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Should rhinoscope be used as a diagnostic tool in young children?

Question:

Should an allergist who is treating children, consider using the rhinoscope as a diagnostic tool in young children?

Answer:

By Dana V. Wallace, MD; Associate Professor, Nova Southeastern Allopathic Medical School; Fort Lauderdale, Florida, U.S.A.
With the assistance of the ACAAI Rhinitis/Sinusitis/Ocular Committee members including rhinoscopy workshop faculty

Rhinoscopy is a useful tool for examining the upper airways of school-age children and even infants. In fact, infants held in the mother’s arms may be relatively easy to scope, e.g., to access adenoid size. Preschool children can be a little more challenging as they tend to be much more active. However, many experienced allergists complete rhinoscopy on children pre-school and school aged, as long as they are cooperative and can tolerate the procedure. Rhinoscopy is particularly useful for looking at adenoids1, as part of making a diagnosis of chronic rhinosinusitis, and for obtaining a directed culture when the child has a resistant sinus infection.  Some school-age children can also tolerate laryngeal area examination with the rhinoscope, useful for evaluating laryngeal diseases and diagnosing laryngeal pharyngeal reflux disease and gastroesophageal reflux disease.

A survey of 764 Italian pediatric otolaryngologists, 38% of whom were in private practice settings, showed that 75% used nasopharyngeal fiberendoscopy and most all considered fiberendoscopy to be safe and defined it as the gold standard diagnostic procedure for upper airway pathology.2 However, 80% judged it to be poorly or only fairly well tolerated and 65% used gentle restraining methods for young children, usually defined as sitting on the parent’s lap. Over 93% had the child, regardless of age, seated, either alone or in the parent’s lap. Only 13.5% performed the procedure on children less than 3 years of age. The indications were nasal obstruction, adenoidal facies, recurrent or chronic middle ear disease, and rhinosinusitis. Of the pediatric otolaryngologists, 94% used a flexible, small-diameter instrument.

Most allergists who scope children use the 2.5 or 2.7 mm flexible scope also referred to as the pediatric rhinoscope. In fact, many allergists find that this is useful for adults who have narrow nasal cavities due to nasal septal perforation and for accessing the sphenoethmoidal recess and superior meatus in all adults and children. With the added maneuverability and patient comfort, it is perhaps the best all-around option for everyone. While the pediatric scope may be a little more expensive, if you must choose just one scope for your practice to use on both adults and children, consider purchasing the 2.5 or 2.7 mm scope.

While some pediatric otolaryngologist will use an Olympia Papoose system to stabilize the child, we are not aware of any allergists that have utilized this immobilization device. If completing the rhinoscopy becomes that difficult, most allergists would likely be referring to an otolaryngologist.

 

1. Pagella, F., Pusateri, A., Chu, F., Cairello, F., Benazzo, M., Matti, E., & Marseglia, G. (2011). Adenoid Assessment in Paediatric Patients: The Role of Flexible Nasal Endoscopy. International Journal of Immunopathology and Pharmacology, 49–54.

2. Torretta S, Marchisio P, Succo G, Capaccio P, Pignataro L. Nasopharyngeal fiberendoscopy in children: a survey of current Italian pediatric otolaryngological practices. Ital J Pediatr. 2016;42:24. Published 2016 Mar 1. doi:10.1186/s13052-016-0234-y