Endoscopy (examination) of the nasal cavity

Examination (endoscopy) of ENT organs is the main method of assessing their condition. For more effective implementation of this procedure, a number of general rules should be followed.

The light source should be located to the right of the patient, at the level of his ear, at a distance of 15-20 cm, slightly behind, so that the light from it does not fall on the examined area. The focused light reflected from the frontal reflector should illuminate the examined area in the normal position of the doctor, who should not bend or lean in search of a "bunny" or an object of examination; the doctor moves the patient's head, giving it the necessary position. A novice otolaryngologist should constantly train to acquire the skill of binocular vision, necessary for manipulation in the deep sections of the ENT organs. To do this, he sets the light spot on the object of examination so that when the right eye is closed, it is clearly visible through the opening of the frontal reflector with the left eye.

The instruments used in endoscopy and various manipulations can be divided into auxiliary and "active". Auxiliary instruments expand the natural passages of the ENT organs and remove some obstacles (for example, hair in the external auditory canal or in the vestibule of the nose); auxiliary instruments include mirrors, funnels, spatulas, etc. Active instruments are used for manipulations carried out in the cavities of the ENT organs. They must be held in the right hand, which ensures greater precision of movement (for right-handers) and does not interfere with the illumination of the cavity being examined. To do this, auxiliary instruments should be held in the left hand, and if certain difficulties arise, persistently train this skill. The ideal for an otolaryngologist is to be able to use both hands.

Endoscopy of the nasal cavity is divided into anterior and posterior (indirect), performed using a nasopharyngeal mirror. Before performing anterior rhinoscopy using a nasal mirror, it is advisable to examine the nasal vestibule by lifting the tip of the nose.

During anterior rhinoscopy, three positions are distinguished, defined as lower (examination of the lower sections of the septum and nasal cavity, lower turbinates), middle (examination of the middle sections of the nasal septum and nasal cavity, middle turbinate) and upper (examination of the upper sections of the nasal cavity, its vault and the area of the olfactory slit).

During anterior rhinoscopy, attention is paid to various signs reflecting both the normal state of endonasal structures and certain pathological conditions of them. The following signs are assessed:

1. the color of the mucous membrane and its moisture;
2. the shape of the nasal septum, paying attention to the vascular network in its anterior sections, the caliber of the vessels;
3. the condition of the nasal conchae (shape, color, volume, relation to the nasal septum), palpating them with a button probe to determine consistency;
4. the size and contents of the nasal passages, especially the middle one, and in the area of the olfactory cleft.

If polyps, papillomas or other pathological tissues are present, their appearance is assessed and, if necessary, tissue is taken for examination (biopsy).

With the help of posterior rhinoscopy it is possible to examine the posterior parts of the nasal cavity, the vault of the nasopharynx, its lateral surfaces and the nasopharyngeal openings of the auditory tubes.

Posterior rhinoscopy is performed as follows: with a spatula in the left hand, the anterior 2/3 of the tongue is pressed downwards and slightly forwards. The nasopharyngeal mirror, pre-heated to avoid fogging of its surface, is inserted into the nasopharynx behind the soft palate, without touching the root of the tongue and the back wall of the pharynx.

A number of conditions are necessary for this type of endoscopy: first of all, the appropriate skill, then favorable anatomical conditions and a low pharyngeal reflex. Obstacles to this type of endoscopy are a pronounced gag reflex, a thick and "unruly" tongue, a hypertrophied lingual tonsil, a narrow pharynx, a long uvula of the soft palate, protruding vertebral bodies with pronounced lordosis of the cervical spine, inflammatory diseases of the pharynx, tumors or scars of the soft palate. If, due to the presence of objective obstacles, conventional posterior rhinoscopy is not possible, then appropriate application anesthesia is used to suppress the gag reflex, as well as pulling the soft palate with one or two thin rubber catheters. After application anesthesia of the mucous membrane of the nose, pharynx and root of the tongue, a catheter is inserted into each half of the nose and its end is brought out of the pharynx with forceps to the outside. Both ends of each catheter are tied together with slight tension, ensuring that the soft palate and uvula do not turn toward the nasopharynx. This immobilizes the soft palate and opens free access for examination of the nasopharynx.

