Nasal Endoscopy and Laryngoscopy

Nasal Endoscopy:

Examination of the nasal cavities may be performed with flexible or rigid endoscopes; the latter provides a higher resolution image and allows simultaneous instrumentation. The following describes the procedure for rigid endoscopy. Flexible fiberoptic endoscopy of the nose is included in the subsequent discussion of laryngoscopy.

Topical anesthetic and nasal decongestant are applied to the nares.
A rigid 0-degree endoscope is passed into the nasal cavity along the floor of the nose.
The inferior turbinate is visualized and its size and mucosal appearance are noted.
The septum is visualized and examined for deviation or perforation.
The endoscope is passed posteriorly into the nasopharynx; the Eustachian tube orifices and fossa of Rosenmüller are examined.
The endoscope is then withdrawn and reinserted between the inferior and middle turbinates.
The middle turbinate is visualized. Any accessory maxillary sinus ostia are noted, along with presence of any mucopurulent drainage.
The endoscope is advanced medially past the middle turbinate. The sphenoethmoid recess is visualized.
The endoscope is withdrawn slowly while it is rotated laterally to examine the uncinate and ethmoid bulla.
The endoscope is inserted superiorly to visualize the olfactory cleft.

Laryngoscopy

This chapter covers technique for flexible fiberoptic laryngoscopy performed in the office setting. Additional details on operative technique for direct laryngoscopy can be found in subsequent chapters.

A topical anesthetic is applied to the bilateral nares, and the patient is asked to sniff to distribute the anesthetic to the pharynx.
The patient should be in an upright, seated position with the head level (not tilted upward).
To prevent fogging, the endoscope lens may be warmed and moistened by asking the patient to open his mouth and touching it briefly to the tongue or floor of mouth to gain a film of saliva.
After a few minutes have elapsed for the anesthetic to take effect, the flexible endoscope is inserted into the nasal cavity along the floor of the nose.
The inferior turbinate and septum are examined as the endoscope is passed posteriorly. Any mucosal lesions, intranasal masses, mucopurulent discharge, or septal deviation is noted.
The endoscope is advanced into the nasopharynx. Presence of adenoidal tissue obstructing the choanae should be noted, particularly in children. The endoscope is flexed and rotated in order to view each Eustachian tube orifice.
The endoscope is further advanced until the oropharynx is visualized. Any asymmetry of the tongue base is noted. The vallecula is best seen when the patient is asked to protrude the tongue.
The epiglottis is examined for mucosal erythema, edema, or lesions.
The hypopharynx is examined for masses or lesions. The pyriform sinuses may be better visualized by asking the patient to puff out their cheeks. Note any pooling of secretions or lesions.
If secretions obscure the view at any point during the examination, they can be cleared by asking the patient to swallow while the endoscope is held in place.
The endoscope is carefully advanced to enable a clear view of the vocal folds, without touching the larynx or the posterior pharyngeal wall. The mucosa of the vocal cords and arytenoids is examined for edema and erythema. Any masses or lesions on the cords should be noted.
The patient is asked to phonate, usually by producing the “E” sound repeatedly. This allows for assessment of vocal fold mobility and completeness of glottic closure.
If unilateral cord paresis is present, the degree of contralateral cord compensation should be noted.
If bilateral cord paresis is present, the position in which the cords are fixed should be noted, along with whether there is visible aspiration of secretions through the glottic opening.
A view of the subglottis may be visible during abduction of the vocal cords; however, direct laryngoscopy is superior for subglottic evaluation.