Both anterior rhinoscopy and indirect nasopharyngoscopy have certain limitations in the observation of the nasal cavity and sinuses. Many important structures in the nose (such as the openings of each sinus) are located in the narrow, hidden middle and upper nasal passages and the pterygoid sieve crypt and cannot be seen directly, which makes clinical diagnosis and disease determination difficult.
At present, the endoscopes commonly used in clinical practice are 0°, 30° and 70°, with a diameter of 4.0mm and a body length of 180mm, which have a large field of view and good brightness. Children can use 2.7mm diameter endoscope. Also should be equipped with a cold light source and light source wire. In order to do some simple operations, the following instruments should also be prepared: 0° and 45° sieve sinus forceps, straight suction tube, curved suction tube, maxillary sinus trocar puncture needle, maxillary sinus biopsy forceps, butterfly sinus occlusal forceps, etc. If there is a video recording system, which helps operation, teaching and data preservation, all nasal hair should be cut before examination.
I. Nasal endoscopy methoditis
1.Indications.
(1) Find the site of nasal bleeding and stop the bleeding under direct endoscopic view.
(2) To find the source of purulent secretions.
(3) Localization and direct vision biopsy of early nasal cavity and nasopharynx tumors.
(4) Locate the fistula of cerebrospinal fluid nasal leakage.
2.Examination methods.
(1) The patient is placed in a sitting or sloping position with the head tilted toward the examiner, routine nasal and facial disinfection, and a sterile towel is laid.
(2) Do surface anesthesia of the nasal mucosa and constriction of the mucosal vessels with l% dicaine ephedrine swabs.
(3) Apply a 0° endoscope to enter through the nasal floor or (and) the inferior nasal tract to observe the anterior inferior turbinate, middle and posterior inferior turbinates, nasal septum and inferior nasal tract from anterior to posterior. The 30° endoscope is used to enter from the base of the nose to the posterior nostril, and the posterior edge of the nasal septum is used as a marker to gently turn the mirror to observe the lateral wall of the nasopharynx and the opening of the eustachian tube, paying attention to the round pillow of the eustachian tube and the pharyngeal fossa. When the posterior end of the middle turbinate is reached, the mirror is turned outward by 30°-45° to observe the septal fossa and the opening of the butterfly sinus. nasal tract, and a few people can also see the uppermost turbinate and the uppermost nasal tract.
The nasal endoscopy should pay attention to the nasal cavity and nasopharyngeal mucosa for congestion, edema, dryness, ulceration, bleeding, vasodilation and neoplasia; pay attention to the primary site, size and scope of neoplasia and the source of purulent secretions; in case of suspected neoplasia, biopsy should be taken, and the purulent secretions in the sinus can be aspirated for bacteriological examination.
Endoscopic examination of maxillary sinus
1. Indications.
(1) X-ray or CT imaging suggests fuzzy maxillary sinus or suspicion of an occupying lesion.
(2) Foreign body in the maxillary sinus.
(3) Odontogenic maxillary sinusitis.
(4) maxillary sinus wall fracture or orbital floor burst fracture
(5) cheek pain or cheek swelling of unknown origin.
(6) Symptoms remain after maxillary sinus surgery.
2.Examination methods.
(1) The patient can be in sitting position, slope lying position or supine position. The nasal face is often disinfected from a distance and sterile towels are spread.
(2) The inferior nasal approach or the acinar fossa approach can be used.
Inferior nasal approach: l% dicaine ephedrine swabs are used for surface anesthesia of the nasal mucosa, focusing on the mucosa of the lateral wall of the inferior nasal tract. If a loop drill is used, the bone and two layers of mucosa can be removed at the same time, forming a circular, 5-8 mm diameter channel between the maxillary sinus and the inferior nasal tract. The bone hole is punctured with a trocar puncture needle and is closed soon after the examination is completed. The cuspid fossa approach: 1% lidocaine epinephrine solution is used for submucosal infiltration anesthesia of the cuspid fossa. The surgeon stands or sits on the right side of the patient, turns the patient’s upper lip with the left thumb, and feels the infraorbital rim with the left index finger to avoid injury to the infraorbital nerve. The maxillary sinus trocar puncture needle is inserted into the maxillary sinus with rotational force through the acinar fossa, and the puncture needle is withdrawn, retaining the trocar.
(3) The 0°, 30°, and 70° endoscopes are inserted sequentially through the trocar into the maxillary sinus, and the walls and natural openings of the maxillary sinus can be visualized by rotating the mirror.
If bleeding affects the observation, the bleeding can be stopped by compressing the stoma with epinephrine swabs, or by repeated flushing with saline and cotton compression, which usually bleeds very little and does not affect the observation. If there is a new organism in the sinus, endoscopic biopsy forceps can be used to take the material and carefully observe the appearance of the swelling, and it is best to take pictures or print photos simultaneously. If the sinus is filled with a mass, the examination can be stopped after taking a biopsy. If there is purulent discharge, it should be aspirated and sent for bacteriological examination and antibiotic sensitivity test.
