Nasolaryngoscopy

Scott E. Moser, MD

KEYWORDS
 Laryngopharyngeal reflux  Larynx  Endoscopy  Hoarseness  Vocal cord

KEY POINTS
 Nasolaryngoscopy is a low-risk, quick means of making a specific diagnosis for voice
complaints.
 Nasolaryngoscopy should be performed before empiric treatment based on history and
general examination alone.
 The most common indications for nasolaryngoscopy are hoarseness, globus sensation,
and chronic cough.
 The most common findings from nasolaryngoscopy in a primary care setting include lar-
yngopharyngeal reflux (43%), chronic rhinitis (32%), and vocal cord lesions (13%).

INTRODUCTION: NATURE OF THE PROBLEM

Hoarseness, chronic cough, globus sensation, and other nasolyngeal complaints are
common reasons for patients to present to a family physician. Laryngeal carcinoma is
also common, especially in smokers. There are no established guidelines for laryngeal
cancer screening, but early diagnosis with definitive surgical treatment is important to
survival.1 The most common benign causes of nasolaryngeal complaints, such as
chronic rhinitis and laryngopharyngeal reflux, are readily treatable by primary physi-
cians. All these can be diagnosed safely and quickly with nasolaryngoscopy. For all
these reasons, nasolaryngoscopy should be performed before empiric treatment
based on history and general examination alone.2 Alternative terms include nasophar-
yngoscopy and rhinolaryngoscopy.
Diagnostic nasolaryngoscopy is an easily mastered skill. The scope is simpler to
operate than gastrointestinal endoscopes. The procedure is performed with only
topical anesthesia, is well tolerated by patients, rarely causes complications, and
can typically be performed in less than 10 minutes.
In addition to the anatomy of the laryngeal structures addressed previously, naso-
laryngoscopy requires an understanding of the nasopharygeal anatomy the operator
will encounter en route. This is also important, because nasolaryngoscopy can be
used to evaluate a variety of nasal, sinus, and pharyngeal problems in addition to
those of the larynx.

Department of Family and Community Medicine, University of Kansas School of

Medicine-Wichita, 1010 North Kansas, Wichita, KS 67214, USA
E-mail address: [email protected]

Prim Care Clin Office Pract 41 (2014) 109–113

http://dx.doi.org/10.1016/j.pop.2013.10.009 primarycare.theclinics.com
0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
110 Moser

As noted in (Fig. 1), key anatomic landmarks in the nose include the vestibule,
septum, turbinates and their associated meati, the sinus ostia, and the choana. Impor-
tant pharyngeal structures include the eustachian tube orifice surrounded by the torus
tubarius and Rosenmüller fossa, the adenoid pad, and the palatine tonsils.

INDICATIONS/CONTRAINDICATIONS

The standard list of indications for nasolaryngoscopy is lengthy (Box 1), but the most
common indications in a primary care setting are hoarseness (51%), globus sensation
(32%), and chronic cough (17%).3 Contraindications are few and straightforward, as
noted in Box 1.

EQUIPMENT

Several manufacturers make excellent nasolaryngoscopes. Most are available in high-

resolution video versions that cost more but offer advantages for instructing learners,
allowing patients to see pathology for themselves, and capturing photos for documen-
tation of findings. Some nasolaryngoscopes can use the same light source and video
equipment with other scopes, minimizing the cost. The decision about which equip-
ment to purchase should be based on both features and local support for staff training
and equipment maintenance.

PATIENT PREPARATION

As with any procedure, the operator must obtain informed consent after careful dis-
cussion of indications, contraindications, anticipated benefits, risks, and alternatives.
The patient is seated upright or in a semi-supine position, most easily managed with
a standard otolaryngology table, although an office examination table can also be
used. The patient should be comfortable with foot support if necessary. Many patients
enjoy being able to watch the procedure for themselves on the video monitor, so the
operator should ask the patient’s preference and position the patient and monitor
accordingly. In addition, patients should be given tissues and a basin in case they
experience sneezing or coughing.

