123 | Rhinoscopy for veterinary nurses: How our role really makes a difference

PodcastNursingEndoscopyRespiratory
Written By Laura Jones

Rhinoscopy is a procedure with a lot going on, and that’s why I think our role in it is underrated.

When I worked in GP, my role assisting with scopes was basically set up, cleaning, and anaesthesia. That was it. And we didn’t have the luxury of multiple nurses, so often I was juggling trying to monitor my patient AND helping the vet with holding the head, biopsy collection, scope troubleshooting and whatever else they may need.

We had a rhinoscope, but it was rarely used. Most of the time, we’d just look at the back of the nose with our bronchoscope, or fish out a grass blade with a spay hook - and that was it.

I didn’t realise how much I could do to support these patients as a vet nurse - and in reality, there are SO many skills we can use while caring for these patients.

Today we’ll look at what those skills are, and just how much our patients benefit from our support throughout their procedure (and beyond). We’ll talk about what happens during a rhinoscopy, the equipment used and how it is managed, and the most important considerations when nursing these patients - before, during, and after their procedure.

You’ll leave the episode ready to assist with these procedures confidently, with new skills to put to use. So let’s waste no time, and get stuck in.

To nurse these patients, we first need to understand what a small animal rhinoscopy (or upper airway endoscopy) procedure involves.

Rhinoscopy, put simply, is where we use an endoscope to image the nose. But it isn’t as simple as that - the nose isn’t the easiest place to examine, and there’s a lot happening inside what is actually a very small space.

Let’s look at the nose in a little more detail first.

The nasal cavity is full of turbinates - lots of tiny, delicate scrolls of bone covered in mucosa, which function to warm and humidify inhaled air.

These turbinates create lots of narrow, blind-ending channels that can be challenging to navigate through with a scope. 

On top of this, the nose is also very vascular, and all of this means our clinicians are having to manouver through a small, bony, blood-rich space full of hidden corners.

This is exactly why foreign bodies and other abnormalities can be incredibly difficult to find, and also why the procedure carries a high risk of bleeding - something we need to be aware of, and have planned for, ahead of the procedure.

Rhinoscopy gives us the only direct visualisation inside the nasal cavity.

We use rhinoscopy to examine the nasal cavity itself (so the rostral aspect of the nose), the choanae (the openings at the back of the nose) and the nasopharynx, which is the region above the soft palate. In some patients we can reach the frontal sinuses (bony air-filled spaces) too. 

As well as visualisation, we can use rhinoscopy to collect guided samples, flush the nose, remove foreign material, and apply targeted treatments where needed.

There are two directions we can approach the nose from.

In most cases, both are performed together as part of a comprehensive assessment of the entire nose.

The first is caudal, or retrograde rhinoscopy, aka retroflex nasopharyngoscopy.

This allows us to examine the choanae and nasopharynx. It is performed by inserting a bronchoscope into the mouth, retroflexing it back on itself, and ‘hooking’ it over the soft palate to visualise the nose from behind.

Then we have anterior, or antegrade rhinoscopy.

This is where we image the front of the nose, by passing a rigid endoscope into each nostril and systematically examine each area of the nasal cavity. In most cases, continuous saline irrigation is used to flush the nose, clear mucous and any bleeding (from the scope coming into contact with the delicate nasal mucosa) and improve visualisation.

When performing a ‘complete’ rhinoscopy, we always start with the retroflex view and then move on to the antegrade view - otherwise we’ll contaminate the nasopharynx with things like blood and fluid.

Samples are collected as needed - usually blind biopsies, as the rhinoscope instrument channel is incredibly small - and the patient is recovered.

So that’s the procedure itself, but which patients need rhinoscopy - when is it indicated?

Like the other endoscopy procedures we've talked about in this series so far, rhinoscopy usually comes fairly late in the diagnostic process - unless we’re doing it for therapeutic purposes, for example to remove a foreign body.

Rhinoscopy is indicated in cats and dogs with:

  • Chronic sneezing or reverse sneezing

  • Nasal discharge

  • Stertor/stridor

  • Epistaxis

The things we're usually looking for are foreign bodies (such as grass seeds), fungal infections (eg aspergillosis, usually associated with plant material) or nasal tumours.

