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Rigid Rhinoscopy

Overview

Introduction

The development of a rod lens system by Harold H. Hopkins in 1959 and the coupling of this system with a fiber optic light transmission technology by Karl Storz in 1960 marked a breakthrough in modern endoscopic surgery. The Hopkins rod-lens endoscope system consists of a series of glass rod lenses separated by air and fiberoptic bundles surrounding the lens for transmission of light. Today, the rigid endoscope (see the image below) allows otolaryngologists to perform nasal endosocopy (rigid rhinoscopy) for both routine diagnostic examinations and complex, minimally invasive sinus surgery.

4.0 mm and 3.0 mm rigid nasal endoscopes.

4.0 mm and 3.0 mm rigid nasal endoscopes.

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The “rod-lens” system of image transmission was a simple but radical departure from the lens system then in use. Instead of an air interspace between glass lenses, Hopkins used solid glass rods with lenses cemented between them. This dramatically increased light transmission and image definition and yielded images of a quality never before seen. These scopes provide a much wider viewing angle and smaller diameter than its predecessors, with improved resolution, contrast, and brightness. For more background on Hopkins or Storz, the author recommends 2 wonderful articles by Linder et al and Morgenstern.

Today, endosocopy can be coupled with high-definition video and digital image-capturing systems to provide brilliant images for education. Currently, most otolaryngologists use telescopes ranging from 2.7-4 mm in diameter. Endoscopes are also available with angled lenses (30º, 45º, 70º) allowing for better visualization of the skull base, ethmoid, maxillary, and frontal sinuses. All of the images seen in this chapter are from a standard rigid rhinoscope.

Rigid rhinoscopy allows for a complete and detailed visualization of the nasal mucosa, turbinates, and nasopharynx. This examination can be performed on adults and children who are able to cooperate with the examination. A wide variety of indications exist for rigid rhinoscopy, including inspection for inflammation in the mucosal membranes, the presence of purulent secretions, turbinate enlargement, or nasal polyps.

Key Considerations

A high-intensity light source is required. Most commercially available unites use halogen or xenon lamps. Xenon is white and the most natural in color. Halogen sources produce a slightly yellow light. Light from the light source is transmitted to the telescope through a fiberoptic light cable. Optical fibers are long, thin strands of glass that are bundled together to form cables. Light is passed from the light source through the optical fibers and flexible cable, without much degradation of the light signal. The light cable is attached to the telescope and the light continues through the rigid telescope. The scopes can be attached via a small video camera (charge-coupled device) to allow the surgeon to look at the video image on a monitor. Current generations of video camera integrate high-definition signals, allowing for 1080p images.

Relevant Anatomy

The septum is a midline bony and cartilaginous structure that divides the nose into 2 similar halves. Regarding the lateral nasal wall and paranasal sinuses, the superior, middle, and inferior concha form corresponding superior, middle, and inferior meatus on the lateral nasal wall. The superior meatus is the drainage area for the posterior ethmoid cells and the sphenoid sinus. The middle meatus provides drainage of anterior ethmoid and the maxillary and frontal sinuses. The inferior meatus provides drainage of the nasolacrimal duct.

The internal nasal valve involves the area bounded by upper lateral cartilage, septum, nasal floor, and anterior head of the inferior turbinate. This makes up the narrowest portion of the nasal airway in the leptorrhine nose.

For more information about the relevant anatomy, see Nasal Anatomy.

Indications

The following are the usual indications for performing rigid rhinoscopy:

Evaluation and examination of the nasal cavity, paranasal sinuses, and nasopharynx

Evaluation of the turbinates and nasal septum, which can contribute to nasal airway obstruction.

Surveillance of previously diagnosed (treated or untreated) tumors of the nasal cavity, paranasal sinuses, and nasopharynx

Evaluation and treatment of epistaxis

Removal of nasal foreign bodies

To obtain biopsies for the diagnosis of nasal masses

To perform therapeutic procedures such as irrigation, obtaining cultures, and balloon dilation of the sinuses

Remove old blood, packing, or scar tissue after nasal or sinus surgery

As a part of functional endoscopic sinus surgery (FESS)

Contraindications

No absolute contraindications exist. Relative contraindications to rigid rhinoscopy include a lack of patient cooperation.

Endosocopic Staging

Nasal endoscopy and imaging are the 2 most widely used objective measures in the diagnosis of chronic rhinosinusitis (CRS). Endoscopy has multiple uses in the management of patients with sinonasal symptoms and plays an important role in both the preoperative and postoperative management of patients.

The Lund-Kennedy endoscopy scoring system quantifies the pathologic states of the nose and paranasal sinuses. The scoring system assesses for the presence of polyps, discharge, edema, scarring, or adhesions and crusting. Endoscopic staging is performed bilaterally and typically takes place during the initial evaluation, preoperatively, postoperatively, and at regular intervals (3, 6, 12, 24, and 36 months recommended).

The scores range from 0-20. Polyps are graded as absent (0), present in middle meatus (1), or present beyond the middle meatus (3). Discharge is graded as not present (0), thin (1), or thick and purulent (2). Edema, scarring, and crusting are each graded as absent (0), mild (1), or severe (2). Interrater agreement studies examining the reliability of the Lund-Kennedy endoscopic scoring system demonstrate that in a high proportion of cases, 2 independent observers agree on the examination findings.

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