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Nasopharyngolaryngoscopy for Family Physicians
Scott M. Strayer, MD, MPH
Assistant Professor
University of Virginia Health System
Department of Family Medicine
Case Presentation
24-year-old female c/o 3 months of hoarseness following weekly choir practice. She is a nonsmoker and doesn’t drink alcohol. No formal vocal training, and started singing solos with the choir about 5 months ago.
Vocal Cord Nodules
Background
1982 survey in Ohio reported that fewer than 30% of primary care physicians could visualize the larynx, and less than 4% included inspection of the larynx as part of a CPE.
First used in 1968. Very low risk
More Background
Fast procedure (most are completed within 5-10 minutes).
Relatively low cost of equipment ($3500-$5000 + need light source).
8.2% of family physicians reported doing this procedure in 2000. (Source: American Academy of Family Physicians, Practice Profile II Survey, May 2000.)
Indications
Chronic hoarseness > 3 weeks.
Chronic sinusitis or sinus discomfort (esp. unilateral).
Chronic serous otitis media in an adult (esp. unilateral).
Recurrent otalgia. Suspected neoplasia. Chronic cough. Chronic nasal
obstruction or postnasal drip.
Chronic rhinorrhea. Halitosis.
Indications
History of previous head and neck cancer.
Head or neck masses or adenopathy.
Recurrent epistaxis. Dysphagia. Chronic foreign-body
sensation in pharynx.
Evaluation of snoring. Reassurance in any
chronic upper-respiratory condition.
Acute Indications
Hemoptysis. Acute sinusitis. Acute epistaxis. Suspected nasal foreign body. Suspected laryngeal foreign body. Acute onset of hoarseness after straining
voice.
Contraindications
Acute epiglottitis. Acute epistaxis. Absence of nasal passage.
Equipment Needed
Nasoscope. Nasal speculum. Sterilizing solution (I.e. Cidex). Decongenstant (I.e. Neo-synephrine). Anesthetic
Lidocaine (2% to 4%) spray (Xylocaine). Benzocaine spray (14%) (Cetacaine).
Evaluation
Thorough head and neck history and examination.
Complete history and physical examination as indicated.
Explain procedure and schedule follow-up appointment.
Patient Education
Spray can be noxious (can use lidocaine jelly instead).
Intense tickling sensation. Patient can talk. No real pain, just pressure. Will be asked to say certain words and
sounds (I.e. “key,” “a”, “e”, “i”, etc.)
Procedure Preparation
Blow nose first, then use decongestant in both nares.
Then insert lidocaine (jelly or spray). For jelly, leave in nose for 5-10 minutes,
then have patient blow out. For spray, have patient tilt back and swallow
after spray (use spray generously).
Procedure Preparation
Anesthesize least obstructed nares (unless looking at both).
Wait 5-10 minutes for decongestant to take effect.
Spray back of throat as well to suppress gag reflex.
Procedure
Place patient in erect sitting position with support behind head so rapid withdrawal is not possible.
Use tripod of fingers to support scope as you insert.
Insert inferior and medially through nasal cavity.
Procedure-Nasal Passage
Visualize inferior turbinate about 1cm into passage.
Note texture and sizePolypoid degeneration or swellingSurgical antral windows into sinus are frequently
located in inferior meatus
Nasal Passages
Procedure-Choana
At 4-5 cm will see choana (junction between nasal fossa and the nasopharynx).
Can move scope laterally and superiorly to enter middle meatus (can wait until withdrawal as this sometimes hurts).
Visualize adenoid pad on posterior wall of pharynx.
Procedure-Torus
Slightly flex tip and rotate 90 degrees to visualize torus tubarius (valve at opening of eustachian tube).
Observe function while patient says “key, key, key.”
Advance slightly and rotate 180 degrees to visualize contralateral torus.
Procedure-Rosenmüller’s fossa
Located posterior to both tori and anterior to adenoid pad.
Carefully inspect as most nasopharyngeal malignancies are found in this area.
Nasopharynx and Oropharynx
Anatomic Divisions of Upper Airway
Procedure-Posterior Pharynx
Advance inferiorly and towards posterior wall of oropharynx.
Have patient breathe through nose.Flex and rotate slightly to view uvula, soft palate,
lateral and posterior walls of pharynx.Epiglottis visible in distance.Look for masses, scarring, inflammation, exudate,
mucosal abnormalities, or pulsations.
Procedure-Oropharynx
After passing the soft palate, enter oropharynx.
Keep scope close to posterior wall without touching it (otherwise gag reflex).
If scope fogs, have patient swallow.Slightly flex and rotate to inspect post. Tongue,
lingual tonsils, palatine tonsils, epiglottis, medial and lateral glossoepiglottic folds, and vallecuale.
Posterior Pharynx
Procedure-Hypopharynx
After passing epiglottis, enter hypopharynx. Try not to swallow at this point.
Visualize arytenoid cartilages, aryepiglottic folds. Inspect pyriform sinuses posterior to cords.Examine true and false cords.Say “eee” to examine symmetry of cord motility.Look for edema, hemorrhages, erythema, nodules, or
masses.Do NOT pass cords.
Larynx
Procedure-Sphenoid sinus
At choana, direct scope superiorly and withdraw.
Visualize superior turbinate, ostia of sphenoid sinus (medial to sup. Turbinate).
Withdraw until complete choana are in view, then move superiorly and laterally to allow examination of middle meatus.
Sphenoid Sinus
Procedure-Middle Meatus
Visualize frontal sinus, anterior ethmoid cells, maxillary sinus ostia.
Look for drainage from ostia, purulent fluid, inflammation, or polyps protruding from or occluding the ostia.
Complications
Adverse reactions to anesthetic or decongestant (most common).
Severe sneezing and gagging. Laryngospasm with possible asphyxia (remain
above cords). Vasovagal reaction. Epistaxis. Vomitting with possible aspiration.