This document discusses the clinical evaluation of rhinosinusitis through physical examination. It begins by outlining the most common signs and symptoms of both acute and chronic rhinosinusitis, including headache, facial pain, nasal congestion, and thick nasal discharge. It then describes the components of the physical examination, including inspection of the face for swelling, palpation of the sinuses for tenderness, anterior rhinoscopy to examine the nasal cavity, and nasal endoscopy which provides the best visualization of the sinus drainage pathways and ostia. The systematic examination with these techniques helps differentiate between viral, bacterial, and allergic causes of rhinosinusitis and guides diagnosis and treatment.

1. Clinical evaluation of
physical examination
rhinosinusitis: History and
JAMESA. HADLEY,MD,and STEVEND. SCHAEFER,MD,Rochester, and New York, New York
Over the past 10 to 15 years endoscopic evaluation
and sinonasal imaging techniques, particularly comput-
ed tomographic (CT) scanning, have revolutionized the
diagnosis and treatment of rhinosinusitis. Because rhi-
nosinusitis affects so many Americans every year and
has a major impact on quality of life, a knowledge of its
clinical presentation is essential for diagnosis and dif-
ferentiation from the common cold or allergic manifes-
tations.1This section of the Task Force report discusses
the current clinical evaluation of patients with the sus-
pected diagnosis of rhinosinusitis. Adjunctive nasal
rhinoscopy and endoscopy are discussed, but laborato-
ry tests and radiographic imaging techniques are cov-
ered in other sections of this publication.
The signs and symptoms of rhinosinusitis include
those of an acute upper respiratory infection and those
associated with the onset of an allergic rhinitis inflam-
matory event. Although most cases of acute rhinosi-
nusitis occur after a viral upper respiratory tract infec-
tion, cases may also occur in association with barotrau-
ma or physical trauma.2 The clinical history and the
physical examination help to differentiate among viral,
bacterial, and allergic causes.
SIGNS AND SYMPTOMS
The most common complications in patients with
acute rhinosinusitis are headache, nasal congestion, and
the production of thick postnasal discharge (Table 1).
Facial pain or pressure is the most pressing symptom
bringing patients to a physician for evaluation. The site
of the acute facial pain or pressure may help in localiz-
ing the infection to a specific paranasal sinus. 3
Maxillary sinusitis may cause infraorbital or cheek dis-
comfort. Upper teeth or gum pain is highly specific for
From the Division of Otolaryngology, University of Rochester
Medical Center (Dr. Hadley), and the Department of
Otolaryngnlogy, New York Eye and Ear Infirmary (Dr. Schaefer).
Reprint requests: James A. Hadley, MD, Rochester Otolaryngology,
Group 2561 LacDeVille Blvd., Rochester, NY 14168.
Otolaryngol Head Neck Surg 1997;117:$8-S 11.
Copyright © 1997 by the American Academy of Otolaryngology-
Head and Neck Surgery Foundation, Inc.
0194-5998/97/$5.00 + 0 23/0/83509
$8
maxillary sinusitis. Lying down relieves the discomfort
in patients with maxillary sinusitis.
Ethmoidal rhinosinusitis, which usually accompa-
nies most other categories of rhinosinusitis, may cause
tenderness over the lacrimal region, with referred ten-
derness to the periorbital and temporal regions.
Bending forward or lying supine exacerbates the pain
from ethmoidal rhinosinusitis.
Frontal sinusitis may constitute an acute medical
problem. One characteristic of acute frontal sinusitis is
severe headache localized to the forehead over the
orbits, with tenderness produced by pressure on the
floor of the frontal sinus.
Discomfort from sphenoidal sinusitis radiates to the
occiput and vertex areas. Headache described as a
chronic dull ache in the back of head, specifically over
the occiput with radiation to the frontal and retro-orbital
regions, is a sign of sphenoidal rhinosinusitis. Acute
sphenoidal rhinosinusitis may represent a medical
emergency, particularly when the infection is near cav-
ernous sinus structures (i.e., cranial nerves III, IV, V1,
V2, and VI) or when diminished visual acuity is
involved.
