Atlas of Primary Care Procedures, 1st Edition

Ear, Nose, and Throat Procedures

56

Flexible Nasolaryngoscopy

Flexible fiberoptic nasolaryngoscopy is an inexpensive and easy-to-learn diagnostic technique performed by primary care physicians. The thin, 3-mm-diameter endoscope permits accurate assessment of the nasal cavity, nasopharynx, and larynx (Table 56-1). The technique provides more complete examinations than historically used indirect techniques and provides a window through which the physician can improve diagnostic accuracy and treatment strategies. In one large series of patients in a family practice setting, 70% of patients had a change in their management plan as a result of undergoing diagnostic flexible nasolaryngoscopy.

TABLE 56-1. ANATOMIC AREAS EXAMINED DURING NASOLARYNGOSCOPY

 

Nose and nasopharynx: nares, septum, inferior meatus, inferior turbinate, middle meatus, middle turbinate, maxillary sinus ostia, infundibulum (osteomeatal complex), torus tubarius (right and left), Eustachian tube ostia (right and left), Rosenmuller's fossa (right and left), adenoid pad or scars (postadenoidectomy, right and left), sphenoid sinus ostia, superior turbinate

Hypopharynx and larynx: uvula, posterior tongue, posterior pharyngeal wall, lingual tonsils, epiglottis, vallecula, aryepiglottic folds (right and left), piriform sinus (right and left), true vocal cords (including symmetric movement), false vocal cords, arytenoid cartilage (corniculate and cuneiform processes, right and left), posterior larynx (upper esophageal sphincter musculature)

 

Allergy and ear, nose, and throat (ENT) specialists have widely incorporated this examination as part of their initial assessment of patients. Specialists often employ larger scopes to incorporate biopsy channels. Primary care physicians generally use thinner scope without a biopsy channel. The thinner scopes are better tolerated by patients, and biopsy procedures can induce significant upper aerodigestive tract bleeding that may be difficult to control in a nonsurgical office setting. Because most primary care procedures do not encounter pathology that requires biopsy, the thinner scopes fit well into the diagnostic armamentarium of generalist physicians.

Scope manipulation during the procedure is relatively simple and uses similar skills required in other primary care endoscopic procedures. The major challenge with this procedure is learning the complex anatomy of the nose and throat. Physicians performing flexible nasolaryngoscopy must master the recognition of normal anatomy and then tackle the identification of pathology. Atlases and

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teaching videotapes can greatly aid the learner. Physicians who perform the procedure infrequently should review the anatomy prior to each procedure.

Several common disease states produce much of the pathology encountered during nasolaryngoscopy in generalist practices (Table 56-2). Allergic rhinitis frequently produces mucosal swelling, clear nasal and postnasal drainage, pharyngeal and postlingual cobblestoning, and it may predispose to sinus ostia closure and sinusitis. Purulent drainage can be identified coming from specific sinus ostia during the examination. Eustachian tube drainage can be observed, as can hypertrophy of lymphoid tissue on the tongue after an upper respiratory infection. Vocal cord swelling may be caused by localized viral infection (i.e., laryngitis), or acid may reflux to the posterior larynx, producing posterior erythema and swelling, and cause acid laryngitis. Solid growths, such as polyps or tumors, are infrequently encountered.

TABLE 56-2. COMMON PATHOLOGY OBSERVED DURING NASOLARYNGOSCOPY

 

Nose and nasopharynx: mucosal swelling, mucosal drainage or rhinitis, turbinate hypertrophy, septal hematoma, foreign body, Eustachian tube drainage, enlarged adenoid, nasopharyngeal cancer, sinus ostia drainage

Hypopharynx or larynx: enlarged tonsil, lymphoid hypertrophy of the tongue or posterior pharynx,Candida infection, clear allergic drainage into hypopharynx, laryngeal polyp, laryngeal edema, laryngeal papilloma, laryngeal cancer, vocal cord nodule, acid laryngitis (or swelling of the posterior larynx), vocal cord paralysis or dysfunction, vocal cord ulceration, foreign body

 

Flexible fiberoptic nasolaryngoscopy is well tolerated by adults and children. Experienced examiners know how to gently insert and withdraw the scope without sudden movements, and they can prevent the scope tip from touching lateral structures. Complications are extremely uncommon for these physicians. If the scope tip is not well controlled during the examination, the patient may experience gagging, coughing, sneezing, bleeding, laryngospasm, or even vagal response or syncope.

