Rhinoscopy / Nasal Endoscopy

Author Credentials 

Jarrett E. Walsh, MD, PhD
Fellow and Clinical Instructor
Department of Otolaryngology Head and Neck Surgery
University of Miami Miller School of Medicine
Miami, FL

Module Summary

Rhinoscopy / endoscopy is a critical component of the overall head and neck exam. This procedure is particularly important in any patients with nasal complaints or headaches. A variety of inflammatory, vascular, and neoplastic conditions affecting the nose and paranasal sinuses can only be diagnosed at early stages in this manner. The extent of disease as determined endoscopically, and further defined radiologically, will help in the planning of a definitive treatment.

Module Learning Objectives 
  1. Utilize a working knowledge nasal and paranasal sinuses anatomy to perform an endoscopic exam.
  2. Discuss indications, limitations, and complications associated with rigid and flexible nasal and paranasal sinus endoscopy.
  3. Identify equipment needed to conduct a thorough endoscopic examination.
  4. Recognize normal anatomic variants in the pre- and post-operated nasal cavity.
  5. Diagnose inflammatory conditions, benign and malignant neoplasms affecting the nose and paranasal sinuses by findings on endoscopic exam.

Embryology

Learning Objectives 

Describe the embryology of the lateral nasal wall and paranasal sinuses.

References 
  1. Wise SK, Orlandi RR, DelGaudio JM. In: Kennedy DW, Hwang PH, editors. Rhinology: Diseases of the Nose, Sinuses and Skull Base. 1st ed. Thieme; 2012:1-20.
  2. Stammberger H. Functional endoscopic sinus surgery. Philadelphia: B.C. Decker; 1991:54-59.

Anatomy

Learning Objectives 

Assess normal anatomy of the unoperated nasal cavity and the expected post-surgical anatomy of the operated sinus cavities

  1. Identify the bony structures, clefts, and spaces of the lateral nasal wall, including:
    1. Head and lamella of the inferior turbinate
    2. Nasolacrimal apparatus and inferior meatus
    3. Osteomeatal complex/middle meatus
    4. Uncinate process
    5. Hiatus semilunaris
    6. Ethmoidal infundibulum
    7. Ethmoidal bulla and lateral sinus
    8. Sinus lateralis
    9. Frontal recess
    10. Anterior and posterior fontanelle areas
    11. Head and ground lamella of the middle turbinate
  2. Identify the bony structures, clefts, and spaces of the sphenoethmoidal recess, including:
    1. Superior and supreme turbinates and their ground lamellas
    2. Drainage pathways for the sphenoid and posterior ethmoid sinuses
  3. Identify the olfactory cleft and cribriform plate.
  4. Recognize the normal anatomy of operated sinus cavities, including:
    1. Maxillary sinus
    2. Posterior ethmoid sinus and posterior ethmoid artery
    3. Sphenoid sinus
    4. Optic nerve
    5. Carotid artery
    6. Pituitary fossa
    7. Anterior ethmoid sinus and the anterior ethmoid artery
    8. Frontal ostium and sinus cavity
References 
  1. Wise SK, Orlandi RR, DelGaudio JM. In: Kennedy DW, Hwang PH, editors. Rhinology: Diseases of the Nose, Sinuses and Skull Base. 1st ed. New York: Thieme; 2012:1-20.
  2. Simmen D, Jones N. Manual of Endoscopic Sinus Surgery and its Extended Applications. 1st ed. Stuttgart: Theime; 2005:106-120.
  3. Casiano RR. Endoscopic sinus surgery dissection manual: a stepwise, anatomically based approach to endoscopic sinus surgery. New York: Marcel Dekker; 2002.
  4. Levine HL, May M, Rontal M, et al. Complex anatomy of the lateral nasal wall: simplified for the endoscopic sinus surgeon. In: Levine HL, May M, editors. Rhinology and sinusology. New York: Thieme; 1993:1-26.
  5. Stammberger H. Functional endoscopic sinus surgery. Philadelphia: B.C. Decker; 1991:60-87.

