After administration of topical decongestion and anesthetic, a 30-degree endoscope is used to examine the patient’s nasal cavities.

The middle meatus is examined bilaterally to demonstrate the absence of polyps or mucopurulence. The nasopharynx appears clear.

Polypoid middle turbinates can be an indication of allergic rhinitis.

History should direct whether patients should undergo allergy testing. In this example, a 33-year-old male presented with bilateral nasal congestion with seasonal exacerbation in the spring and summer. Skin testing was positive for dust mite, cat, dog, Bermuda grass, Timothy grass, oak tree, and maple tree.

Typically in allergic rhinitis, turbinates have a pale edematous appearance. Erythematous mucosa suggests other etiologies, such as exposure to tobacco smoke, irritants, rhinitis medicamentosa, or food allergy.

This patient had been using oxymetazoline 2 or 3 times a day for several months.

Note the upregulation of seromucinous glands characterized as “cobblestoning” along the septum and the inferior turbinate.

The mucosa is typically erythematous and friable. Septal perforations can also be seen in patients with chronic use of a topical decongestant spray.

Patients presenting with mucopurulent drainage benefit from having an endoscopically directed culture obtained to facilitate decision making for antibiotic therapy.

Maxillary sinus taps (MSTs) have largely fallen out of favor as a preferred method for obtaining culture data.

A Calgi swab is bent at a 30-degree angle at the tip and followed to the middle meatus with a 30-degree endoscope. A 0-degree endoscope can be used if visualization is adequate.

The culture swab is inserted carefully so as not to contaminate it with bacteria from the nasal vestibule.

Typically, aerobic cultures only are necessary. For suspected odontogenic infections, anaerobic cultures are indicated.

Occasionally, patients’ sinus infections are refractory to both surgical and medical intervention.

The biofilm is readily apparent in this patient by rigid endoscopy with a 30-degree endoscope.

Patients with stenotic sinuses or purulence along the floor or anterior aspect of the sinus may require flexible fiberoptic examination for visualization and diagnosis.

Cultures of the purulent exudate can be obtained, and irrigation can be performed.

A 3-mm curved suction facilitates aspiration and irrigation of the sinus.

This patient demonstrates collapse of the nasal valve with inspiration, due to lack of support from the lower lateral cartilages.

Surgery of the septum and the inferior turbinates would not successfully resolve this situation.

The condition was treated with cartilage battens added to the lower lateral cartilages to strengthen them to prevent closure with inspiration.

The more rapidly a patient inspires, the more vigorous the closure of the nasal valve. This is due to the Bernoulli effect of a vacuum produced by increased velocity of the inspired air.

Patients who complain of nasal obstruction and in whom no site of obstruction is detected on physical examination with the nasal speculum should be evaluated for nasal valve collapse.

Epistaxis commonly occurs from the anterior nasal septum, often called Little area or Kiesselbach plexus.

In such a patient, the nasal cavity should be decongested and anesthetized with topical tetracaine 2% and oxymetazoline.

If the nose is actively bleeding, the source should be identified if possible and selectively cauterized with silver nitrate.

Opposing areas of the septum should not be cauterized, due to the risk of septal perforation.

Telangiectasias can also be a source of significant bleeding, often only visible as a 1- to 3-mm domelike lesion.

If gently touched with the silver nitrate stick, brisk bleeding will often then occur, identifying this as the source of epistaxis. Usually this is successfully treated with cauterization.

Symptomatic perforation bleeding and crusting can often be controlled with the placement of a Silastic septal button.

Septal buttons are commercially available through several manufacturers and are available in different sizes.

The septal perforation should first be measured, and then the button should be fashioned to fit the defect. Most perforations are not perfectly round but oval shaped, and therefore care should be taken to trim the button to the appropriate shape.

The nasal cavity is first anesthetized, and then, using the endoscope or a headlight for visualization, the button is introduced into the nose on one side.

The flange is extracted through the contralateral side, and then the button is positioned to optimally span the perforation.

Placement of a water-soluble antibiotic ointment to the nasal cavity daily may delay the formation of a bacterial biofilm.

However, crusting along the button may require removal. At this point the perforation may be sufficiently mucosalized, so there is no further bleeding or crusting.

Atrophic rhinitis is commonly caused by Klebsiella ozaenae, but other bacteria may be responsible.

Citrobacter koseri was cultured from this 80-year-old Cambodian woman with a 1-year history of a foul smell from her nose.