INDICATIONS

  • Cancer screening of high-risk individuals (e.g., positive family history, smokers with chronic symptoms)
  • Survey of the entire upper aerodigestive tract, especially when examining for multifocal or synchronous squamous cell carcinoma
  • Evaluation of persistent hoarseness, suspected sinusitis, suspected foreign body, suspected neoplasia, chronic cough, chronic postnasal drip, recurrent epistaxis, recurrent otalgia, head or neck masses, hemoptysis, dysphagia, foreign body sensation in the hypopharynx, nasal obstruction, persistent nasal or pharyngeal pain, chronic halitosis, history of previous head and neck cancer, chronic rhinorrhea, or recurrent serous otitis media in an adult

CONTRAINDICATIONS

  • Uncooperative patient
  • Epiglottitis because scope passage can induce airway closure
  • Bleeding diathesis, active bleeding in the upper respiratory tract, or uncontrolled epistaxis

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PROCEDURE

The patient is placed in the seated position, with the chin held slightly forward in a sniffing position (Figure 1A). If the patient is seated on an electric table or adjustable chair, the height of the patient's head can be adjusted to a level that is just below or at the same height as the examiner's head (Figure 1B). Some examiners place a drape over the patient's shoulders and torso and give the patient some tissues and a plastic emesis basin to hold in one hand.

 

(1) The patient is placed in the seated position with the chin held slightly forward in a sniffing position.

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Topical decongestant spray (2 sprays of 0.05% oxymetazoline hydrochloride in each nostril) and topical anesthetic spray (2 to 10 sprays of 4% lidocaine) are administered. The lidocaine must be transferred from the stock bottle into a small plastic spray bottle or atomizer. When administering the sprays from multiuse containers, make sure the tip of the spray bottle is not contaminated by patient contact. The nondominant hand can gently squeeze open the nares, and the tip of the bottle is held just outside the nose (but not in contact with the patient) to administer the sprays. The sprays are then repeated until the patient achieves adequate anesthesia (i.e., the patient reports numbness on the back of the throat).

 

(2) Topical decongestant spray and topical anesthetic spray are administered.

PITFALL: The lidocaine solution has a bitter taste. Warn the patient about this unpleasant effect. The examiner should pause for a few seconds after administering the first two sprays to allow the anesthetic to take effect and to permit the patient to respond to the taste.

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Hold the flexible fiberoptic scope in the left hand between the thumb and index finger. The eyepiece is held up, and the scope tip hangs down toward the floor. The thumb is placed over the up-and-down knob, and the scope body traverses the palmar crease of the left hand. Make sure the light source is turned on and that adequate light projects from the scope tip. Adjust the focus as necessary.

 

(3) Hold the flexible fiberoptic scope in the left hand between the thumb and index finger, with the eyepiece up and the scope tip hanging down toward the floor.

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The distal scope is lubricated with 2% lidocaine jelly. The jelly is applied with 4 × 4 gauze and administered to the distal 4 to 5 cm of the scope.

 

(4) Lubricate the distal scope with 2% lidocaine jelly.

PITFALL: Do not apply the jelly to the scope tip, because it will obscure viewing through the scope. Always apply the jelly from the end of the scope moving proximally, so that jelly is not dragged onto the tip.

The third, fourth, and fifth fingers of the right hand are applied to the patient's left cheek for insertion of the scope. By anchoring the insertion hand to the patient, the hand is steadied and moves with the patient's head if sudden movement occurs. The first and second fingers pinch the scope for insertion, grasping the scope 3 to 7 cm from the tip and perpendicular to the axis of the scope.

 

(5) Apply the third, fourth, and fifth fingers of the right hand to the patient's left cheek for insertion of the scope.

PITFALL: A patient's glasses can interfere with anchoring the hand to the patient's face or be hit during the procedure. Consider asking the patient to remove glasses before the procedure.

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Up-and-down motions of the scope tip are controlled by the action of the left thumb on the knob on the scope head (Figure 6A). Strong twisting action of the right first and second fingers torque the scope tip from its vertical motion to the right and left, and continued up-and-down movement of the left thumb facilitates right and left turning (Figure 6B).

