22. Simple physical examination, endoscopy and modern imaging of the nose and paranasal sinuses.

what history do you ask

• nasal obstruction

• discharge

• allergy

• headaches

• olfactory dysfunction

describe visual inspection

• mouth breathing may suggest nasal airway obstruction

• shape of external nose can suggest intranasal abnormalities

  • cartilaginous nasal deviation

• skin changes such as swelling and erythema→ paranasal inflammation

describe palpation

• detect bony discontinuities → fracture

• done on patients with suspected neuralgia by checking tenderness

What is anterior rhinoscopy

• Evaluate nasal vestibule and anterior nasal cavity

• posterior nasal cavity is better visualised with endoscopy

Describe the anterior rhinoscopy technique

• hold nasal speculum in left hand

• pull left index finger on patients right nostril → insert speculum to left nostril → open speculum

• tild head with right hand to visualise different areas of nasal cavity

• withdraw speculum while open

where do you palpate the paranasal sinuses

• Forehead → frontal sinuses

• Periorbitally, between the eyes → ethmoidal sinus

• Face → maxillary sinus

• Crown of the head, referring to the occipital area → sphenoid sinus

What is the use of endoscopy for nose and paranasal sinuses

Visualise posterior nasal cavity and get a better view of the conchae

What are the types of endoscopy used

• rigid endoscopes

• flexible

  • can visualise nasopharynx, pharynx, larynx

  • weaker light intensity and poorer image resolution

  • takes 2 hands to operate

What is the technique for using an endoscopy

• decongest nasal mucosa with vasoconstrictors and topical anesthetics

• 3 pass technique

  • first pass is along the floor of nasal cavity between septum and inferior nasal concha

  • second pass is below middle nasal concha

  • third pass lateral to middle nasal concha into the middle nasal meatus

What other imaging do you do for nose and paranasal sinuses

• X ray

• CT

• MRI

• US

Describe x ray

• indication

  • acute inflammation and midfacial fractures

• method

  • occipitomental projection evaluate the maxillary sinus and gives limited view over thet sphenoid sinus

  • occipitofrontal projection evaluates ethmoidal cells and frontal sinus

Describe CT

• indication

  • malformation, chronic sinusitis, trauma and tumours

• method

  • coronal planes evaluate the paranasal sinuses

  • axial planes are used for special investigations

Describe MRI

• indications

  • diseases of paranasal sinuses and cranial cavity or orbit

  • differentiate between soft tissue lesions

  • differentiate between solid tumours and inflammatory lesions

• method

  • T1 weighted images before and after IV contrast administration

  • then T2 weighted → axial, coronal, sagittal

Describe US

• indications

  • diseases of the paranasal sinuses

  • follow up acute inflammatory lesions