The nasal cavities can be débrided using Tobey forceps and using a 0- or 30-degree endoscope.

After extensive débridement of her nasal cavity, initiation of topical antibiotics directed toward the pathogen (gentamicin 80 mg per 500 mL of saline with 20-mL irrigations twice a day), and after several months of an oral fluoroquinolone, the patient’s foul-smelling crusting resolved.

Patients with refractory CRS with polyposis often present with eosinophilic mucin, as shown in this video.

This patient’s evaluation via culture and pathology did not exhibit a bacterial or fungal etiology. Note the tenacity of the mucous secretions, which often show copious eosinophils and Charcot-Leyden crystals on pathology.

If the mucin is filling the sinus, local irrigation can help with removal of the tenacious secretions.

The mucin should be sent for histopathologic evaluation for the presence of fungi. Hyphae present in eosinophilic mucin in conjunction with elevated immunoglobulin E (IgE) to the cultured fungus are diagnostic of allergic fungal rhinosinusitis.

An attempt should be made to remove all eosinophilic mucin, if possible, to help to remove the source of inflammation and allow for effective topical therapy.

Patients with CRS have symptoms at least 12 weeks or longer of nasal obstruction, discolored drainage, facial pain/pressure, and diminished sense of smell.

Nasal endoscopy helps to confirm the diagnosis by determining whether the patient has polyps in the nasal cavity or the middle meatus or purulent mucous/edema in the middle meatus or anterior ethmoid area. Radiographic imaging showing inflammation can also confirm the diagnosis of CRS when endoscopy is normal and patients present with the symptoms described.

This patient’s endoscopy (seeVideo 94.11 ) demonstrates polyps completely filling the nasal cavities. Unilateral polyps are concerning for tumor or possible encephalocele.

Polyps can be debulked in the office for appropriately selected patients who have nasal obstruction, are not appropriate candidates for general anesthesia, or who do not wish to undergo sinus surgery. Appropriate preparation as followed for FESS is applicable, including discontinuation of anticoagulation and pretreatment and posttreatment with oral steroids.

A disorder of exclusion and of unclear etiology but assumed to be a reaction to a variety of antigens that induce noncaseating granulomas in the nose, skin, and lungs particularly but also other organ systems

This patient presented with cutaneous manifestations, as well as significant nasal crusting and inflammation as shown in this video.

Staphylococcus aureus is commonly cultured from these patients, and, with appropriate immunomodulatory therapy, topical steroids, and culture-directed antibiotics, patients can have improvement in their symptoms, as shown in the second endoscopic examination.

Sarcoidosis may be localized to the nose and have a remitting or active course. Systemic involvement without adequate diagnosis and treatment can be fatal.

On endoscopic examination of the nasal cavity, sarcoidosis should be suspected when the septal mucosa appears cobblestoned, reflecting very small collections of lymphocytes and submucosal granulomas. Crusting and mucopurulent secretions can also be seen.

Biopsy of the affected nasal lining can facilitate the diagnosis.

A systemic disorder that is a form of vasculitis characterized by both granulomas and polyangiitis and if untreated has a high mortality rate secondary to pulmonary and renal damage

Patients often present with serous otitis media, as demonstrated in this video, as well as significant nasal inflammation with a friable lining and mucopurulent exudate present on nasal endoscopy.

After being appropriately treated with immunomodulator therapy, topical steroids, and culture-directed antibiotics, the patient can have reasonable control of disease, as shown in the subsequent nasal endoscopies.

The course is often one of remission and relapse. Early relapse can be suspected by return of nasal bleeding and excoriations, as well as evaluation of anti-neutrophil cytoplasmic antibody serology.

Biopsy of the affected nasal lining can facilitate the diagnosis.

The most common benign tumor of the nasal cavity, inverted papilloma, should be suspected with unilateral polypoid lesions and unilateral sinusitis.

Biopsy can be performed in the office, but a maxillofacial CT scan should be performed to rule out skull base dehiscence or other pathology.

The site of suspected inverted papilloma is first injected with 1% lidocaine with epinephrine 1:100,000, and the cup biopsy forceps are used to obtain the biopsy.

Localized bleeding can be controlled with oxymetazoline on pledgets.

In this patient with cicatricial pemphigoid, complete restenosis of the right side of her nose is seen and well over 50% restenosis of the left side despite several prior surgical procedures.

The left side of her nose is kept patent only with the insertion of a stent, which is only removed for cleaning and then is reinserted.