180 • The ear, nose and throat
trauma. Bilateral obstruction can be due to rhinitis (allergic or
non-allergic), or chronic rhinosinusitis with or without polyps.
• unilateral or bilateral discharge (rhinorrhoea)
• anterior discharge or postnasal drip.
Clear, bilateral watery discharge suggests allergic or non-allergic
rhinitis. Purulent discharge can point to acute bacterial rhinosinusitis
or chronic rhinosinusitis. A unilateral, purulent discharge in a child
raises the possibility of a foreign body in the nose. Following a
head injury, unilateral clear rhinorrhoea suggests a possible CSF
leak secondary to an anterior skull-base fracture.
Epistaxis (bleeding from inside the nose)
• unilateral or bilateral bleeding
• frequency and duration of episodes
The paranasal sinuses are air-filled spaces in the skull. There
are paired frontal, sphenoid, maxillary and anterior and posterior
ethmoid sinuses. The anterior nasal sinuses (frontal, maxillary
and anterior ethmoid) drain into the middle meatus (between
the middle turbinate and lateral wall of the nose). The posterior
ethmoid and sphenoid sinuses drain into the sphenoethmoidal
recess (between the superior turbinate and nasal septum).
• unilateral or bilateral obstruction
• associated symptoms (bleeding, swelling, pain).
Unilateral nasal obstruction may be caused by anatomical
blockage, such as a deviated septum possibly secondary to
A Frequency in hertz (Hz) Hearing level in decibels (dB)
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Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
B Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
C Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
conduction, Left air conduction, Bone conduction)
If bleeding is unilateral and associated with nasal obstruction
and pain, the possibility of sinonasal malignancy should be
considered. In adolescent males with unilateral nasal obstruction
and epistaxis, the rare diagnosis of juvenile angiofibroma should
be excluded on nasendoscopy by an ear, nose and throat
• whether symptoms occur all year round, only during
certain seasons, or during contact with allergens.
Sneezing is a protective sudden expulsive effort triggered by
local irritants in the nose and is most commonly due to allergy
• complete loss of smell (anosmia)
• reduced sense of smell (hyposmia)
• unpleasant smells (cacosmia)
• associated nasal symptoms such as obstruction
and rhinorrhoea, which may suggest rhinitis or nasal
A sudden onset of anosmia can occur following a significant
head injury or viral URTI due to damage to the olfactory
epithelium. Inflammation and swelling in the nasal mucosa as
a result of rhinitis, chronic rhinosinusitis or nasal polyps usually
cause hyposmia. Cacosmia is usually caused by infection in the
nose or sinuses, or occasionally by a foreign body in the nose.
Phantosmia describes olfactory hallucinations, which may occur
Nasal pain is rare, except following trauma. Facial pain can
be caused by a number of problems but is often incorrectly
attributed to sinusitis. The key to identifying the cause of facial
• provoking factors such as trauma, sneezing, or blowing or
• bleeding from the front or back of the nose.
The nasal septum has a very rich blood supply, particularly in
Little’s area (anterior septum), which is a common site for bleeding.
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