The symptoms of chronic rhinosinusitis are more
subtle, with facial pain and pressure less likely to be
primary complications. Nasal congestion with obstruc-
tion and the production of thickened nasal secretions
are the most common problems.3-5 Other signs of
chronic sinusitis include fatigue, cough, and a sensation
of facial fullness with pressure. These low-grade symp-
toms are the result of persistent inflammation and
obstruction of the outflow tracts of the paranasal sinus-
es.
Most patients with rhinosinusitis report a significant
change in nasal airflow accompanied by a sensation of
congestion. Inflamed mucous membranes in the nose
and paranasal sinuses are responsible for the sensation
of congestion. The production of thickened secretions
causes a feeling of increased postnasal drainage and
sore throat. However, physicians should not rely solely
on colored nasal drainage as an indication for antibiot-
ic therapy. Decongestants may provide some relief of
the symptoms, but they have no influence on the reduc-
tion of inflammation. Treatment with decongestants

2. Otolaryngology-
Head and Neck Surgery
Volume 117 Number 3 Part 2 HADLEYand SCHAEFER $?
Table 1. Clinical evaluation of rhinosinusitis
Symptom complex
Major criteria
Headache
Facial pain and pressure
Nasal congestion
Thick, colored postnasaldrainage
Olfactory disturbance
Minor criteria
Fever
Halitosis
Children only:
Cough
Irritability
and mucoevacuants may help to maintain ostial paten-
cy and to reduce inflammation by promoting drainage.
Cough, a nonspecific symptom of rhinosinusitis,
may be confused with the onset of an asthmatic condi-
tion. This symptom, which is common in children with
rhinosinusitis, usually diminishes or is eliminated with
treatment of the infection. Cough tends to be more
common at night.6 In acute and chronic flfinosinusitis
the cough reflex may be provoked by the p:roduction of
chemical mediators, leukotrienes, and other factors that
give rise to hronchoconstriction and irrkated neural
endings. A vagal reflex, mediated from pressure recep-
tors within the paranasal sinuses, may also be institut-
ed.
Another common symptom and one of tile major cri-
teria for the diagnosis of rhinosinusitis is a diminished
or lost sense of smell. The inflammatory response of the
nasal mucosa hinders odorants from migrating to the
olfactory placode in the upper recesses of the nasal cav-
ity. Chronic rhinosinusifis may predispose', patients to
nasal polyposis, which aggravates hyposmia and may
lead to anosmia.7
Fever is more common in the early stages of acute
rhinosinusitis. Although fever is more common in chil-
dren and adolescents, it may also be present in adult rhi-
nosinusitis shortly after an upper respiratory infection.
Knowledge of the seasonal recurrence of symptoms
and known triggers of symptoms is helpful in differen-
tiating allergic rhinitis from acute rhinosinusitis. In
patients with allergy the nasal membranes; respond to
provocation by allergens with the release of chemical
mediators from the resident mast cells of the nasal
mucosa. Histamine is the primary mediator of the early
phase leading to rhinorrhea, edema, and the symptoms
of sneezing and congestion. Late-phase reactions from
the influence of cellular responses prolong :he reaction,
giving the impression of persistent nasal congestion.
Patients with allergic rhinitis usually have a history
of allergic response.6 Typical symptoms include a thin
watery nasal discharge, intermittent sneezing, and a
Table 2. Physical signs
External physical findings: swelling and erythema
Swelling and erythema: maxillary region, ocular or
orbital region, and frontal region
Findings on anterior rhinoscopy
Hyperemia
Edema
Crusts
Purulence
Polyps
After topical nasal decongestion: improvement or
worsening of symptoms
Findings on nasal endoscopy*
Bluish discoloration of turbinates
Purulence at ostiomeatal complex or other sinus ostia
Polyp formation, with size and location of polyps noted
Septal deflections
Concha bullosa
Paradoxic turbinates
Other anomalies
*Examinationwitha rigid or flexiblenasalendoscopeshouldbe a
standardpart of the physicalexaminationin the specialist'soffice.
