Before performing invasive prodecures such as FESS, a full patient history must be completed.  Information is generated which allows the surgeon to give a diagnosis.  This diagnosis is confirmed using diagnostic nasal endoscopy in the outpatient setting.  A patient can then be made aware of the diagnosis and the best course of treatment which may be pharmacological or surgical or else in some cases no treatment is required.

HISTORY

The following topics should be investigated by the surgeon when the patient first presents at the ENT clinic

•      airway obstruction
•      runny nose (rhinorrhoea)
•      sneezing
•      loss of smell (anosmia)
•      facial pain
•      snoring associated with nasal obstruction

•      Allergies/atopic disease
•      Smoking
•      Pets at home
•      Occupation
•      History of previous surgery
•      History of trauma
•      General medical history
•      Seasonal or daily variation in symptoms

Standardised symptoms score assessments coupled with imaging investigations such as X-ray and CT scan and the endoscopic appearance of the patient provide enough information to guide the investigator towards the best course of treatment.

OUT-PATIENT ENDOSCOPY

A standard ENT examination followed by nasal endoscopy forms the basis of the initial diagnostic assessment.

Nasendoscopy involves an endoscopic evaluation of the nasal cavity.  It is best performed with the patient lying supine on the examination couch.
 

The nasal cavity can be visualised either through an eyepiece attached to the endoscope or by attaching the output to a video screen.  Either method is used in the outpatient setting, although video-nasendoscopy allows other clinicians and the patient to visualise the nasal cavity under examination as well as the sinus surgeon.

It is necessary to prepare the nasal mucosa with two agents:

• A local anaesthetic
• Vasoconstrictor solution

Preparations containing both of these agents are commercially available e.g. Co-phenycaine Forte®.

A small diameter endoscope is used as it is better tolerated by the patient and allows clearer visualisation of the recesses of the nasal cavity.  The head of the endoscope can be angulated up to 70º, with 30º being the most common angulation in the ENT clinic.

Some initial steps must be taken before performing the examination such as

• Camera orientation including focus and light balance
• Lens defog
• Retract ala prior to endoscope insertion (to prevent fogging)
• Assess nasal valve

These areas can be visualised with three endoscope passes through each nasal cavity.  A pass is the insertion and further advancement of the endoscope.  The nasal cavity can be divided into three separate portions as follows

• FIRST PASS

• SECOND PASS

• THIRD PASS

An initial view of the nasal cavity at nasendocopy can be seen below.  This shows a narrow nasal cavity due to right septal deviation.  Hence, nasendoscopy would be performed on the other side.
 

As this is an invasive procedure, patient's are likely to be unsure of what to expect.  Therefore, it is important to gain patient trust by causing them the least possible discomfort and pain.  This is achieved by leaving the most uncomfortable part of the procedure until last.  Assesment of the infundibulum requires retraction of the middle turbinate which can cause some discomfort.  This should not be attempted in the outpatient setting unless the patient has reletively normal anatomy.

A therapeutic trial is usually the first line of treatment.  This ensures that the patient does not undertake and invasive surgical procedure with its associated risks if there is a possible alternative.  Follow this link to find out more about the pharmacological treatments of sinus disease.

When all the preliminary investigations have been completed, the sinus surgeon must decide whether the patient requires surgery.  As with every surgical procedure, the best results can only be achieved by stringent patient selection, separating those who will benefit from the procedure intended from those who will not.

The process of patient selection includes

• pre-operative assessment
• diagnostic strategy
• realising the best course of action in any one patient
• gaining patient consent through appropriate explanation and discussion