Equipment

A flexible rhinoscope is necessary for this procedure. Numerous scopes are available, and the choice of equipment is at the discretion of the physician. In general, pediatric rhinoscopes have a diameter of 2.4–3 mm, while adult scopes range from 3.4–4.8 mm. Length of scopes also varies, but a typical scope is 300 mm.

The end of the scope can angulate 90-130°, and the field of view is 75–110°. The light source can take the form of a portable battery-powered unit or a plugged-in source lamp. Suction equipment should also be available in case there is crusting or mucous that obscures the physician's view. An 8- or 10-Frazier suction can be used in adults, while a smaller Frazier suction or flexible catheter suction can be used in pediatric patients.

Anesthesia

Flexible rhinoscopy can be safely carried out without any systemic anesthesia. Topical 2% or 4% lidocaine (Xylocaine) is a commonly used anesthetic.^{[2, 3]}Its onset of action is 1–5 minutes and duration of action is 15–30 minutes. Oxymetazoline (Afrin) is also commonly administered intranasally for decongestion. It may be useful to examine the native nose prior to application and then again after decongestion.^{[4, 5]}

Positioning

Patients should be seated upright during the examination. However, if a patient is unwilling or unable to sit upright, the examination can be completed with the patient lying down.

Monitoring & Follow-up

Patients should be instructed that anesthesia following the procedure can persist for an additional half an hour. With anesthesia, the gag reflex can be diminished or absent; therefore, patients should not take anything by mouth until the anesthesia has worn off.

Complications

Patient discomfort and epistaxis are potential complications. As mentioned previously, anesthesia is not necessary, but can help reduce discomfort secondary to the procedure. The physician should also be careful to avoid abrading the nasal mucosa or disturbing any raw surfaces. If epistaxis is evoked by the procedure, oxymetazoline nasal spray should be sprayed in the nose and firm nasal pressure applied for 10 to 15 minutes. If this fails to control the bleeding and the source of bleeding is clearly visible, nasal cautery with silver nitrate can be performed. Alternatively, a hemostatic agent such as Surgicel can be applied. Nasal packing should be reserved for intractable cases. If a patient requires nasal packing, an antibiotic with gram positive coverage such as cephalexin (Keflex) or clindamycin (Cleocin) if penicillin allergic should be prescribed while the packing is in place because there have been cases of toxic shock syndrome from nasal packing.