Flexible Rhinoscopy

Flexible rhinoscopy is a quick, office-based procedure used to examine the entire nasal cavity.

It is most commonly performed by otolaryngologists in the evaluation of nasal obstruction, sinusitis, epistaxis, anosmia, other symptoms of rhinitis, and head and neck cancer. It can also be performed by allergists in the evaluation of allergic rhinitis and radiation oncologists to assess the response of malignancy to radiation therapy. Internal medicine, family medicine, and emergency medicine doctors may also use flexible rhinoscopy to evaluate patients with epistaxis or nasal foreign bodies.

Flexible rhinoscopy is commonly performed in the office or at the bedside with no specific preprocedure restrictions. An average evaluation takes less than 2 minutes and is well-tolerated by the majority of patients.

Key considerations

Nasal obstruction is a sensation that one or both nasal passages are blocked. There are many causes of nasal obstruction, and the etiology is often multifactorial. Diagnosis requires a thorough history and physical examination, with imaging reserved for surgical planning and evaluating intracranial spread or invasion into adjacent structures. Flexible rhinoscopy is a useful adjunct to the physical examination that allows direct visualization of structures within the superior and posterior nasal cavities that may not be visible with anterior rhinoscopy alone.

The differential diagnoses of nasal obstruction are considerable (see below). A thorough history, including onset, duration, current medications, and aggravating/relieving factors, can help to narrow the differential diagnoses. Constant unilateral obstruction usually results from anatomic obstruction, whereas a seasonal congestion or one that responds to topical decongestants is typically due to an inflammatory pathology. Pediatric patients can present with life-threatening respiratory distress secondary to some congenital causes of nasal obstruction; therefore, prompt evaluation and treatment is essential in these patients.

Differential diagnoses

Congenital causes of nasal obstruction include the following:

• Choanal atresia

• Pyriform aperture stenosis

• Midnasal stenosis

• Encephalocele

• Nasal dermoid

• Glioma

• Teratoma

• Nasolacrimal duct cyst

• Turbinate hypertrophy

• Septal deviation

• Neonatal rhinitis

• Vascular lesions

• Craniofacial abnormalities

Anatomic causes of nasal obstruction include the following:

• Septal deviation

• Turbinate hypertrophy

• Nasal valve collapse

• Concha bullosa

• Nasal/sinus tumor

• Nasal polyposis

• Septal perforation

• Synechiae

Inflammatory causes of nasal obstruction include the following:

• Allergic rhinitis

• Nonallergic rhinitis

• Rhinosinusitis ^[1]

• Rhinitis medicamentosa

Systemic causes of nasal obstruction include the following:

• Hypothyroidism

• Medications (antihypertensives, antidepressants, antipsychotics, beta-blockers)

• Rhinitis of pregnancy (rhinopathia gravidarum)

• Wegener granulomatosis

• Tuberculosis

• Sarcoidosis

• Rhinoscleroma

• Rhinosporidiosis

Flexible rhinoscopy is indicated for the thorough evaluation of any patient with nasal obstruction or any nasal complaint not fully evaluated with anterior rhinoscopy. In addition, flexible rhinoscopy is commonly used for postoperative follow-up and as an adjunct to the evaluation of head and neck cancer.

Complication prevention

Discomfort and epistaxis are the most common complications. Allowing time for adequate anesthesia can help decrease the discomfort experienced by some patients. Knowledge of the intranasal anatomy and the rhinoscope's maneuverability can decrease the length of the examination. Epistaxis can be avoided by minimizing contact with the nasal mucosa.