Nasopharyngeal diseases, such as stenosis (narrowing) or polyps, are also relatively common - especially in cats. And in the absence of specific abnormalities we can actually see, we may be left with a diagnosis of chronic rhinitis - non-specific inflammation within the nose.

Examination findings that raise our suspicion for nasal disease include unilateral nasal discharge or nasal airflow changes, facial asymmetry or facial pain, nasal depigmentation, or clinical signs not responding to appropriate treatment. 

Before a rhinoscopy, other diagnostics are typically performed.

These include routine bloodwork (to assess general health, look for non-nasal causes of bleeding, and as part of anaesthesia risk planning) as well as coagulation testing in most cases.

This is important, because we know that 1) many patients present with epistaxis, and 2) bleeding is a significant complication of the procedure.

We need to check our patient has sufficient platelets +/- normal clotting times before going ahead and scoping or biopsying the nose.

Other diagnostics include blood pressure assessment (hypertension can cause epistaxis), and likely diagnostic imaging - usually a CT of the head.

When is rhinoscopy more risky, and how can we minimise this risk as veterinary nurses?

Any patient with a bleeding disorder or a haemostatic defect should not undergo rhinoscopy, because the nose is highly vascular and bleeding is a significant risk.

Some patients with nasal tumours present a real challenge for us during their procedure, because many masses are highly vascular - but rhinoscopy WILL be required for diagnosis. This is where having a haemorrhage plan comes in, and where our role in identifying risks and planning strategies to minimise them is vital - something we’re great at as veterinary nurses and technicians. In many cases, we’ll use things like endoscopy-guided laser to cauterise those vessels and safely debulk and sample the tumour.

We also need to be extremely careful where there's evidence that disease has broken through the cribriform plate. The cribiform plate is a thin, perforated plate of bone, and it separates the nasal cavity from the brain. Patients with destructive nasal diseases, such as fungal infections or tumours, can have defects in this bone, meaning there’s communication between where we’re scoping and the brain.

Rhinoscopy is also contraindicated in patients with increased intracranial pressure, because we’re going to potentially increase that further by causing sneezing or instilling fluid within the nose.

Now of course, none of this - whether these procedures are performed in specific patients or not - is our call to make as veterinary nurses. That decision lies with our clinician. But despite this, being aware of these considerations is vital - it impacts how we approach these patients, what we monitor for, and the p we need to prepare for.

Speaking of those complications, how do we support rhinoscopy patients as veterinary nurses - before, during and after the procedure?

I’ve mentioned already there’s a LOT we can do to care for these patients - so let’s look at what they need from us and the skills we can put to use in the process.

Before the procedure itself, we need to be careful in how we handle these patients.

They’re often dealing with reduced airflow and this can make them panic and be resentful of handling, especially having their neck extended (for things like jugular sampling). So careful handling, minimal restraint, reducing stress and working with your patient’s preferences and limitations is vital.

We need to assess bleeding function, neurological status, and perform a thorough pre-anaesthetic assessment, identifying any increased risks associated with their procedure.

During the procedure itself, there’s a lot to think about.

Aside from general anaesthesia support and monitoring, we need to pay attention to:

  • Aspiration - we’re flushing fluid into the nose, so the ET tube should be checked for leaks, and throat packs used (paying attention to pack counts and ensuring all are removed before recovery).

  • Bleeding - checking volumes of blood lost (as far as possible, given we’re diluting it with saline) and cardiovascular parameters under anaesthesia.

  • Analgesia - utilising multimodal analgesic protocols, including things like nerve blocks.

I personally would advise having a few items on hand throughout the procedure and into recovery as well, just to make the procedure safer and help you be prepared should complications arise.

These include suction (unit, tubing, and a flexible suction catheter), a laryngoscope and large cotton buds (to clear blood, mucous and fluid from around the larynx prior to extubation) and a haemorrhage action plan (where one is needed). This might include pre-calculated doses of things like tranexamic acid or etamsylate, or in severe cases, rapid rhino devices.

These are inflatable cellulose balloons that can be placed into the nose to pack it in the event of severe haemorrhage.

And our nursing care continues into recovery.

In recovery, patients should be monitored for aspiration, bleeding, pain and neurological signs. Sneezing is normal, as is some residual bleeding especially in a patient sneezing lots - but this should resolve by itself.

