The most common symptoms at the time of presentation include dyspnea on
exertion, palpitations, hemoptysis, or chest pain. Patients presenting
with epistaxis, GI tract bleeding, hematuria, or neurologic symptoms
should be evaluated for coexisting OWRD. As many as 75% of patients
may have cyanosis, clubbing, pulmonary vascular bruits, or systolic
murmurs on physical examination. Careful auscultation can detect
murmurs that can be intensified by inspiring against a closed glottis
(Müller’s maneuver) and alleviated by the Valsalva maneuver.
Ear, nose, and throat examination may confirm the diagnosis of OWRD by
demonstrating the presence of nasopharyngeal or oral mucosal
telangectasias. Neurologic symptoms, including headaches, confusion,
dizziness, syncope, and cerebral vascular accidents may arise from the
associated hypoxia and secondary polycythemia or paradoxical emboli.
Brain abscesses, probably caused by paradoxical septic emboli, have
also been reported.