Flexible Nasopharyngoscopy

Article Author:
Sirhan Alvi
Article Editor:
Savita Lasrado
Updated:
3/20/2019 10:04:26 PM
PubMed Link:
Flexible Nasopharyngoscopy

Introduction

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.[1]

Anatomy

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.

Nasal cavity

A three pass technique is used to examine all areas of the nasal cavity.

  • Septal deviation, bony spurs, turbinate hypertrophy
  • External and internal nasal valve areas
  • Nasal obstruction, mucopurulent debris, sinus drainage, mucosal edema
  • Bleeding points, septal perforations
  • Polyps, adhesions, and crusting 

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.

Epiglottis

In children, abnormalities of the epiglottis (omega-shaped) and aryepiglottic folds can be seen in laryngomalacia [2].

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. 

Piriform fossae

Any pooling of saliva, fullness, or masses seen here require further investigation.

Larynx

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.

Indications

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[3][4][5][6]:

  1. Removal of a foreign body that is easily accessible
  2. Evaluation of obstructive sleep apnoea, e.g., the Muller maneuver, although it is still difficult to evaluate from this the patients that will do well with surgery
  3. Velopharyngeal insufficiency
  4. Examining the acute airway and establishing if patients require intensive therapy unit (ITU) care or airway management
  5. Fibre endoscopic evaluation of swallowing (FEES) done in association with the speech and language therapists in patients with swallowing problems
  6. Vocal cord office based injections for vocal cord palsies
  7. Tracheoscopy

Contraindications

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 [7]. Relative contraindications include coagulopathies which may result in significant bleeding and craniofacial trauma where inadvertent intracranial instrumentation can occur.

Equipment

  • Flexible nasopharyngoscope - fibreoptic or digital chip-on-the-tip technology; the size of scope diameter varies from 1.9mm (pediatric) to 6mm (adult)
  • A viewing camera can be attached to the viewing port of the scope (if not a digital scope)
  • A light source (can be portable) 
  • Light lead (if required)
  • Screen/monitor with picture acquisition and an image printer
  • A decontamination system for scopes: a disposable endoscopic sheath; chlorine dioxide multi-wipe system; endoscope washer disinfector units
  • Topical decongestant/anesthetic spray
  • Lubrication gel
  • Alcohol wipes
  • Tissues

Personnel

  • ENT surgeon
  • Maxillofacial surgeon
  • Speech and language therapists (fiberoptic evaluation of swallowing)
  • Oncologist

Technique

Step 1: Preparation:

  • Appropriately clean the nasopharyngoscope or source a clean one, according to the local hospital policy
  • Apply an endoscopic sheath if using one
  • Check the light source is working and light lead transmits the light adequately
  • Chat with the patient:
    • Explain the necessity for doing the procedure
    • Explain the procedure
    • Discuss the risks: it can be uncomfortable, make their eyes water and may make them sneeze; if used, the local anesthetic spray tastes very bitter; they should not eat or drink for one hour after; rarely there can be a reaction to the topical spray
    • Discuss the benefits: it provides a lot of useful information
    • Obtain the patient's informed consent 
  • Position the patient's head
    • Sit upright, "breathing the morning air", with head support 
  • Where indicated, use a topical nasal anesthetic spray

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:

  • If not previously noted, request the patient to sniff and let you know which nasal passage they feel is the more patent
  • For nasal conditions, you may wish to visualize both nasal passages - otherwise, if the posterior nasal space, the base of tongue, hypopharynx or larynx are of interest, then use one side
  • Focus the lens, using some writing or a label
  • Lubricate the scope avoid getting any on the tip
  • Touching the end of the scope on the patient's tongue or using an alcohol wipe can reduce fogging
  • Aim the scope at the center of space into requiring movement without touching the sides and picking up debris if possible
  • When moving from the nasopharynx to oropharynx, asking the patient to breathe normally through their nose allows the soft palate to open up, and allows the scope to be advanced without resistance

 Step 3: Examination[8]:

  • Examine the nose, posterior nasal space, the base of tongue, pharynx, and larynx methodically
  • Perform maneuvers that help improve visibility:
    • Protruding the tongue helps to visualize the tongue base and valleculae
    • Blowing out of the cheeks gives a better view of the pyriform fossae - alternatively moving the head to the right and left will do the same
    • Check vocal cord movements: making an 'Eeeee' sound or counting numbers aloud should abduct both vocal cords against each other in the midline; breathing in should have the opposite effect and abduct the cords equally
  • Foreign bodies can be removed with handheld forceps using the scope for visual guidance

