Third pass: Is the most important of
all the three passes. This pass studies the crucial middle
turbinate area. The middle turbinate is evaluated for its
shape and size as well as its relationship to the lateral nasal wall
and septum. A bulge just above and anterior to the attachment
of the middle turbinate suggests an enlarged agge nasi cells.
Sometimes the anterior tip of the middle turbinate may be
triangular. This shape has no significane unless it causes
obstruction to the middle meatus. A middle turbinate that is
concave medially rather than laterally is considered
paradoxical. But paradoxical turbinate which is symptomatic
needs to be treated. If the middle turbinate is enlarged due
to the presence of a large air cell inside the middle turbinate it
is known as concha bullosa. The middle turbinate is
gently medialised using its plasticity. The middle meatus
comes into view. The attachment of the uncinate process is
carefully noted. Discharge if any from this area is also
recorded. If accessory ostium is present it comes into view
now. Accessory ostium is present more posteriorly.
Normal ostium is actually not visible during diagnostic nasal
endoscopy. Accessory ostium is spherical in shape and oriented
anteroposteriorly, while the natural ostium of maxillary sinus
is oval in shape and oriented transversely.