Only individual sections of the examined area are visible in the nasopharyngeal mirror (diameter 8-15 mm), therefore, to examine all the formations of the nasopharynx, slight turns of the mirror are made, sequentially examining the entire cavity and its formations, focusing on the posterior edge of the nasal septum.

In some cases, a digital examination of the nasopharynx is necessary, especially in children, since indirect posterior rhinoscopy is rarely successful in them. To perform this examination, the doctor stands behind the seated patient, grasps his head and neck with his left hand, presses the left part of the cheek tissue into the open mouth with the first finger (to prevent biting), and places the remaining fingers and palm under the lower jaw and thus, fixing the head, provides access to the oral cavity. The second finger of the right hand is inserted along the surface of the tongue, slightly pressing the latter downwards, bends, moves behind the soft palate and palpates the anatomical structures of the nasopharynx with it. This procedure, with the appropriate skill, lasts 3-5 seconds.

During a digital examination of the nasopharynx, its overall size and shape are assessed, the presence or absence of partial or complete obliteration, adhesions, adenoids, choanal obstruction, hypertrophied posterior ends of the inferior turbinates, choanal polyps, tumor tissue, etc. are determined.

Posterior rhinoscopy is of great importance in the presence of inflammatory diseases of the sphenoid sinus, tumor processes in it, in the parasellar areas, in the sella turcica area, and other diseases of the specified area. However, this method does not always give the desired results. Comprehensive visual information about the state of the cavities of the nasal septum can be obtained using modern television endoscopy techniques using fiber optics. For this purpose, approaches to probing the paranasal sinuses through their natural openings, developed at the beginning of the 20th century, are used.

Probing of the paranasal sinuses. This same method served as a means of catheterization of the sinuses to evacuate pathological contents from them and administer medicinal substances.

Catheterization of the maxillary sinus consists of the following. Application anesthesia of the corresponding half of the nose is performed with triple lubrication with anesthetic (1 ml of 10% lidocaine solution, 1 ml of 1-2% pyromecaine solution, 1 ml of 3-5% dicaine solution) of the mucous membrane under the middle nasal concha (in the area of the hyatus semilunare) and subsequent application of adrenaline hydrochloride solution in a concentration of 1:1000 to the specified area of the mucous membrane. After 5 minutes, catheterization begins: the curved end of the catheter is inserted under the middle nasal concha, directed laterally and upwards to the area of the posterior third of the middle nasal passage and an attempt is made to enter the outlet by touch. When it enters the opening, a sensation of fixation of the end of the catheter occurs. In this case, an attempt is made to introduce an isotonic sodium chloride solution into the sinus using a syringe with light pressure on its plunger.

Catheterization of the frontal sinus is performed in a similar manner, only the end of the catheter is directed upward at the level of the anterior end of the middle nasal concha in the area of the funnel of the frontonasal canal. This procedure is performed less successfully with a high position of the nasal opening of the frontonasal canal and requires great caution due to the proximity of the cribriform plate. To avoid touching it with the end of the catheter, it is directed upward and somewhat laterally, focusing on the inner corner of the eye.

Catheterization of the sphenoid sinus is performed under visual control using a Killian nasal mirror (medium or long). Anesthesia and adrenaline stimulation of the nasal mucosa should be deep enough. The final position of the catheter is determined in the direction of an oblique line upwards, forming an angle of about 30° with the bottom of the nasal cavity, the depth is until it stops against the anterior wall of the sphenoid sinus - 7.5-8 cm. In this area, the opening is searched for mostly by touch. When it enters it, the catheter easily enters it by another 0.5-1 cm and rests against the posterior wall of the sphenoid sinus. If it is successfully entered, the catheter remains fixed in the opening and does not fall out if released. Flushing is performed as carefully as in the previous cases.

In recent years, a method of catheterization of the paranasal sinuses with flexible conductors and catheters has been developed. The technique is simple, atraumatic and allows for successful catheterization of the paranasal sinuses with the catheter remaining in them for a period of time sufficient for a course of non-surgical treatment.

The relevance of the above-described methods today lies in the increasing prevalence of TV-endoscopic examination methods and paranasal sinus surgery in rhinology.

Instrumental methods of endoscopy. Instrumental methods of endoscopy are those that use various technical means, the principle of which consists of transilluminating the paranasal sinuses (diaphanoscopy) or examining them from the inside using light guides and special optical means inserted directly into the cavity being examined.

