Flexible nasopharyngoscopy (also called fiberoptic nasendoscopy/flexible nasolaryngoscopy/flexible fiberoptic nasopharyngolaryngoscopy) is an essential skill for any otorhinolaryngologist (ENT surgeon). It is a diagnostic procedure used for examination of the nose, throat, and airway. Fiberoptic imaging became prominent in the 1950s due to the innovations of Hopkins and Stortz. The first medically functioning fiberoptic scope was designed in 1963 by Hirschowitz.[1]
Nasopharyngoscopy can be performed in adults, cooperative children, and babies with parental permission. It is typically done to investigate any area of concern or follow-up in a treated area (surgery/radiotherapy/chemotherapy) that is otherwise difficult to access and visualize.
As there are too many abnormalities and pathologies that are identifiable on scoping, that to mention all would be impossible. Some of the important and commoner ones are listed below.
Nasal Cavity
A three-pass technique is used to examine all areas of the nasal cavity.
Posterior Nasal Space
The Eustachian tube orifices, fossa of Rossenmuller, and adenoidal pad are inspected.
Adenoids should regress in adulthood, and prominent adenoids warrant investigation. Any untoward mass seen should be further investigated.
The Base of Tongue and Valleculae
The base of tongue and valleculae are inspected for any masses, cysts, or irregularities. Lymphoid tissues of the lingual tonsils can be found here and often account for the irregularity seen. Any untoward mass seen should be further investigated, as this is a common site for oropharyngeal squamous cell carcinoma.
Epiglottis
In children, abnormalities of the epiglottis (omega-shaped) and aryepiglottic folds can be seen in laryngomalacia.[2]
Epiglottitis is a contraindication for scoping, unless done in experienced hands in a stabilized patient in an appropriate environment, due to the risk of laryngospasm and airway deterioration.
Piriform Fossae
Any pooling of saliva, fullness, or masses seen here requires further investigation.
Larynx
Abnormalities of the arytenoids, if any, should be inspected.
Vocal cord movements, swelling, edema, masses, or mucosal changes also require examination. Any stridor or airway concerns again need to be scoped in a safe environment and experienced hands, with support from the anesthetists.
The majority of scope investigations occur in the hospital setting for acute assessments of the airway, persistent hoarseness, globus sensation, recurrent epistaxis, and tumor/cancer investigation and surveillance. In addition to this, the other main indications are listed below:[3][4][5][6]
There are few contraindications for flexible nasopharyngoscopy. The main two are acute epiglottitis and croup. In epiglottitis, there is an actual risk of sending the patient into laryngospasm, so this needs to be left to an experienced ENT surgeon to perform the procedure if required.[7] Relative contraindications include coagulopathies, which may result in significant bleeding and craniofacial trauma where inadvertent intracranial instrumentation can occur.
Step 1: Before you start
Step 2: Preparing to pass the nasopharyngoscope
Step 3: The Examination
Step 4: Aftercare
Step 5: Post-procedure
The following represent some of the possible comlications[10][11][12]:
Flexible nasopharyngoscopy and fiberoptic imaging have revolutionized ENT outpatient clinics. Technology has moved further forward with the new chip-on-the-tip digital flexible scopes. This method is a far cry from the ENT doctors using indirect laryngoscopy with hand-held mirrors and head mirrors.
In a typical head and neck cancer clinic, nearly all patients will have a flexible nasopharyngoscopy to look at cancer surveillance, treatment response, or disease recurrence. In the acute setting, it is also used very often, for example, in all airway concerns or neck abscesses. It has become a routine tool in the ENT surgeon's armament, as common as using an otoscope, and one that is used regularly.
