Nasal laryngoscopy

Aka: Nasal laryngoscopy, Laryngeal Exam, Nasopharyngoscopy, Rhinolaryngoscopy, Nasolaryngoscopy, Nasolaryngoscope, Laryngeal Lesion, Vocal Fold Lesion

1. Indications
   1. Hoarseness or Dysphonia evaluation
      1. Persistent Hoarseness beyond 2 weeks
      2. Higher risk for Laryngeal Neoplasm
         1. Tobacco Abuse
         2. Alcohol Abuse
      3. Associated symptoms
         1. Dyspnea
         2. Laryngeal pain
         3. Aspiration
         4. Dysphagia
   2. Chronic Problems
      1. Chronic Sinusitis
      2. Chronic Serous Otitis Media
      3. Recurrent or persistent Otalgia
      4. Chronic Cough
      5. Chronic Pharyngitis
      6. Chronic Rhinorrhea
      7. Chronic nasal obstruction
   3. Acute Problems
      1. Angioedema
      2. Stridor
      3. Foreign Body Aspiration or Sensation
      4. Hemoptysis
      5. Acute Sinusitis
      6. Suspected Nasal Foreign Body
      7. Nasotracheal Intubation
      8. Suspected adult Epiglottitis, Bacterial Tracheitis or abscess
         1. Risk of triggering complete airway closure
         2. If performed, stay well above the epiglottis, and have emergency airway equipment ready
         3. May be performed as part of fiberoptic Nasotracheal Intubation
2. Complications
   1. Laryngospasm
      1. Occurs if scope were to touch Larynx (avoid this)
   2. Epistaxis
      1. Higher risk if Anticoagulant or antiplatelet use
   3. Exacerbation of craniofacial injury
      1. Example: Skull base Fracture with risk of entering intracranial space
3. Preparation
   1. Informed Consent for procedure
   2. Patient gently blows nose
   3. Mix Topical Decongestant with Lidocaine
      1. Phenylephrine or Oxymetazoline (0.05% to 2%)
      2. Lidocaine 2 to 4% (4% preferred)
   4. Atomize solution into nares
      1. Atomizer example: Wolff Tory Mucosal Atomization Device (MAD)
   5. Spray or apply intranasally in least obstructed naris (typically into both)
   6. Wait 5-10 minutes
   7. Equipment
      1. Nasolaryngoscope (3-6 mm diameter)
      2. Suction
4. Technique
   1. Patient sits upright with head slightly forward
      1. "Sniffing" position
   2. Consider applying K-Y jelly to shaft of scope (not to head)
   3. Pass tube into nare and along the floor of the nose
      1. Stop and redirect if resistance is met (and switch to opposite nare if resistance persists)
      2. Examiner's right hand (or dominant hand) is on the scope control at the scope's base
      3. Examiner's left hand is on the end of the scope closest to the nare
      4. Keep the scope straight (elongated, not sagging) while inserting to allow for maximal control
      5. Pass the scope between the nasal septum and the inferior turbinate
      6. Rotate the scope inferiorly after entering the posterior pharynx
   4. To defog scope
      1. Defogging solution OR
      2. Mucus from nose also defogs lens (gently touch sidewall)
      3. Swallowing will clear lens of mucus (may cause gag)
   5. Patient should breath through nose to keep nares open
   6. Patient repeatedly says "K" to elevate Soft Palate
      1. Also opens eustachian tube
   7. Patient protrudes Tongue to visualize vallecula
   8. Cord Movement
      1. Patient repeatedly says "E" to view cord movement
      2. Patient takes deep breath to see full abduction
5. Anatomy: Landmarks
   1. Nose
      1. Inferior Meatus
         1. Nasolacrimal ostia
      2. Middle Meatus (Osteomeatal complex)
         1. Frontal Sinus ostia
         2. Anterior Ethmoid Sinus ostia
         3. Maxillary Sinus ostia
