Office-Based Laryngoscopy Good Practicing Laryngoscopy Part2

Position of the Patient and Examiner

Patient sitting, examiner sitting. Height of both chairs is adjustable, the head of the examiner is slightly higher.

Patient sitting, examiner standing. Note that the examiner’s left elbow is angled, his right arm adducted.

• When choosing your position for examination ensure that the monitor is within easy line of sight - avoid extreme head rotation to either side for longer examinations.

• Adjust the height of both chairs – it is usually more comfortable for the examiner to sit in a slightly higher position than the patient.

• The examiner’s arms should be adducted during prolonged endoscopy procedures.

• The examiner’s elbows should be comfortably flexed.

• Rigid endoscopy with a 90° or with a 70° endoscope can be performed either from a standing or sitting position.

• In some countries, it is common for both the examiner and patient to sit.

• However, when using some cameras, it may be easier to stand while the patient remains seated.

• While seeking a particular view, it may be necessary to alter the normal positions for examination.

Note that by holding the endoscope in this manner both sitting and standing are possible and convenient.

Gripping the camera as illustrated is easiest from a standing position.

Patient sitting, examiner sitting. Note the manner in which the endoscope is held from below.

Patient sitting, examiner standing. Note the manner in which the endoscope is held.

• Examinations with flexible endoscopes can be performed while the examiner is either sitting or standing.

• Especially for longer procedures, e.g. examination of swallowing, it is sometimes more comfortable for the examiner to stand in order to reduce the strain on their arms.

• Another possibility for flexible endoscopy is to stand behind the patient so the examiner and patient can watch the monitor. We are not fond of this technique because the examiner cannot see the patient’s face, and is therefore unable to check their reactions, e.g. an impending vagal response.

A) Standard handling, right index finger controls tip deflection

B) Right thumb controls tip deflection in this examination.

A) Standard grip, index finger controls tip deflection

B) Endoscope rotated, thumb controls tip deflection

C) Endoscope held horizontally. This handling requires examination in a standing position.

• Flexible endoscopy is more ergonomic and thus easier to perform than rigid endoscopy when the patient is lying in a supine or semirecumbent position.

• The examiner may sit or stand as appropriate, using whichever position is the most comfortable.

The semirecumbent patient with the examiner sitting on the edge of the bed. This arrangement is helpful when the bed is so wide that the examiner has to bend sidewards in order to reach the patient.

The semirecumbent patient with the examiner standing. This is a convenient position for the examination of swallowing. The examiner can watch both the patient and monitor easily.

When the patient is lying supine, the examiner may sit at the head end of the bed. In this position it may be helpful to rotate the endoscope and use the thumb to control the tip deflection. Note the repositioned monitor.

• For both rigid and flexible endoscopy it is important to find a neutral, comfortable (i.e. not tiring) position, especially for the arms, head, and back.

• The examiner’s elbows should not be abducted, nor held any higher than necessary.

• The examiner’s arms should be adducted during long endoscopy exams.

• During protracted examinations, standing may be a more comfortable option for the examiner.

• The distance between the examiner and patient should not be so great as to prevent the examiner from sitting or standing upright with a straight back and neck.

• Make sure that the monitor is positioned so that the examiner can see the screen and the patient with a minimal amount of head turning.

Example of good ergonomic posture. The examiner has a straight back and his arms in a low, elbows-in position.

Note the examiner’s left elbow is angled and the distal part of the flexible endoscope is not straightened. The examiner’s right arm should be relaxed with the elbow dropped towards the body during protracted endoscopy exams.

Make sure that you can see the monitor and the patient with a minimal amount of head turning.

Note the examiner sits up straight. The distance between the patient and examiner should be reasonably short, as shown here.

• Foot pedals may be required during some examinations in order to operate recording, stroboscopy, laser, etc.

• Be prepared to reach all necessary foot pedals.

• Sit or stand up straight.

• Avoid getting your feet tangled in cables.

• There are several options for where to place your feet when sitting opposite a patient. When using a foot pedal, the patient’s knees should be facing the examiner, who can then arrange his own legs to the left or to either side of the patient’s knees.

• Check that the distance between examiner and patient is small enough to permit both to sit upright.

Check the position of the standing and free leg

Check how easy it is to reach all the necessary foot pedals. Try to avoid getting the feet tangled in stray cables.

Position of the examiner’s legs on either side of the patient’s knees.

Position of the examiner’s legs to one side. Both are turned towards the monitor.

• Note the bent back and arms held high and abducted.

• Note the distance between the examiner and the patient.

• Also note the wide angular change in direction required to view either the patient or the monitor.

The distance between the examiner and patient is too great, causing unnecessary forward bending of the examiner’s back and neck.

Poor location of the monitor demands considerable and unnecessary head turning.

Examiner’s arms are both held too high with the elbows abducted

Once again the distance between the examiner and patient is too great, despite the back and neck not being bent. Both arms are abducted and too high.