Nasal endoscopy

1. Nasal endoscopy
Equipment
1)The most commonly used endoscope for nasal examination is the 4.0mm,30
0
rigid scope.
In adults with narrow nasal passages or in children a 2.7mm, 30
0
rigid endoscope or a flexible
nasopharyngoscope may be better tolerated.
45
o
or 70
0
are used to view more difficult areas of maxillary & frontal sinuses especially tumour
surveillance.
2)A high intensity light source.
3) Straight & curved suction tips,
4)Flexible metal cotton-tipped applicators ,
5) Straight & upbiting forceps,
Topical decongestant & antifog solution.
Technique
Preparation :
To explain the procedure to the patient, it will help the patient to relax & co-operate with the
examiner.
A nasal speculum & head light to perform the Anterior rhinoscopy.
Nasal endoscopy can be performed either sitting or supine position
General principles
All attempt should be made as atraumatic as possible.
Telescope is held lightly in the left hand using thump& first two fingers & introduced under direct
vision.
Avoid of forceful contact & abrasion of the nasal mucosa.
Several clues can alert the examiner
1)Progressive collection of mucus on the edge of the scope indicates the tip is embedding
into adjacent mucous membrane.
2)The mucous membrane may blanch indicating direct pressure from scope tip or about to
contact .

2. 3)2.7mm endoscope is bent excessively, they develop a grey or black meniscus along the
periphery of the endoscopic view.
First pass
The first pass is along the floor of the nose,the inferior meatus is the first area to inspect. If inferior
meatus is too narrow,medialize of the turbinate by freer elevator.once adequate access is
established the examiner will see the nasolacrimal duct. Tear may be seen by gentle pressure over
the lacrimal sac.
After inspection of the inferor meatus, the scope is advanced through the nasal cavity towards
nasopharyx.the eustachain tube orifices, torus tubarius, adnoid pad (if present) & entire
nasopharynx can be visualised by rotating a 30
0
endoscope.
Secretions originating from the osteomeatal complex will typically drain below the Eustachian tube
orifice while those coming from the posterior ethmoid or sphenoid sinuses will pass above the torus
tubaris. The effect of the palatal musculature on the ET orifice can also be visualised by having
swallow at this point in the examination.
Second pass
The examination progresses superiorly as the endossope is reinserted between the superior &
inferior turbinates. The sphenoethmoidal recess is visualised by passing the scope medial to
posterior aspect of the middle turbinate& rotating it superiorly. Also able to see superior turbinates
& the natural sphenoid os.(examination of this area may require multiple applications of topical
decongestants & may require the use of a 2.7mm 45 or 70
o
endoscope.)
Third pass
Final portion of examination occurs while withdrawing the endoscope. The scope is rotated laterally
beneath the middle turbinates to gain access to the deeper areas of the middle meatus .
visualization of the bulla, hiatus semilunaris, infundibular entrance is obtained, uncinate process &
its overlying mucosa is obtained as the scope is withdrawn even further.
Clinical uses of nasal endoscope
1)Inflammatory disease
2)Neoplastic disease
3) Skull base defect
4)Epistaxis
5) Opthalmologic procedures.
Inflammatory disease
1)Nasal endoscope can evaluate & treat the inflammatory diseases of the paranasal sinuses.
2)Meticulous examination can detect subtle change such as mucosal hypertrophy,inflammation,

3. erythaemia, & pathological secretions, long before such changes become apparent on radiographic
studies.
3) Endoscopic examination of the osteomeatal complex may help in determining the anatomic or
mucasal abnormalities that can contribute to the development of chronic rhinosinusitis.
4) Endoscopic is helpful in differentiating between inflammatory disease that may be due to
allergies, autoimmune disease, & infectious aetiologies.
5) Cultures can be taken directly from the involved sinus using a sterile calcium alginate-tipped
applicator.
Endoscope &CT
The CT scan provides objective information about the condition of the sinuses ,often in sites that are
impossible to visualize endoscopically.
1)CT provides one data point in time.The clinical course of chronic rhinosinusitis patients are a
dynamic one with alternating periods of quiescence & exacerabations.
2) CT provides information regarding mucosal hypertrophy & retained secretions,It does not
provide information regarding mucosal atrophy & erythaema.
3)CT may not be able to differentiate between secretions, mucosal thickening, polyps or mass
lesions the cause of sinus opacification.
4)CT provides little information regarding the type of inflammatory disease present such as
allergic fungal rhinosinusitis, invasive fungal rhinosinusitis, bacterial rhinosinusitis,or nasal
polyposis.
5)CT more likely to miss synchiae, septal deformities& subtle mucosal change that can be
detected with endoscope.
Neoplastic disease
Nasal endoscope clearly provides visualization &biopsy of intranasal neoplastic lesion with a degree
of precision that was previously impossible.
Neoplasm of all paranasal sinuses, inverted papilloma, juvenile angiofibroma,fibro-osseous lesion,
pituitary gland, anterior & lateral skull base & clivas can now be treated with endoscope.
Skull base defects
Solitary polyp ,particularly those arising from medial to the middle turbinate , should raise suspicion
of the possibility of a meningococle or meningoencephalococle.
In cases of gross of CSF rhinorrhoea, nasal endoscopy without the use of inthrathecal dye may allow
identification of the leak site. However, in many cases, the use of an inthrathecal dye may be
required. One tenth of one cc of 10% fluorescein administered in 10cc of the patient’s own CSF over
5 minutes period is recommeneded. The patients can then be placed in a head down position for
one to two hours to allow the fluorescein to circulate intracranially. Endoscopic examimation is then

4. performed, initially with a standard white, if this does not demonstrate the leak, with a blue light & a
blocking filter. Blue light endoscope & with a blocking filter is extremely sensitive for the presence of
CSF leak.
Epistaxis
Nasal endoscope is essential in the evaluation & treatment of the epistaxis patient. The site of orgin
can then be determined & neoplastic source can be ruled out. Most cases can be treated with
cautery or gelfoam.
Severe cases, may require either endoscopic ligation of sphenopalatine artery or internal maxillary
arteries or embolization.
Ophthalmological procedures
Orbital decompression dacrocystorhinostomy,optic nerve decompression & medial orbital wall
blowouts can all be treated endoscopically.
Best clinical practice
Nasal endoscopy is critical in the evaluation & treatment of patients with inflammatory, neoplastic
or bleeding disorders.
Endoscopy &CT scan are complimentary studies & should be frequently correlated during clinical
evaluation & surgical treatment of paranasal sinus diseases.