Laryngeal Exam

Aka: Laryngeal Exam, Direct Laryngoscopy, Nasopharyngoscopy, Rhinolaryngoscopy

1. 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
2. Complications
   1. Laryngospasm (if scope were to touch Larynx)
   2. Epistaxis
3. Preparation
   1. Patient gently blows nose
   2. Mix Topical Decongestant with Lidocaine
      1. Phenylephrine (0.25% to 2%)
      2. Lidocaine 2 to 4% (4% preferred)
   3. Spray or apply intranasally in least obstructed naris
   4. Wait 5-10 minutes
4. 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
      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
5. 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
6. 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
7. Protocol: Equipment care
   1. Avoid bending scope into tight angles
   2. Clean lens with lens cleaner and paper
   3. Soak in glutaraldehyde for 20 minutes
   4. Rinse scope of cleaning solution
   5. Hang up to dry
8. Charges: CPT Codes
   1. 31575 Nasolaryngoscopy
   2. 92511 Diagnostic Nasopharyngscopy with endoscope
   3. 99070 Supplies and disinfection charge
9. Background: Scope Manufacturers
   1. Fujinon: 800-872-0196
   2. Olympus: 800-645-8160
   3. Pentax: 800-535-6663
   4. Welch Allen: 800-535-6663
10. Reference
    1. Hocutt (1990) Am Fam Physician 42(5): 1257
    2. Patton (1992) Primary Care and Cancer 12(5): 13