Three adult presentations should send you to the nasendoscope before anything else: unilateral nasal obstruction, unilateral epistaxis, and a unilateral middle-ear effusion. Each is common enough to be dismissed and specific enough to matter.
A serous effusion in one adult ear is nasopharyngeal carcinoma until the postnasal space has been seen. It is not glue ear, adults do not get glue ear, and a grommet inserted without looking at the nasopharynx converts a curable cancer into a delayed one. The same logic applies to a nose that has blocked on one side over months, or that bleeds repeatedly from one side only.
In India this is not a rare-disease caveat. Nasopharyngeal carcinoma is markedly commoner in the north-eastern states, and it presents to a general clinic long before it presents to an oncologist - most often as a neck node or an ear that feels full. Look at the nasopharynx, and record what you saw.
- Never insert a grommet in an adult without first examining the nasopharynx.
- Treat unilateral nasal obstruction of gradual onset in an adult as needing endoscopy, not a trial of steroid spray.
- Ask about a neck lump in anyone with a unilateral effusion; it is often the first sign.
- Record the nasopharyngeal view explicitly in the notes, including a negative one.
- Have a lower threshold again in patients from the north-eastern states or with a family history.
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