Diagnostic nasal endoscopy

Ppt on Diagnostic Nasal Endoscopy (DNE), one of most important clinical investigation in ENT. Sourced from Medscape.

1. DIAGNOSTIC NASAL ENDOSCOPY Dr.Abam Fasal ENT PG II YEAR AL-AMEEN MEDICAL COLLEGE

2. INTRODUCTION Nasal endoscopy involves evaluation of the nasal and sinus passages with direct vision using a magnified high-quality view. It is a commonly performed procedure in the otolaryngologist’s office and serves as an objective diagnostic tool in the evaluation of nasal mucosa, sinonasal anatomy, and nasal pathology.

3. INTRODUCTION Nasal endoscopy may be accomplished with either a flexible fiberoptic endoscope or a rigid endoscope. When performed by experienced practitioners, both flexible endoscopy and rigid endoscopy are usually well tolerated.

4. INTRODUCTION The fiberoptic telescope has the advantage of being flexible and generally smaller in diameter, which means that it is readily manipulated in multiple directions to permit visualization of tight areas. However, flexible endoscopy requires 2 hands for manipulation of the instrument and is thus a more difficult procedure.

5. INTRODUCTION Traditionally, flexible endoscopy has provided inferior visualization, but this drawback has been overcome with the development of digital flexible endoscopes. The rigid endoscope provides superior image clarity, facilitates culture and tissue sampling, controls epistaxis better, and affords the endoscopist the ability to perform surgery.

6. INTRODUCTION Rigid endoscopes for the nose come in diameters of 2.7-4 mm and have tips of different angles (generally 0-70º), allowing the physician to visualize various sinuses and areas within the nasal cavity and sinuses. In addition to affording superior visualization, nasal endoscopy provides improved illumination, greater magnification, and the ability to navigate directly to pathologic areas.

7. INTRODUCTION In one study, rigid nasal endoscopy identified nasal pathology in almost 40% of patients who had normal examinations on anterior rhinoscopy. Endoscopy plays an important role in the preoperative, postoperative, and medical management of patients with sinonasal complaints .

8. INDICATIONS Nasal endoscopy has a clear role in the identification of sinonasal disease in patients presenting to the otolaryngologist's office. It should be viewed as an essential component of a complete examination of the nose and sinuses. Indications for nasal endoscopy include, but are not limited to, the following

9. INDICATIONS Initial identification of disease in patients experiencing sinonasal symptoms (eg, mucopurulent drainage, facial pain or pressure, headache, nasal obstruction or congestion, or decreased sense of smell) Evaluation of patient ’ s response to medical treatment (eg, resolution of polyps, purulent secretions, or mucosal edema and inflammation after treatment with topical nasal steroids, antibiotics, oral steroids, and antihistamines)

10. INDICATIONS Evaluation of unilateral disease . Evaluation of patients with complications or impending complications of sinusitis . Obtaining a culture of purulent secretions . Debridement and removal of crusting, mucus, and fibrin from obstructed nasal and sinus cavities after functional endoscopic sinus surgery .

11. INDICATIONS Evaluation for recurrence of pathology after FESS to (this is particularly valuable in monitoring for recurrence of intranasal tumors) . Evaluation and biopsy of nasal masses or lesions . Evaluation of the nasopharynx for lymphoid hyperplasia, eustachian tube problems, and nasal obstruction . Evaluation of cerebrospinal fluid (CSF) leak .

12. INDICATIONS To determine the effects of conditions such as severe allergies, immune deficiencies and mucociliary disorders (disorders that affect mucous membranes and cilia) . Evaluation and treatment of epistaxis . Evaluation of hyposmia or anosmia . Evaluation and treatment of nasal foreign bodies .

13. CONTRAINDICATIONS No absolute contraindications to nasal endoscopy exist; however, some patient populations are at increased risk for complications. In patients who have a history of a bleeding disorder or are receiving anticoagulants, nasal endoscopy should be performed carefully so as not to provoke bleeding.

14. CONTRAINDICATIONS Additionally, in an anxious patient or a patient with cardiovascular disease, there is a risk of a vasovagal episode.