Patient Evaluation

Learning Objectives 
  1. List the proper equipment necessary to conduct a thorough endoscopic examination of the nose and paranasal sinuses and perform minor office-based procedures, including:
    1. Light source
    2. Optical instruments
    3. Photographic documentation
    4. Surgical instrumentation
  2. Discuss the indications, limitations, potential complications, and technique of rigid and flexible fiberoptic endoscopy of the nose and paranasal sinuses such as:
    1. Patient preparation and positioning
    2. Topical anesthesia and decongestant
    3. Endoscopic technique and exam sequence
      1. Rigid or flexible endoscopic rhinoscopy
        • Inspection of the nasal vestibule, the nasopharynx, and inferior nasal meatus
        • Examination of the sphenoethmoidal recess and superior nasal meatus
        • Examination of the middle meatus
    4. Endoscopic examination of the maxillary sinus
      1. Inferior meatal approach
      2. Canine fossa approach
    5. Endoscopic examination of the frontal sinus through the anterior wall; trephination technique
    6. Endoscopic examination of the sphenoid sinus through the natural or surgically created ostium area through the sphenoethmoidal recess
  3. Endoscopically diagnose a variety of specific and nonspecific inflammatory conditions, vascular lesions, and benign and malignant neoplasms affecting the nose and paranasal sinuses:
    1. Common inflammatory conditions
      1. Acute and chronic rhinosinusitis
      2. Allergic rhinitis
      3. Rhinitis medicamentosum
      4. Granulomatosis with polyangiitis
      5. Sarcoidosis
    2. Nasal polyposis
    3. Choanal polyp
    4. Vascular lesions
      1. Telengiectasias
      2. Varices
    5. Benign and malignant neoplasms
    6. Source of bleeding in patients with epistaxis.
References 
  1. Simmen D, Jones N. Manual of Endoscopic Sinus Surgery and its Extended Applications. 1st ed. Stuttgart: Theime; 2005:106-120.
  2. AlHaddad S. Anesthesia for endoscopic sinus surgery. In: Levine HL, May M, editors. Endoscopic Sinus Surgery. New York: Thieme; 1993:91-102.
  3. Dolen WK, Selner JC. Upper airway endoscopy. In: Gershwin ME, Incaudo GA, editors. Diseases of the sinuses. Towata (NJ): Humana Press; 1996:477-85.
  4. Draf W. Endoscopy of the paranasal sinuses. Berlin: Springer-Verlag; 1983:4-27.
  5. Draf W. Endoscopy of the paranasal sinuses. Berlin: Springer-Verlag; 1983:70-95.
  6. Messerklinger W. Endoscopy of the nose. Baltimore (MD): Urban and Schwarzenberg; 1978:2-6.
  7. Messerklinger W. Endoscopy of the nose. Baltimore (MD): Urban and Schwarzenberg; 1978:19-54.
  8. Stammberger H. Functional endoscopic sinus surgery. Philadelphia (PA): B.C. Decker; 1991:232-45.

Measurement of Functional Status

Learning Objectives 
  1. Correlate patient impact of the disease process to endoscopic findings with accepted outcome instruments
    1. Sinonasal Outcome Test (SNOT)-22
    2. Visual Analog Scale for nasal obstruction
References 
  1. Hopkins C, Gillett S, Slack R, Lund VJ, Browne JP. Psychometric validity of the 22-item Sinonasal Outcome Test. Clin Otolaryngol. 2009;34:447-454.

Imaging

Learning Objectives 

Effectively utilize adjunctive imaging studies (including computed tomography and/or magnetic resonance imaging) to complement the endoscopic evaluation of the nose and paranasal sinuses in symptomatic patients, when indicated.

