Nasopharyngolaryngoscopy for Family Physicians
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Transcript 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.