3. Several common microscopic patterns.
(1) normal maxillary sinus: the mucosa is thin and transparent, the submucosal yellow bone wall can be seen, fine blood vessels are clearly visible, the natural opening can be seen on the medial wall, and sometimes the submucosa can be seen. Behind the natural opening there is a depression, slightly blue in color, which is the thin wall between the maxillary sinus and the posterior group of sieve sinuses.
(2) Maxillary sinusitis: acute maxillary sinusitis has bright red and edematous mucosal congestion, dilated and thickened tiny blood vessels, and accumulation of mucus or purulent secretions. Early odontogenic maxillary sinusitis from periapical infection is seen with limited congestion and edema at the sinus floor. In chronic maxillary sinusitis the mucosa is swollen and thickened and there may be scattered edema, polyps, fibrous degeneration, cysts and purulent secretions, and the natural opening is often obstructed.
(3) Metaplastic maxillary sinusitis: pale edema of the mucosa, loss of vascular texture, sometimes visible sinus filled with polyps, and if secondary infection is present, mucosal congestion and accumulation of purulent secretions are seen.
(4) maxillary sinus cyst: mucus cyst is often located in the lower wall of the sinus, the cyst wall is very thin, smooth surface, yellow transparent, the mucosa outside the cyst is normal in form. If the cyst wall is palpated by the endoscope, the cyst disappears because the contents flow out. Odontogenic cysts are usually larger and often the cyst wall ruptures when the endoscope is inserted, and the fluid that flows out is dark brown and contains cholesterol crystals. Medical Education Network
(5) Maxillary sinus tumor: endoscopy can detect small tumors and tumors that recur after surgery, and the diagnosis can be made by biopsy. Large tumors should be combined with imaging to determine the extent of the tumor.
III. Endoscopy of pterygoid sinus (not commonly used clinically)
1.Indications.
(1) Pterygoid sinus lesions: such as pterygoid sinusitis, pterygoid sinus mucus cyst, pterygoid sinus tumor.
(2) Cerebrospinal fluid nasal leakage, with difficulty in locating the fistula hole.
(3) nasal bleeding, looking for the site of bleeding.
2. Contraindications.
(1) Those with undeveloped pterygoid sinus confirmed by imaging.
(2) underage children or adolescents.
3.Examination methods.
(1) Patient in supine position, routine nasal and facial disinfection, lay sterile towel.
(2) 1% dicaine epinephrine swabs are fully contracted to anesthetize the middle turbinate, middle nasal tract and olfactory fissure.
(3) The middle turbinate is displaced toward the lateral fracture and the 0° endoscope is inserted posteriorly from the anterior nostril along the septum to the posterior end of the middle turbinate. The pterygoid septum is found between the nasal septum and the inferior border of the superior turbinate. The opening of the pterygoid sinus is located within the pterygoid septal fossa and varies in size and shape. If the endoscope cannot enter the pterygoid sinus through the opening, it can be punctured below the opening near the midline, taking care not to damage the optic canal in the lateral wall of the pterygoid sinus. The sinus secretions are aspirated and sent for bacteriological and cytological examination, and the sinus is carefully observed. Special care should be taken when taking biopsies from the superior and lateral walls of the pterygoid sinus. Pulsatile masses should be listed as contraindications to biopsy.
Four, frontal sinus endoscopy (not commonly used in clinical practice)
1, indications.
(1) frontal sinus lesion: such as frontal sinusitis, frontal sinus mucus cyst, frontal sinus tumor.
(2) cerebrospinal fluid nasal leakage, looking for fistulae.
2.Examination methods.
(1) Preoperative shaving of the eyebrows. The patient lies supine and the skin is sterilized with a sterile towel.
(2) Local infiltration anesthesia with l% lidocaine and a small amount of epinephrine in the medial arch of the eyebrow. The frontal sinus is entered by drilling a hole in the anterior wall of the frontal sinus with a loop drill, aspirating the secretions and flushing the sinus cavity before placing the endoscope. Both anterior rhinoscopy and indirect nasopharyngoscopy have limitations in the visualization of the nasal cavity and sinuses. Many important structures in the nose (such as the opening of each sinus) are located in the narrow, hidden middle and upper nasal passages and the septal fossa of the butterfly, which makes clinical diagnosis and disease determination difficult.
At present, the endoscopes commonly used in clinical practice are 0°, 30° and 70°, with a diameter of 4.0mm and a body length of 180mm, which have a large field of view and good brightness. Children can use 2.7mm diameter endoscope. Cold light source and light source wire should also be available. In order to do some simple operations, the following instruments should also be prepared: 0° and 45° sieve sinus forceps, straight suction tube, curved suction tube, maxillary sinus trocar puncture needle, maxillary sinus biopsy forceps, butterfly sinus occlusal forceps, etc. If a video recording system is available to help with operation, teaching and data preservation, all nasal hairs should be clipped before the examination.