Pathology

Learning Objectives 

Distinguish the histologic appearance of important endoscopically identified inflammatory and neoplastic processes:

  1. Chronic Rhinosinusitis
  2. Inflammatory nasal polyp
  3. Allergic Fungal Sinusitis
  4. Invasive Fungal Sinusitis
  5. Inverted papilloma
  6. Squamous cell carcinoma
  7. Juvenile nasal angiofibroma
  8. Mucosal melanoma
References 
  1. Montone KT, LiVolsi VA. Inflammatory and Infectious Lesions of the Sinonasal Tract. Surg Pathol Clin. 2017;10(1):125-154.
  2. Purgina B, Lai CK. Distinctive Head and Neck Bone and Soft Tissue Neoplasms. Surg Pathol Clin. 2017;10(1):223-279.
  3. Williams MD. Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumors: Mucosal Melanomas. Head Neck Pathol. 2017;11(1):110-117.
  4. Vorasubin N, Vira D, Suh JD, Bhuta S, Wang MB. Schneiderian papillomas: comparative review of exophytic, oncocytic and inverted types. Am J Rhinol Allergy. 2013;27(4):287-292.
  5. Lewis JS. Sinonasal Squamous Cell Carcinoma: A Review with Emphasis on Emergic Histologic Subtypes and the Role of Human Papillomavirus. Head Neck Pathol. 2016;10(1):60-67
  6. Hellquist HB. Nasal polyps update. Histopathology. Allergy Asthma Proc. 1996;17(5):237-242.

Treatment

Learning Objectives 
  1. Perform endoscopic biopsy of lesions or culture of purulence in the nose and paranasal sinuses.
  2. Perform endoscopic control of epistaxis.
  3. Perform office-based procedures as applicabl
References 
  1. Bolger WE, Kennedy DW. Surgical complications and postoperative care. In: Kennedy DW, Bolger WE, Zinreich SJ, editors. Diseases of the sinuses, diagnosis and management. Hamilton (Ontario): B.C. Decker; 2001:308-9.
  2. Joe SA, Bolger WE, Kennedy DW. Nasal endoscopy: diagnosis and staging of inflammatory sinus disease. In: Kennedy DW, Bolger WE, Zinreich SJ, editors. Diseases of the sinuses, diagnosis and management. Hamilton (Ontario): B.C. Decker; 2001:119-28.
  3. Thamboo A, Patel ZM. Office Procedures in Refractory Chronic Rhinosinusitis. Otolaryngol Clin North Am. 2017 Feb;50(1):113-128.
  4. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Pharmacology

Learning Objectives 
  1. Identify appropriate topical anesthetic and vasodilatory medications used to improve patient comfort and aid in visualization during endoscopy
    1. Oxymetazoline
    2. Phenylephrine
    3. Tetracaine
    4. Lidocaine

Staging

Learning Objectives 

Describe the currently available clinical staging modalities for chronic rhinosinusitis.

References 
  1. Bolger WE, Kennedy DW. Surgical complications and postoperative care. In: Kennedy DW, Bolger WE, Zinreich SJ, editors. Diseases of the sinuses, diagnosis and management. Hamilton (Ontario): B.C. Decker; 2001:308-9.
  2. Joe SA, Bolger WE, Kennedy DW. Nasal endoscopy: diagnosis and staging of inflammatory sinus disease. In: Kennedy DW, Bolger WE, Zinreich SJ, editors. Diseases of the sinuses, diagnosis and management. Hamilton (Ontario): B.C. Decker; 2001:119-28.
  3. Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryngol Head Neck Surg. 1997; 117(3 Pt 2):S35-40.

