Office-Based Diagnosis of Sinonasal Disorders




Introduction


Nasal endoscopy is integral to the physical examination of patients with sinonasal symptoms seeking management from the otolaryngologist. With proper local decongestion and anesthesia, it is possible to obtain excellent visualization of the nasal mucosal lining, middle meatus, inferior meatus, sphenoethmoid recess, olfactory cleft, turbinates, septum, and nasopharynx with minimal discomfort to the patient.


Anesthesia is accomplished with a variety of techniques, including atomizers using disposable nasal tips with the topical anesthetics 4% lidocaine or 2% tetracaine. Frequently a topical decongestant, such as oxymetazoline 0.05%, is added. These agents may also be used on cotton pledgets that are placed in the nose for 5 to 10 minutes until decongestion and anesthesia are achieved.


The examination is facilitated if there is access to small-caliber endoscopes, such as the 2.9-mm rigid Hopkins telescope ( Fig. 94.1 ). A 30-degree endoscope is typically most useful for office-based diagnosis of sinonasal disease. For patients who have had sinus surgery, a 70-degree endoscope can be helpful to visualize the frontal and maxillary sinuses. A video camera and high-definition monitors are a critical part of visualizing the examination. Video documentation with archiving can be helpful in monitoring the patient’s progress over time.




Fig. 94.1


A 2.9-mm 30-degree Hopkins telescope can be useful in performing a complete nasal endoscopy with minimal discomfort to the patient, especially in patients who have not had sinus surgery.


The following discussions (and accompanying videos) highlight some of the common disorders encountered in endoscopic diagnosis of the nose and sinuses.




Key Operative Learning Points




  • 1.

    Nasal endoscopy should be performed in a standardized manner and include examination of the nasal mucosal lining, middle meatus, inferior meatus, sphenoethmoid recess, olfactory cleft, turbinates, septum, and nasopharynx.


  • 2.

    Failure to inspect the nasopharynx will lead to inability to diagnose common disorders that mimic sinusitis (i.e., Thornwaldt cysts, hypertrophic adenoid tissue or tumors).


  • 3.

    In addition to anatomic description, the diagnostic examination evaluates the presence of mucopurulent drainage, presence of polyps, masses, and characteristics of the sinonasal mucosal lining.


  • 4.

    Vasculitic diseases should be considered if the mucosa is abraded or bleeding (i.e., granulomatosis with polyangiitis [GPA], formerly known as Wegener granulomatosis), as well as cocaine or intranasal opioid abuse.


  • 5.

    Sarcoidosis can present with cobblestone appearance of the mucosa with inflammation and edema refractory to decongestion.


  • 6.

    If the mucus is tenacious and appears to contain eosinophil by-products, send it for fungal cultures and stains to evaluate for possible allergic fungal sinusitis.


  • 7.

    Endoscopically obtained cultures can help to direct antibiotic therapy.



History




  • 1.

    History of present illness



    • a.

      Determine symptoms that are most troublesome to the patient in order to best direct therapeutic recommendations.


    • b.

      Patients with suspected chronic rhinosinusitis (CRS) should be questioned regarding symptoms of nasal obstruction, discolored drainage, facial pain/pressure, and loss of the sense of smell.



      • 1)

        Antibiotic and steroid treatment


      • 2)

        Imaging, if available


      • 3)

        Allergic rhinitis symptoms and, if positive, history of allergy testing and treatment


      • 4)

        Past surgical procedures, specifically endoscopic sinus surgery (ESS)




  • 2.

    Past medical history


  • 3.

    Social history



    • a.

      Patients with allergic rhinitis should be asked about environmental exposures at work and home


    • b.

      Occupation


    • c.

      Tobacco history



  • 4.

    Family history



    • a.

      Allergic rhinitis


    • b.

      Asthma


    • c.

      Nasal polyposis or cystic fibrosis




Physical Examination




  • 1.

    Proper topical decongestion and anesthetic should be administered before nasal endoscopy.


  • 2.

    A 30-degree Hopkins endoscope can be used to visualize all key landmarks in patients who have not had ESS. A 70-degree endoscope is helpful to visualize the frontal sinus osteum and the maxillary sinus in patients who have had ESS.



    • a.

      First pass along the middle meatus with the endoscope angled at the 4-o’clock position. The light source can then be angled superiorly to visualize the olfactory cleft.


    • b.

      Second pass visualizing the inferior meatus with the endoscope angled at 6-o’clock position and then toward the nasopharynx, passing the scope medial to the inferior turbinate. The light source can then be angled superiorly to visualize the sphenoethmoid recess superiorly.



  • 3.

    Examination of the cranial nerves can help to evaluate patients suspected of a sinonasal malignancy or a granulomatous process.



Imaging


Maxillofacial computed tomography (CT) scan is indicated in patients suspected of having the following:



  • 1.

    CRS


  • 2.

    Nasal polyposis


  • 3.

