What is the procedure to check inside the nostril at an Ear, Nose, and Throat (ENT) office to rule out an aneurysm?

Nasal Endoscopy

The procedure to check inside the nostril at an ENT office to rule out an aneurysm is nasal endoscopy (also called nasendoscopy or rhinoscopy). 1

Primary Examination Method

Nasal endoscopy is the gold standard for visualizing the nasal cavity, middle meatus, sphenoethmoidal recess, and nasopharynx. 1 This procedure allows direct visualization of vascular lesions, masses, and other pathology that could present with bleeding or other concerning symptoms. 1

Technique and Equipment

• The examination is typically performed with either a rigid endoscope (4mm 30-degree or 2.7mm, or zero-degree) or a flexible endoscope. 1
• The patient should be upright, and topical decongestant/anesthetic spray is usually applied to the nasal mucosa before the procedure. 1
• The standard three-pass technique examines: (1) the floor of the nose to nasopharynx, (2) above the inferior turbinate to the middle meatus and sphenoethmoidal recess, and (3) laterally into the middle meatus during withdrawal. 1

Diagnostic Accuracy

• Nasal endoscopy improves diagnostic accuracy to 69.1-85% compared to anterior rhinoscopy alone. 1
• The procedure has high specificity (up to 95%) for detecting nasal pathology. 1
• It is essential for examining the posterior nasal cavity and nasopharynx, which cannot be adequately visualized with anterior rhinoscopy alone. 1

Alternative Examination Methods

Anterior Rhinoscopy

• Anterior rhinoscopy using an otoscope or nasal speculum is a simpler alternative but has lower sensitivity (54-58%) for detecting pathology. 1, 2
• This method is appropriate for initial screening in primary care settings but should not be relied upon to rule out serious pathology like vascular lesions or tumors. 1
• The American Academy of Otolaryngology recommends anterior rhinoscopy as a minimum standard but emphasizes it may miss significant findings. 1

Critical Clinical Context for Aneurysm Concerns

When Nasal Endoscopy is Mandatory

The clinician should perform, or refer to a clinician who can perform, nasal endoscopy in patients with:

• Recurrent unilateral nasal bleeding (which could indicate a vascular lesion or tumor). 1
• Difficult to control epistaxis or concern for unrecognized pathology. 1
• Adolescent males with unilateral, unprovoked, profuse epistaxis (to rule out juvenile nasopharyngeal angiofibroma, a highly vascular tumor). 1, 3

Important Caveat

While the question asks about ruling out an "aneurysm," true intracranial aneurysms are not diagnosed by nasal endoscopy. However, nasal endoscopy is critical for identifying:

• Vascular tumors (like juvenile nasopharyngeal angiofibroma) that can cause life-threatening bleeding. 1, 3
• Nasal or nasopharyngeal malignancies that may present with bleeding. 1
• Other vascular lesions in the nasal cavity or nasopharynx. 1

If there is genuine concern for an intracranial aneurysm extending into the nasal cavity, imaging (CT or MRI angiography) would be required in addition to endoscopy. However, nasal endoscopy remains the essential first step for direct visualization of any intranasal vascular abnormality. 1