Endoscopy (examination) of the nasal cavity

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

The light source should be located to the right of the subject, 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 surveyed area. Reflected from the frontal reflector, focused light should illuminate the area under examination in the normal position of the physician, who should not bend and incline in search of a "bunny" or object of inspection; the doctor moves the patient's head, giving it the necessary position. A novice otorhinolaryngologist must constantly train to acquire the skill of binocular vision, which is necessary for manipulation in deep ENT organs. To do this, he sets the light spot on the inspection object so that when the right eye is closed, it is clearly visible through the opening of the frontal reflector with the left eye.

Instruments that are used in endoscopy and various manipulations can be conditionally divided into auxiliary and "active" ones. Auxiliary tools extend the natural pathways of the ENT organs and eliminate some obstacles (for example, the hair in the external ear canal or on the threshold of the nose); to auxiliary instruments are mirrors, funnels, spatulas, etc. Active instruments are used for manipulations carried out in the cavities of ENT organs. They need to be held in the right hand, which provides greater accuracy of movements (for right-handed people) and does not interfere with the illumination of the cavity in question. To do this, the auxiliary tools should be kept in the left hand, and with certain difficulties - persistently train this skill. Ideal for otorhinolaryngologist is the possession of both hands.

Endoscopy of the nasal cavity is divided into the anterior and posterior (indirect), carried out with the help of a nasopharyngeal mirror. Before anterior rhinoscopy with a nasal mirror, it is advisable to examine the vestibule of the nose by raising the tip of the nose.

With front rhinoscopy, three positions are identified, defined as the lower one (examination of the lower parts of the septum and nasal cavity, lower nasal concha), the middle (examination of the middle sections of the septum of the nose and the nasal cavity, the middle nasal concha) and the upper (examination of the upper parts of the nasal cavity, and the region of the olfactory gap).

With front rhinoscopy, attention is drawn to various signs that reflect both the normal state of endonasal structures and those or other pathological states of them. Assess the following features:

1. color of the mucosa and its humidity;
2. the shape of the septum of the nose, drawing attention to the vasculature in its anterior sections, the caliber of the vessels;
3. the condition of the nasal concha (shape, color, volume, relation to the septum of the nose), palpate them with a buttoned probe to determine the consistency;
4. the size and content of the nasal passages, especially the middle, and in the region of the olfactory gap.

In the presence of polyps, papillomas or other pathological tissues, their appearance is evaluated and, if necessary, they take tissues for examination (biopsy).

With the help of a back rinsoscopy, it is possible to examine the posterior sections of the nasal cavity, the nasopharynx arch, its lateral surfaces, and the nasopharyngeal openings of the auditory tubes.

The posterior rhinoscopy is performed as follows: with a spatula in the left hand, squeeze the front 2/3 of the tongue downward and somewhat forward. The nasopharyngeal mirror, preheated to avoid fogging its surface, is injected into the nasopharynx over the soft palate, without touching the root of the tongue and the posterior pharyngeal wall.

To implement this type of endoscopy, a number of conditions are necessary: first of all, the appropriate skill, then favorable anatomical conditions and a low pharyngeal reflex. Disturbed emetic reflex, thick and "unruly" tongue, hypertrophied lingual tonsil, narrow yawn, long tongue of soft palate, protruding vertebral bodies with pronounced lordosis of the cervical spine, inflammatory diseases of the pharynx, tumors or scars of the soft palate are impediments for this type of endoscopy. If, due to the presence of objective interference, the usual posterior rhinoscopy fails, then appropriate applica- tion anesthesia is applied to suppress the emetic reflex, as well as delaying the soft palate by using one or two thin rubber catheters. After the applica- tion anesthesia of the nasal, pharyngeal and tongue tongue, a catheter is inserted into each half of the nose and the end is ejected from the pharyngeal outward from the pharynx. Both ends of each catheter are tied together with a slight tension, making sure that the soft palate and tongue do not wrap around the nasopharynx. Thus, immobilization of the soft palate and opening of free access to examination of the nasopharynx is achieved.

