Nasopharyngolaryngoscopy for Family Physicians

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Nasopharyngolaryngoscopy for Family Physicians

• Scott M. Strayer, MD, MPH
• Assistant Professor
• University of Virginia Health System
• Department of Family Medicine

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Case Presentation

• 24-year-old female c/o 3 months of hoarseness
  following weekly choir practice. She is a
  nonsmoker and doesnt drink alcohol. No formal
  vocal training, and started singing solos with
  the choir about 5 months ago.

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Vocal Cord Nodules
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Background

• 1982 survey in Ohio reported that fewer than 30
  of primary care physicians could visualize the
  larynx, and less than 4 included inspection of
  the larynx as part of a CPE.
• First used in 1968.
• Very low risk

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More Background

• Fast procedure (most are completed within 5-10
  minutes).
• Relatively low cost of equipment (3500-5000
  need light source).
• 8.2 of family physicians reported doing this
  procedure in 2000. (Source American Academy of
  Family Physicians, Practice Profile II Survey,
  May 2000.)

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Indications

• Chronic hoarseness 3 weeks.
• Chronic sinusitis or sinus discomfort (esp.
  unilateral).
• Chronic serous otitis media in an adult (esp.
  unilateral).

• Recurrent otalgia.
• Suspected neoplasia.
• Chronic cough.
• Chronic nasal obstruction or postnasal drip.
• Chronic rhinorrhea.
• Halitosis.

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Indications

• History of previous head and neck cancer.
• Head or neck masses or adenopathy.
• Recurrent epistaxis.
• Dysphagia.
• Chronic foreign-body sensation in pharynx.

• Evaluation of snoring.
• Reassurance in any chronic upper-respiratory
  condition.

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Acute Indications

• Hemoptysis.
• Acute sinusitis.
• Acute epistaxis.
• Suspected nasal foreign body.
• Suspected laryngeal foreign body.
• Acute onset of hoarseness after straining voice.

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Contraindications

• Acute epiglottitis.
• Acute epistaxis.
• Absence of nasal passage.

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Equipment Needed

• Nasoscope.
• Nasal speculum.
• Sterilizing solution (I.e. Cidex).
• Decongenstant (I.e. Neo-synephrine).
• Anesthetic
• Lidocaine (2 to 4) spray (Xylocaine).
• Benzocaine spray (14) (Cetacaine).

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Evaluation

• Thorough head and neck history and examination.
• Complete history and physical examination as
  indicated.
• Explain procedure and schedule follow-up
  appointment.

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Patient Education

• Spray can be noxious (can use lidocaine jelly
  instead).
• Intense tickling sensation.
• Patient can talk.
• No real pain, just pressure.
• Will be asked to say certain words and sounds
  (I.e. key, a, e, i, etc.)

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Procedure Preparation

• Blow nose first, then use decongestant in both
  nares.
• Then insert lidocaine (jelly or spray).
• For jelly, leave in nose for 5-10 minutes, then
  have patient blow out.
• For spray, have patient tilt back and swallow
  after spray (use spray generously).

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Procedure Preparation

• Anesthesize least obstructed nares (unless
  looking at both).
• Wait 5-10 minutes for decongestant to take
  effect.
• Spray back of throat as well to suppress gag
  reflex.

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Procedure

• Place patient in erect sitting position with
  support behind head so rapid withdrawal is not
  possible.
• Use tripod of fingers to support scope as you
  insert.
• Insert inferior and medially through nasal cavity.

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Procedure-Nasal Passage

• Visualize inferior turbinate about 1cm into
  passage.
• Note texture and size
• Polypoid degeneration or swelling
• Surgical antral windows into sinus are frequently
  located in inferior meatus

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Nasal Passages
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Procedure-Choana

• At 4-5 cm will see choana (junction between nasal
  fossa and the nasopharynx).
• Can move scope laterally and superiorly to enter
  middle meatus (can wait until withdrawal as this
  sometimes hurts).
• Visualize adenoid pad on posterior wall of
  pharynx.

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Procedure-Torus

• Slightly flex tip and rotate 90 degrees to
  visualize torus tubarius (valve at opening of
  eustachian tube).
• Observe function while patient says key, key,
  key.
• Advance slightly and rotate 180 degrees to
  visualize contralateral torus.

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Procedure-Rosenmüllers fossa

• Located posterior to both tori and anterior to
  adenoid pad.
• Carefully inspect as most nasopharyngeal
  malignancies are found in this area.

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Nasopharynx and Oropharynx
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Anatomic Divisions of Upper Airway
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Procedure-Posterior Pharynx

• Advance inferiorly and towards posterior wall of
  oropharynx.
• Have patient breathe through nose.
• Flex and rotate slightly to view uvula, soft
  palate, lateral and posterior walls of pharynx.
• Epiglottis visible in distance.
• Look for masses, scarring, inflammation, exudate,
  mucosal abnormalities, or pulsations.

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Procedure-Oropharynx

• After passing the soft palate, enter oropharynx.
• Keep scope close to posterior wall without
  touching it (otherwise gag reflex).
• If scope fogs, have patient swallow.
• Slightly flex and rotate to inspect post. Tongue,
  lingual tonsils, palatine tonsils, epiglottis,
  medial and lateral glossoepiglottic folds, and
  vallecuale.

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Posterior Pharynx
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Procedure-Hypopharynx

• After passing epiglottis, enter hypopharynx.
• Try not to swallow at this point.
• Visualize arytenoid cartilages, aryepiglottic
  folds.
• Inspect pyriform sinuses posterior to cords.
• Examine true and false cords.
• Say eee to examine symmetry of cord motility.
• Look for edema, hemorrhages, erythema, nodules,
  or masses.
• Do NOT pass cords.

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Larynx
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Procedure-Sphenoid sinus

• At choana, direct scope superiorly and withdraw.
• Visualize superior turbinate, ostia of sphenoid
  sinus (medial to sup. Turbinate).
• Withdraw until complete choana are in view, then
  move superiorly and laterally to allow
  examination of middle meatus.

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Sphenoid Sinus
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Procedure-Middle Meatus

• Visualize frontal sinus, anterior ethmoid cells,
  maxillary sinus ostia.
• Look for drainage from ostia, purulent fluid,
  inflammation, or polyps protruding from or
  occluding the ostia.

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Complications

• Adverse reactions to anesthetic or decongestant
  (most common).
• Severe sneezing and gagging.
• Laryngospasm with possible asphyxia (remain above
  cords).
• Vasovagal reaction.
• Epistaxis.
• Vomitting with possible aspiration.