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CLINICAL EXAMINATION                               13

anterior end of the inferior concha is immediately seen bulging from the lateral
wall of the cavity. If the concha is large it may obscure the view of the rest of
the nose. In this event the specialist may place a pledget of cotton-wool
soaked in 10 per cent^cocgjne hydrochloride against the concha to reduce
the oedema. This may succeed in an allergic swelling, but it may fail if the
enlargement is due to hypertrophy. It must be remembered that some persons
are sensitive to cocaine, and tend to become restless or excited, or with
greater absorption of the drug to become pale and sweating with a rapid
pulse and dilated pupils. In this event they should be advised to place their
head between their knees, or to lie flat.

The nasal septum is easily seen, and should be examined for deviation from
the midline, or dislocation, and the bleeding area should be inspected for
dilated blood vessels in the anastomotic area. If the inferior concha is not
enlarged the olfactory cleft and the middle concha will be seen, and occasion-
ally details of the middle meatus may be inspected.

Examination of the nose, apart from noting septal deflections, should be
directed to the colour of the mucous membrane, the width of airway in the
olfactory cleft, the presence or absence of nasal polypi, and the occurrence
and nature of any secretions.

Fig. 14. Posterior rhinoscopy.

Posterior rhinoscopy is essentially a specialist examination because it
demands a strong light source, and even in such hands it is not invariably
successful because of hypersensitivity of the pharynx. It is performed by
depressing the tongue with a spatula and passing a small mirror, angled on a
handle, below the soft palate. The mirror should be heated in the flame of a
spirit lamp so that it does not steam over from the moisture of the breath.
The patient is encouraged to relax and to breathe through his nose. The light
is directed into the mouth and on to the mirror from which it is reflected into