Using the endoscope allows us to inspect all the way back into the nasophanynx and perform a 3-pass nasal examination. By using this equipment and technique, we are able to examine along the interior turbinate and inferior meatus, the middle turbinate and middle meatus, and the superior turbinate and meatus.
When examining the nose, structures to be assessed include the nasal septum, situated medially, which should be assessed for the deflections causing obstruction, ulceration, crusting, or bleeding sites. Laterally, the inferior turbinate, which is situated inferiorly, immediately superior to the nasal floor, should be assessed for color, secretions and hypertrophy. The area of the middle turbinate and middle meatus should then be assessed by directing the light and gaze somewhat superiorly and posteriorly. The middle meatus should be examined for the presence of secretions and of masses such as nasal polyps.
These are examples of healthy nasal cavities
In-office nasal examination
Here we see the nasal speculum placed in the left nostril, demonstrating large nasal polyps filling the nasal cavity.
For examination of the left side: index finger should rest on the tip of the nose.
For examination of the right side: index finger should rest on the cheek.
Turbinate Enlargement (Hypertrophy)
The anterior end of the inferior turbinate is a component of the internal nasal valve, and therefore can greatly affect the degree of airflow through the nose if it is enlarged. Here we see a hypertrophied inferior turbinate, which is causing symptoms of nasal airway obstruction due to its crowding of the nasal valve area.
The differential diagnosis for a perforated septum is long and includes digital or iatrogenic trauma, cocaine abuse, vasculitic or granulomatous diseases, and even neoplasia. It is important to note the size and location, as these will impact on the patients symptoms.
However, it is especially important to recognize inflammatory appearing margins, which suggest an ongoing underlying disease process that mandates a diagnostic workup including surgical biopsies. On the left, we see an example of a clean septal perforation, whereas on the right, we see an image consistent with a vasculitic appearing perforation.
A deviated septum is a very common disorder and it is most often caused by impact trauma or otherwise can be congenital in nature. Here we can see the septum from the right nasal cavity, which does not remain in the midline resulting in asymmetrical appearance. We pay particular attention to the location and shape of the deviation: we may see a smooth convexity in the anterior septum or a sharp spur in the posterior part of the septum such as in this case. We also look at whether other structures are affected; our concern for this patient is poor drainage of the sinuses.
Uncomplicated Mild- Moderate Abs
Here is an example of uncomplicated mild-moderate acute bacterial sinusitis. The patient was referred due to her persistent nasal obstruction and left-sided maxillary facial pain that lasted over nine days. Here we can clearly see the purulent secretions arising from the middle meatus that suggests bacterial infection.
This is an example of the pale boggy mucosa characteristic of the inferior turbinate hypertrophy that is caused by allergic rhinitis. The remainder of the nasal cavity is also characterized by pale edema and abundant clear mucus. Symptoms include nasal congestion, nasal itchiness, sneezing, and may include allergic conjunctivitis symptoms. Allergies may be seasonal or perennial.
Complications of Acute Sinusitis
The complications of acute bacterial rhinosinusitis often occur by direct spread. Transgression through the medial orbital wall may result in any of the following orbital complications: cellulitis, abscess, blindness, and even cavernous sinus thrombosis. Spread superiorly through the skull base may result in the following cerebral complications: meningitis, extadural abscess, or Intradural abscess. Finally, spread through the bone itself (particularly the frontal bone) can result in osteomyelitis.
These figures are of the same patient and demonstrate the intracranial spread of infection originating in the frontal sinus and resulting in a subdural abscess involving the frontal lobe of the brain. Graphic 9 represents a CT scan and 10 represents an MRI, both are in the coronal plane.
This patient presented with pale greyish masses present in the middle meatus bilaterally. The patient was pain free but requested an examination for long term nasal obstruction and intermittent yellowish anterior nasal discharge . He had been treated in the past for acute sinusitis. This coronal CT scan of the sinuses, soft-tissue window, reveals completely opacified maxillary sinuses with double densities which may suggest non-invasive fungal disease.
Normal Sinus CT
Arrow shows patient osteomeatal complex (OMC) and maxillary drainage passage.
Note potential obstruction to maxillary sinus drainage passage by a large anterior ethmoid cell (short arrow) and pneumatised middle turbinate (Concha bullosa; long arrow) narrowing the OMC. Controlateral side shows obstruction relieved after endoscopic sinus surgery (ESS).
Mucosal thickening the osteomeatal complex (arrow) suggests chronic rhinosinusitis contributing to exacerbations. Also note concha bullosa narrowing OMC.
Chronic Rhinosinusitis With Allergic Fungal Sinusitis
Severe diffuse opacification throughout the right maxillary and ethmoid sinuses is suggestive of CRS with allergic fungal sinusitis.