Outpatient Examination

It is best to examine the nose initially without any anesthetic as the solution can irritate the mucosa, producing a reactive rhinorrhea and edema, which makes it difficult to know whether there is any underlying mucosal disease or not. A rigid 30°, 2.7 mm endoscope is good for outpatient examination (Fig. 6.2a, b). It provides good access and control and is also a durable instrument. Its only drawback is that it does not provide enough light or a wide enough view to record a good image. For this, a 4 mm rigid endoscope is needed.

It is important not to produce any discomfort, so the endoscope should be advanced slowly, avoiding any contact with the septum or lateral nasal wall. The middle meatus is often the most spacious area to examine, and this is often the best area to examine first so as to give patients confidence that they will not feel much discomfort during this procedure. It is possible to advance the endoscope to visualize the postnasal space and to see whether there is any mucopus tracking back from the middle meatus, the posterior ethmoid sinuses, or the sphenoethmoid recess (Fig. 6.3). The anterior aspect of the olfactory cleft can be seen by angling the endoscope upward as soon as it is introduced past the nasal vestibule. However, it is important not to touch the anterior end of the middle turbi-nate when you do this, as it is very sensitive. One key aspect of using the endoscope is to make every move-

Fig. 6.2 a Microscopic and b endoscopic examination of the nose.

Fig. 6.2 a Microscopic and b endoscopic examination of the nose.

b a ment slowly and gently. Patients can tolerate some pressure on the mucosa as long as it is applied very slowly; sudden movements cause more discomfort. We tell the patient to let us know by grunting if they are going to sneeze in order to warn us to withdraw the endoscope.

After the overview, you may think that local anesthetic should be applied for a more thorough examination, for example, when the nose is crowded or the initial inspection has produced discomfort. We use cotton wool soaked in a local anesthetic and a de-congestant, placing it in the middle meatus or where we need to examine.

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