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Examination of Children

General Remarks

  • There are various settings in which children may be examined.

  • The most suitable setting will depend on the child’s age and ability to cooperate.

  • Rigid endoscopy can only be performed when the child is cooperative, it is seldom possible in babies and toddlers.

  • There are big differences in children’s ability to cooperate.

  • Flexible endoscopy can be performed at any age, provided that the child may be held in a controlled position during the examination.

  • In our experience, flexible endoscopy without immobilizing the child can often be performed from the age of 4–6 years and upwards.

  • In our experience, rigid endoscopy can often be performed in children from the age of 6–8 years and upwards.

  • For rigid endoscopy, a 70° endoscope is most suitable due to the superior cervical position of the larynx.

  • In neonates and babies, flexible endoscopy can be performed with the baby sitting or lying and it is possible to perform a transnasal or transoral endoscopy. However, when small children have teeth they might bite on the flexible endoscope. In this case use transnasal access.

  • In babies it often takes time to see the vocal folds and to assess their mobility because of the superior, anteriorly tilted arytenoid complex. Keep the endoscope tip positioned at the level of the uvula until you have seen enough.

  • When examining a baby in a sitting position, the baby should sit upright and not half-lying. It is important to view the larynx from above and not from an anterior-superior angle – you will not see the vocal folds from the latter position.


  • Video recording is highly recommended for subsequent off-line analysis and archiving a full record!

  • For transnasal flexible endoscopy use topical local anesthetic in the nasal cavity (preferably using anesthetic gel for application).

  • Keep calm and do not fight with or bully the child.

  • Explain to the parents that the examination – particularly when using the small flexible endoscope (diameter <2 mm) – does not hurt, but that the child has to be held in a controlled manner in order to prevent wriggling.

  • The less the child moves the less it will be affected by the endoscope.

  • Give precise instructions to the parents about the best way to hold the child so they feel safe even though their movement is restricted.

Transoral Rigid Endoscopy of Children

  • Immobilizing a child is unhelpful for rigid endoscopy. However, holding them may offer some reassurance. To distract the child, involve them in the procedure. Have the child do something Ú e.g. holding their tongue with a gauze square.

  • Ask the child to pant during the examination.

Child capable of tolerating rigid endoscopy alone

Transnasal Flexible Endoscopy of Children

For better visualization of the setting, the examiner holds the endoscope like a left-handed examiner.

Anesthetization: Children tolerate the application of lidocaine gel with a syringe better than spraying. Note that both hands are holding the syringe and the right hand holds contact with cheek.

Compliant child able to tolerate transnasal endoscopy

Transnasal endoscopy. Child, held by father

Child, held in controlled position. Note the position of the father’s left hand and right arm.

Child, held in controlled position. Note the position of the father’s legs.

Transnasal and Transoral Endoscopy of Babies (Flexible and Rigid)

Baby, sitting and held by father during anesthetization. Note that both hands hold the syringe and the right hand holds contact with cheek.

Baby, held by father for transnasal endoscopy in sitting position.

Baby, lying and held by father for anesthetization of the nasal cavity. Note that the right hand with the syringe is stabilized on the baby’s cheek.

Baby lying for transnasal flexible endoscopy, father holding the child, examiner at head and looking at the monitor.

Alternative: Baby, lying for transoral flexible endoscopy. Note that the distal hand holding the endoscope is stabilized by contact with the cheek or mouth of the baby.

Same as before, enlarged

Alternative: Baby, lying for transoral 70° rigid endoscopy. Note that the distal hand with the endoscope is stabilized by contact with the cheek or mouth of the baby.

Same as before, note the different angle of the rigid endoscope after passing the velum. You can place one finger intraorally to guide the endoscope.
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