Download Nasopharyngolaryngoscopy for Family Physicians

Nasopharyngolaryngoscopy for
Family Physicians
Scott M. Strayer, MD, MPH
Assistant Professor
University of Virginia Health System
Department of Family Medicine
Case Presentation
 24-year-old female c/o 3 months of
hoarseness following weekly choir practice.
She is a nonsmoker and doesn’t drink
alcohol. No formal vocal training, and
started singing solos with the choir about 5
months ago.
Vocal Cord Nodules
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
More Background
 Fast procedure (most are completed within 510 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.)
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.
Indications
 History of previous
 Evaluation of snoring.
head and neck cancer.
 Reassurance in any
 Head or neck masses or
chronic upperadenopathy.
respiratory condition.
 Recurrent epistaxis.
 Dysphagia.
 Chronic foreign-body
sensation in pharynx.
Acute Indications
 Hemoptysis.
 Acute sinusitis.
 Acute epistaxis.
 Suspected nasal foreign body.
 Suspected laryngeal foreign body.
 Acute onset of hoarseness after straining
voice.
Contraindications
 Acute epiglottitis.
 Acute epistaxis.
 Absence of nasal passage.
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).
Evaluation
 Thorough head and neck history and
examination.
 Complete history and physical examination
as indicated.
 Explain procedure and schedule follow-up
appointment.
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.)
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).
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.
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.
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

Nasal Passages
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.
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.
Procedure-Rosenmüller’s fossa
 Located posterior to both tori and anterior to
adenoid pad.
 Carefully inspect as most nasopharyngeal
malignancies are found in this area.
Nasopharynx and Oropharynx
Anatomic Divisions of Upper
Airway
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.

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.
Posterior Pharynx
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.

Larynx
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.
Sphenoid Sinus
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.
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.