Nasal examination, especially nasal endoscopy, should be obligatory for every lacrimal patient [6, 9, 10, 14, 20, 26]. The examination of the lacrimal area with the nasal speculum and headlight provides only a poor view of this region and is not sufficient, endoscopy provides a clear diagnostic look for nasal polyps, imporant anatomic variations, tumors, and other pathological endonasal conditions such as septal deviation (Fig. 3.10).
The nasal mucosa is topically decongested and anesthetized with a spray or pledges soaked with anesthetics. The patient sits or lies, and it is advantageous especially if some endonasal manipulation with forceps is assumed, e.g., in a patient's subsequent surgery.
The examination of the nasal cavity and the lateral nasal wall is performed in a systematic fashion and usually involves three steps :
1. The general survey and orientation and visual inspection of the nasal vestibule, nasopharynx, inferior turbinate, lower septum, and inferior meatus (the nasolacrimal duct opening is sometimes observed).
2. Endoscope is directed at the posterior end of the middle turbinate to evaluate the spheno-ethmoidal recess and superior nasal meatus.
3. Endoscopy of the middle meatus and lateral nasal wall, including an examination of the maxillary line and the middle meatus.
However, endoscopy is very important in postoperative care and after unsuccessful lacrimal surgery, e.g., unsuccessful dacryocystorhinostomy (Table 3.6).
Fig. 3.10. Nasal examination. a Nasal endoscopy with rigid or flexible telescope provides an excellent view and many abnormalities are detected. b Endoscopic view of right nasal space with the endoscope above the inferior turbinate to examine the lacrimal ridge and view the middle turbinate. The middle turbinate may be partially pneumatized. c Right nasal cavity with polyps in the middle meatus and between middle turbinate and septum. d Endoscopy of the left inferior meatus. Well-developed ostium of the nasolacrimal duct
Table 3.6. Nasal endoscopy in lacrimal surgery
Assessment of anatomical abnormalities potentially affected proposed lacrimal surgery (nasal cavity extent, septal deviation, hypertrophic turbinate, mucosa appearance, previous nasal surgery)
Assessment nasal pathology causing lacrimal symptoms (tumor, Wegener's granulomatosis, etc.) Observation of lacrimal transport (fluorescein)
Lacrimal pathways intubation (turbinate infraction, dacryocystocoele incision, extraction of probes, etc.)
Endonasal dacryocystorhinostomy (translumination, middle turbinate resection, septoplasty, bleeding control, laser EDCR, etc.)
Conjunctivocystorhinostomy with primary EDCR (control tube position, turbinate resection, septoplasty, etc.)
Endonasal follow-up post-endonasal and external lacrimal surgery (cleaning of the nasal cavity, size, and location of the DCR opening, Jones tube position, etc.
Failed lacrimal surgery (to determine any compromise of the opening, to diagnose any lesions obstructing the opening such as granulomas, fibrous tissue, polyps, synechiae, etc.)
Revision DCR (middle turbinate resection, anterior ethmoidectomy, removing fibrous tissue, etc.)
Conjunctivodacryocystorhinostomy (reinsertion and removing obstruction tissue)
Fig. 3.10. (Continued) e Coronal CT scan of orbits and sinuses shows right maxillary sinus carcinoma with intraorbital growing. The patient was treated with a endonasal DCR for epifora and dacryocystitis. Suspected masses were found around the sac and spinocelullar carcinoma was histologically determined. (From )
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