Fig. 1. Anatomic landmarks of the nose and pharynx. (From Fowler GC, Montalvo RO.
Nasolaryngoscopy. In: Pfenninger JL, Fowler GC, editors. Pfenninger and Fowler’s proce-
dures for primary care. 3rd edition. Philadelphia: Saunders; 2011; with permission.)
 Nasolaryngoscopy 111

Box 1
Indications and contraindications for nasolaryngoscopy

Indications:
Persistent hoarseness (>3 weeks)
Chronic sinusitis or sinus discomfort, especially unilateral
Suspected foreign body
Suspected neoplasia
Nasal polyps
Chronic cough
Chronic postnasal drip
Recurrent epistaxis
Recurrent otalgia
Hemoptysis
Dysphagia
Head and neck masses
Nasal obstruction or pain
Chronic bad breath
History of previous head and neck cancer
Chronic rhinorrhea
Recurrent or chronic serous otitis media in an adult
Contraindications:
Uncontrolled bleeding disorder
Unable or unwilling to cooperate (eg, too young)
Acute epiglottitis
Acute epistaxis
Recent facial trauma or surgery

TECHNIQUE

First, the operator determines which of the nares to enter with the nasolaryngoscope.
This should be the symptomatic side for nasal problems and the most patent side for
laryngeal problems. To determine the most patent side, the operator may occlude 1
nostril at a time with his or her gloved hand and instruct the patient to inhale through
his or her nose. The quietest side is the most patent.
Commonly, the operator then applies a combination of topical decongestant to
open the nasal passage and reduce the chance of bleeding and a topical anesthetic
for comfort, including reduction of the risk of patient gagging. The need for these
agents has been questioned in a meta-analysis of 8 randomized controlled trials.4 A
variety of techniques may be used. One common method is to allow the patient to
spray oxymetazoline, 0.05% decongestant spray (Afrin), 2 to 3 puffs himself or herself
from a standard 1 oz plastic mist bottle. Then the operator uses an atomizer to spray 2
or 4% plain lidocaine solution into the nose, making sure to direct the spray in several
directions, including the nasal floor, the septum, and the spheno-ethmoidal recess. An
112 Moser

alternative is to partly empty the oxymetazoline bottle and add lidocaine to it in a 1:1
ratio as a single combined application.5 Topical cocaine can achieve both deconges-
tion and anesthesia in a single application, but keeping such a controlled substance
available in the office setting is problematic.
While waiting a couple of minutes for the anesthetic to take effect, the operator
makes sure the scope and video equipment are operating properly and lenses are
clean. The scope is more delicate than intestinal endoscopes, so gentle handling is
critical. The scope is designed for the controls to be handled with the left hand and
the tip with the right. The scope is directed up and down with the control knob and
side to side by gentle twisting of the entire scope.
The operator rests the right hand on the patient’s cheek in tripod fashion, control-
ling the scope tip with thumb and index finger, and inserts the tip into the nasal
fossa, advancing it under direct vision to just above the epiglottis. Encouraging
the patient to breathe through the nose facilitates soft palate movement away
from the pharyngeal wall for a better view. If the scope fogs over, it can by cleared
by instructing the patient to swallow. Similar to other endoscopic procedures, the
focus during entry is on following the lumen with more careful examination as the
scope is withdrawn. The operator should keep the tip of the scope above the level
of the epiglottis and vocal cords in order to avoid laryngospasm. While viewing
the cords, the patient is instructed through several maneuvers to observe cord func-
tion. When the patient says “E-E-E-E,” both cords should come together symmetri-
cally. When the patient whispers, only the anterior portion of the cords should
approximate symmetrically. The vallecula can be evaluated by asking the patient
to stick out his or her tongue.
After viewing laryngeal structures, the operator withdraws the scope to view pharyn-
geal and nasal structures. Palate and eustachian tube function can be evaluated with,
“key- key- key.” The area around the eustachian tube orifice should be observed on
both right and left, paying special attention to Rosenmüller fossa, an important poten-
tial site for carcinoma. As the scope tip reaches the choana, the operator directs it
superiorly to view the sphenoid recess. The maneuver can cause the patient to
sneeze, so it should be performed gently and quickly. As the scope is further with-
drawn, the superior and middle meati are evaluated, including visualization of various
sinus ostia for pus or polyps. Finally, the scope is straightened to remove.

