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Office Examination/Evaluation
Sinus and Nasal disorders are traditionally diagnosed through careful history and physical
examination. However, sinonasal symptoms can provide limited information for diagnosis.
Thus, objective information is sought through physical examination. Although there are many
methods available to directly evaluate the nasal passages, three are typically employed for most
patients with long standing sinus or nasal complaints. They are: anterior rhinoscopy (looking
into the nose with a headlight and nasal speculum to open nostrils), nasal endoscopy (looking
into the nasal passages with an endoscope or telescope) and CT scanning. These techniques
reveal important information necessary for proper diagnosis, treatment and monitoring. Often
times, nasal endoscopic findings compliment findings seen on CT imaging, but they are not
always the same. Interestingly, abnormalities detected on endoscopy or imaging can be present
without symptoms.

In order to facilitate your nasal examination, your nose will typically be sprayed with a
decongestant and a topical anesthetic spray, which will numb the lining of your nose. You
should inform the nurse at each visit if you are allergic to either of these medications.
When your nose is sprayed please do not sniff in. The spray atomizer will help the medicine be
delivered adequately. Sniffing in can lead to more medication being delivered inside your
throat than in your nose. Anesthetic spray in the throat can lead cause slight irritation initially
followed by a temporary sensation of numbness, perception of difficulty swallowing or even a
perception of difficulty breathing even though there is no airway swelling. These side effects
can be attributed to the numbness present in your throat. Additionally, you should not drink or
eat until you feel normal return of sensation of your throat (about 1/2 hour) following an
examination with these sprays. This to avoid any inadvertent burn or choking on improperly
swallowed food or drink.

Once these sprays have taken sufficient effect, usually after six to ten minutes, an endoscope
may be used to exam your nose and sinuses. Either a flexible or rigid endoscope is used.
Although nasal endoscopy may be an uncomfortable experience, most patients do not find it to
be painful. The endoscopic exam yields useful information regarding the nature and extent of
disease present in the nasal cavity and the drainage paths of the paranasal sinuses.

1. Anterior rhinoscopy
Anterior rhinoscopy is the basic tool of the physical examination that most specifically relates
to determining the existence of disease (pathology) in the sino-nasal passages. During anterior
rhinoscopy the nostril is spread open with a small bunt speculum and the nasal passages can be
directly examined with a headlight. This examination gives limited view of the interior of the
nasal cavity.

2. Nasal endoscopy
In contrast to anterior rhinoscopy, endoscopy introduces brilliant illumination into the dark
cavities and permits magnified direct visualization of the mucosa, turbinates, and, in postsurgical
patients, the sinuses. Nasal endoscopy helps identify redness, swelling, polyps,
crusting, mucous, and/or pus deep in the nasal cavity.
There are two types of endoscopes available for evaluating the sinonasal passages—flexible
fiberoptic endoscopes and rigid telescopes. They differ mainly in terms of patient tolerance and
safety.

With regard to patient comfort and direct access to sinus cavities, flexible endoscopy is
generally superior to rigid endoscopy. However, image clarity, the facility to obtain cultures
and sample tissues, the ability to control epistaxis, and the ability to perform surgery is superior
with rigid endoscopy.
Risks of Nasal Endoscopy
Although it is generally a very safe and very well-tolerated procedure, the most common
adverse effects of endoscopy are patient discomfort/pain, nasal bleeding, and feeling faint or
lightheaded from anxiety.
Indications for Nasal Endoscopy

These include but are not limited too:

  •  Sinonasal symptoms refractory to appropriate empiric therapy or in suspected chronic rhinosinusitis
  •  Unilateral disease without septal deviation
  •  Severe and disabling symptoms attributed to the nose or sinuses
  •  Actual or impending complication of sinonasal disease
  •  Patients who have sinonasal complaints and are immunocompromised (transplant, diabetes, leukemia, etc.)
  •  Evaluation of surgical treatments after sinus surgery and/or trauma.

Although some debate exists over the value of endoscopically obtained cultures, many leaders
who study nasal and sinus diseases collect them to guide therapy. Cultures should be obtained
by skilled experienced endoscopists. Otherwise, the results from the specimen may be
misleading. Endoscopic sinus cultures may be performed with either a sterile swab or by
suctioning pus into a sterile trap.
3. CT Imaging

This computerized x-ray of the sinuses gives fine detail about soft tissue swelling, the presence
of fluid, and anatomic abnormalities deep in the sinus cavities. These images are often best
obtained while you lay down on your stomach with your chin down and your neck extended.
Additional tests or studies used to evaluate sinus and nasal problems include but are not limited
to:

1. MRI
2. Allergy Testing – skin and blood testing
3. Nasal Function Studies
a. Smell Identification Test
b. Acoustic rhinometry
c. Ciliary motility studies
4. Endoscopic Sampling of Nasal Discharge
a. Gram stain to identify evidence of infection
b. Culture & sensitivity to identify micro-organisms
c. Beta-2 transferrin to identify cerebrospinal fluid leak
d. Cytology
5. Blood work
6. Chest X-ray
7. Breathing tests