Diaphanoscopy. In 1989, Th.Heryng first demonstrated a method of light illumination of the maxillary sinus by inserting a light bulb into the oral cavity.

Subsequently, the design of the diaphanoscope was repeatedly improved. At present, there are significantly more advanced diaphanoscopes that use bright halogen lamps and fiber optics, which allow the creation of a powerful stream of focused cold light.

The technique of diaphanoscopy is extremely simple, it is absolutely non-invasive. The procedure is carried out in a dark booth with a floor size of 1.5 x 1.5 m with weak lighting, preferably dark green light (photo flashlight), which increases the sensitivity of vision to the red part of the spectrum. After a 5-minute adaptation of the examiner to this light, the procedure begins, which lasts no more than 2-3 minutes. To illuminate the maxillary sinus, the diaphanoscope is inserted into the oral cavity and the light beam is directed at the hard palate. The patient firmly fixes the diaphanoscope tube with his lips so that light from the oral cavity does not penetrate outside. Normally, a number of symmetrically located reddish light spots appear on the anterior surface of the face: two spots in the area of the dog fossae (between the zygomatic bone, the wing of the nose and the upper lip), which indicate good airiness of the maxillary sinus. Additional light spots appear in the area of the lower edge of the orbit in the form of a crescent with an upward concavity (evidence of the normal state of the upper wall of the maxillary sinus).

To illuminate the frontal sinus, a special optical attachment is provided, focusing the light into a narrow beam; the transilluminator with the attachment is applied to the superomedial angle of the orbit so that the light does not penetrate into it, but is directed through its superomedial wall in the direction of the center of the forehead. Normally, with symmetrical airiness of the frontal sinus, dull dark red spots appear in the area of the superciliary arches.

The results of diaphanoscopy are assessed in combination with other clinical signs, since the difference in brightness between the corresponding sinuses (or even the complete absence of luminescence on any side) can be caused not only by a pathological process (swelling of the mucous membrane, the presence of exudate, pus, blood, tumor, etc.), but also by anatomical features.

Optical methods of endoscopy of the nose and paranasal sinuses have become increasingly widespread in recent years. Modern endoscopes are complex electron-optical devices equipped with ultra-short-focus optics with a wide viewing angle, digital video signal converters, television video recording devices that allow quantitative color spectrum analysis of the image. Thanks to endoscopy, it is possible to detect early a number of precancerous and tumor diseases, conduct differential diagnostics, and take biopsies. Medical endoscopes are equipped with auxiliary instruments, attachments for biopsy, electrocoagulation, administration of drugs, transmission of laser radiation, etc.

By purpose, endoscopes are divided into endoscopic ones, biopsy endoscopes and surgical ones. There are modifications of endoscopes for children and adults.

Depending on the design of the working part, endoscopes are divided into rigid and flexible. The former retain their shape during examination or surgery, and are used on organs located close to the body surface. Such endoscopes have found wide application in otolaryngology. The latter, thanks to the use of glass flexible fiber optics, are able to take the shape of the "channel" being examined, such as the esophagus, stomach, duodenum, trachea, bronchi, etc.

The principle of operation of rigid endoscopes is based on the transmission of light from a source through a lens optical system; the light source is located at the working end of the endoscope. The optical system of flexible fiber endoscopes is designed in the same way as the lens system, but the transmission of light and the image of the object is carried out through a fiberglass light guide, which made it possible to move the lighting system outside the endoscope and achieve bright illumination of the surface being examined, sufficient for television transmission of an image close to the natural color range; the object of study does not heat up.

Preparation of the patient for endoscopic examination or endoscopic surgery is determined by the specific task that the doctor has to solve. Diagnostic endoscopy of the nasal cavity is performed mainly under local application anesthesia of the nasal mucosa, sometimes with the use of barbiturates (hexenal or thiopental sodium), diphenhydramine, atropine, minor tranquilizers. In some cases, anesthesia for diagnostic endoscopy requires approval by an anesthesiologist. An endoscopic procedure involving penetration into the paranasal sinuses requires general intubation anesthesia for effective implementation. Complications during diagnostic endoscopies of the nose and paranasal sinuses are rare.

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