Culturesobtainedunderendoscopicguidanceculturesmay be
obtainedto aid in the diagnosis.
runny, itchy nose. Allergic responses can predispose
patients to have acute or chronic rhinosinusitis as a
result of the inflammatory response and resultant
obstruction of the ostia of the paranasal sinuses.
The differential diagnosis of chronic rhinosinusitis
includes asthma, gastroesophageal reflux disease, and
chronic allergic rhinitis. All of these conditions may
exist simultaneously.
PHYSICAL EXAMINATION
In addition to the major symptom complex for rhi-
nosinusitis, the physical examination plays a major role
in the diagnosis of acute or chronic rhinosinusitis. The
examination begins with the facial features. Swelling,
erythema, and edema localized over the involved
cheekbone or periorbital area may be immediately rec-
ognized in the acute forms of the disease (Table 2).
These signs are apparent predominantly in the morning,
and they improve gradually while the patient is upright.
Patients with chronic rhinosinusitis usually have no
facial swelling or edema.
The sinuses are palpated to test for tenderness.
Percussion of the teeth may direct attention toward an
inflamed paranasal sinus.
ANTERIOR RHINOSCOPY
Anterior rhinoscopy is an examination of the nasal
cavity performed with a nasal speculum under good
illumination. The examination should include visual-
ization of the nasal septum to assess for septal deviation
causing obstruction and identification of the nasal
turbinates and their characteristics.

3. $I0 HADLEYand SCHAEFER
Otolaryngology-
Head and Neck Surgery
September 1997
Acute rhinosinusitis is characterized by hyperemia
of the nasal mucosa and edema. Hyperemia is defined
as an increase in the vascularity of the nasal mucosa, so
that it appears reddened as opposed to the normal pink
color. The presence of nasal crusts represents drying of
the nasal mucus or purulence. These crusts may be
sparse, or they may involve most of the affected side.
Mucopurulent discharge is common in the middle mea-
tus (between the inferior and middle turbinates).
Purulence located in the middle meatus is found in
patients with acute maxillary, ethmoidal, and frontal
sinusitis. Purulence located more posteriorly in the
superior meatus and sphenoidal recess is characteristic
of posterior ethmoidal or sphenoidal sinusitis.
Nasal polyposis predisposes patients to the recurrent
symptoms of chronic sinusitis. Polyps present as glis-
tening pedunculated masses with a sometimes bluish or
yellowish hue that differentiates them from the normal
pink-colored nasal mucosa.7 Polyps may be hidden
within the recesses of the middle meatus complex.
Therefore despite good illumination, they may not be
seen on the routine nasal examination. Polyps are rela-
tively common in chronic rhinosinusitis, but they are
present only infrequently in acute stages unless the
patient has an underlying predisposition for nasal poly-
posis.
Topical nasal decongestion with an ct-agonist agent
such as phenylephrine hydrochloride is useful in the
diagnosis of acute or chronic rhinosinusitis. The reac-
tion of mucous membranes to the application of an ct-
agonist agent aids in visualizing the recesses of the
nasal cavity. After the topical administration of this
agent, the physician should look for signs of the
improvement of congestion or the worsening of symp-
toms.
Nasal cultures obtained without endoscopy are not
specific for the identification of bacteria responsible for
acute rhinosinusitis. 8-1° These cultures are frequently
contaminated with Staphylococcus aureus and are not
well correlated with the results of paranasal sinus aspi-
ration.
NASAL ENDOSCOPY
Nasal endoscopy has revolutionized the diagnosis
and treatment of rhinosinusitis, a'4 As standard proce-
dure patients with a history of recurrent acute or chron-
ic rhinosinusitis should be examined with a rigid or
flexible nasal endoscope in the specialist's office. The
concepts of rigid nasal endoscopy are difficult to learn
in the primary care office, and the technique requires
extensive training and expertise.
Nasal endoscopy provides reliable visualization of
all accessible areas of the sinus drainage pathways.
