Flexible nasopharyngoscopy (also called fiberoptic nasendoscopy/flexible nasolaryngoscopy/flexible fiberoptic nasopharyngolaryngoscopy) is an essential skill for any otorhinolaryngologist (ENT surgeon). It is a diagnostic procedure used for examination of the nose, throat, and airway. Fiber-optic imaging became prominent in the 1950s due to the innovations of Hopkins and Stortz. The first medically functioning fiberoptic scope was designed in 1963 by Hirschowitz.
Nasopharyngoscopy can be performed in adults, co-operative children, and babies with parental permission. It is typically done to investigate any area of concern or follow-up in a treated area (surgery/radiotherapy/chemotherapy) that is otherwise difficult to access and visualize.
As there are too many abnormalities and pathologies that are identifiable on scoping, that to mention all would be impossible. Some of the important and commoner ones are listed below.
A three pass technique is used to examine all areas of the nasal cavity.
Posterior nasal space
The eustachian tube orifices, fossa of Rossenmuller, and adenoidal pad are inspected.
Adenoids should regress in adulthood, and prominent adenoids warrant investigation. Any untoward mass seen should be further investigated.
The base of tongue and valleculae
The base of tongue and valleculae are inspected for any masses, cysts, or irregularity. Lymphoid tissues of the lingual tonsils can be found here and often account for the irregularity seen. Any untoward mass seen should be further investigated, as this is a common site for oropharyngeal squamous cell carcinoma.
In children, abnormalities of the epiglottis (omega-shaped) and aryepiglottic folds can be seen in laryngomalacia .
Epiglottitis is a contraindication for scoping, unless done in experienced hands in a stabilized patient in an appropriate environment, due to the risk of laryngospasm and airway deterioration.
Any pooling of saliva, fullness, or masses seen here require further investigation.
Abnormalities of the arytenoids, if any, should be inspected.
Vocal cord movements, swelling, edema, masses, or mucosal changes also require examination. Any stridor or airway concerns again need to be scoped in a safe environment and experienced hands, with support from the anesthetists.
The majority of scope investigations occur in the hospital setting for acute assessments of the airway, persistent hoarseness, globus sensation, recurrent epistaxis, and tumor/cancer investigation and surveillance. In addition to this, the other main indications are listed below:
There are few contraindications for flexible nasopharyngoscopy. The main two are acute epiglottitis and croup. In epiglottitis, there is an actual risk of sending the patient into laryngospasm, so this needs to be left to an experienced ENT surgeon to perform the procedure if required . Relative contraindications include coagulopathies which may result in significant bleeding and craniofacial trauma where inadvertent intracranial instrumentation can occur.
Step 1: Preparation:
Many patients do tolerate the scope without a spray. On starting endoscopy, pain, edema or mucus may be noted. The use of co-phenylcaine (lidocaine and epinephrine) or xylometazoline can help to numb and decongest the nose, but allow a few minutes for it to work.
Step 2: Passing the nasopharyngoscope:
Step 3: Examination:
Step 4: Communication:
A simple drawing is a useful way of recording your findings. Most out-patient clinic systems will allow picture capture and printing, which permits the medicolegal documentation of findings and allows comparison of findings between visits. Some departments require a separate procedural log to be noted which allows for correct tariffs to be billed and allows traceability. If there is a cleaning or traceability sticker from the nasopharyngoscope, stick them in the notes.
Step 5: Post procedure instructions
Flexible nasopharyngoscopy and fiberoptic imaging have revolutionized ENT outpatient clinics. Technology has moved further forward with the new chip-on-the-tip digital flexible scopes. This method is a far cry from the ENT doctors using indirect laryngoscopy with hand-held mirrors and head mirrors.
In a typical head and neck cancer clinic, nearly all patients will have a flexible nasopharyngosocpy to look at cancer surveillance, treatment response or disease recurrence. In the acute setting, it is also used very often, for example, in all airway concerns or neck abscesses. It has become a routine tool in the ENT surgeon's armament, as common as using an otoscope, and one that is used regularly.
Interpretation and ability to carry out flexible nasopharyngoscopies remains a skill and a learning curve. Although the ENT surgeon does these procedures daily, and so theIR learning curve is much faster, other related specialists including anesthesiologists, nurse anesthetists, and the pulmonologists can use this tool and quickly pick up the expertise also. New gadgets used in stroboscopy, digital chip-on-the-tip technology, and endoscopic smartphone adapters keep the technology moving forward.
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