Transnasal Flexible Laryngoscopy Research Articles

Evaluation of face shields used during aerosol generating procedures

Transnasal flexible laryngoscopy is considered an aerosol generating procedure. A negative pressure face shield (NPFS) was developed to control aerosol from the patient during laryngoscopy. The purpose of this study was to determine the effectiveness of the NPFS at controlling virus aerosol compared to a standard disposable plastic face shield. The face shields were placed on a simulated patient coughing machine. MS2 bacteriophage was used as a surrogate for SARS-CoV-2 and was aerosolized using the coughing machine. The aerosolized virus was sampled on the inside and outside of the face shields. The virus aerosol concentration was not significantly different between the inside and outside of the traditional plastic face shield (p = 0.12). However, the particle concentrations across all particle sizes measured were significantly decreased outside the face shield. The virus and particle concentrations were significantly decreased (p < 0.01) outside the NPFS operating at a flow rate of 38.6 L per minute (LPM). When the NPFS was operated at 10 LPM, virus concentrations were not significantly different (p = 0.09) across the face shield. However, the number particle concentrations across all particle sizes measured were significantly different (p < 0.05).

Optimization of Subglottic View During Flexible Laryngoscopy With Patient Positioning.

Determine the ideal head position to optimize visualization of the subglottis using flexible laryngoscopy. Prospective cohort study. Outpatient multidisciplinary airway clinic at a tertiary care center. Patients presenting to a multidisciplinary airway clinic undergoing nasoendoscopic airway examination were enrolled. Three head positions were utilized to examine the subglottis during laryngoscopy: "sniffing,"chin tuck, and stooping positions. In-office reviewers and blinded clinician participants evaluated views of the airway based on Cormack-Lehane (CL) scale, airway grade (AG), and visual analog scale (VAS). Demographic data were obtained. Statistical analysis compared head positions and demographic data using Student's t test, analysis of variance, and Tukey's post hoc analysis. One hundred patients participated. No statistical differences existed amongin-clinic or blinded reviewers for the CL score in any head position (p = .35,.5, respectively). For both AG and VAS, flexed and stooping positions were rated higher than the sniffing positions by both in-clinic and blinded reviewers (p < .01 for all analyses), but there was no statistical difference between these two positions (p = .28,.18, respectively). There was an inverse correlation between age and scores for AGand VAS in the flexed position for both sets of reviewers (p = .02, <.01 respectively), and a higher body mass index was significantly associated with the need to perform tracheoscopy for full airway evaluation (p < .01). Both flexion and stoop postures can be implemented by an experienced endoscopist in awake, transnasal flexible laryngoscopy to enhance visualization of the subglottic airway.

