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.

Nasal discharge

Ask about:

• unilateral or bilateral discharge (rhinorrhoea)

• purulent or clear nature

• 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)

Ask about:

• 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).

The history

Common presenting symptoms

Nasal obstruction

Ask about:

• 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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Fig. 9.12 Hearing test (audiogram). A Normal-hearing right and left ears. B Right sensorineural loss. C Right conductive hearing loss. ( Right air

conduction, Left air conduction, Bone conduction)

The history • 181

9

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

specialist.

Sneezing

Ask about:

• associated itchy, red eyes

• 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

or viral URTIs.

Disturbance of smell

Ask about:

• 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

polyps

• recent head injury

• recent URTI.

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

in temporal lobe epilepsy.

Nasal and facial pain

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

pain is an accurate history.

• provoking factors such as trauma, sneezing, or blowing or

picking nose

• 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.