    Unilateral sinusitis


  • 4.

    Concern for malignancy


  • 5.

    Cerebrospinal fluid (CSF) rhinorrhea and associated skull base defect



Indications


Diagnostic nasal endoscopy is indicated in patients suspected of the following:



  • 1.

    Symptoms suggestive of CRS with or without polyposis


  • 2.

    Acute bacterial rhinosinusitis


  • 3.

    Unilateral symptoms


  • 4.

    Concern for malignancy



Contraindications




  • 1.

    Patients unable to tolerate rigid endoscopy; rare if adequate topical decongestion and anesthetic is used


  • 2.

    Patients with hereditary hemorrhagic telangiectasia (HHT) require caution when performing endoscopy and if actively bleeding or with packing in place; endoscopy and control of epistaxis is best done in the operating room.



Preoperative Preparation




  • 1.

    Topical anesthesia and decongestion should be administered before endoscopy (see section on Anesthesia).


  • 2.

    Patients should be positioned appropriately for endoscopy (see section on Positioning).


  • 3.

    Maxillofacial CT scan should be performed for patients with CRS, nasal polyposis, unilateral disease, CSF rhinorrhea/skull base defect, or any patient with concern for malignancy.


  • 4.

    It is helpful to turn off the overhead lights for optimal visualization of the monitor during the procedure.



Anesthesia




  • 1.

    Topical anesthesia can be accomplished with 4% lidocaine either via atomization into the nasal cavities or on pledgets.


  • 2.

    Use of 2% tetracaine can be helpful in patients who require in-office procedure, débridement, or inadequate anesthesia with topical lidocaine.


  • 3.

    Oxymetazoline is commonly added to the topical anesthetic to provide concomitant mucosal decongestion.



Positioning


Seated and reclined if possible with the patient head turned facing the physician. The patient, the screen, and the physician should be coaxial.


Perioperative Antibiotic Prophylaxis


None necessary


Monitoring


None necessary


Instruments and Equipment to Have Available




  • 1.

    Hopkins telescopes: 0-, 30-, 70-degree endoscopes. The 30-degree endoscope is the most popular scope, and, if available, a 2.9-mm scope allows for improved visualization of the sphenoethmoid recess and nasopharynx with minimal discomfort to the patient.


  • 2.

    Flexible endoscope for patients who cannot tolerate rigid endoscopy or when the floor or anterior wall of the maxillary sinus cannot be fully examined with a rigid endoscope.


  • 3.

    Topical decongestant and anesthetic. We prefer 4% lidocaine with oxymetazoline either on pledgets or via an atomizer. For patients who require débridement, biopsy, or in-office procedures, 2% tetracaine is preferred. The window of toxicity with tetracaine should be considered, with the use of doses not to exceed 100 mg.





Key Anatomic Landmarks




  • 1.

    Middle meatus


  • 2.

    Sphenoethmoid recess


  • 3.

    Nasopharynx


  • 4.

    Inferior meatus


  • 5.

    For patients who have had functional ESS (FESS), visualization of all sinus cavities should be performed.



Prerequisite Skills




  • 1.

    Appropriate use of the rigid nasal endoscope to visualize key anatomic landmarks


  • 2.

    Flexible laryngoscopy



Operative Risks




  • 1.

    Epistaxis


  • 2.

    Vasovagal episode



Surgical Technique


Allergic Rhinitis ( )




  • 1.

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


  • 2.

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


  • 3.

    Polypoid middle turbinates can be an indication of allergic rhinitis.


  • 4.

    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.


  • 5.

    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.



Rhinitis Medicamentosa ( )




  • 1.

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


  • 2.

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


  • 3.

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



Acute Bacterial Rhinosinusitis With Endoscopically Directed Middle Meatal Culture ( )




  • 1.

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


  • 2.

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


  • 3.

    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.


  • 4.

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


  • 5.

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



Maxillary Sinus Tap in Acute Bacterial Sinusitis ( )




  • 1.

    This procedure is rarely needed due to endoscopic approaches that can be performed in the operating room or with balloon dilation techniques in the office for patients who cannot tolerate general anesthesia. Unilateral maxillary sinusitis should also raise the concern for an odontogenic source or obstructive mass. Imaging should be conducted prior to instrumentation of the sinus. In this case of acute bacterial sinusitis, the nasal cavity is first anesthetized for an MST.


  • 2.

    A cotton pledget with 4% Xylocaine and a few drops of epinephrine 1:1000 is placed into the nasal cavity.


  • 3.

    After a few minutes, when the mucosa is partially decongested and anesthetized, this pledget is removed and a second pledget is placed under the inferior turbinate into the inferior meatus.


  • 4.

