Endoscopic Evidence of Mucosal Disease

Endoscopic findings must be interpreted in the light of patients' symptoms and response to medical treatment. You will be caught out if you intervene on the basis of an abnormal endoscopic examination alone.

Clear Mucus Sinuses
Fig. 6.11 An accessory ostium of the right maxillary sinus with clear mucus filling it.
Maxillary Sinus Ostium Anatomy
Fig. 6.13 The outflow area of the frontal recess.

However, endoscopy is far more reliable than CT—we cannot emphasize this point enough (Fig. 6.16). Endos-copy is particularly helpful in patients who have had radiology that has shown changes, and when the history and examination indicate that the problem is not due to their sinuses. These patients can be told or shown via a camera their endoscopic appearance. For most patients an intranasal view of their disease with an image on a monitor is particularly helpful in supporting the surgeon's opinion and may help

Inferior Turbinates Mucosal Disease
Fig. 6.14a, b When the endoscope is withdrawn, you obtain an overview of the anterior part of the middle meatus.
Hasner Valve
Fig. 6.15 Hasner's valve lies 1 cm behind the anterior end of Fig. 6.16 An incidental mucus retention cyst found in 1 in 30 the inferior turbinate. asymptomatic people.

counteract any information they have gleaned from their radiology report that may have insinuated that they have significant paranasal sinus pathology when these changes are often incidental (Bolger and Kennedy, 1992; Benninger, 1997; Hughes and Jones, 1998).

One of the key aspects of the examination is to establish whether the lining of the nose and the outlet areas of the sinuses have normal mucosa. Nineteen percent of most populations have allergic rhinitis. Of these, many will have marked hypertrophy of the inferior turbinates, but on inspection of the middle mea-tus that area of mucosa will look normal. A minority, particularly those with intermittent (seasonal) rhini tis, will have some edema of the mucosa throughout the nasal airway. They will often have "wet" mucosa with clear mucus, although occasionally this will have a light yellow stain because of the presence of eosinophils. The same can be found in patients with late-onset asthma who have rhinitis. Patients with late-onset asthma or allergic rhinitis pose a diagnostic problem, as it is not possible to be sure whether there is any coexisting paranasal sinus disease on the basis of endoscopy (and often on history). A trial of medical treatment is often a useful indicator, but it is best to focus on the patient's main symptoms and response to medical treatment in the light of the endoscopic signs rather than the other way around. You may make use of a diary of symptoms kept by the patient, see the patient on more than one occasion or, best of all, see them when they are symptomatic in order to help ascertain whether there is any infective component contributing to their symptoms.

In the majority of patients, with a clear middle meatus and a normal lining, the normal appearance is of particular value as it means that symptoms of pain and pressure are extremely unlikely to be attributable to sinus disease. It is worth asking a patient who has recurrent acute episodes of pain to attend when they are symptomatic—you may be surprised to find out how infrequently these patients have an abnormal en-doscopic examination when they are examined. In patients who have had previous surgery, endoscopy is also far more useful than CT. When a patient returns after previous sinus surgery and has some residual symptoms, it is tempting to arrange for a CT scan. Resist the temptation. You will serve your patients better by retaking the history and doing a thorough endo-scopic examination (Fig. 6.17). A CT scan will often show some mucosal thickening, which is often an incidental finding (Maclennan and MacGarry, 1995).

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