 

(6) Up-and-down motion of the scope tip is controlled by the action of the left thumb on the knob on the scope head.

The scope tip is gently inserted into the nares. The first two fingers stabilize the scope and thread the scope into the nose after the scope tip is confirmed in a nonobstructed position.

 

(7) The scope tip is gently inserted into the nares and is threaded into the nose with the first two fingers.

PITFALL: Warn the patient that initial insertion of the scope tip can produce a tickling sensation or even sneezing.

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The inferior turbinate is seen and the scope slid along the floor of the nose or inferior meatus (meatus means open area; in the nose, it means the area under a turbinate). Pass the scope through the largest passage to reach the nasopharynx.

 

(8) The inferior turbinate is noted, and the physician slides the scope along the floor of the nose.

PITFALL: Enlargement of a turbinate (i.e., hypertrophy) or prior nasal septal deviation can make passage along the floor of the nose impossible. Insertion of the scope to the nasopharynx may need to be accomplished above the nasal cavity floor (alongside the turbinate).

The torus tubarius is the large mound of tissue surrounding the Eustachian tube opening. Rosenmuller's fossa is the vertical cleft immediately posterior to the torus tubarius and is a common location for the development of nasopharyngeal cancer. The adenoid pad is located on the posterior wall and can contain an enlarged adenoid or stellate scar if the patient has undergone prior adenoidectomy.

 

(9) Examine the nasopharynx.

PITFALL: During insertion of the endoscope, mucus can adhere and obscure the view through the scope. Gently tap the tip of the scope against the wall of the nasopharynx to clean the view on the scope. It is almost never necessary to completely withdraw the scope to clear the lens.

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Ask the patient to repeat “K—K—K.” Pronouncing the letter produces movement in the soft palate. Turn the scope tip down past the distal soft palate, and on passing the uvula, the laryngeal structures can be visualized in the distance.

 

(10) Turn the scope tip down past the distal soft palate, and on passing the uvula, visualize the laryngeal structures.

Slowly and carefully move the scope tip to just above the epiglottis. Survey the structures of the larynx. Ask the patient to say “EEEEE” to observe movement in the vocal cords, and then ask the patient to stick out the tongue to observe the vallecula. Observe all laryngeal structures for pathology.

 

(11) Slowly and carefully move the scope tip to just above the epiglottis, and survey the structures of the larynx.

PITFALL: Touching the scope tip to the posterior pharyngeal wall will induce coughing and possible discomfort. Keep a firm grasp on the scope with the fingers of the right hand, and keep the scope tip in the center of the pharyngeal cavity, away from the tongue and posterior or lateral structures.

PITFALL: Do not insert the scope tip between or beneath the vocal cords. Touching the scope tip to laryngeal or hypolaryngeal structures can induce laryngospasm. If laryngospasm occurs, immediately withdraw the scope from the patient. Laryngospasm is scary for the patient and physician but is fortunately only rarely fatal.

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Withdraw the scope tip from above the larynx to the posterior nasopharynx. The opening to the sphenoid sinus and superior turbinate can be observed by sharply turning the scope tip upward along the posterior wall of the nasopharynx. A rapid movement is required for this technique; the scope tip is inserted while simultaneously pushing the left thumb downward, moving the scope tip upward.

 

(12) Examine the opening to the sphenoid sinus and superior turbinate by sharply turning the scope tip upward along the posterior wall of the nasopharynx.

PITFALL: The posterior nasopharynx receives little of the anesthetic spray, and flipping the scope tip upward along the back wall of the nose can be somewhat painful. A rapid assessment is recommended, and if the scope tip is not easily passed into the upper posterior nasopharynx, this portion of the examination can be deferred.

The scope is again straightened and withdrawn to the middle portion of the nasal floor. An attempt is made to examine the middle meatus (i.e., under the smaller middle turbinate). The area is anatomically narrow, and examination may be impossible or uncomfortable for your patient. Attempt to visualize the infundibulum area (i.e., osteomeatal complex) and the maxillary sinus ostia. The scope is withdrawn, and the other nasal cavity examined if necessary. Give the patient the opportunity to blow his or her nose. The physician reviews the findings with the patient.

 

(13) Attempt to visualize the infundibulum area and the maxillary sinus ostia.