 Step 4: Communication:

  • Record and describe your findings in the clinical case notes

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

  • The patient should refrain from eating and drinking until the anesthetic spray fully wears off (about 1 hour)
  • If the patient feels faint, keep them seated
  • At the end of the scope procedure, follow local departmental endoscope sterilization procedures

Complications

The following represent some of the possible comlications[9][10][11]:

  • Although complications are rare, the most common are sneezing, and mucosal tearing and bleeding secondary to injury - to prevent this, adequate nasal decongestion and limited force should be used
  • Laryngospasm, a serious risk, although reported in less than 1% of procedures
  • Gagging and adverse reaction to the nasal decongestant are other potential risks
  • Damage to anatomic structures is more common with the use of rigid scopes, and rarely seen with flexible scopes

Clinical Significance

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.

Enhancing Healthcare Team Outcomes

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.[12][13][14]


References

[1] Campbell IS,Howell JD,Evans HH, Visceral Vistas: Basil Hirschowitz and the Birth of Fiberoptic Endoscopy. Annals of internal medicine. 2016 Aug 2;     [PubMed PMID: 27479222]
[2] Demirci S,Tuzuner A,Callioglu EE,Akkoca O,Aktar G,Arslan N, Rigid or flexible laryngoscope: The preference of children. International journal of pediatric otorhinolaryngology. 2015 Aug;     [PubMed PMID: 26100057]
[3] Schäfer J,Pirsig W,Lenders H,Meyer C, [What is new in nasopharyngeal video fiber optic endoscopy in the diagnosis of snoring and patients with obstructive apnea?]. Laryngo- rhino- otologie. 1989 Sep;     [PubMed PMID: 2803400]
[4] Dudas JR,Deleyiannis FW,Ford MD,Jiang S,Losee JE, Diagnosis and treatment of velopharyngeal insufficiency: clinical utility of speech evaluation and videofluoroscopy. Annals of plastic surgery. 2006 May;     [PubMed PMID: 16641626]
[5] Bentsianov BL,Parhiscar A,Azer M,Har-El G, The role of fiberoptic nasopharyngoscopy in the management of the acute airway in angioneurotic edema. The Laryngoscope. 2000 Dec;     [PubMed PMID: 11129012]
[6] Zeleník K,Walderová R,Kučová H,Jančatová D,Komínek P, Comparison of long-term voice outcomes after vocal fold augmentation using autologous fat injection by direct microlaryngoscopy versus office-based calcium hydroxylapatite injection. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2017 Aug;     [PubMed PMID: 28478500]
[7] Cantrell RW,Bell RA,Morioka WT, Acute epiglottitis: intubation versus tracheostomy. The Laryngoscope. 1978 Jun;     [PubMed PMID: 651516]
[8] Choy AT,Gluckman PG,Tong MC,Van Hasselt CA, Flexible nasopharyngoscopy for fish bone removal from the pharynx. The Journal of laryngology and otology. 1992 Aug;     [PubMed PMID: 1402362]
[9] Ngan JH,Fok PJ,Lai EC,Branicki FJ,Wong J, A prospective study on fish bone ingestion. Experience of 358 patients. Annals of surgery. 1990 Apr;     [PubMed PMID: 2322040]
[10] Wrigley SR,Black AE,Sidhu VS, A fibreoptic laryngoscope for paediatric anaesthesia. A study to evaluate the use of the 2.2 mm Olympus (LF-P) intubating fibrescope. Anaesthesia. 1995 Aug;     [PubMed PMID: 7645703]
[11] Ricchetti A,Becker M,Dulguerov P, Internal carotid artery dissection following rigid esophagoscopy. Archives of otolaryngology--head     [PubMed PMID: 10406322]
[12] Jones JW,Perryman M,Judge P,Baumanis MM,Sykes K,Dowdall J,Cabrera-Muffly C,Garnett JD,Kraft S, Resident Education in Laryngeal Stroboscopy and Perceptual Voice Evaluation: An Assessment. Journal of voice : official journal of the Voice Foundation. 2018 Dec 10;     [PubMed PMID: 30545492]
[13] Mistry N,Coulson C,George A, endoscope-i: an innovation in mobile endoscopic technology transforming the delivery of patient care in otolaryngology. Expert review of medical devices. 2017 Nov;     [PubMed PMID: 28972409]
[14] Schröck A,Stuhrmann N,Schade G, [Flexible 'chip-on-the-tip' endoscopy for larynx diagnostics]. HNO. 2008 Dec;     [PubMed PMID: 18618088]