Approach Considerations

The steps of flexible rhinoscopy are described below.

While the anesthesia is allowed to take effect, the flexible scope should be focused and adequate lighting should be confirmed
Defog is then applied to the tip of the scope, and lubricant may also be applied to the shaft
The scope is placed along the floor of the nasal vault
The septum and inferior turbinate are evaluated first
Any septal deviation or spurs should be noted
Turbinate hypertrophy or atrophy is documented
If the rhinoscopy is being performed for recurrent epistaxis, the Kiesselbach plexus (located on the anterior inferior septum and represents the confluence of the anterior ethmoid artery, greater palatine artery, sphenopalatine artery, and septal branch of the superior labial artery) should be carefully examined; anterior nosebleeds frequently originate from this area
Following anterior inspection, the scope should gently be advanced posteriorly toward the nasopharynx
Any mass should be inspected, with special attention paid to its origin and appearance, which can assist with the diagnosis^{[6, 7, 8, 9]}
If endoscopy is being performed for epistaxis, the area of Woodruff plexus (located at the posterior aspect of the inferior meatus) is examined;^[10]this is the source for many posterior nosebleeds since it is composed of large, thin-walled veins
The scope is taken posteriorly to the nasopharynx, where the nasopharyngeal mucosa, eustachian tube orifice, and fossa of Rosenmüller are examined
The sphenoid rostrum may also be visualized, and the presence of purulent drainage or polyposis should be noted
The scope is then gently withdrawn and placed above the inferior turbinate to view the middle turbinate; the size of the turbinate is noted as well as any mucosal changes, crusting, edema, purulence, or polypoid degeneration; in postoperative patients, the turbinate may be lateralized, medialized, or absent
Synechiae can also be seen in postoperative patients
The true maxillary ostium should be hidden behind the uncinate process, so any ostia that are visualized are likely accessory ostia
A mass arising from the middle meatus should raise the suspicion of an inverted papilloma
Visualization superoposteriorly is typically limited by the ethmoid complex unless the patient has had prior sinus surgery; in these cases, the ethmoid labyrinth should be examined for the presence of synechiae, polypoid degeneration, residual air cells, and any other masses/lesions
The cribriform area should be inspected medial to the middle turbinate; this is the location of the olfactory epithelium and may be a site for neoplasms, encephaloceles, and other pathology
The procedure is then repeated in the contralateral nasal passage

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