In the nasopharyngeal mirror (diameter 8-15 mm), only a few parts of the examined area are visible, therefore, to inspect all nasopharyngeal formations light turns of the mirror are made, sequentially inspecting the entire cavity and its formations, focusing on the posterior edge of the septum of the nose.

In some cases, there is a need for finger examination of the nasopharynx, especially in children, because they rarely manage to successfully carry out an indirect back rhinoscopy. To conduct this examination, the doctor becomes behind the sitting patient, covers his head and neck with his left hand, presses the left part of the cheek tissue (prevention of bite) into the open mouth, and puts 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 inserts over the surface of the tongue, slightly pressing the last down, bends, winds over the soft palate and palpates the anatomical formations of the nasopharynx. This procedure with the appropriate skill lasts 3-5 seconds.

In the finger examination of the nasopharynx, the overall size and shape of the nasopharynx is assessed, the presence or absence of partial or complete obliteration, seneses, adenoids, obstruction of the khohans, hypertrophied posterior ends of the inferior nasal concha, polypov khon, tumor tissue, etc., is assessed.

Rear Rhinoscopy is of great importance in the presence of inflammatory diseases of the sphenoid sinus, tumor processes in it, in parasellar regions, in the field of the Turkish saddle of other diseases of this area. However, this method does not always give the desired results. Exhaustive visual information on the state of the cavities of the septum of the nose can be obtained using modern television endoscopy techniques using fiber optics. To do this, approaches are used to probe the paranasal sinuses through their natural openings developed at the beginning of the 20th century.

Probing of the paranasal sinuses. The same method served as a means of catheterization of the sinuses for the evacuation of pathological contents from them and the administration of medicinal substances.

The catheterization of the maxillary sinus is as follows. Apply an anesthetic of the corresponding half of the nose with a three-time lubrication with an anesthetic (1 ml of a 10% solution of lidocaine, 1 ml of a 1-2% solution of pyromecaine, 1 ml of a 3-5% solution of dicaine), a mucosa under the middle nasal (in the hyatus semilunare) application of the solution of epinephrine hydrochloride at a concentration of 1: 1000 to the indicated site of the mucosa. After 5 minutes proceed to the catheterization: the bent end of the catheter is inserted under the middle nasal concha, directed laterally and upward into the region of the posterior third of the middle nasal passage, and try to enter the exit hole. If it enters the opening, there is a sensation of fixing the end of the catheter. In this case, an attempt is made to insert an isotonic solution of sodium chloride into the sinus with a syringe under light pressure on its piston.

The frontal sinus catheterization is similarly performed, only the end of the catheter is directed upward at the level of the anterior end of the middle nasal shell into the funnel of the frontal-nasal canal. This procedure is performed less successfully with a high location of the nasal opening of the frontal-nasal canal and requires great care due to the proximity of the trellis plate. To avoid touching it with the end of the catheter, it is directed upward and somewhat lateral, focusing on the inner corner of the eye.

Catheterization of the sphenoid sinus is performed under the control of vision using the Killian nose mirror (medium or long). Anesthesia and adrenalinization of the nasal mucosa should be sufficiently deep. The final position of the catheter is determined in the direction of the oblique line upward, making an angle of about 30 ° with the bottom of the nasal cavity, depth - up to the stop in the anterior wall of the sphenoid sinus - 7,5-8 cm. In this region, for the most part, a hole is searched for by touch. If it enters the catheter easily, it enters another 0.5-1 cm and rests against the back wall of the sphenoid sinus. With a successful hit, the catheter remains fixed in the hole and, if released, does not fall out. Washing is carried out as carefully as in the previous cases.

In recent years, the method of catheterization of paranasal sinuses by flexible conductors and catheters has been developed. The procedure is simple, atraumatic and allows for successful catheterization of the paranasal sinuses with the retention of a catheter in them for a time sufficient for the course of nonoperative treatment.

The relevance of the methods described above these days is the increasing dissemination in rhinology of the methods of TV-endoscopic research and surgery of the paranasal sinuses.