COMPLICATIONS AND MANAGEMENT

Complications are rare and usually minor, such as blood pressure elevation, sneezing
or gagging severe enough to limit the procedure, and vasovagal reaction. Potentially
serious risks include: adverse reaction to the decongestant or anesthetic, laryngo-
spasm, vomiting with potential aspiration, and bleeding secondary to injury.

POSTOPERATIVE CARE

Patients should be instructed to take nothing by mouth until they sense the anesthetic
has worn off, usually less than 1 hour. Then they should try sips of water. If patients
tolerate sips without difficulty, they can return to normal diet and activity.

REPORTING, FOLLOW-UP, AND CLINICAL IMPLICATIONS

Because the procedure is performed under local anesthesia, the operator should
discuss findings with the patient immediately and negotiate the next steps of the
plan. As with any diagnostic procedure, a brief note explaining the final diagnosis
 Nasolaryngoscopy 113

and plan handed to the patient on exit is a good idea. The operator should im-
mediately and carefully annotate the procedure, findings, and plan in the patient’s
medical record. The scope should be cleaned and dried per manufacturer’s
recommendations.

OUTCOMES

The most common findings from nasolaryngoscopy in a primary care setting include
laryngopharyngeal reflux (43%), chronic rhinitis (32%), and vocal cord lesions
(13%). More than 1% of patients in 1 study were discovered to have laryngeal cancer.3
The high prevalence of carcinoma and benign treatable conditions reinforces the value
of this procedure in primary care.

CURRENT CONTROVERSIES/FUTURE CONSIDERATIONS

Stoboscopy, adding variable speed strobe lighting while viewing the vocal folds, offers
the opportunity to more accurately assess function of the cords as they vibrate. This
feature improves diagnostic accuracy by as much as 47% in subtle cases but is not
considered standard of care for routine evaluation of hoarseness. It should be consid-
ered anytime the patient’s symptoms seem out of proportion to the findings on stan-
dard nasolaryngoscopy.2

SUMMARY

Nasolaryngoscopy is a low-risk, quick means of making a specific diagnosis for voice

complaints. Because most laryngeal problems are benign and treatable without
referral, and because early diagnosis and treatment are important for laryngeal carci-
noma, nasolaryngoscopy should be performed before empiric treatment based on his-
tory and general examination alone. Under topical anesthesia, the scope is inserted
through the nose and advanced to directly view the larynx. During withdrawal, struc-
tures of the pharynx and nose are also evaluated. Complications are rare and usually
minor.

REFERENCES

1. Sadri M, McMahon J, Parker A. Management of laryngeal dysplasia: a review. Eur

Arch Otorhinolaryngol 2006;263:843–52.
2. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideling: hoarseness
(dyphonia). Otolaryngol Head Neck Surg 2009;141:S1–31.
3. Wilkins T, Gillies RA, Getz A, et al. Nasolaryngoscopy in a family medicine clinic:
indications, findings, and economics. J Am Board Fam Med 2010;23(5):591–7.
4. Conlin AE, McLean L. Systematic review and meta-analysis assessing the effec-
tiveness of local anesthetic, vasoconstrictive, and lubricating agents in flexible
fibre-optic nasolaryngoscopy. J Otolaryngol Head Neck Surg 2008;37(2):240–9.
5. Strauss RA. Flexible endoscopic nasopharyngoscopy. Atlas Oral Maxillofac Surg
Clin North Am 2007;15:111–28.