Rhinologic Evaluation in Orbital and Lacrimal Disease

Sinonasal Examination

Examination and palpation of the external nose shows deformities and crepitation and confirms soft-tissue or firm masses. Transillumination of the frontal and maxillary sinuses is an unreliable maneuver. Anterior rhinoscopy can assess the anterior septum and inferior turbinates but rarely provides the entire picture. Tests of olfaction, nasal airflow, or mucociliary flow are rarely indicated in orbital or lacrimal disease. The most important rhinologic examination technique is performed via endoscopy. Endoscopic examination reveals the full range of pathology within the nasal cavity and provides a strong indication of problems within the sinuses as they may relate to the orbit.

Rigid nasal telescopes provide an excellent view of the nasal structures but, depending on the size of the scope, may be difficult to maneuver into certain areas such as the sphenoethmoidal recess. Angled scopes (e.g., 30 degrees, 45 degrees) may help in visualization, or alternatively a flexible nasolaryngoscope may be used. With modern versions of the flexible scope, such as with the camera in the tip of the scope, excellent views of sinonasal anatomy and pathology can be obtained with less discomfort for the patient compared with rigid telescopes.

For endoscopic evaluation, some clinicians use no topical pretreatment. Others prefer some combination of a topical vasoconstrictor and/or local anesthetic. It is helpful to view the mucosa before decongestion to assess swelling and color. Although color and swelling per se are not specific to any disease, the presence of granular, friable mucosa should raise the suspicion of an underlying granulomatous process such as sarcoidosis or granulomatosis with polyangiitis.

After decongestion, a better assessment into the inferior meatus, middle meatus, and sphenoethmoidal recess can be obtained. A systematic approach is advisable so as not to miss anything. Classically three passes with a rigid 30-degree endoscope were described by Stammberger and Wolf, including passes along the nasal floor, middle meatus, and sphenoethmoidal recess. Regardless of which approach is used, the examiner needs to carefully assess the septum, inferior meatus, middle meatus, sphenoethmoidal recess, and the area of the cribriform plate and then repeat the examination on the contralateral side. The nasopharynx, opening of the eustachian tubes, and fossa of Rosenmüller should be assessed.

The region of the middle turbinate is carefully examined identifying the agger nasi (“agger mound”) at the junction of the middle turbinate anteriorly with the lateral wall of the nose. The middle turbinate is assessed for pneumatization (concha bullosa), lateralization, or paradoxical bend. In some patients, the endoscope can be passed between the middle turbinate and septum to visualize the superior turbinate, sphenoethmoidal recess, and opening of the sphenoid sinus.

The examiner is looking for changes in color, swelling, asymmetry, displacement of structures, purulence, polyps, and abnormal fluid. Sometimes palpation of the eye or any external deformity helps to show their connection to intranasal structures by movement intranasally while palpating externally. For sinonasal neoplasms, sensation of branches of the trigeminal nerve should be assessed and extraocular motion and pupillary reflexes should be assessed. The dentition and palate should be assessed for loosening of teeth and abnormal swelling or fullness. The face and neck should be assessed for lymphadenopathy in suspected neoplasia.

The quality and quantity of mucus should be considered. Unilateral watery discharge should raise suspicion of a cerebrospinal fluid leak. Thick tenacious secretions may be associated with an underlying mucociliary problem such as primary ciliary dyskinesia. Discoloration may indicate infection and/or a cellular infiltrate. Thick inspissated secretions may point to allergic fungal rhinosinusitis.

Polypoid changes are commonly seen in the nasal cavity, most often affecting the area of the middle meatus. Typical nasal polyposis is a bilateral disease except in the case of an antrochoanal polyp. The degree of polyposis on both sides is often asymmetric and the polyps are described as smooth, glistening with a “peeled grape” appearance. The size of the polyps can be documented by a variety of grading scales. Unilateral masses of any kind should raise the possibility of a neoplastic process and be considered for biopsy. It is important to consider imaging before any biopsy of a unilateral nasal mass to rule out a connection between the dura and brain, especially in children.

Lacrimal Disease