Nasopharyngolaryngoscopy for Family Physicians

1. Nasopharyngolaryngoscopy for Family Physicians Scott M. Strayer, MD, MPH Assistant Professor University of Virginia Health System Department of Family Medicine

2. 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.

3. Vocal Cord Nodules

4. 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

5. 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.)

6. 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

7. 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. Indications

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

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

10. 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).

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

12. 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.)

13. 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).

14. 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.

15. 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.

16. 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

17. Nasal Passages

18. 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.

19. 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.

20. 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.

21. Nasopharynx and Oropharynx

22. Anatomic Divisions of Upper Airway

23. 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.

24. 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.

25. Posterior Pharynx

26. 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.

27. Larynx

28. 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.

29. Sphenoid Sinus

30. 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.

31. 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.