OtoRhinoLaryngology Portal

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Anterior Rhinoscopy

Anterior rhnoscopy implies examination of the anterior part of the nose.  Classically, Bull's lamp and reflecting mirror being used to achieved examination of this area.  Nowadays, headlight supplied by battery or electrical source are used more commonly.  The depth of examination is usually good up to mid-nasal cavity; the vestibular area, nasal valve, anterior nasal septum and inferior turbinate are visualised well.

Nose Examination

Nasal Airflow Patency Test

Figure shows clinical assessment of nasal passage patency by using a shiny metal rod.  Metal tongue depressor or indirect laryngoscopy mirror can also be used for similar purpose.  Asymmetric, reduced, or absent misting either unilateral or bilaterally need to be documented and followed by anterior rhinoscopy and endoscopy to rule out internal obstruction of any cause.

 

The "Cold Spatula" Test

Cottle's Manoeuvre

                    Before                                                      After

 

Nasal valve is the narrowest region of the nasal cavity and contribute significantly to airway resistance.  Cottle's manoeuvre is a simple clinical test that give clue to this segmental airway narrowing.  With few finger the skin close to the nasolabial fold of the side of nasal cavity to be examined in gently pulled in an upward and outward direction (towards ipsilateral zygoma).  Subjective and objective improvement in breathing or nasal patency observed (positive response). 

Figures show widening of nasal valve area on right Cottle's manoveure in a patient with deviated nasal septum.  Similar action improves delivery of intranasal spray application of medication in the presence of such narrowing e.g. intranasal corticosteroid spray therapy in allergic or vasomotor rhinitis.

 

Watch video of deviated nasal septum @ YouTube

Video 1                              Video 2

The Use of Aural Speculum To Avoid Nasal Vibrissae For Better Viewing of Little's Area & Nasal Valve Region

The Nasal Turbinates As Seen On Endoscopic Examination

The Middle Meatus: Intraoperative View after Decongestion

S- nasal septum, MT- middle turbinate, B/BE- bulla ethmoidalis,

stars- uncinate process.

 

Video of left middle meatus without prior decongestion.

Primary Sinus Ostium

The primary ostium of maxillary sinus is located behind the uncinate process.

Natural sphenoid sinus ostium as seen from left nasal cavity (arrow). (Dashed line - sphenoethmoid recess, red arrow - direction towards nasopharynx)

Accessory Maxillary Ostium

 Ostium (slit-like)                                 Ostium (elliptical)

 Accessory sinus ostia (arrows). (MT - middle turbinate, S - septum)

                                                     Ostia (multiple)

 

The secondary ostium of maxillary sinus is located anterior

to the uncinate process and can be multiple.

 Natural maxillary sinus ostium (white arrow) versus accessory sinus ostium (red arrow).  White line - uncinate process, S - nasal septum (deviated).  This may contribute to the phenomena of recirculation and predisposes to sinusitis. 

Uncinate Process:  Endoscopic Appearance of Anatomical Variations

 

The concealed type.

A straight forward easy to see uncinate process.

Medialized right uncinate process.

 

Elevated/off-ground left uncinate process.

 Broad-based uncinate process attachment superiorly

with a paradoxically curved right middle turbinate.

Pneumatized uncinate process attachment (circle).

 

Medialized and almost fully pneumatized uncinate process.

Medialized and pneumatized uncinate process.

Confluence of agger nasii cells

and pneumatized cum separated uncinate process.

"Stand alone" and pneumatized uncinate process.

"Obstructive" uncinate process.

 Polypoid and medialized uncinate process (UP).  [MT - middle turbinate, S - nasal septum, ANC - pneumatized agger nasii, arrow - septal spur]

S - nasal septum, MT - middle turbinate, UP - uncinate process

 

Watch video of uncinate process @ YouTube

Bulla Ethmoidalis

Variant of bulla ethmoidalis.

 

Compare with normal as describe under [The Middle Meatus:

Intraoperative View after Decongestion] section above.

Agger Nasii Cell

Agger nasii represents the embryonic remnant of ascending portion of the first ethmoturbinal (ridge on the lateral nasal wall).  Agger nasii can be pneumatized by the anterior ethmoid cell: the anterior-most ethmoid air cells.  These cells are located anterior, lateral, and inferior to the frontal recess.

 

Pneumatized agger nasii (yellow cicle)

 Agger nasii area (red circle)

 

Prominence just anterior to the middle turbinate attachment (circles).

Conchal Bullosa (Pneumatized) Middle Turbinate Bone

                 Globular-shaped                              Diffused banana-shaped

 Inferiorly-placed ostea of concha (arrow)  Laterally-placed ostea of concha (arrow)

 

                                   Small slit-like opening of conchal bullosa.

                                        S - septum, MT - middle turbinate

 

Intra-operative close-up view of left concha bullosa.

 

Another close-up view of CT-scan proven left middle turbinate concha bullosa.  

 

Watch video of conchal bullosa ostium/ostea at YouTube

Video 1                                   Video 2

 

 

The Nasopharynx as Seen by Using a Postnasal Mirror

 

The conventional postnasal mirrors.  Light is then shine onto it and reflected at desired viewing area of nasopharynx.

View of nasopharynx by using a postnasal mirror.

 

Currently, postnasal mirror has been superseded by endoscopic examination which offers superb view and well-tolerable by most patients.

The Nasopharynx as Seen by Using Retrograde Transoral  Nasopharyngoscopy Technique

This is the view of nasopharynx as seen by using a 70 degree endoscope.  The panoramic view is excellent and most of the main structures can be identified.  It is a good alternative to transnasal endoscopy and a better tolerated procedure

by most patients.

Close-up view

Hypertrophy of the inferior turbinate tail (IT) in parennial allergic rhinitis.

TT- torus tubarius, black stars- vomerine posterior free border.

 

IT- tail of inferior turbinate, MT- middle turbinate, yellow star- superior turbinate,

V- vomer, arrows- nasopharyngeal eustachian tube opening.

Salpingo-pharyngeal folds (stars).

The nasopharynx of a patient with cleft palate. 

[Star- torus tubarium leading to salpingopharyngeal fold, green arrow-

fossa of Rosenmuller, red arrow- nasopharyngeal eustachian tube opening]

 

Watch video of nasopharyngeal view as seen by using

transoral nasopharyngoscopy technique @ YouTube

Soft Palate Elevation and Velopharyngeal Closure Upon Swallowing

                        At rest                                          Upon swallowing

Transnasal nasopharyngoscopy showing dorsal aspect of soft palate

upon swallowing. Arrow - nasopharyngeal eustachian tube opening,

TT - torus tubarius, SP - soft palate,

yellow line - course of levator palati,

red line - course of tensor palati.

 

Video clip of palatal movements upon swallowing.

Soft Palate Elevation Upon Phonating Vowel "e"

                          At rest                                            Upon phonation

Velopharyngeal Isthmus Closure: The Passavant's Ridge

Transnasal rigid endoscopy view upon initiation (left)

and near completion (right) of velopharyngeal closure.

Transoral 70 degree nasopharyngoscopy in a patient with cleft palate.

 

Watch video of Passavant's ridge upon velopharyngeal closure @ YouTube

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