RAPID RECOVERY FROM MYCOBACTERIUM TB EPIGLOTTITIS REQUIRING ENDOTRACHEAL INTUBATION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Laryngeal Tuberculosis (LTb) currently accounts for <1% of all Tb cases. Patients most often present with dysphonia, weight loss, and typically respond well to targeted antimicrobial regimens [1]. To our knowledge, there is minimal data regarding time to liberation from mechanical ventilation and the efficacy of corticosteroids in LTb. We present a case of LTb in a 37-year-old immunocompetent female requiring endotracheal intubation with a subsequent rapid recovery. CASE PRESENTATION: A 37-year-old female presented to the Emergency Department for a 2-week history of dyspnea, and 3 months of intermittent fevers, weight loss, and dysphonia. She had no known past medical history. The patient was febrile, tachycardic, and hypoxic requiring 100% oxygen via non-rebreather mask. Physical exam was remarkable for respiratory distress and mild stridor. Laboratory studies found a leukocytosis of 18.3 K/μL with a neutrophilic predominance to 84%. HIV screening was negative. A CXR revealed bilateral interstitial opacities. Chest CT angiography found diffuse, bilateral centrilobular nodules, tree-in-bud opacities, and bilateral upper lobe cavitary lesions measuring up to 3.9cm (Image 1). Contrast-enhanced Neck CT demonstrated marked swelling of the epiglottis and moderate narrowing of the airway (Image 2). Nebulized racemic epinephrine, albuterol, ipratropium, and IV dexamethasone resulted in mild improvement of her stridor. Transnasal flexible fiberoptic laryngoscopy revealed an enlarged epiglottis with >50% obstruction of the supraglottic airway. She underwent endotracheal intubation for airway protection, and a flexible bronchoscopy was performed. Bronchoalveolar lavage fluid analysis revealed 95% neutrophils, cultures grew Mycobacterium tuberculosis, and cytology was negative for malignant cells. Rifampin, isoniazid, pyrazinamide, ethambutol (RIPE), and pyridoxine were initiated. She also received dexamethasone 6mg IV daily for seven days. Twelve days after intubation, the patient was extubated without signs of stridor. DISCUSSION: LTb has two categories: primary, in which bacteria seed the larynx directly, and secondary, via invasion by advanced pulmonary Tb [1]. Diagnosis is often a combination of visualization of laryngeal lesions via laryngoscopy, tissue culture, and laryngeal histopathology [1]. A review of the literature identified 13 cases of LTb requiring mechanical ventilation, all via tracheostomy. Time to decannulation ranged from 2-6 months, with one case reporting 2 weeks [2]. Data regarding the efficacy of corticosteroids in LTb with airway compromise is limited. However, a recent retrospective study found steroid use in pulmonary Tb with acute respiratory failure to be beneficial [3]. CONCLUSIONS: When treated with appropriate antimicrobials along with consideration to adjunct corticosteroid use, LTb patients may demonstrate a rapid recovery obviating the need for tracheostomy. REFERENCE #1: Benwill JL, Sarria JC. Laryngeal tuberculosis in the United States of America: a forgotten disease. Scand J Infect Dis. 2014;46(4):241-249. doi:10.3109/00365548.2013.877157 REFERENCE #2: Gupta R, Fotedar S, Sansanwal P, et al. Obstructing mass lesion of epiglottis: it can be tubercular. Indian J Tuberc. 2008;55(2):100-103. REFERENCE #3: Yang JY, Han M, Koh Y, et al. Effects of Corticosteroids on Critically Ill Pulmonary Tuberculosis Patients With Acute Respiratory Failure: A Propensity Analysis of Mortality. Clin Infect Dis. 2016;63(11):1449-1455. doi:10.1093/cid/ciw616 DISCLOSURES: No relevant relationships by Nathaniel Allison, source=Web Response No relevant relationships by Christopher Lee, source=Web Response No relevant relationships by John Prudenti, source=Web Response No relevant relationships by Lourdes Sanso, source=Web Response

Laser plume containment during flexible transnasal laryngoscopy.

ObjectiveTo evaluate a negative pressure microenvironment designed to contain laser plume during flexible transnasal laryngoscopy.MethodsThe Negative Pressure Face Shield (NPFS) was previously reported as well tolerated with initial use on 30 patients. Diagnostic transnasal laryngoscopy was performed on an additional 108 consecutive patients who were evaluated by questionnaires and sequential pulse oximetry. Further study addressed operative transnasal potassium‐titanyl‐phosphate (KTP) laser laryngoscopy with biopsy done on four patients employing the NPFS.ResultsThe previously described NPFS version 3 (v.3), a transparent acrylic barrier with two anterior instrumentation ports, was modified by repositioning the side suction port closer to the level of the nose and deepening the lateral sides, squaring off the lower projection. A post‐procedure questionnaire employing a 5‐point Likert scale ranging from no symptoms (rating of 1) to intolerable (rating of 5) identified excellent patient tolerance of the new design (v.4), among 22 patients evaluated and similar in the comparison to the 116 patients using version 3. Among the 138 patients analyzed, only one patient rated the experience as greater than “mild claustrophobia.” 100% of patients answered either “none” or “mild” to the pain and shortness of breath questions. The NPFS (v.4) was then successfully used in four patients for laser laryngoscopy with biopsy of laryngeal papilloma (3/4) and hemorrhagic polyp (1/4). Post‐procedure questionnaire identified no shortness of breath (4/4), no claustrophobia (4/4), no pain (4/4) and no significant changes in pulse oximetry during use.ConclusionExtensive experience in performing diagnostic laryngoscopy with the NPFS directed design changes leading to successful use for transnasal flexible laser laryngoscopy with biopsy in a negative pressure microenvironment.Level of EvidenceLevel 2b (Cohort Study).