As well as nursing the patient, our role includes preparing, handling and processing the equipment - so let’s talk about the endoscopes themselves.

We use two different endoscopes during a rhinoscopy procedure - our flexible bronchoscope (as we discussed in last week’s episode, episode 122) for the retroflex view, and then a rigid metal telescope for the antegrade view. Both are connected to a camera head and light cable and then to the endoscopy tower itself.

The scope we use is usually an angled rigid telescope, which the clinician can rotate to increase their field of view throughout the nose. It is placed inside a working sheath, which has ports to pass instruments and attach fluids.

The telescope is incredibly delicate and needs to be handled with care to prevent cracking or knocks which can impact image quality. It should not be inserted into the nose outside of its sheath, and when not in use, should be stored in a plastic protective cover.

Beyond the scope itself, there’s also a lot of ancillary kit required for rhinoscopy.

This includes biopsy forceps - both the flexible cup type that go down the channel and rigid ones to pass alongside - grasping or foreign body forceps, sample pots, mouth gags and throat packs.

There’s also a lot of fluid needed for this procedure. We use 0.9% saline (the bigger bags - 2 or 3 litres - can be really helpful, especially for long procedures) attached to a giving set inside a pressure infuser.

Make sure this saline is warm, because cool saline lavage will contribute to hypothermia, and it’ll also fog your clinician’s scope, limiting their view.

Just like with the GI scope and the bronchoscope earlier in this series, all of this kit needs preparing and double-checking before the patient is anaesthetised.

Our flexible bronchoscope is prepared, cleaned and maintained as we’ve already discussed earlier in the series - leak tested, white balanced, and cleaned carefully in a high-level cleaning and disinfectant solution OK’d by the manufacturer.

The rigid scope is cleaned in a similar manner, but there’s no leak testing needed - this is exclusive to flexible scopes. Though some rigid endoscopes are autoclavable, the heating and cooling cycles in some standard bench-top autoclaves can be damaging, so always check with the manufacturer before doing so. If you have access to EO sterilisation, that is usually preferred as it’s safer for the equipment.

We’re also going to be collecting and processing samples in many of these procedures - and this is another important aspect of our role.

As we discussed in episode 121, how we handle and process our samples directly impacts their diagnostic quality and the answers our clinicians get from the lab - so while sample processing may seem like a ‘basic’ skill, how we do it is really important.

Samples should be collected carefully, using unspiked, oval, fenestrated forceps. They should be rinsed off or shaken off of the sample cups into a pot of saline rather than teased off with a needle, as this can damage the both forceps and the samples. 

At the end of the procedure, the samples should be potted as needed.

Histology samples should placed in formalin, ideally on a cellsafe container, to keep the samples together since they are so small.

Culture samples are often collected during rhinoscopy - either bacterial, fungal, or both - and where this test is required, a sample should be submitted in sterile saline, in a plain tube.

Including a complete history, overview of the clinician’s endoscopy findings, and the CT report (if one has been performed) is also essential - as this helps the lab accurately comment on the sample and improves the diagnostic information we get back from them.

So as you can see, our role in rhinoscopy is so much bigger than monitoring the patient and setting up the scope.

Today’s episode was another detailed one, so I want to leave you with the key points from everything we’ve chatted about - as well as the nursing skills you can use with your own rhinoscopy patients.

Rhinoscopy is the direct visualisation of the nose - the nasal cavity, the choanae, and the nasopharynx. We use it to investigate chronic sneezing, discharge, epistaxis, foreign bodies, fungal disease, tumours and polyps among other things. 

It’s usually preceded by bloodwork and imaging, and we need to make sure we’ve assessed haemostasis - and created an action plan where it’s deemed high risk - before going ahead.

Our role in nursing these patients is vast, involving careful pre-anaesthetic handling and support, checking bloodwork, collaborating with the vet on tailored anaesthesia planning, performing nerve blocks, close monitoring, and much more.

We’re the ones setting up and handling the kit, processing the samples, counting the throat packs, protecting the airway, monitoring for bleeding or neurological changes in recovery, and generally using our skills to make this a safe and successful procedure for our patients and our entire team. Which is exactly why the importance of our role cannot be overestimated.

Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!

References and Further Reading

Laura Jones
Next

122 | Bronchoscopy doesn't need to be scary - here's exactly how to approach it as a vet nurse