    An ear curette is useful in positioning the pledget under the inferior turbinate. After this pledget has been in place for approximately 5 to 10 minutes, it is removed and 0.5 to 1 mL of 1% Xylocaine with 1:100,000 epinephrine is injected into the mucosa of the inferior meatus using a 1.5-inch long 25-gauge needle. This is usually painless after the topical anesthetic has been in place for 5 to 10 minutes.


  • 5.

    Anesthetizing the inferior turbinate allows one to painlessly medialize the inferior turbinate, if needed, in the placement of either a 16- to 18-gauge spinal needle or a commercial antral tap trocar.


  • 6.

    The antral tap trocar or needle is introduced through the thin bone in the lateral inferior meatus into the maxillary sinus. The bone is usually thin and easiest to penetrate in the superior lateral aspects of the inferior meatus.


  • 7.

    Occasionally, very thick bone or nasal anatomy precludes inferior meatal antral tap. After the needle or trocar is introduced through the bone into the sinus, the trocar is removed and the purulent exudate is aspirated from the maxillary sinus with a syringe.


  • 8.

    The aspirated specimen obtained is sent for Gram stain and aerobic and anaerobic cultures. Depending on the circumstances, such as in an immunocompromised patient or fungal sinusitis, fungal cultures should be obtained.


  • 9.

    After the culture specimen is obtained, the sinus can be irrigated. If the sinus tap is free of secretions, then a small amount of sterile saline is introduced into the maxillary sinus and re-aspirated.


  • 10.

    To irrigate the sinus, the patient is given a basin and asked to lean forward while the sinus is gently irrigated with 10 to 50 mL of sterile saline. If the procedure is uncomfortable to the patient, it should be stopped because sometimes the outflow tract of the sinus is obstructed with edema, preventing fluid egress.


  • 11.

    MST and irrigation can be not only diagnostic but also therapeutic. At the end of the irrigation, air is usually introduced into the sinus cavity. Topical antibiotics can also be introduced, if desired.



Chronic Bacterial Sinusitis With Biofilm ( )




  • 1.

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


  • 2.

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


  • 3.

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


  • 4.

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


  • 5.

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



Complete Internal and External Nasal Valve Collapse With Inspiration ( )




  • 1.

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


  • 2.

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


  • 3.

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


  • 4.

    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.


  • 5.

    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.



Anterior Epistaxis ( )




  • 1.

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


  • 2.

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


  • 3.

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


  • 4.

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


  • 5.

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


  • 6.

    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.



Septal Perforation With Placement of Nasal Septal Button ( )




  • 1.

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


  • 2.

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


  • 3.

    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.


  • 4.

    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.


  • 5.

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


  • 6.

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


  • 7.

    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 ( )




  • 1.

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


  • 2.

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


  • 3.

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


  • 4.

    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.



Eosinophilic Mucin Rhinosinusitis ( )




  • 1.

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


  • 2.

    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.


  • 3.

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


  • 4.

    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.


  • 5.

    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.



Chronic Rhinosinusitis With Polyposis and In-Office Polypectomy ( )




  • 1.

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


  • 2.

    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.


  • 3.

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


  • 4.

    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.



Sarcoidosis




  • 1.

    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


  • 2.

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


  • 3.

    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.


  • 4.

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


  • 5.

    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.


  • 6.

    Biopsy of the affected nasal lining can facilitate the diagnosis.



Granulomatosis With Polyangiitis, Formerly Referred to as Wegener Granulomatosis




  • 1.

    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


  • 2.

    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.


  • 3.

    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.


  • 4.

    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.


  • 5.

    Biopsy of the affected nasal lining can facilitate the diagnosis.



Inverted Papilloma




  • 1.

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


  • 2.

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


  • 3.

    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.


  • 4.

    Localized bleeding can be controlled with oxymetazoline on pledgets.



Cicatricial Pemphigoid




  • 1.

    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.


  • 2.

    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.



Common Errors in Technique




  • 1.

    Inadequate decongestion and anesthesia leading to incomplete endoscopic examination


  • 2.

    Improper positioning


  • 3.

    Instrumentation and endoscope should move in tandem, and typically the instrument should be below the endoscope to allow for proper visualization.



Postoperative Management




  • 1.

    Patients who undergo procedures in the office are advised to avoid nose blowing or strenuous activity.


  • 2.

    Appropriate use of topical analgesics should eliminate the need for opioid medications.



Complications




  • 1.

    Epistaxis can occur in patients with inadvertent abrasions to the mucosa during nasal endoscopy or in-office procedures.


  • 2.

    Vasovagal episodes



Alternative Management Plan




  • 1.

    Flexible endoscopy may be necessary in patients who cannot tolerate rigid endoscopy.


  • 2.

    Management in the operating room for patients who require extensive débridement, extensive polypectomy, biopsy, control of epistaxis, or other procedures that would be difficult to accomplish in the office due to patient discomfort and equipment needs


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Apr 3, 2019 | Posted by in OTOLARYNGOLOGY | Comments Off on Office-Based Diagnosis of Sinonasal Disorders
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