Transnasal Flexible Laryngoscopy Using Different Topical Preparations and Methods of Application-A Randomized Study

The field of laryngology has grown exponentially since the advent of the transnasal flexible laryngoscopy. Flexible laryngoscopy when performed skillfully using the proper technique, facilitates a good view of the hidden areas of the larynx. To compare the effectiveness of the topical agents in providing a more comfortable experience for the patient, allowing the practitioner to advance the endoscope with less friction, pain and discomfort for the patient using 10% lidocaine spray, 2% lidocaine gel, 4% lidocaine with xylometazoline (1:1) soaked pledgets, or aqueous gel. A prospective randomized single-blinded clinical trial was conducted in a tertiary care teaching hospital in South India where 376 patients were recruited and allocated into four groups based on the topical preparation used. Following endoscopy, each subject filled a questionnaire grading their experience on a visual analogue scale. The clinician also then answered a questionnaire on aspects of the endoscopy performed. The pain score and the ease of performing the procedure among the different groups were comparable. Those in the 10% lidocaine arm experienced significant burning sensation (P=0.0001). The other variables such as throat pain (P=0.783), gag reflex (P=0.318), unpleasant taste (P=0.092), globus (P=0.190), swallowing difficulty after the procedure (P=0.273), difficulty in breathing (P=0.744) and willingness to have a repeat procedure (P=0.883) were also comparable. Aqueous gel can be used topically during a flexible nasopharyngolaryngoscopy instead of an anesthetic agent alone or one combined with a nasal decongestant.

Which one is favorable in the elderly? Transoral rigid laryngoscopy or transnasal flexible fiberoptic laryngoscopy.

To determine whether transoral rigid laryngeal endoscopy (TORLE) or transnasal flexible fiberoptic laryngoscopy (TNFFL) is more favorable for laryngeal endoscopic examination in the elderly population. This randomized prospective study carried out in a tertiary reference center. TORLE or TNFFL were performed to patients who were over 65years at their first visit according to randomization list. At their second visit, other method was performed. Patients' physiological parameters (Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen (O2) saturation before and immediately after laryngeal examination were recorded. Patients' pain-irritation, gag reflex, and dyspnea status were evaluated using visual analog scale after first and second endoscopic examinations. Further patient preferences for TORLE and TNFFL were recorded. Of 96 patients included in the study, 69.8% (n=67) preferred TORLE while 30.2% (n=29) preferred TNFFL. Major factor influencing patient preferences was pain-irritation in TNFFL. Pain-irritation scores were significantly higher in TNFFL than those in TORLE (p<0.001). However, no significant difference was found between two methods with respect to gag reflex and dyspnea scores (p=0.194, p=0.327, respectively). In TORLE, there was no statistically significant difference between the values measured before and after examination in terms of SBP, DBP, HR, and O2 saturation (p=0.641, p=0.134, p=0.119, p=0.414, respectively). However, in TNFFL, statistically significant decrease was observed after examination in HR and O2 saturation (p<0.001, p<0.001, respectively). TORLE is more suitable for laryngeal examination in elderly patients since it is more comfortable for patient and does not change physiological parameters.

Dipping and rotating: two maneuvers to achieve maximum magnification during indirect transnasal laryngoscopy

