The Nose
I tell you, the old doctor who could cure you of every illness has all but vanished and you find nothing but specialists these days…. If you have something the matter with your nose, for instance, they’ll send you to Paris…. The specialist looks inside your nose and announces: Well, all right, I’ll take care of your right nostril, but I really don’t handle left nostrils; for that you’ll have to go to Vienna where there’s a really great leftnostril specialist.
—FYODOR DOSTOYEVSKY, THE BROTHERS KARAMAZOV, PART FOUR, BOOK ELEVEN, CHAPTER 9
POINTS TO REMEMBER:
The nose is affected by systemic or local conditions involving skin, cartilage, bone, and mucous membranes. Sometimes an “elevator diagnosis” can be made by looking at the nose.
Signs of congenital conditions, trauma, or drug abuse may be prominently displayed on or in the nose.
In a patient with rhinorrhea, the most critical diagnosis not to miss is a cerebrospinal fluid leak.
Impairment of the sense of smell may occur in endocrine, neurologic, metabolic, congenital, nutritional, infectious or postinfectious, neoplastic, or autoimmune conditions, as well as trauma or conditions localized to the nose.
External Appearance
The bulbous swollen nose of rhinophyma (a variant of acne rosacea) permits an “elevator diagnosis” (Fig. 12-1). The term comes from the Greek word rhino, which means nose, and phyma, which means growth. Rhinophyma involves a proliferation of connective tissue, which occurs with long-standing rosacea. There is a relationship between a tendency for pronounced facial flushing and the development of acne rosacea (Swerlich and Lawley, 1994). Rhinophyma has a statistical association with ingestion of alcohol and other vasoactive influences such as a hot climate. However, the sign is of unknown specificity and, as most patients with alcoholism do not have it, of low sensitivity to alcoholism. An association with basal cell carcinoma has been clearly established (Roenigk, 1987).
Saddle nose is caused by the erosion of the bony portion of the nose. It is seen in congenital syphilis (Fig. 12-2).
An appearance similar to the saddle nose, but actually caused by destruction of the cartilaginous portion, is also seen in what other disease? (If you are reading this work in sequence, you have already come across this disease in Chapter 11, with the advice that you learn to cross-refer readings in this work with those in your favorite medical textbook.)
Destruction of the tissue of the external nose may be caused by basal cell carcinoma or by the gummas of late syphilis (Fig. 12-3).
The nostrils flare during normal respiration only in diseases of the chest or in those abdominal conditions touching on the diaphragm (Silen, 1979).
Midline granuloma can completely destroy the nose and other central facial structures including bone. At this stage, it is not usually a diagnostic problem. Leprosy, fungi, trauma, and tumors may also destroy the external nose, though they are less devastating to other structures than midline granuloma is.
Nose piercing for decorative purposes may cause infection and swelling, particularly if the stud is retained within the tissues. If the stud penetrates the lateral nasal cartilages, there is the possibility of perichondritis and necrosis of the cartilage, leading to alar collapse. In most cases, simple removal of the retained stud leads to uneventful healing (Watson et al., 1987).
Internal Appearance
Methods of Examination
The internal examination of the nose may be performed with (a) an otoscope with the nasal speculum inserted in place of the ear speculum, (b) a handheld Vienna nasal speculum (the type that opens when you squeeze the handle), or (c) simply a light and one’s fingers. Most nonspecialists do not use the Vienna speculum, with or without a head mirror, so they are not able to do as detailed an examination as the specialist. Students should seek opportunities to work in the ear, nose, and throat (ENT) clinic and practice the use of a head mirror. (Mastering the technique requires a great deal of practice. Dr Douglas Lindsey of Arizona suggests assembling model airplanes in the focal point of light from a head mirror.) Outside the clinic or office, a head mirror is impractical, and a penlight or otoscope with the nasal speculum must suffice.
Use of Otoscope with Nasal Attachment
Place the nasal speculum on the otoscope head and turn on the light.
With your nondominant hand, push the tip of the nose lightly up so as to make it easier to introduce the nasal speculum into the nostril. (The dominant hand is used to position the patient’s head, manipulate instruments, or to hold the light if you do not have a head mirror.)
FIGURE 12-1 Rhinophyma. Potrait d’un Vieillard et d’un Jeune Garcon (Portrait of an Old Man and His Grandson) by Ghirlandaio, the Louvre. (Courtesy of the Réunion des Musées Nationaux, Paris, France, with permission.)
Observe the color of the nasal mucosa, and check for ulcerations.
Check the septum for deviation or perforation.
If possible, visualize the middle and inferior turbinates. Check the middle meatus for purulent discharge or polyps.
Repeat the examination for the other nostril.
Clean the nondisposable plastic nasal speculum with soap and water, and then soak it in a 10% solution of sodium hypochlorite (bleach) for 15 to 20 minutes. (Alcohol has also been used for this purpose, but bleach is effective for killing viruses, such as those of hepatitis and the acquired immunodeficiency syndrome [AIDS].1 It is best to use a disposable speculum.)
 FIGURE 12-2 A: A false positive for the saddle nose of congenital syphilis. (Redrawn from the portrait of the Duke of Urbino [Federigo Da Montefeltro] by Piero della Francesca in the Uffizi, Florence.) B: How the Duke’s nose would have looked if he truly had had congenital syphilis. |
 FIGURE 12-3 Gummatous involvement of the nose mimicking basal cell carcinoma. (From U.S. Public Health Service. Syphilis: A Synopsis. Publication no. 1660. Washington, DC: U.S. Public Health Service; 1968, with permission.) |
Use of Vienna Nasal Speculum
To expedite the examination, especially if a disease of the nose is suspected or if the membranes are swollen, use 0.5% phenylephrine (as a spray or applied with cotton) to shrink the membranes.
Hold the speculum in your nondominant hand.
Insert the speculum so that it opens in an up-and-down direction, stabilizing it by placing your forefinger on the side of the patient’s nose.
Inspect the intranasal structures in turn, as described above.
Clean the metal speculum with soap and water, then soak it in a disinfectant solution (preferably 10% sodium hypochlorite) for 20 minutes, or boil or autoclave it for 15 to 20 minutes.
The Nasal Septum
A Method
If you are concerned about the possibility of a septal perforation, you may wish to perform the following special test:
In a darkened room, shine a light in one nostril (as with the otoscope and nasal speculum).
Look up the other nostril and see whether the beam of light shines through the septum. (This is not simply transillumination, which may occur normally if the light is sufficiently strong.)
Repeat from the other side.
Causes of Perforation
Septal perforation can result from trauma (“Major,” Delp and Manning, 1975); chromium poisoning (Leopold, 1952); infection, including tuberculosis (DeGowin, 1965), infected intranasal hematoma, and syphilis (once the most common cause) (Adams et al., 1978); cocaine or heroin inhalation (Sapira and Cherubin, 1975);
and a variety of connective tissue diseases, including Wegener granulomatosis, midline granuloma, systemic lupus erythematosus, mixed cryoglobulinemia, rheumatoid arthritis, psoriatic arthritis, progressive systemic sclerosis, and mixed connective tissue disease (Wilkens et al., 1976).
and a variety of connective tissue diseases, including Wegener granulomatosis, midline granuloma, systemic lupus erythematosus, mixed cryoglobulinemia, rheumatoid arthritis, psoriatic arthritis, progressive systemic sclerosis, and mixed connective tissue disease (Wilkens et al., 1976).
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