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CODING INFORMATION

Many additional codes can be reported if sinus endoscopy, surgery, or biopsy is performed with the procedure. Most primary care physicians report only code 31575 if they do a complete evaluation of the nasopharynx and larynx. Technically, multiple endoscopy codes can be billed if multiple areas are examined as part of the diagnostic evaluation.

 

CPT® Code

Description

2002 Average 50th Percentile Fee

 

31231

Nasal endoscopy, diagnostic (unilateral or bilateral)

$226

31575

Laryngoscopy, flexible fiberoptic, diagnostic

$265

92511

Nasopharyngoscopy with endoscope

$188

 

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

Nasolaryngoscopes may be ordered from Olympus USA, 2 Corporate Center Drive, Melville, NY 11747 (http://www.olympusamerica.com); WelchAllyn, 4341 State Street Road, Skaneateles Falls, NY 13153 (phone: 800-535-6663; http://www.welchallyn.com/medical); Endosheath Technology, Vision Sciences, 9 Strathmore Road, Natick, MA 01760 (phone: 800-874-9975; http://www.endosheath.com); and Pentax, 30 Ramtand Road, Orangeburg, NY 10962 (phone: 800-431-5880; http://www.pentax-endoscopy.com). Used equipment may be obtained from HMB Endoscopy Products or Endoscopy Support Services (http://www.medcatalog.com/endoscop.htm).

Lidocaine hydrochloride (4% solution or 2% jelly) can be obtained from Astra Pharmaceuticals, Westborough, MA (phone: 508-366-1100) or through a local pharmacy. Oxymetazoline hydrochloride (0.05%) (Afrin spray) is produced by Schering-Plough, Kenilworth, NJ (phone: 908-298-4000) and can be obtained through a local pharmacy.

Several online atlases are available to assist physicians:

  • University of Toronto Medical Student ENT atlas
  • Wake Forest University Gallery of Laryngeal Pathology (http://www.bgsm.edu/voice/gallery.html)
  • University of Munich ENT Gallery

BIBLIOGRAPHY

Castellanos J, Axelrod D. Flexible fiberoptic rhinoscopy in the diagnosis of sinusitis. J Allergy Clin Immunol 1989;83:91–94.

Curry RW. Flexible fiberoptic nasolaryngoscopy. Fam Pract Recert 1990;12:21–36.

DeWitt DE. Fiberoptic rhinolaryngoscopy in primary care: a new direction for expanding in-office diagnostics. Postgrad Med 1988;84:125–44.

Hayes JT. Flexible nasolaryngoscopy: a low-risk, high-yield procedure. Postgrad Med 1999;106:107–110, 114.

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Hocutt JE, Corey GA, Rodney WM. Nasolaryngoscopy for family physicians. Am Fam Physician 1990;42:1257–1268.

Koufman JA, Amin MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg 2000;123:385–388.

Lancer JM, Jones AS. Flexible fibreoptic rhinolaryngoscopy: results of 338 consecutive examinations. J Laryngol Otol 1985;99:771–773.

Lancer JM, Moir AA. The flexible fibreoptic rhinolaryngoscope. J Laryngol Otol 1985;99:767–770.

O'Hollaren MT. When dyspnea comes from the larynx. J Respir Dis 1991;12:845–860.

Patton D, DeWitt D. Flexible nasolaryngoscopy: a procedure for primary care. Prim Care Cancer 1992;12:13–21.

Reulbach TR, Belafsky PC, Blalock PD, et al. Occult laryngeal pathology in a community-based cohort. Otolaryngol Head Neck Surg2001;124:448–450.

Rosen CA, Murray T. Diagnostic laryngeal endoscopy. Otolaryngol Clin North Am 2000;33:751–758.

Shanmugham MS. The role of fibreoptic nasopharyngoscopy in nasopharyngeal carcinoma (NPC). J Laryngol Otol 1985;99:779–782.

Tenenbaum DJ. A buyer's guide to nasopharyngoscopes. Fam Pract Manag 1995;2:43–45.

Tenenbaum DJ. Should you be doing nasopharyngoscopy? Fam Pract Manag 1995;2:35–41.

Wallner F, Knoch H. The potential uses and limitations of flexible laryngoscopy under local anesthesia in clinical practice. HNO1999;47:702–705.

Zuber TJ. Office procedures. AAFP Academy collection quick reference guides for family physicians. Baltimore: Williams & Wilkins, 1999:51–60.