How To Do Flexible Laryngoscopy

Chronic cough

Chronic throat pain

Dysphagia

Dysphonia

Foreign body in the throat

Hoarseness or change in voice

Odynophagia

Sensation of a lump in the throat

Symptoms of aspiration

Sometimes hemoptysis

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Stridor

Angioedema

Active epistaxis or an uncontrolled bleeding disorder

Injury to the mucosa, which may cause bleeding

Laryngospasm and airway compromise

Flexible laryngoscope (nasopharyngolaryngoscope) with light source

Gloves

Protective eyewear

Mask

Nasal speculum

Lubricant

Wall suction connected to a Frazier-tip catheter

Topical vasoconstrictor/anesthetic (eg, 4% cocaine, 0.05% oxymetazoline plus either 1% tetracaine or 4% lidocaine)

Cotton swabs or pledgets for nonspray topical decongestants and/or anesthetics

Flexible laryngoscopy provides only a limited view of the subglottic larynx and proximal trachea. To assess these regions, use another procedure, such as bronchoscopy.

The pharynx includes the nasopharynx, oropharynx, and hypopharynx.

The larynx connects the pharynx to the trachea and is suspended from the hyoid bone. It includes 3 single and 3 paired cartilage structures: single (epiglottis, thyroid, and cricoid) and paired (arytenoid, cuneiform, and corniculate). The larynx extends from the tip of the epiglottis down to the inferior aspect of the cricoid cartilage and includes the vocal folds.

The patient should sit upright with the head against a headrest, and leaning forward slightly.

Legs should not be crossed.

Check that the laryngoscope, including the light source and suction, are working properly.

Adjust eyepiece focus (use letters such as on drug or equipment packaging).

Check both nares and use the one that appears more widely patent.

Hold the nares open with a nasal speculum. Insert the speculum with the handle parallel to the floor and open the speculum vertically; stabilize your hand by placing one or two fingers against the patient's nose.

Apply the topical vasoconstrictor/anesthetic.

Lubricate the laryngoscope tip.

Insert the laryngoscope tip into the nose and advance it slowly adjacent to the inferior turbinate (either above or below) parallel to the floor of the nose.

Advance it into the nasopharynx, inspecting the eustachian tube opening in the lateral nasopharynx and the adenoid tissue on the posterior wall.

Tell the patient to breathe through the nose (which makes the soft palate drop). Use the thumb control on the laryngoscope to flex the tip down to go past the palate, and then straighten to avoid curling forward into the uvula.

Inspect the base of the tongue, valleculae, epiglottis, piriform sinuses, arytenoids, false and true vocal cords, and the larynx below the vocal cords.

Do not pass the laryngoscope through the vocal cords because contact can cause laryngospasm.

Fully inspect the vocal cords. Instruct the patient to say "eeee," which will contract the vocal cords and allow more thorough inspection.

Avoid touching the mucosa or epiglottis because this may provoke a gag reflex.

Gently withdraw the laryngoscope.

Instruct patient to avoid eating and drinking for at least 20 minutes to prevent aspiration due to residual laryngopharyngeal anesthesia.

Inserting the scope too forcefully, causing bleeding and/or discomfort

Losing situational awareness of the direction of the scope tip

Using too little anesthesia or vasoconstrictor

Give the patient a tissue prior to the procedure because tearing may occur.

Remind the patient to breathe during the procedure because some patients reflexively hold their breath.

Before inserting the scope, refamiliarize yourself with the tip controls.

Ask the patient not to swallow during the procedure unless directed to help clear the scope.