Office-Based Laryngoscopy Good Practicing Laryngoscopy Part1

ANESTHESIA

General Remarks

• Topical anesthesia can help a lot and is frequently necessary if a good-quality recording is to be achieved.

• In our office, anesthesia of the oral cavity and/or nasal cavity is used routinely.

• But, before administering topical anesthesia

• Ask about any history of allergic reactions (extremely rare for lidocaine)

• Ask for patient’s general health condition and history concerning medication.

• Explain the effects of topical anesthesia, e.g. when anesthetizing the pharynx: “First it might burn for some seconds, then you will taste the medicine and for some minutes you will experience a sensation of swelling and an inability to swallow – this all is just a sensation, nothing like that will actually happen”.

• A burning sensation comes from the alcohol as a component of some lidocaine products. In children, use anesthesia without alcohol.

Examples for topical anesthetics

In some cases the application of lidocaine gel in the nasal cavity, applied with a syringe, is a good alternative to spraying.

Anesthetizing the Oropharyngeal Region ·

• To anesthetize the oropharynx depress the tongue with a spatula.

• Ask the patient to say “aaah” and spray the velum, posterior pharynx and right and left faucial pillars.

• Count the squirts and keep the daily maximum dose of local anesthesia in mind.

Ask the patient to breathe through their mouth. Be prepared for a sudden cough in response

First squirt goes onto the soft palate (velum).

Second squirt onto right posterior pharyngeal wall without touching it. Allow for swallowing if patient so wishes.

Last squirt onto left posterior pharyngeal wall. Allow for swallowing. Wait for one minute before starting endoscopy.

Anesthetizing the Nasal Cavity

• The nasal cavities are frequently asymmetrical, with one side being narrower than the other. Check both sides before inserting an endoscope.

• When anesthetizing the nasal cavity choose the side with a larger aperture in the vestibulum and anterior nasal cavity.

• Open the nostrils with a speculum and spray decongestant and local anesthetic into the lower and middle nasal meatus.

• Keep in mind that there is a daily maximum dose for local anesthetic agents.

• When choosing the side, also consider whether a particularly clear view of the left or right vocal fold is necessary – then you should choose the contralateral nasal cavity to pass the endoscope.

Intranasal spray to the right nasal cavity: How to hold the speculum with the left hand; When spraying the nasal cavities, apply a decongestant before applying local anesthetic.

Intranasal spray to the left nasal cavity: How to hold the speculum with the left hand

Anesthetizing with nasal packing where the nasal cavity is very narrow

Putting the nasal packing into the right nasal cavity

A good alternative to spraying is to apply lidocaine gel with a syringe. This may be particularly helpful for bedside examination or when examining children.

For application of the gel into the lower meatus, slightly lift the tip of the nose.

Anesthetizing the Larynx

• Anesthetizing the larynx can be very helpful in patients with a pronounced gag response.

• It is recommended for flexible endoscopy of the subglottis and trachea.

• It is obligatory in indirect phonosurgery.

• When spraying the larynx you may want an angled spray nozzle. The standard spray nozzle can be re-shaped to suit the individual patient.

Normal spray nozzle

Bending the spray nozzle to 90° with an instrument

Bend the spray nozzle more than 180° so it will finally stay in a position of 90°

Anesthetizing the larynx transorally with a bent spray nozzle (A).

Insert into mesopharynx (B), lower tip behind the tip of the epiglottis (C), ask for long phonation of “eee” and spray during phonation (D).

Avoid spraying into the trachea and causing any unnecessary tracheal burning sensation (E).

D) Spray while patient is phonating “eee” ...

E) … and not during respiration.