15. TECHNICAL CONSIDERATIONS Nasal endoscopy and imaging are the 2 most widely used objective measures in the diagnosis of chronic rhinosinusitis (CRS). Endoscopy has multiple uses in the management of patients with sinonasal symptoms and plays an important role in both the preoperative and postoperative management of patients.

16. TECHNICAL CONSIDERATIONS The Lund-Kennedy endoscopic scoring system quantifies the pathologic states of the nose and paranasal sinuses, focusing on the presence of polyps, discharge, edema, scarring, or adhesions and crusting. Endoscopic staging is performed bilaterally and typically takes place during the initial evaluation, preoperatively, and postoperatively at regular intervals (intervals of 3, 6, 12, 24, and 36 months are recommended).

17. TECHNICAL CONSIDERATIONS Lund-Kennedy scores range from 0 to 20. Polyps are graded as absent (0), present in the middle meatus (1), or present beyond the middle meatus (3). Discharge is graded as not present (0), thin (1), or thick and purulent (2). Edema, scarring, and crusting are each graded as absent (0), mild (1), or severe (2).

18. TECHNICAL CONSIDERATIONS Interrater agreement studies examining the reliability of the Lund-Kennedy endoscopic scoring system demonstrate that in a high proportion of cases, 2 independent observers agree on the examination findings. The addition of nasal endoscopy to the care of patients with CRS has resulted in improved diagnostic accuracy.

19. TECHNICAL CONSIDERATIONS In combination with established symptom criteria, endoscopic findings improve the specificity, positive predictive value, and negative predictive value of assessment for CRS. This development suggests that the use of diagnostic endoscopy may help decrease the need for computed tomography (CT) and reduce costs and radiation exposure.

20. TECHNICAL CONSIDERATIONS Ferguson et al in their 2012 study found that the sensitivity of nasal endoscopy was 24% and the specificity was 100%, with the finding of mucopurulence only present in those patients with positive CRS on CT. Diagnostic endoscopy has also proven to be an integral aspect of staging for allergic fungal sinusitis (AFS). Kupferberg-Kuhn created 4 stages of disease for AFS on the basis of findings from nasal endoscopy.

21. TECHNICAL CONSIDERATIONS E ndoscopy is also considered the criterion standard for tissue sampling and culture collection when performed properly. Traditionally, inferior meatal puncture was the diagnostic method used to identify pathogens in sinusitis .

22. TECHNICAL CONSIDERATIONS S tudy results have documented a greater than 90% correlation between endoscopically obtained cultures and maxillary sinus aspirates, making endoscopically guided cultures the current criterion standard. 90% of the specimens collected by nasal endoscopy resulted in a culture with 2 or fewer bacterial isolates, and 55% of these contained a single isolate. These results are superior to those obtained by means of a nasopharyngeal swab.

23. EQUIPMENT 4 mm 0 and 30" sinuscopes 2.7 mm 0° and 30" sinuscopes in cases of children and narrow nasal cavity Freer's elevator Suction cannula Biopsy forceps Antifog solution/savlon to avoid fogging.

24. EQUIPMENT Rigid endoscopes are made in various angles (eg, 0º, 30º, 45º, and 70º). The angled telescopes are used to see around corners and to evaluate areas not easily examined under direct vision. The 4 mm 30º scope has been shown to provide sufficient illumination and an adequate field of vision and may therefore be the most useful telescope in an average patient.

25. EQUIPMENT Nasal endoscopes also come in pediatric sizes (2.7 mm), which are also available in various angles and which may be used for increased comfort in adults. The use of video systems has become increasingly popular in nasal endoscopy.

26. EQUIPMENT Minimum requirements for basic nasal endoscopy include an endoscope, a high-quality light source and light cable, and a suction device to clear secretions. In addition, sinus instruments (eg, a Freer elevator, a Blakesley forceps, or a through-cutting instrument for obtaining biopsy specimens) can be useful for performing procedures.

27. PATIENT PREPARATION Patient preparation includes adequate anesthesia and appropriate positioning Anesthesia Before nasal endoscopy, nasal cavities are often sprayed with a nasal decongestant, such as oxymetazoline.

