Procedures: Nasal Endoscopy

Nasal endoscopy is a brief in-office examination that uses a thin lighted scope to look deep inside the nose, the sinus drainage pathways and the back of the nasal passages.

What nasal endoscopy is

Nasal endoscopy is an in-office examination that lets an ear, nose, and throat (ENT) specialist look directly inside the nose, the sinus drainage pathways, and the back of the nasal passages (the nasopharynx). It uses a thin instrument called an endoscope, which carries a light and a lens or camera so the inside of the nose can be seen clearly on an eyepiece or a video screen.

The examination goes well beyond what can be seen by simply shining a light into the nostrils (a method called anterior rhinoscopy). A plain look into the front of the nose shows only the first inch or so of the nasal cavity. An endoscope provides magnification of the front of the nose and, importantly, a direct view of the deeper and back structures that are otherwise hidden, including the areas where the sinuses drain and the space behind the nose where the ear tubes (eustachian tubes) open. In one series, endoscopy revealed problems not seen on a routine nasal look in nearly 39% of patients.

Nasal endoscopy is one of the most common procedures performed in ENT offices, and it is also performed by some allergists and primary care clinicians.

Why it is done

A clinician may recommend nasal endoscopy to investigate or monitor a range of concerns, including:

• Chronic sinus symptoms such as nasal congestion, facial pressure, or nasal discharge. Endoscopy can confirm chronic rhinosinusitis by directly showing pus or polyps, and a positive finding can often avoid the need for a CT scan.

• Nosebleeds that are recurrent or hard to control, where endoscopy helps locate the source of bleeding (successful in roughly 87% to 93% of cases) and can guide treatment.

• Nasal blockage before possible nasal or sinus surgery, where endoscopic findings can change the surgical plan.

• Nasal polyps, masses, or other growths, a one-sided blockage, or a suspected foreign object, each of which warrants a direct look.

• Hoarseness, chronic cough, or throat symptoms, when the scope is passed further to view the throat and voice box (see fiberoptic laryngoscopy).

• Follow-up after sinus surgery, to inspect healing, clear crusting, and detect recurrence.

During the examination, the clinician can also collect a sample of abnormal mucus for laboratory testing or culture, which plain examination of the nose does not allow.

Two types of endoscope

Both approaches examine the nose through the nostril and are often done the same day in the office. The choice depends on what needs to be seen and on each person's anatomy.

Flexible fiberoptic nasal endoscopy uses a soft, bendable scope, typically very thin. Because it bends, it can follow the natural curves of the nasal passage and continue past the back of the nose to view the throat, the base of the tongue, and the voice box, as in fiberoptic laryngoscopy. The flexibility makes it well suited to narrow nasal passages, to people who are more sensitive to discomfort, and to examining how structures move during breathing, speaking, or swallowing.

Rigid nasal endoscopy uses a straight, firm rod-lens scope that often provides a very bright, high-resolution image. Rigid scopes come in different viewing angles (such as 0, 30, 45, or 70 degrees) that let the clinician look around corners toward the sinus openings. They give an excellent view of the nasal cavity and sinus drainage areas and are commonly used when detailed inspection of the sinuses is the goal. Because the rigid scope does not bend, a narrow or deviated passage can make it more difficult to advance.

What the examination involves

Nasal endoscopy is usually a brief procedure done while the person is awake and seated, without the sedation used for procedures such as colonoscopy.

• Preparation of the nose. A spray is often applied inside the nose beforehand. This commonly combines a decongestant, which shrinks the lining to open the passage, with a numbing medication to improve comfort. Numbing medication is not always necessary, particularly for flexible examinations, and practice varies among clinicians. The numbing spray can leave a temporary odd taste or a sensation of numbness in the throat.

• The examination. The clinician gently passes the scope into one nostril and advances it slowly while viewing the image, sometimes examining both sides. A systematic look covers the nasal passages, the turbinates (the ridges along the side wall), the sinus drainage areas, and the back of the nose; a flexible scope may continue to the throat and voice box. The scope itself takes only a few minutes.

• Comfort. The procedure is generally well tolerated but can feel uncomfortable, with a sensation of pressure or fullness as the scope passes; some people find it more unpleasant than others. Breathing quietly through the nose and staying relaxed can ease the examination.

• Afterward. Because no sedation is used, normal activities, including driving, can usually resume right away. The clinician can often discuss the findings immediately, since the view is available in real time.

Risks and safety

Nasal endoscopy is considered very safe. The main drawbacks are temporary discomfort and a small chance of a minor nosebleed. There can also be rare, mild effects from the procedure or the medications used, such as a brief change in taste, lightheadedness, or watering of the eyes. The risk of bleeding is somewhat higher in people with a bleeding disorder, those taking blood thinners, or those with previous nasal surgery or injury, and it is helpful for the clinician to know about these in advance. Overall, the benefit of a clear, direct look inside the nose generally outweighs these small risks.

Questions worth raising with the clinician

• The specific reason the examination is being recommended and what it is expected to show.

• Whether a flexible or rigid scope will be used, and why.

• Any personal use of blood thinners or history of easy bleeding or prior nasal surgery.

• How and when the findings and any sample results will be shared.