Nasal endoscopy is usually performed with a 0-degree or 30-degree rigid endoscope attached to a camera and viewed on a monitor. Endoscopy is considered a critical part of the rhinologic physical examination. Indications are broad and can be diagnostic and therapeutic. In a diagnostic capacity, nasal endoscopy allows for direct visualization of the nasal mucosa and some parts of the sinus outflow tracts (middle meatus, sphenoethmoidal recess, etc.). This allows for assessment of possible causes of nasal obstruction and the presence of infection, as well as an appreciation for sinonasal anatomy before and after surgical intervention. In the postoperative setting, progression of healing or recurrence of disease or tumor surveillance can also be performed longitudinally. These maneuvers may be coupled with attempts at endoscopic biopsy for lesions or cultures in cases of infection.

From a therapeutic standpoint, nasal endoscopy can facilitate a myriad of different treatments targeted at different pathologies. These may include balloon sinus and eustachian tube dilation, sinus debridement, or removal of lesions. Turbinate procedures and limited septoplasty can also be performed in the office setting under endoscopic visualization.

No absolute contraindications exist for performing rigid nasal endoscopy under topical anesthesia. However, caution must be used in certain circumstances, such as patients prone to bleeding or patients who have anxiety, as vasovagal episodes can occur. Providers should be prepared to manage these rare complications. The decision to proceed with nasal endoscopy should be made jointly by the provider and the patient after a discussion of the indication as well as possible concerns.

Sinus debridement is generally indicated after endonasal surgery to remove crusting and to allow the provider to directly assess wound healing and even intervene early if any sort of obstruction or adhesions are developing. Diligent endoscopic care in the early postoperative period may hasten wound healing and encourage successful outcomes. Contraindications similarly revolve around bleeding risk and patient tolerance.

When planning for rigid nasal endoscopy, it is essential to ensure that certain instruments are readily available. Key instruments for this procedure include rigid 3-mm or 4-mm endoscopes with various angles (flexible endoscopes can be used for diagnostic purposes as well), a light source and cable, a high-definition camera and a monitor to display the image ( Fig. 19.1 ). Suction capability with different-sized Frazier and curved olive tip suctions is also important. Sinus instruments such as grasping and cutting forceps, Freer elevators, and bayonet forceps may be useful for things such as debridement, lysis of synechiae, and obtaining biopsies ( Fig. 19.2 ). It is worth investing in a high-definition video system and recording device to allow for image and video capture, which can facilitate patient counseling and allow for comparative surveillance.

Room setup for nasal endoscopy.

Commonly used tools for nasal endoscopy and debridement.

Before undergoing nasal endoscopy, informed consent is obtained, and the steps of the procedure and expectations are clearly explained to the patient. Depending on the indication, anterior nasal endoscopy may be performed before any application of topical decongestants (if inferior turbinate hypertrophy is suspected, examination before and after decongestant can be useful). Once an initial assessment is made, topical decongestant (generally either oxymetazoline or phenylephrine) and topical anesthetic (generally tetracaine or lidocaine) can be applied after confirming the patient is not allergic to the planned medications. ^, These medications are often applied with either an atomizer or with cotton pledgets. ^, The patient should be seated slightly reclined with their head in a comfortable position that allows for easy access to the nasal cavity.

Each side is examined in three passes. First, the inferior meatus and floor of the nose are examined back to the nasopharynx. The Eustachian tube is assessed during this pass as well. Second, the middle meatus is assessed. The upper septum, middle turbinate, uncinate process, and anterior ethmoids are examined, as well as the ostiomeatal complex. Last, the sphenoethmoid recess, superior turbinate, and olfactory cleft are assessed. During the examination, if any purulence is seen, a culture can be obtained. If there are concerning masses or lesions, a biopsy could be considered as well. If there is any obstructive mucus or crusting, this can be removed with suction or sinus surgery instruments to allow for complete examination.

For endoscopic nasal debridements, having instruments, including a variety of suction cannulas, a Freer/Cottle elevator, Blakesley and through-cutting forceps, bayonet forceps, and some frontal instruments, is important. Easy access to hemostatic materials if needed is also critical. As for any procedure, preparation is key. Having an assistant available (even in the room) can also be beneficial, especially for more involved debridements. The nose is decongested and anesthetized as previously described for nasal endoscopy. Allowing adequate time to elapse to ensure full anesthetic effect is particularly important for debridements, which, although well tolerated by most patients, can be unpleasant for some. Endoscopy is targeted at the areas previously operated on. Familiarizing oneself with the details of the surgery may be helpful. The nasal cavity is thoroughly examined, and obstructive resorbable packing and mucus are first removed. Crusting and drainage are best removed with a combination of suction cannula and grasping forceps (Blakesley or bayonet forceps). Any early adhesions or synechiae noted are also readily lysed during debridement using the shaft of the suction cannula or a Freer elevator. This is usually very well tolerated in the early stages of wound healing. Angled scopes are used to ensure patency of the operated sinuses. If these are obstructed, any sort of crusting or blockage is removed with suction and grasping forceps. As crusting is removed, it may be necessary to reapply topical anesthetic as the mucosa becomes exposed. A topical decongestant is generally sufficient to ensure hemostasis, but one should be prepared to handle epistaxis before embarking on any sort of postoperative debridement. The goals of the debridement procedure are to establish a nasal airway, ensure the sinuses are unobstructed so they can return to healthy function, and assess for wound healing.

Nasal endoscopy has been established as a safe, effective procedure for diagnosing many different pathologies. As the gold standard for examining the sinonasal tract, endoscopy is reliably more effective than anterior rhinoscopy in diagnosing pathologies, including polyps, synechiae, turbinate hypertrophy, and mucopurulence in the middle meatus or lesions more posteriorly located in the nose and nasopharynx. Nasal endoscopy can also have a role in reducing the need for computed tomography (CT) scans, allowing for more expeditious diagnosis while sparing some patients radiation.

There are numerous arguments for postoperative debridement, and it is one of the most commonly performed procedures in otolaryngology. Despite the ubiquity of the procedure, guidelines and recommendations are variable and lacking. The American Academy of Otolaryngology–Head and Neck Surgery Foundation states, “It is the position of the Academy that postoperative debridement aids healing and optimizes the ability to achieve open, functional sinus cavities.” However, a Cochrane review from 2018 found that postoperative debridement had little to no effect on patient-reported outcome measures and disease severity. The authors acknowledged that debridement does seem to reduce adhesions at 6 months postoperatively. Data currently are of relatively low quality, and further investigation is warranted given how commonly the procedure is undertaken.

A more recent randomized prospective study assessed the utility of postoperative debridement and found that SNOT-22 scores were significantly lower in the immediate postoperative period but unaffected at the 6-month mark. The authors conclude that debridement may have a role in short-term improvement, but it is unlikely to offer a durable benefit. Many providers debride all postoperative patients at predetermined time points. However, with these studies in mind, a more judicious use of postoperative debridement may be considered. Limiting debridement can make care more cost-effective while also reducing the requirements of patients to travel for multiple appointments. Further, debridement has been found to have a negative association with patient satisfaction scores and inconvenience scores. Debridement has also been found to result in more facial pain and discomfort. These factors further encourage a more minimalistic approach to postoperative debridement.