Diagnosis And Nasal Endoscopy In The Evaluation Of The Sinus Disease

The history  of examination of the nose dates  from the Egyptian and Indian ancient times of Sushruta (500 BC) However, the commonly used  nasal speculum was  designed and developed by John Louis William Thudichum in 1829 a German born physician and Biochemist. By the late 19th century  in 1880  Zanfal  tried to examine nasopharynx. Later on various physicians tried to innovate specula to examine the various parts of the nose as shown.The thudicum speculation  has been used to examine the nose in recent years which allowed very limited view of the  front of the nasal cavity let alone middle and posterior part of the nasal cavity. However,since the advent of  better illumination and wide angle panoramic scopes became  available which has made a great leap forward  in the thorough examination and the diagnosis of the nose and sinus pathology.

Tools for nasal endoscopy- various endoscopes are now available as illustrated

We described systematic examination of the nasal cavity as published in Clinical Otolaryngology in Editorial, (1992 a)  No.17, 193-194

Commonly used scopes are 4mm 0, 25 or 30 degree and 2.7 mm for older children and adults with some deviation of the nasal septum

In addition to the understanding of the mucociliary mechanism of the para nasal sinuses in recent years and its implication to the treatment of tackling the sinus disease mainly to the OMC, the advent of multi angled endoscopes has been a great revolution in the diagnosis of the sinus disease. Any surgeon is first a clinician and a  precise diagnosis of the sinus disease  is  mandatory for the successful  outcome of the disease and causing least discomfort to our patients.

A  systematic examination can be accomplished in  3 “passes” to evaluate either  the health or a diseased state of the sinuses.

The examination is performed in an outpatient sitting with a 4 mm 0 or 30 degree endoscope. 

We have not found necessary to use local anaesthetic prior to the examination but in a “nervous” patient this can be done with   pledgets   of merocele or  sterile  cotton wool  soaked in local anaesthetic  solution and WELL Quizzed.  We very occasionally use local anaesthetic to examine the 3rd.pass which is between the upper part of the septum and superior turbinate. In a majority of the patients using 30 degree scope and rotating it 180 degree will allow the examination of the spheno ethmoidal recess in 3rd. pass. 

 

It is useful to inform the patient what is involved in this nasal examination, as some patients get a bit “nervous” seeing long instruments going into the nose !  

THE most important aspect of the nasal endoscopy is to pass scope in  the cavity of the nose NOT touching the septum or the lateral wall of the nose. It is also advisable to steady the patient  with the examiner’s four fingers and the thumb used as a fulcrum  (as shown) to steady the gentle movement of the scope. This is something one can achieve with routine practice in a short time.

3 passes of nasal endoscopy

1st Pass – the scope is gently  negotiated along the  floor of the nose examining   inferior meatus in case a patient had previous surgery to the maxillary sinus. Gliding slowly the scope is now advanced towards the post nasal space examining the E. tube  ,the cascade of mucus or mucous if any, whether  in front of  or  behind the E.tube which will signify which group of sinuses are affected.
The scope is then slowly withdrawn.

The 2nd pass – This is the most important pass as it examines the osteo meatal complex as follows.

Identify the uncinate process, assess whether it is medially or laterally rotated or any pathology on the thickening of the mucosa or polyps.

Pass the scope gently between middle turbinate and the lateral wall of the nose to assess middle meatus, bulla ethmoidalis, hiatus semilunaris, any accessory ostium which looks like a “punched out” hole in the sagittal plane of lateral wall of the nose. identify any mucopus coming out at the lower end of the hiatus semilunaris ie, from the natural ostium of the maxillary sinus or any other pathologies ie, polyps, fungus etc.

The 3rd.pass – for 3rd.pass withdraw the scope slightly  and gently pass between the septum and the superior turbinate to assess the spheno ethmoidal recess, many times simply rotating a 30 or 25 degree scope one can assess the recess. This is not an easy pass but needs gentle movements of the scope, a 2.7 mm scope which is much smaller in  diameter can enhance the scope of viewing this  area. Occasionally a small cotton wool  or a merocel  pack can be inserted in this area to make the examination easier. Note any pathologies in the spheno ethmoidal recess.

Following are various clinical examples of the findings of the nasal endoscopy