Thus endoscopic examination should be performed
before evaluation by CT scanning. After the nasal cav-
ity is anesthetized with a topical agent, the rigid endo-
scope is advanced to visualize the middle turbinate,
which is displaced medially. Nasal endoscopy should
visualize all regions of the ostiomeatal complex to
appreciate subtle signs of obstruction and to detect
nasal polyps hidden from routine nasal examination.
The procedure is easily performed with the use of topi-
cal anesthesia in adults and adolescents and in cooper-
ative children.
During nasal endoscopy the physician should look
specifically for purulence at the ostiomeatal complex
and the sphenoethmoidal recess, polyp formation at the
junction of opposing mucosal surfaces, structural
abnormalities that predispose patients to recurrent rhi-
nosinusitis, and other findings. Appropriate directed
nasal cultures obtained with nasal endoscopy may cor-
relate better with those obtained by sinus aspiration.
Cultures directed with endoscopy are obtained with a
microculturette that is directed into the appropriate
sinus ostia.
SYSTEMATIC NASAL ENDOSCOPY
To diagnose and evaluate the extent of sinonasal dis-
orders, the nasal endoscopist requires appropriate
equipment and a systematic approach to the nasal
examination.4 Appropriate equipment includes at least
one 0-degree telescope or one wide-angle 25-degree
telescope, a fiberoptic light source, and a light cord.
The telescopes are manufactured in diameters of 4.0
and 2.7 mm. The smaller scopes are recommended for
use in children or in patients with difficult nasal anato-
my such as a deviated nasal septum.
Because the sinuses and nose are elements of the
upper aerodigestive tract, the examination of this
region should be performed in the context of a com-
plete examination of the head and neck. Unless con-
traindicated, topical vasoconstrictive and anesthetic
agents should be used to enhance visualization of the
nose; some investigators recommend examining the
nose both before and after the administration of these
agents. Otoscopy and examination of the other regions
of the head and neck can be performed first, thereby
allowing several minutes for the topical agent to
enhance the nasal examination. The nose should then
be systematically examined.
One approach is to divide the examination into three
regions. The inferior examination consists of passing a
0-degree endoscope along the floor of the nose to visu-
alize the orifice of the nasolacrimal duct, the inferolat-
eral nasal wall, the eustachian tube orifice, and the
nasopharynx. The second passage should be at approx-

4. Otolaryngology-
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Volume 117 Number 3 Part 2 HADLEYand SCHAEFER S! 1
imately a 30-degree angle from the floor of the nose to
examine the sphenoethmoidal recess, the middle mea-
tus, and the sphenoidal ostium. Then the superior pas-
sage should be directed toward the frontal recess to
examine these cells, the attachment of the middle
turbinate, and the superior recess between the middle
turbinate and the nasal septum.
Endoscopic findings can be divided iJlto allergic or
inflammatory, infectious, and anatomic. Nonspecific
allergic and inflammatory findings include a bluish dis-
coloration and boggy distention of the nasal mucosa.
Inflamed red mucous membranes may a{so be seen. 11
Nasal polyps reflect an inflammatory process, which
correlates positively with allergy testing in 50% of
patients. Infectious findings include purulent secretions
draining from the involved sinus(es), fungal hyphae,
inspissated secretions from allergic fungal rhinosinusi-
tis, and loss of nasal tissue from invasive bacterial and
fungal pathogens. Physical findings in the acquired
immunodeficiency syndrome are nonspecific. Anatomic
findings should be viewed in the context of the patient's
specific problem. For example, a concha bullosa or a
deviated septum is significant when lhe structure
obstructs the outflow of a specific sinus.
CONCLUSION
Because rhinosinusitis is an illness with a significant
impact on quality of life, 1,12 it must be appropriately
diagnosed and treated. The physician needs to properly
assess the patient's history and symptoms and then
progress through a structured physical examination to
look for signs that lead to an appropriate diagnosis.
Proper medical treatment is based on the findings of a
sound history and a careful physical examination.
Although imaging techniques can accurately show the
inflammation within sinus ostia, they are relatively
expensive to use for following a patient's response to
therapy.
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