Tonsillar hypertrophy, macroglossia and oropharyngeal masses should be evaluated. Evaluation of the voice quality includes as assessment of nasality and clarity. Having the child to speak words that enhance nasality such as lemon, milkman, Mickey Mouse, ninety nine, bananas are normally nasal transmitted words and words such as baseball and Jack are normally non-nasal transmitted words. The ears should be evaluated as otitis media certainly is associated with nasal obstruction problems. Bony nasal anomalies, external masses, pits, etc. should be evaluated.
Anterior rhinoscopy is relatively easy to perform in a small child.
The otoscope with a large speculum is ideal for this purpose. The nasal speculum is rarely needed and may be uncomfortable and frighten the small child. The posterior nasal cavity may be seen with this technique if minimal anterior disease is present. Posterior rhinoscopy and nasopharyngoscopy will require a topical decongestant and local anesthetic and insertion of either a rigid telescope or flexible fiberoptic nasopharyngoscope in a cooperative child. This may be difficult to do younger than age 4.