28. PATIENT PREPARATION It is sometimes useful to performing endoscopy without decongestion, however, particularly for patients with presumed turbinate hypertrophy, in whom it is worthwhile to perform endoscopy before and after decongestion. In certain patients, especially those who will be undergoing a surgical procedure, local anesthesia is employed as well; lidocaine 4% is a commonly used topical anesthetic.

29. PATIENT PREPARATION When cultures are indicated, however, anesthetics should be avoided so as to provide the best chances of bacterial growth on the swab medium. Anesthetics are typically applied either with a spray atomizer or directly on a cotton pledget.

30. PATIENT PREPARATION The topical anesthetic should be applied to the inferolateral surface of the middle turbinate, to the surface of the inferior turbinate, and to any other sites where pressure may be exerted by insertion of the scope. About 7 ml of 4% xylocaine is mixed with 10 drops of xylometazoline. Cotton pledgets are dipped in the solution, squeezed dry and used to pack the nasal cavity.

31. PATIENT PREPARATION Pledgets are packed in the inferior, middle and superior meati. Packs are left in place for full 5 minutes.  

32. PATIENT PREPARATION Positioning During the endoscopic examination, patients should be seated upright in the examination chair. The patient’s head can be manipulated as needed to afford better viewing of the nasopharynx or the olfactory cleft area. Procedure can be done in lying down patient also

33. TECHNIQUE After applying a nasal decongestant and, occasionally, a local anesthetic to the nasal cavities, the endoscope is introduced. Typically, a 3 mm or 4 mm 0º or 30º scope is selected first, and an antifog solution is applied before its introduction into the nasal cavity. The examiner then performs 3 separate passes of the scope in each nasal cavity.

34. TECHNIQUE With each pass, the appearance of the nasal mucosa and the structures of the nasal cavity are examined. In particular, the examiner notes the color of the nasal mucosa (pale vs hyperemic), the presence of inflamed or hypertrophic mucosa, the presence of nasal polyps or secretions (purulent, thick, or thin), and any visible anatomic abnormalities (eg, a septal deviation or spur, concha bullosa, or accessory ostia).

35. TECHNIQUE For thorough and complete examination, the scope is passed through the standard three paths. The examination is conducted while inserting and withdrawing the scope. First pass Second pass Third pass

36. FIRST PASS The 0 endoscope (or 30 ) is passed along the floor of nasal cavity between inferior tubinate and septum. Septum – mucosa , spur or deviations. Inferior turbinate.

37. FIRST PASS Posterior choana. Posterior wall and roof of nasopharynx. Eustachian tube & fossa of rosenmullar. Inferior meatus – nasolacrimal duct opening.

38. SECOND PASS Scope is passed along the floor upto posterior choana and then moved upward medial to the middle turbinate along the roof of posterior choana. Superior turbinate and meatus. Sphenoethmoidal recess.

39. SECOND PASS Sphenoid ostium lies 1- 1.5 cm above the roof of posterior choana. Below ostium at the roof of posterior choana is mesh of blood vessels – woodruf’s plexus . The septal branch of sphenopalatine artery runs across anterior wall of sphenoid.

40. THIRD PASS Examine middle meatus. Gently retracting middle turbinate with freer’s elevator or advance scope posteriorly and roll the scope under inferior border of the middle turbinate to enter posterior roomy part and withdrawn from posterior to anterior .

41. THIRD PASS Uncinate process Bulge of bulla seen behind uncinate process. Groove btw these two – hiatus semilunaris . Palpated with ballpoint goes into infundibulum.

42. COMPLICATIONS OF PROCEDURE Overall, rigid nasal endoscopy is a safe and low-risk procedure. Potential complications associated with the procedure include an adverse reaction to the topical decongestant or anesthetic, pain or discomfort, epistaxis, and vasovagal episodes. Before the topical medications are administered, the patient’s allergies should be verified.

43. COMPLICATIONS OF PROCEDURE In patients at increased risk for bleeding (eg, those with a family history or personal history of bleeding disorders and those currently receiving anticoagulants), care must be taken; nasal hemorrhage secondary to mucosal trauma may occur. Additionally, nasal biopsies obtained in these patients may result in a significant degree of hemorrhage.

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