Prior to nasal endoscopy, the nose is inspected for any visible abnormalities, such as structural deviations, using a head light (Fig. 8.2). For nasal endoscopy, the patient’s nose should be prepared by applying a topical local anesthetic with a decongestant to anesthetize the nasal cavity before the procedure. Our preference is to use two sprays of co-phenylcaine spray (5 % lignocaine with 0.5 % phenylephrine) into each nasal cavity (Fig. 8.3), which should be left for at least 5 min before attempting any instrumentation, to allow sufficient time for the anesthetic and vasoconstrictive effect. The patient can be examined in either a sitting position, facing the examiner or if preferred lying down, then the examiner would be on his/her right side. Diagnostic nasal endoscopy can then be performed with a 2.7-mm, 30° nasal endoscope, using a three pass technique. The endoscope should be held with the right hand and supported between the thumb and index finger of the left hand to avoid any sudden movements (Fig. 8.4). With each pass, the condition of the nasal mucosa and normal anatomical structures are examined, as well as carefully noting of any anatomical variations or intranasal pathology.

During the first pass, the endoscope is introduced along the floor of the nasal cavity, between the inferior turbinate and the septum, toward the choana. This first pass allows examination of the inferior part of the nasal cavity including the inferior meatus where the nasolacrimal duct drains, and the nasal septum, as well as the nasopharynx and Eustachian tube openings. The endoscope is then withdrawn and gently reinserted for the second pass between the middle and inferior turbinate to examine the middle meatus. It is during the second pass that the lateral nasal wall is inspected including the maxillary line and attachment of the middle turbinate (Fig. 8.5). For the third pass, the endoscope should be gently maneuvered medial and posterior to the middle turbinate to examine the sphenoethmoid recess where the posterior ethmoid and sphenoid sinus drain.

A wide spectrum of anatomical variations and pathologies may be noted while examining the nasal cavity with endoscopy. Careful assessment is essential to help plan any endoscopic lacrimal surgery, and in particular, anatomical variations that may impede access during such surgery need specific consideration. Significant anterosuperior septal deviations (Fig. 8.6) or septal spurs (Fig. 8.7) may limit access of the endoscope or additional instruments for surgery, and in such cases, endoscopic septoplasty may need to be performed in order to create adequate space for safe instrumentation. Indeed, Tsirbas and Wormald quoted a 46 % rate of concomitant septoplasty, in their original landmark paper in lacrimal surgery describing endonasal dacryocystorhinostomy [1], thereby highlighting the need to carefully assess septal alignment during the preoperative nasal examination. In our experience, endoscopic septoplasty for such localized deviations is required in about 30 % of patients. For more severe septal deviations where the airway is significantly obstructed, a formal septoplasty may be required (Fig. 8.7). Another important anatomical variant is large concha bullosa of the middle turbinate (pneumatized middle turbinate) (Fig. 8.8a, b), which may also impede surgical access and therefore require adjuvant endoscopic reduction.