BackgroundSince many years, office-based flexible transnasal laryngoscopy is a common routine procedure. The development of new technical equipment such as high-definition cameras and flexible tip-chip endoscopes nowadays allows for much more precise examination than a few years ago. In contrast to rigid laryngoscopy, it is possible to move the tip of the endoscope close to the vocal folds and to other structures of interest. Nevertheless, without professional handling of the equipment, one cannot benefit from the potential of the newest technology.MethodTwo easily performed and very helpful maneuvers in flexible endoscopy are described. The “dipping maneuver” enables a maximum magnification of the mucosal surfaces of the endolarynx as well as the examination of the subglottal region and the trachea by positioning the tip of the endoscope very close to the vocal folds or even in the upper trachea during long transnasal inspiration. During the “rotation laryngoscopy”, the tip of the endoscope is positioned in the posterior interarytenoid region by rotating the flexible endoscope by 180° and advancing it close to the glottis. This allows a close-up examination of the anterior commissure, the inferior aspect of the vocal folds and the inside of the Morgagni’s ventricle. Before performing transnasal flexible endoscopy, we routinely apply topical anesthesia sprayed intranasally.ConclusionThe described techniques of flexible endoscopy are easily performed and allow a maximum magnification of the mucosal surfaces and otherwise not visible regions of the endolarynx.

Principles of Subglottic and Tracheal Visualization with Transnasal Flexible Laryngoscopy

The subglottic area and trachea are important parts of the upper airway, and can be visualized easily using transnasal flexible laryngoscopy (TFL). The aim of this study was to develop a clinical grading system to assist in documentation of the subglottic area and trachea with TFL, and to demonstrate the basic principles of visualization of these anatomic areas as a laryngology practice. The TFL videos of 100 randomized patients were evaluated by three laryngologists. The simple head extension (SHE) position and flexion position (FP) were applied to the patients during the visualization of the subglottic area and trachea. A paired t test was used to compare the grades of the subglottic and tracheal view according to the SHE and FP scores. This study examined 50 male and 50 female patients ranging in age from 28 to 83 years (mean age: 50.09 ± 13.05 years). For the SHE and FP, the numbers of patients constituting grade 1 were 2 and 35, grade 2 were 2 and 37, grade 3 were 30 and 19, and grade 4 were 41 and 9, respectively. There was a statistically significant difference between SHE and FP (P < 0.05). The k score was 0.785 between the ratings of observer 1 and observer 2; 0.771 between observer 1 and observer 3; and 0.757 between observer 2 and observer 3 (P < 0.001). This new grading system for the visualization of the subglottis and trachea can help physicians assess and identify the upper airways, and FP provides a better subglottic and tracheal view than SHE.

Validation of the Brazilian Portuguese Version of the Reflux Finding Score

Laryngopharyngeal reflux (LPR) poses a diagnostic challenge. Clinical diagnosis, based on suggestive symptoms and laryngoscopic signs of inflammation, should be acceptable, as long as diligent differential diagnosis is sought. In order to minimize subjectivity, a number of diagnostic instruments have been proposed, being the most common the Reflux Symptom Index and the Reflux Finding Score (RFS). The latter has been translated into several languages including Portuguese, but it still has not been properly validated in this language. To validate the Brazilian Portuguese version of the RFS. For validity and internal consistency, 172 adults were studied (106 with LPR and 66 healthy controls). Flexible transnasal laryngoscopy images were randomly examined twice by each of the two experienced otolaryngologists with a 72-hour interval. Strict exclusion criteria were applied to avoid other possible known causes of chronic laryngitis. For assessment of reproducibility and temporal stability, a random sample of 108 subjects (53 patients and 55 controls) were tested and retested. A statistically significant difference was observed in the mean RFS between patients with LPR (10.26±3.58) and controls (5.52±1.34) (P < 0.001). The interclass correlation coefficient comparing test and retest for both raters was high (R1=0.956; R2= 0.948). The Brazilian Portuguese version of the RFS proved to be a reliable and reproducible instrument for the diagnosis of LPR with a sensitivity of 82.08%, a specificity of 93.94%, a positive predictive value of 95.60%, and a negative predictive value was 76.54%.

Pre-operative transnasal endoscopy as a predictor of difficult airway: A prospective cohort study.

