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Nasal laryngoscopy

Aka: Nasal laryngoscopy, Laryngeal Exam, Nasopharyngoscopy, Rhinolaryngoscopy, Nasolaryngoscopy, Nasolaryngoscope

I. Indications

  1. Hoarseness evaluation
    1. Persistent Hoarseness beyond 2 weeks
    2. Higher risk for Laryngeal Neoplasm
      1. Tobacco abuse
      2. Alcohol Abuse
    3. Associated symptoms
      1. Dyspnea
      2. Laryngeal pain
      3. Aspiration
      4. Dysphagia
  2. Chronic Problems
    1. Chronic Sinusitis
    2. Chronic Serous Otitis Media
    3. Recurrent Otalgia
    4. Chronic Cough
    5. Chronic Rhinorrhea
    6. Chronic nasal obstruction
  3. Acute Problems
    1. Hemoptysis
    2. Acute Sinusitis
    3. Suspected Nasal Foreign Body
    4. Nasotracheal Intubation

II. Complications

  1. Laryngospasm (if scope were to touch Larynx)
  2. Epistaxis

III. Preparation

  1. Patient gently blows nose
  2. Mix Topical Decongestant with Lidocaine
    1. Phenylephrine or Afrin (0.25% to 2%)
    2. Lidocaine 2 to 4% (4% preferred)
  3. Atomize solution into nares
    1. Atomizer example: Wolff Tory Mucosal Atomization Device (MAD)
  4. Spray or apply intranasally in least obstructed naris (typically into both)
  5. Wait 5-10 minutes

IV. Technique

  1. Patient sits upright with head slightly forward
    1. "Sniffing" position
  2. Consider applying K-Y jelly to shaft of scope
  3. To defog scope
    1. Defogging solution OR
    2. Mucus from nose also defogs lens (gently touch sidewall)
    3. Swallowing will clear lens of mucus (may cause gag)
  4. Patient should breath through nose to keep nares open
  5. Patient repeatedly says "K" to elevate Soft Palate
    1. Also opens eustachian tube
  6. Patient protrudes Tongue to visualize vallecula
  7. Cord Movement
    1. Patient repeatedly says "E" to view cord movement
    2. Patient takes deep breath to see full abduction

V. Anatomy: Landmarks

  1. Nose
    1. Inferior Meatus
      1. Nasolacrimal ostia
    2. Middle Meatus (Osteomeatal complex)
      1. Frontal Sinus ostia
      2. Anterior Ethmoid Sinus ostia
      3. Maxillary Sinus ostia
    3. Superior Meatus
      1. Posterior Ethmoid Sinus ostia
    4. Above superior meatus
      1. Sphenoid Sinus ostia
  2. Nasopharynx
    1. Torus tubarius
      1. Eustachian tube ostia (encased in torus tubarius)
    2. Rosenmuller's fossa
      1. Cleft posterior to torus tubarius
      2. Common site for nasopharyngeal cancer
    3. Adenoids
      1. Posterior to torus tubarius
  3. Oropharynx
    1. Epiglottis
    2. Vallecula
    3. Tongue base (lingual tonsil)
  4. Hypopharynx and Larynx
    1. Central Larynx
      1. False Vocal Cords
      2. True Vocal Cords
      3. Ventricle (between true and false cords)
    2. Posterior Larynx
      1. Piriform sinus
      2. Corniculate and Cuneiform cartilage
        1. Contiguous "lumps" on aryepiglottic folds
      3. Aryepiglottic fold

VI. Findings

  1. Nose
    1. Nasal Foreign Body
    2. Acute Sinusitis
    3. Septal perforation
    4. Septal abscess or Septal Hematoma
    5. Nasal Polyp
  2. Oropharynx
    1. Obstructive airways (Sleep Apnea)
      1. Large adenoids
      2. Large lingual tonsils
  3. Larynx
    1. Laryngeal contact ulcer
      1. Direct Trauma (e.g. intubation)
    2. Laryngeal inflammation
      1. Allergy
      2. Post-intubation
      3. Inhaled Corticosteroids
      4. Tobacco abuse
      5. Reflux Laryngitis
    3. Leukoplakia (white, thickened epithelium)
      1. Carcinoma or dysplasia
      2. Benign Leukoplakia
    4. Laryngeal Neoplasm ( Exophytic or ulcerated lesions)
    5. Laryngeal papillomatosis
      1. Human Papillomavirus Infection (HPV)
    6. Laryngeal granuloma
      1. Trauma (e.g. post-intubation)
      2. Vocal cord abuse
      3. Inhaled Corticosteroid related
      4. Reflux Laryngitis
    7. Laryngeal cysts or Nodules
      1. Vocal cord abuse
    8. Laryngeal Polyps
      1. Allergy
      2. Tobacco abuse
      3. Vocal cord abuse
    9. Reinke Edema (Superficial lamina propria swelling)
      1. Reflux Laryngitis
      2. Tobacco abuse
      3. Vocal cord abuse
    10. Displaced vocal cord (paramedian or lateral)
      1. Recurrent laryngeal nerve injury
      2. Vagus Nerve injury

VII. Protocol: Equipment care

  1. Avoid bending scope into tight angles
  2. Clean lens with lens cleaner and paper
  3. Scope Sterilization
    1. Soak in glutaraldehyde for 20 minutes
    2. Rinse scope of cleaning solution
    3. Hang up to dry
  4. Disposable scope sheeth
    1. Alternative to sterilization of scope itself in glutaraldehyde
    2. Allows for more rapid, safe reuse of Nasolaryngoscope

VIII. Charges: CPT Codes

  1. 31575 Nasolaryngoscopy
  2. 92511 Diagnostic Nasopharyngscopy with endoscope
  3. 99070 Supplies and disinfection charge

IX. Background: Scope Manufacturers

  1. Fujinon: 800-872-0196
  2. Olympus: 800-645-8160
  3. Pentax: 800-535-6663
  4. Welch Allen: 800-535-6663

X. Reference

  1. Hocutt (1990) Am Fam Physician 42(5): 1257 [PubMed]
  2. Patton (1992) Primary Care and Cancer 12(5): 13

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Related Studies (from Trip Database) Open in New Window

Ontology: Nasopharyngoscopy (C0189025)

Definition (NCI) Endoscopic examination of the nasopharynx.
Concepts Diagnostic Procedure (T060)
SnomedCT 82941002
CPT 92511
English EUAPNS, Nasopharyngoscopy with endoscope (separate procedure), nasopharyngoscopy, Examination of the nose and throat using an endoscope, Nasopharyngoscopy, EUAPNS - Examination under anaesthesia of postnasal space, EUAPNS - Examination under anesthesia of postnasal space, Examination of nasopharynx, Examination of postnasal space, Nasopharyngoscopy (procedure), NASOPHARYNGOSCOPY, NASOPHARYNGOSCOPY W/ENDOSCOPE SPX
Spanish Nasofaringoscopia con endoscopio (procedimiento separado), nasofaringoscopia (procedimiento), nasofaringoscopia
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Nasal laryngoscopy (C0396616)

Concepts Diagnostic Procedure (T060)
SnomedCT 232670008
English Nasal laryngoscopy, Nasal laryngoscopy (procedure)
Spanish laringoscopia nasal (procedimiento), laringoscopia nasal
Derived from the NIH UMLS (Unified Medical Language System)

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