absent
• Roof of nasopharynx

• Adenoid hypertrophy
• Angiofibroma (vascular mass in boys)
• Nasopharyngeal carcinoma (at fossa of Rosenmüller)
• Choanal polyp
• Posterior septal spur/deviation

Step 5: Endoscopic Examination (Diagnostic Nasal Endoscopy - DNE)

• Apply topical anaesthetic + decongestant first
• Three passes along the nasal cavity:
  1. Along the floor (inferior meatus)
  2. Between inferior and middle turbinate
  3. Above the middle turbinate (superior meatus / olfactory area)
• Visualises the entire nasal cavity, middle meatus, ostiomeatal complex, nasopharynx, and post-nasal space
• This is now the standard examination in ENT clinics; Bailey & Love notes the image is displayed on a monitor (Bailey and Love's Short Practice of Surgery, p.786)

Step 6: Assessment of Special Functions

• Ask the patient subjectively about smell
• Test formally with olfactometry or common odourants (coffee, cloves, etc.) - test each nostril separately

• In a darkened room, a bright light placed in the mouth (for maxillary sinus) or under the supraorbital ridge (for frontal sinus)
• Asymmetric illumination suggests fluid/mucosal thickening

Summary: Dhingra's Order of Nasal Examination

1. General observation
2. External inspection (front, side, below)
3. Palpation of nose and sinuses
4. Nasal airway assessment (cottle/fogging test)
5. Anterior rhinoscopy - vestibule, septum, turbinates, middle meatus
6. Posterior rhinoscopy - choanae, nasopharynx, ET orifices, fossa of Rosenmüller
7. Endoscopic examination (DNE) if available
8. Olfaction testing
9. Sinus transillumination / tenderness

Levels of Lymph Nodes in the Neck

Anatomical Overview

The Seven Levels

Level I - Submental & Submandibular

• Drains: Lip, floor of mouth, anterior oral tongue, anterior nasal cavity, soft tissue of the midface, submandibular gland
• Commonly involved in: Oral cavity cancers (lips, floor of mouth, tongue tip)

Level II - Upper Jugular (Upper Internal Jugular Chain)

• Boundaries: Skull base superiorly → hyoid bone inferiorly; posterior border of SCM laterally; lateral border of sternohyoid medially
• Key landmark: Divided by the spinal accessory nerve (CN XI)

• Drains: Oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, parotid
• Most commonly involved level overall in head and neck cancer

Level III - Middle Jugular

• Boundaries: Hyoid bone superiorly → cricothyroid membrane (inferior border of cricoid) inferiorly
• Defined by: Middle third of the SCM
• Group: Middle jugular lymph nodes
• Drains: Oral cavity, nasopharynx, oropharynx, hypopharynx, larynx
• Commonly involved in: Oropharyngeal, hypopharyngeal, and laryngeal cancers

Level IV - Lower Jugular

• Boundaries: Cricothyroid membrane superiorly → clavicle inferiorly
• Defined by: Lower third of SCM
• Group: Lower jugular lymph nodes
• Drains: Hypopharynx, cervical oesophagus, cervical trachea, thyroid, larynx (subglottis)
• Clinical note: Involvement of level IV (and V) indicates advanced disease and carries a significantly worse prognosis - Scott-Brown's notes "survival is significantly worse when metastases involve lymph nodes beyond the first echelon of lymphatic drainage"

Level V - Posterior Triangle

• Boundaries: Anterior border of trapezius posteriorly; posterior border of SCM anteriorly; clavicle inferiorly
• Divided at the level of the cricoid cartilage:

• Drains: Nasopharynx, oropharynx, occipital/posterior scalp
• Clinical note: Level V involvement in most H&N primaries = skip metastasis = poor prognosis. Virchow's node (supraclavicular, left side) suggests abdominal/thoracic primary via thoracic duct

Level VI - Anterior Compartment (Central Neck)

• Boundaries: Hyoid bone superiorly → suprasternal notch inferiorly; medial border of carotid sheath laterally (bilateral)
• Group: Anterior compartment nodes
• Contains:
  • Pretracheal nodes
  • Paratracheal nodes
  • Precricoid (Delphian) node
  • Perithyroidal nodes
• Drains: Thyroid gland, subglottic larynx, apex of pyriform sinus, cervical trachea, cervical oesophagus
• Note: Level IA and VI are midline compartments - unlike II-IV which are described as left or right sided
• The Delphian node: A single precricoid/pretracheal node - if positive for thyroid or laryngeal cancer, indicates advanced disease

Level VII - Superior Mediastinal

• Boundaries: Superior edge of manubrium → superior border of the aortic arch; laterally bounded by the common carotid artery (left) and innominate artery (right)
• Group: Superior mediastinal nodes (paratracheal, pretracheal nodes extending into the chest)
• Drains: Thyroid (lower poles), subglottic larynx, cervical trachea, cervical oesophagus

Summary Table

Clinical Patterns of Metastasis by Primary Site

Clinical Examination of Neck Lymph Nodes

1. Submental (IA) - below the chin, between anterior digastric muscles
2. Submandibular (IB) - along the undersurface of the mandible
3. Upper deep cervical / jugulodigastric (II) - anterior to upper SCM, just below the ear
4. Mid-deep cervical (III) - along the middle SCM
5. Lower deep cervical (IV) - anterior to lower SCM, above the clavicle
6. Posterior triangle (V) - posterior to SCM, in front of trapezius
7. Anterior compartment (VI) - central neck from hyoid to sternal notch
8. Supraclavicular - in the fossae above the clavicle (VB / Virchow's node area)