Instrumental methods of endoscopy. By instrumental methods of endoscopy, they are meant such that various technical means are used, the principle of which is to scan the paranasal sinuses (diaphanoscopy) or to examine them from within with the help of light guides and special optical devices that are introduced directly into the examined cavity.

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

Subsequently, the construction of the diaphanoscope was repeatedly improved. At present, there are much more advanced diaphanoscopes, which use bright halogen lamps and fiber optics, which allows creating a powerful stream of focused cold light.

The method of diaphanoscopy is extremely simple, it is absolutely non-invasive. The procedure is carried out in a dark cabin with a floor size of 1.5x1.5 m with a weak backlight, preferably a dark green light (photophon), at which the sensitivity of the vision to the red part of the spectrum increases. After a 5-minute adaptation of the examiner to this light, proceed to a procedure that lasts no more than 2-3 minutes. For the transmission of the maxillary sinus, a diaphanoscope is inserted into the oral cavity and a beam of light is directed to the hard palate. Obsessed with the lips tightly fixes the tube diaphanoscope, so that the light from the mouth does not penetrate outside. Normally, a series of symmetrically located light spots of reddish color appear on the front surface of the face: two spots in the canine pits area (between the zygomatic bone, the nose wing and the upper lip), which indicate good airiness of the maxillary sinus. Additional light spots appear in the region of the lower edge of the orbit in the form of a crescent concavity to the top (evidence of the normal state of the upper wall of the maxillary sinus).

For transmission of the frontal sinus, a special optical nozzle is provided, which focuses the light into a narrow beam; a diaphanoscope with a nozzle is applied to the upper medial angle of the orbit so that light does not penetrate it, but is guided through its upper medial wall in the direction of the center of the forehead. Normally, with a symmetrical airway of the frontal sinus, dull dark red spots appear in the region of the superciliary arches.

The results of diaphanoscopy are evaluated in conjunction with other clinical signs, since the difference in brightness between the corresponding sinuses (or even a complete absence of luminescence on either side) may be due not only to the pathological process (edema of the mucosa, the presence of exudate, pus, blood, tumor and so on), but also by anatomical features.

Optical methods of endoscopy of the nose and paranasal fennels have become more widespread in recent years. Modern endoscopes are complex electronic-optical devices equipped with a wide-angle optics with a wide viewing angle, digital video converters, television video recording devices that allow for quantitative color spectral analysis of the image. Due to endoscopy, early detection of a number of precancerous and tumorous diseases, differential diagnosis, biopsy taking is possible. Medical endoscopes are equipped with auxiliary instruments, attachments for biopsy, electrocoagulation, administration of medicines, transfer of laser radiation, etc.

By appointment endoscopes are divided into proper endoscopic, endoscopes for biopsy and operating rooms. There are modifications to endoscopes for children and adults.

Depending on the design of the working part, endoscopes are divided into rigid and flexible. The first retain their shape during the study or surgery, they are used on organs that are at a close distance from the surface of the body. Such endoscopes have found wide application in otorhinolaryngology. The second, thanks to the use of glass flexible fibers, can take the form of the investigated "channel", for example, the esophagus, stomach, duodenum, trachea, bronchi, etc.

The principle of action 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 end of the endoscope. The optical system of flexible fiber endoscopes is constructed in the same way as the lens system, but light and image transmission of the object is carried out along the glass fiber waveguide, which made it possible to remove the lighting system from the endoscope and achieve bright illumination of the surface under consideration, sufficient for television transmission of an image close to the natural color scale ; In this case the object of investigation does not heat up.

Preparation of the patient for endoscopic examination or endoscopic surgery is determined by the specific task that the doctor will have to solve. Diagnostic endoscopy of the nasal cavity is carried out mainly under local application anesthesia of the nasal mucosa, sometimes with the use of barbiturates (hexenal or thiopental sodium), dimedrol, atropine, and minor tranquilizers. In some cases, anesthesia with diagnostic endoscopy requires agreement with the anesthesiologist. Endoscopic procedure associated with penetration into the paranasal sinuses, requires for effective implementation of a general intubation pain relief. Complications with diagnostic endoscopy of the nose and paranasal sinuses are rare.

[1], [2], [3]