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Transnasal Flexible Laryngoscopy – Handling the Endoscope

Insertion of the Endoscope

  • Insert the endoscope slowly and with permanent skin contact of the fingers of your left hand with the patient’s nose or cheek. This helps prevent accidental displacement of the endoscope should the patient
    move unexpectedly.
  • When the endoscope tip has passed the anterior nasal cavity, advance the endoscope slowly using just the thumb and index finger.
  • Keep finger contact with the nose throughout the examination.
  • Be careful not to hurt or to scare the patient with any sudden movements of the endoscope.
  • When finishing the examination, withdraw the endoscope slowly and cautiously to avoid hurting the patient.
  • During the examination, you should have slackened the flexible shaft of the endoscope into a siphon configuration (see chapter 2.4.3.).

Check that both fingers are holding the endoscope before advancement. Then, push endoscope in.

Advance the endoscope slowly and by moving only the thumb and index finger.

Rotation of the Endoscope

  • The flexible shaft of the endoscope should not be straight but bowed into a siphon configuration so you can rotate the tip of the endoscope with the fingers of your left hand (A).

  • Alternatively, you can rotate the tip by rotating the whole endoscope when the flexible shaft is held straight (B).

A) Having formed a siphon shape in the flexible shaft, it is now possible to rotate just the tip of the endoscope

B) When the flexible shaft is fully extended, the tip can only be rotated by turning the whole endoscope.

Flexible Endoscopy – How NOT to Do It

These are fairly common mistakes.

Right arm too high and the flexible part of the endoscope too straight.

Examiner pulling down on the endoscope, thus straightening the flexible shaft.

No contact of left hand to nose or cheek of patient. When the patient suddenly comes forward, the endoscope might injure the nasal mucosa.

The tip of the endoscope is too high up. The position of the left hand does not allow the endoscope to be inserted with movements of the thumb and index finger.

Again, the position of the left hand does not permit insertion of the endoscope using movements of the thumb and index finger. Also note that the flexible part of the endoscope is too straight.

Transnasal Passage and Sequence of Endoscope Positions

  • Before introducing the endoscope decide which side is more suitable for the nasal passage (e.g. by anterior rhinoscopy).

  • The choice of side also depends on what you want to see. For instance, the contralateral vocal fold will mostly be exposed better.

  • For the patient the procedure is more convenient after anesthetization of the nasal cavity.

  • In some cases decongestant spray is helpful.

  • During transnasal endoscopy the nasal cavity, nasopharynx, velopharyngeal function, oro- and hypopharynx, and the larynx can be examined.

  • For special indications different examination positions might be chosen.

  • Useful maneuvers in flexible laryngoscopy depending on the position of the of endoscope tip.

Fig. 4.1.: Transnasal passage of the flexible endoscope with important reference points (1–7)

Transnasal Passage: Nose and Nasopharynx

  • Avoid advancing towards the septum – the mucosa of the turbinates will generally yield but the mucosa of the septum does not.

  • Where the nasal cavity is narrow, try the middle meatus. The two turbinates will generally yield enough space to permit passage of the endoscope. Try the inferior meatal route only when this approach fails.

Positions of the Endoscope Tip within the Nasal Cavity

Anterior nasal cavity, right side: See asterisk at inferior (*) and middle (**) turbinate In some cases decongestant spray is helpful. Here: Before …

… and after decongestant spray. Note the lumen enlargement.

Middle turbinate (right side)

Meatus between inferior and middle turbinate (right side)

Posterior nasal cavity and nasopharynx
  • When passing the endoscope into the nasopharynx, ask the patient to breathe through his nose so that the velum relaxes.

  • When examining velopharyngeal function, ask the patient to swallow or to phonate e.g. “eee” or “coke”.

Positions of the Endoscope Tip within the Posterior Nasal Cavity

Velum, seen from above while breathing through the nose

Velum, seen from above, while articulating “coke”

Velum, seen from above, while swallowing

Transnasal Passage: Oro- and Hypopharynx, Larynx, Trachea

  • With flexible endoscopy it is possible to evaluate the vocal tract configuration during speaking, singing and special maneuvers.

  • For assessing the morphology of the vocal folds it is recommended to position the tip of the endoscope very close to the glottis. It is often possible to pass the glottis and have a look at subglottis and trachea.

  • In case subglottis and trachea are part of the clinical question anesthetize the larynx.

Positions of Endoscope Tip within the Naso-, Oro-, and Hypopharynx and the Larynx

Larynx with vocal tract, seen from nasopharynx.

Larynx seen from base of uvula level

Larynx seen from uvula tip level; the epiglottis typically covers the anterior glottic area.

Larynx seen from oropharyngeal level

Larynx seen from upper epiglottal level

Larynx with vocal folds, tip of endoscope next to the arytenoids

Larynx with vocal folds, tip of endoscope close to glottis

Passing the glottis enables a good view of subglottic region and upper trachea.

Numbers According to Reference Points  (see Fig. 4.1.)

Position of Endoscope Maneuver Pay Special Attention to:
2, 3 Posterior nasal cavity above velum and nasopharynx Breathe through nose Spontaneous movements of velum and upper pharyngeal muscles; velopharyngeal distance
Swallow Velopharyngeal closure, regurgitation
Articulation of e.g. “coke” Velopharyngeal contact
4 Oropharynx Breathing at rest Spontaneous movements of lower pharyngeal and laryngeal muscles, acute signs of VCD, tremor, dystonia
Repeated phonation of “eee” following by sniffing Mobility of arytenoids
Throat-clearing, coughing, laughing Nonphonatory rapid movements, diadochokinesis of arytenoids
Counting softly and with habitual loudness level Vocal tract configuration
Oro- and hypopharynx Examination of swallowing Intraoral control of bolus, pre-, intra-, and postdeglutitive laryngeal penetration/aspiration
4, 5, 6 Oro- and hypopharynx, larynx Forced and rapid inspiration Extent of edema Pedunculated lesions Stability of arytenoid complex
Inspiratory phonation Pliability of mucosa Extent of edema, pedunculated lesions
Stroboscopy: 10 sec. “eee” with habitual loudness level and pitch Phonatory involvement of mucosal wave, pliability of mucosa, regularity of vibration
6, 7 Position close to glottis or subglottis / in trachea Long nasal inspiration (dipping maneuver) Fine structures of vocal fold Morphology of Morgagni’s ventricle, anterior commissure, subglottis, trachea
(in case of tracheostomy)
Transstomal and intratracheal Breathing at rest Visualization of glottis transstomal Visualization of trachea Cannula-induced ulcers
Phonation Respiratory mobility
Examination of swallowing with transstomal visualization Aspiration (turn endoscope upwards to inspect glottis and downwards to inspect lower trachea)

Table 4.2.: Flexible laryngoscopy: Useful maneuvers depending on position of endoscope (see Fig. 4.1)

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