Interpretation and ability to carry out flexible nasopharyngoscopies remains a skill and a learning curve. Although the ENT surgeon does these procedures daily, and so their learning curve is much faster, other related specialists, including anesthesiologists, nurse anesthetists, and the pulmonologists, can use this tool and quickly pick up the expertise also. New gadgets used in stroboscopy, digital chip-on-the-tip technology, and endoscopic smartphone adapters keep the technology moving forward.[13][14][15]
[1] | Campbell IS,Howell JD,Evans HH, Visceral Vistas: Basil Hirschowitz and the Birth of Fiberoptic Endoscopy. Annals of internal medicine. 2016 Aug 2; [PubMed PMID: 27479222] |
[2] | Demirci S,Tuzuner A,Callioglu EE,Akkoca O,Aktar G,Arslan N, Rigid or flexible laryngoscope: The preference of children. International journal of pediatric otorhinolaryngology. 2015 Aug; [PubMed PMID: 26100057] |
[3] | Schäfer J,Pirsig W,Lenders H,Meyer C, [What is new in nasopharyngeal video fiber optic endoscopy in the diagnosis of snoring and patients with obstructive apnea?]. Laryngo- rhino- otologie. 1989 Sep; [PubMed PMID: 2803400] |
[4] | Dudas JR,Deleyiannis FW,Ford MD,Jiang S,Losee JE, Diagnosis and treatment of velopharyngeal insufficiency: clinical utility of speech evaluation and videofluoroscopy. Annals of plastic surgery. 2006 May; [PubMed PMID: 16641626] |
[5] | Bentsianov BL,Parhiscar A,Azer M,Har-El G, The role of fiberoptic nasopharyngoscopy in the management of the acute airway in angioneurotic edema. The Laryngoscope. 2000 Dec; [PubMed PMID: 11129012] |
[6] | Zeleník K,Walderová R,Kučová H,Jančatová D,Komínek P, Comparison of long-term voice outcomes after vocal fold augmentation using autologous fat injection by direct microlaryngoscopy versus office-based calcium hydroxylapatite injection. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2017 Aug; [PubMed PMID: 28478500] |
[7] | Cantrell RW,Bell RA,Morioka WT, Acute epiglottitis: intubation versus tracheostomy. The Laryngoscope. 1978 Jun; [PubMed PMID: 651516] |
[8] | Kramer A,Kohnen W,Israel S,Ryll S,Hübner NO,Luckhaupt H,Hosemann W, Principles of infection prevention and reprocessing in ENT endoscopy. GMS current topics in otorhinolaryngology, head and neck surgery. 2015; [PubMed PMID: 26770284] |
[9] | Choy AT,Gluckman PG,Tong MC,Van Hasselt CA, Flexible nasopharyngoscopy for fish bone removal from the pharynx. The Journal of laryngology and otology. 1992 Aug; [PubMed PMID: 1402362] |
[10] | Ngan JH,Fok PJ,Lai EC,Branicki FJ,Wong J, A prospective study on fish bone ingestion. Experience of 358 patients. Annals of surgery. 1990 Apr; [PubMed PMID: 2322040] |
[11] | Wrigley SR,Black AE,Sidhu VS, A fibreoptic laryngoscope for paediatric anaesthesia. A study to evaluate the use of the 2.2 mm Olympus (LF-P) intubating fibrescope. Anaesthesia. 1995 Aug; [PubMed PMID: 7645703] |
[12] | Ricchetti A,Becker M,Dulguerov P, Internal carotid artery dissection following rigid esophagoscopy. Archives of otolaryngology--head [PubMed PMID: 10406322] |
[13] | Jones JW,Perryman M,Judge P,Baumanis MM,Sykes K,Dowdall J,Cabrera-Muffly C,Garnett JD,Kraft S, Resident Education in Laryngeal Stroboscopy and Perceptual Voice Evaluation: An Assessment. Journal of voice : official journal of the Voice Foundation. 2018 Dec 10; [PubMed PMID: 30545492] |
[14] | Mistry N,Coulson C,George A, endoscope-i: an innovation in mobile endoscopic technology transforming the delivery of patient care in otolaryngology. Expert review of medical devices. 2017 Nov; [PubMed PMID: 28972409] |
[15] | Schröck A,Stuhrmann N,Schade G, [Flexible 'chip-on-the-tip' endoscopy for larynx diagnostics]. HNO. 2008 Dec; [PubMed PMID: 18618088] |