      3. Superior Meatus
         1. Posterior Ethmoid Sinus ostia
      4. Above superior meatus
         1. Sphenoid Sinus ostia
   2. Nasopharynx
      1. Torus tubarius
         1. Eustachian tube ostia (encased in torus tubarius)
      2. Rosenmuller's fossa
         1. Cleft posterior to torus tubarius
         2. Common site for nasopharyngeal cancer
      3. Adenoids
         1. Posterior to torus tubarius
   3. Oropharynx
      1. Epiglottis
      2. Vallecula
      3. Tongue base (lingual Tonsil)
   4. Hypopharynx and Larynx
      1. Central Larynx
         1. False Vocal Cords
         2. True Vocal Cords
         3. Ventricle (between true and false cords)
      2. Posterior Larynx
         1. Piriform sinus
         2. Corniculate and Cuneiform cartilage
            1. Contiguous "lumps" on aryepiglottic folds
         3. Aryepiglottic fold
6. Findings
   1. Nose
      1. Nasal Foreign Body
      2. Acute Sinusitis
      3. Septal perforation
      4. Septal abscess or Septal Hematoma
      5. Nasal Polyp
   2. Oropharynx
      1. Obstructive airways (Sleep Apnea)
         1. Large adenoids
         2. Large lingual Tonsils
   3. Larynx
      1. Laryngeal contact ulcer (mucosa or arytenoid cartilage)
         1. Direct Trauma (e.g. intubation)
         2. Inhaled Corticosteroid
         3. Vocal Abuse
         4. Reflux Laryngitis
      2. Laryngeal inflammation
         1. Allergy
         2. Post-intubation
         3. Inhaled Corticosteroids
         4. Tobacco Abuse
         5. Reflux Laryngitis
      3. Leukoplakia (white, thickened epithelium)
         1. Carcinoma or dysplasia (esp. male smokers over age 60 years)
         2. Benign Leukoplakia
      4. Vocal fold Hemorrhage (subepithelial, typically unilateral)
         1. Vocal Abuse
         2. Direct Trauma
         3. Anticoagulants
      5. Laryngeal Neoplasm (Exophytic or ulcerated lesions)
      6. Laryngeal papillomatosis
         1. Human Papillomavirus Infection (HPV)
      7. Laryngeal Granuloma
         1. Trauma (e.g. post-intubation)
         2. Vocal Abuse
         3. Inhaled Corticosteroid
         4. Reflux Laryngitis
      8. Laryngeal cysts, pseudocysts or Nodules (or bilateral mid-vocal fold fibrous masses)
         1. Vocal cord abuse
      9. Laryngeal Polyps (sessile or pedunculated)
         1. Allergic Rhinitis
         2. Tobacco Abuse
         3. Vocal Abuse
      10. Reinke Edema (Polypoid chorditis, Superficial lamina propria swelling)
          1. Reflux Laryngitis
          2. Tobacco Abuse
          3. Vocal cord abuse
      11. Displaced vocal cord (paramedian or lateral)
          1. Recurrent laryngeal nerve injury
          2. Vagus Nerve injury
7. Protocol: Equipment care
   1. Avoid bending scope into tight angles
   2. Clean lens with lens cleaner and paper
   3. Scope Sterilization
      1. Soak in glutaraldehyde for 20 minutes
      2. Rinse scope of cleaning solution
      3. Hang up to dry
   4. Disposable scope sheeth
      1. Alternative to sterilization of scope itself in glutaraldehyde
      2. Allows for more rapid, safe reuse of Nasolaryngoscope
8. Charges: CPT Codes
   1. 31575 Nasolaryngoscopy
   2. 92511 Diagnostic Nasopharyngscopy with endoscope
   3. 99070 Supplies and disinfection charge
9. Reference
   1. Patton (1992) Primary Care and Cancer 12(5): 13
   2. Vaught (2021) Crit Dec Emerg Med 35(6): 19-23
   3. Hocutt (1990) Am Fam Physician 42(5): 1257 [PubMed]
   4. Feierabend (2009) Am Fam Physician 80(4): 363-70 [PubMed]
   5. House (2017) Am Fam Physician 96(11): 720-8 [PubMed]