Office-Based Diagnosis of Sinonasal Disorders

Introduction

Nasal endoscopy is integral to the physical examination of patients with sinonasal symptoms seeking management from the otolaryngologist. With proper local decongestion and anesthesia, it is possible to obtain excellent visualization of the nasal mucosal lining, middle meatus, inferior meatus, sphenoethmoid recess, olfactory cleft, turbinates, septum, and nasopharynx with minimal discomfort to the patient.

Anesthesia is accomplished with a variety of techniques, including atomizers using disposable nasal tips with the topical anesthetics 4% lidocaine or 2% tetracaine. Frequently a topical decongestant, such as oxymetazoline 0.05%, is added. These agents may also be used on cotton pledgets that are placed in the nose for 5 to 10 minutes until decongestion and anesthesia are achieved.

The examination is facilitated if there is access to small-caliber endoscopes, such as the 2.9-mm rigid Hopkins telescope ( Fig. 94.1 ). A 30-degree endoscope is typically most useful for office-based diagnosis of sinonasal disease. For patients who have had sinus surgery, a 70-degree endoscope can be helpful to visualize the frontal and maxillary sinuses. A video camera and high-definition monitors are a critical part of visualizing the examination. Video documentation with archiving can be helpful in monitoring the patient’s progress over time.

Fig. 94.1, A 2.9-mm 30-degree Hopkins telescope can be useful in performing a complete nasal endoscopy with minimal discomfort to the patient, especially in patients who have not had sinus surgery.

The following discussions (and accompanying videos) highlight some of the common disorders encountered in endoscopic diagnosis of the nose and sinuses.

Key Operative Learning Points

1.
Nasal endoscopy should be performed in a standardized manner and include examination of the nasal mucosal lining, middle meatus, inferior meatus, sphenoethmoid recess, olfactory cleft, turbinates, septum, and nasopharynx.
2.
Failure to inspect the nasopharynx will lead to inability to diagnose common disorders that mimic sinusitis (i.e., Thornwaldt cysts, hypertrophic adenoid tissue or tumors).
3.
In addition to anatomic description, the diagnostic examination evaluates the presence of mucopurulent drainage, presence of polyps, masses, and characteristics of the sinonasal mucosal lining.
4.
Vasculitic diseases should be considered if the mucosa is abraded or bleeding (i.e., granulomatosis with polyangiitis [GPA], formerly known as Wegener granulomatosis), as well as cocaine or intranasal opioid abuse.
5.
Sarcoidosis can present with cobblestone appearance of the mucosa with inflammation and edema refractory to decongestion.
6.
If the mucus is tenacious and appears to contain eosinophil by-products, send it for fungal cultures and stains to evaluate for possible allergic fungal sinusitis.
7.
Endoscopically obtained cultures can help to direct antibiotic therapy.

History

1.
History of present illness
- a.
  Determine symptoms that are most troublesome to the patient in order to best direct therapeutic recommendations.
- b.
  Patients with suspected chronic rhinosinusitis (CRS) should be questioned regarding symptoms of nasal obstruction, discolored drainage, facial pain/pressure, and loss of the sense of smell.
  - 1)
    Antibiotic and steroid treatment
  - 2)
    Imaging, if available
  - 3)
    Allergic rhinitis symptoms and, if positive, history of allergy testing and treatment
  - 4)
    Past surgical procedures, specifically endoscopic sinus surgery (ESS)
2.
Past medical history
3.
Social history
- a.
  Patients with allergic rhinitis should be asked about environmental exposures at work and home
- b.
  Occupation
- c.
  Tobacco history
4.
Family history
- a.
  Allergic rhinitis
- b.
  Asthma
- c.
  Nasal polyposis or cystic fibrosis

Physical Examination

1.
Proper topical decongestion and anesthetic should be administered before nasal endoscopy.
2.
A 30-degree Hopkins endoscope can be used to visualize all key landmarks in patients who have not had ESS. A 70-degree endoscope is helpful to visualize the frontal sinus osteum and the maxillary sinus in patients who have had ESS.
- a.
  First pass along the middle meatus with the endoscope angled at the 4-o’clock position. The light source can then be angled superiorly to visualize the olfactory cleft.
- b.
  Second pass visualizing the inferior meatus with the endoscope angled at 6-o’clock position and then toward the nasopharynx, passing the scope medial to the inferior turbinate. The light source can then be angled superiorly to visualize the sphenoethmoid recess superiorly.
3.
Examination of the cranial nerves can help to evaluate patients suspected of a sinonasal malignancy or a granulomatous process.

Imaging

Maxillofacial computed tomography (CT) scan is indicated in patients suspected of having the following:

1.
CRS
2.
Nasal polyposis
3.
Unilateral sinusitis
4.
Concern for malignancy
5.
Cerebrospinal fluid (CSF) rhinorrhea and associated skull base defect

Indications

Diagnostic nasal endoscopy is indicated in patients suspected of the following:

1.
Symptoms suggestive of CRS with or without polyposis
2.
Acute bacterial rhinosinusitis
3.
Unilateral symptoms
4.
Concern for malignancy

Contraindications

1.
Patients unable to tolerate rigid endoscopy; rare if adequate topical decongestion and anesthetic is used
2.
Patients with hereditary hemorrhagic telangiectasia (HHT) require caution when performing endoscopy and if actively bleeding or with packing in place; endoscopy and control of epistaxis is best done in the operating room.

Preoperative Preparation

1.
Topical anesthesia and decongestion should be administered before endoscopy (see section on Anesthesia).
2.
Patients should be positioned appropriately for endoscopy (see section on Positioning).
3.
Maxillofacial CT scan should be performed for patients with CRS, nasal polyposis, unilateral disease, CSF rhinorrhea/skull base defect, or any patient with concern for malignancy.
4.
It is helpful to turn off the overhead lights for optimal visualization of the monitor during the procedure.

Anesthesia

1.
Topical anesthesia can be accomplished with 4% lidocaine either via atomization into the nasal cavities or on pledgets.
2.
Use of 2% tetracaine can be helpful in patients who require in-office procedure, débridement, or inadequate anesthesia with topical lidocaine.
3.
Oxymetazoline is commonly added to the topical anesthetic to provide concomitant mucosal decongestion.

Positioning

Seated and reclined if possible with the patient head turned facing the physician. The patient, the screen, and the physician should be coaxial.

Perioperative Antibiotic Prophylaxis

None necessary

Monitoring

None necessary

Instruments and Equipment to Have Available

1.
Hopkins telescopes: 0-, 30-, 70-degree endoscopes. The 30-degree endoscope is the most popular scope, and, if available, a 2.9-mm scope allows for improved visualization of the sphenoethmoid recess and nasopharynx with minimal discomfort to the patient.
2.
Flexible endoscope for patients who cannot tolerate rigid endoscopy or when the floor or anterior wall of the maxillary sinus cannot be fully examined with a rigid endoscope.
3.
Topical decongestant and anesthetic. We prefer 4% lidocaine with oxymetazoline either on pledgets or via an atomizer. For patients who require débridement, biopsy, or in-office procedures, 2% tetracaine is preferred. The window of toxicity with tetracaine should be considered, with the use of doses not to exceed 100 mg.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here