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How To Do Flexible Laryngoscopy


Vikas Mehta

, MD, MPH, Montefiore Medical Center

Reviewed/Revised Mar 2023
Topic Resources

Flexible laryngoscopy is viewing of the pharynx and larynx using a flexible laryngoscope (also called a nasopharyngolaryngoscope).

Flexible laryngoscopy is generally done to evaluate symptoms of disorders of the pharynx and larynx.

Indications for Flexible Laryngoscopy

Laryngoscopy may be indicated for the evaluation of patients with the following:

  • 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

In particular, patients at high risk of head and neck cancer (eg, heavy smokers or alcohol users) may benefit from laryngoscopy, especially if they have had hoarseness, sore throat, or ear pain for > 2 weeks.

Urgent laryngoscopy may be indicated in patients with angioedema, stridor, epistaxis, and/or craniofacial trauma.

Flexible laryngoscopy can be tried for patients who do not tolerate direct laryngoscopy.

Contraindications for Flexible Laryngoscopy

Absolute contraindications

Relative contraindications

  • Stridor

  • Angioedema

  • Active epistaxis or an uncontrolled bleeding disorder

In patients with stridor or angioedema Angioedema Angioedema is edema of the deep dermis and subcutaneous tissues. It is usually an acute but sometimes a chronic mast cell–mediated reaction caused by exposure to a drug (eg, angiotensin-converting... read more Angioedema , stimulation of the laryngopharynx may further compromise the airway. If laryngoscopy is essential, it should be done in the controlled setting of an operating room with a person skilled at difficult airway management (including surgical techniques) present.

Complications of Flexible Laryngoscopy

  • Injury to the mucosa, which may cause bleeding

  • Laryngospasm and airway compromise

The procedure may cause gagging, coughing, and/or vomiting. Occasionally, patients have a vasovagal reaction.

Equipment for Flexible Laryngoscopy

  • 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

Additional Considerations for Flexible Laryngoscopy

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

Relevant Anatomy for Flexible Laryngoscopy

  • 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.

Positioning for Flexible Laryngoscopy

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

  • Legs should not be crossed.

Step-by-Step Description of Flexible Laryngoscopy


  • 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.


Do the following about 5 to 15 minutes after the application of the 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.

Aftercare for Flexible Laryngoscopy

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

Warnings and Common Errors for Flexible Laryngoscopy

  • 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

Tips and Tricks for Flexible Laryngoscopy

  • 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.

Drugs Mentioned In This Article

Drug Name Select Trade
12 Hour Nasal , Afrin, Afrin Extra Moisturizing, Afrin Nasal Sinus, Afrin No Drip Severe Congestion, Dristan, Duration, Genasal , Mucinex Children's Stuffy Nose, Mucinex Full Force, Mucinex Moisture Smart, Mucinex Sinus-Max, Mucinex Sinus-Max Sinus & Allergy, NASAL Decongestant, Nasal Relief , Neo-Synephrine 12-Hour, Neo-Synephrine Severe Sinus Congestion, Nostrilla Fast Relief, Reliable-1 12 hour Decongestant, Rhinase D, RHOFADE, Sinex 12-Hour, Sudafed OM Sinus Cold Moisturizing, Sudafed OM Sinus Congestion Moisturizing, Upneeq, Vicks Qlearquil Decongestant, Vicks Sinex, Vicks Sinex Severe, Visine L.R., Zicam Extreme Congestion Relief, Zicam Intense Sinus
AK-T Caine, Pontocaine, Pontocaine in Dextrose, Pontocaine Niphanoid, Tetcaine, TetraVisc, TetraVisc Forte, Viractin
7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, AsperFlex, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidocan II, DermacinRx Lidocan III, DermacinRx Lidogel, DermacinRx Lidorex, DermacinRx Lidotral, DERMALID, Dologesic, Ela-Max, GEN7T, Glydo, Gold Bond, Icy Hot , LidaFlex, LidaMantle, Lido King Maximum Strength, Lidocan, LIDOCANNA, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , LidoLite, Lidomar , Lidomark, Lidopin, LidoPure, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, Lidtopic, Lidtopic Max, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lubricaine, Lubricaine For Her, Lydexa, MENTHO-CAINE , Moxicaine, Numbonex, Professional DNA Collection Kit, Proxivol, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Regenecare HA, Salonpas Lidocaine, Senatec, Solarcaine, SOLUPAK, SUN BURNT PLUS, Suvicort, Topicaine, Tranzarel, VacuStim Silver, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, ZiloVal, Zingo, Zionodi, ZTlido
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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