Case Studies

  1. A 40-year-old female nonsmoker presents with progressive unilateral nasal obstruction and blood-tinged mucous for a three-month duration. Endoscopic evaluation of the nose reveals a friable irregular nasal mass filling the middle meatus.
    1. Neoplasm should be suspected when the lesion is unilateral. The most common benign neoplasm is an inverted papilloma. The most common malignant neoplasm is a squamous cell carcinoma.
    2. A biopsy and imaging studies will allow a definite diagnosis and an appropriate treatment plan.
  2. A 36-year-old male presents with a six-year history of bilateral nasal obstruction and intermittent discolored secretions. He also reports a history of severe allergies and asthma. Endoscopic exam reveals nonfriable, pinkish-pale, masses, filling most of the nasal vault bilaterally.
    1. Nasal polyps are the most likely diagnosis. A definite biopsy can be performed if there is any doubt.
    2. Extensive medical therapy directed at the chronic inflammatory process should be attempted before contemplating surgical options.
    3. Endoscopically directed cultures are encouraged to guide antimicrobial therapy if purulence is present. In geographically at-risk areas, suspect allergic fungal sinusitis.
  3. A 75-year-old male with history of tobacco abuse, cardiovascular disease and COPD, requiring supplemental oxygen, presents with frequent episodes of epistaxis. Endoscopic exam identifies dry nasal mucosa and prominent superficial vessels along a septal spur.
    1. Epistaxis is frequent in the elderly as nasal mucosa dries with age.
    2. Patients requiring nasal oxygen supplementation or have significant septal deviations or spurs are at an increased risk of epistaxis due to excessive drying of the nasal mucosa. Control can be exacerbated by chronic hypertension and anticoagulants frequently taken in patients with cardiovascular disease.
    3. Endoscopic evaluation of the source of bleeding and subsequent cauterization is key in management

Complications

Learning Objectives 

Understand that an endoscopic examination of the nose rarely results in complications. Following are the most common complications:

  1. Epistaxis may occur secondary to inadvertent trauma to normal nasal structures by the endoscope. The presence of inflammatory disease or neoplasm in the nose may also predispose the patient to epistaxis during a routine endoscopic examination.
  2. A vasovagal reaction may rarely occur. It tends to occur more frequently in recently operated (sinus surgery) patients. A patient with a known history of fainting during previous endoscopic examinations may be examined in a recumbent position.
  3. Pain and discomfort:
    1. Trigeminal neuralgia or migraine headaches may be triggered in select patients with a history of these disorders.
    2. Pain may also result from poorly administered anesthesia or from anatomic limitations (e.g., septal deviation, enlarged turbinates, or an obstructive nasal mass making the introduction of a rigid endoscope difficult).
  4. Rebound rhinitis and nasal obstruction because of inferior turbinate congestion may occur after administration of topical decongestants during routine rhinoscopy. This is typically seen in allergic patients. Oral and topical corticosteroids as well as oral antihistamine/decongestants may be necessary if this occurs.
  5. Temporary aspiration of secretion and coughing may rarely occur because of the use of topical anesthetics. This problem is usually self-limiting once the anesthesia wears off.
  6. Laryngeal spasm occurs rarely in patients who undergo flexible fiberoptic nasolaryngoscopy. When this occurs, it usually is of a very short duration (seconds). Controlled breathing and reassurance is all that is necessary in most patients.
References 
  1. Bolger WE, Kennedy DW. Surgical complications and postoperative care. In: Kennedy DW, Bolger WE, Zinreich SJ, editors. Diseases of the sinuses, diagnosis and management. Hamilton (Ontario): B.C. Decker; 2001:308-9.

Review

Review Questions 
  1. List the necessary equipment for performing an intranasal endoscopic examination.
  2. Discuss the appropriate technique (including patient positioning and anesthesia) for intranasal endoscopy with a rigid or a flexible fiberoptic endoscope.
  3. List the potential complications from intranasal endoscopy.
  4. Endoscopically identify normal intranasal structures, as well as normal anatomic variants of these structures, in an unoperated nose.
  5. Endoscopically identify the anatomy of the sinus cavities and approximate location of adjacent neurovascular structures in an operated nose.
  6. Endoscopically identify common inflammatory, vascular, and neoplastic lesions in the nose, nasopharynx, and paranasal sinuses.
Resources 

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