Consequences of failed endotracheal intubation can be catastrophic and predicting difficulty is therefore a critical issue. There is no consensus on the best way to predict difficulty. To evaluate the role of transnasal flexible endoscopic laryngoscopy (TFEL), a minimally invasive procedure, in the prediction of difficult intubation. Prospective cohort study. San Raffaele Hospital, Milan, a tertiary university hospital. One hundred and sixty nine adults scheduled for elective ear, nose and throat surgery under general anaesthesia with pre-operative TFEL. In addition to routine pre-operative evaluation by an anaesthesiologist, glottis exposure during TFEL was assessed with a scoring system similar to the modified Cormack-Lehane (MCL). The extent to which TFEL improves the prediction of difficult direct laryngoscopy, measured with the MCL score, and of difficult intubation, measured with the intubation difficulty scale score. When added to bedside evaluation, TFEL performed during tongue protrusion significantly (P = 0.005) improved the prediction of MCL. The area under the receiver operating characteristics curve was 0.75 [95% confidence interval (CI) 0.67 to 0.83] vs. 0.65 (95% CI 0.58 to 0.74). For the intubation difficulty scale (P = 0.049), the area under the receiver operating characteristics curve was 0.70 (95% CI 0.61 to 0.80) vs. 0.66 (95% CI 0.58 to 0.74). TFEL is a useful tool in predicting difficult intubation, improving predictability of routine bedside evaluation. ClinicalTrials.gov identifier: NCT02671877.

The Effect of Obesity on Transnasal Flexible Laryngoscopy

Transnasal flexible laryngoscopy (TFL) is a practical and cost-effective procedure, allowing excellent evaluation of the upper airway with minimal risk of complications. The effect of obesity on endoscopic examination still remains unclear. The aim of this study was to determine if obesity has an effect on TFL. Demographic data including age and gender, and physical and endoscopic examinations including body mass index (BMI), neck circumference, and grade of the laryngeal view according to Tasli classification (TC), Mallampati classification (MC), Friedman classification, and Moore tongue base classification (MTC) scores of 200 patients were evaluated. The patients were divided into two categories as obese and nonobese, and the scores of patients were compared. Evaluation was made of 99 (50.5%) obese and 97 (49.5%) nonobese patients ranging in age from 18 to 65 years (mean age: 37.89 ± 13.55 years). Of the 196 patients in this study, 101 (51.5%) were male, and 95 (48.5%) were female. The mean BMI of the obese and nonobese patients was 33.18 ± 5.18 (min: 25, max: 45) and 22.48 ± 1.5 (min: 19, max: 24), respectively. According to cutoff points, 27 patients (27.3%) were classified as overweight, 30 (30.3%) as obese, and 42 (42.4%) as morbidly obese. According to TC, there was no statistically significant difference between the obese and nonobese groups (mean difference 0.12, P: 0.39). In Pearson correlation analysis, the scores for a correlation between TC, and MC and MTC were 0.206 (very weak) and 0.653 (strong), respectively, which were statistically significant (P < 0.05). There was no correlation between TC and BMI values (r = -0.051; P: 0.48). The results of this study demonstrated that obesity influences the scores of MC, Friedman classification, and MTC, but does not affect the laryngeal view on TFL.

Enhancing Visibility of the Hypopharyngeal-Esophageal Region by Introduction of a Physiological Eructation Maneuver

Background: In routine medical examination, the hypopharyngeal-esophageal area (HER) is difficult to assess due to its position and anatomical complexity. The purpose of this study was to evaluate the feasibility of a volitional eructation maneuver during transnasal flexible laryngoscopy and its influence on the visibility of the HER. Methods: Twenty healthy volunteers underwent flexible laryngoscopy. Once the larynx was freely visible during laryngoscopy, the subjects were asked to trigger a “burp.” The volitional belching during the study was assisted by drinking a carbonated cold drink. The triggered relaxation of the upper esophageal sphincter along with the widening of the hypopharynx region was recorded and subsequently analyzed frame by frame. Results: Out of 20 volunteers, 16 (80%) were able to volitionally induce an eructation. Significant widening of the hypopharynx region up to the relaxant upper esophageal sphincter could be recorded. The structures were clearly visible in the offline analysis. In 13 (81%) of the 16 subjects who could induce an eructation, the upper esophageal sphincter was partially visible or free for full inspection. Conclusion: The eructation method as a simple physiological function can be used as a complementary method during flexible transnasal endoscopy to enhance visibility of the entire hypopharynx region as well as the upper esophageal sphincter.

Exercise-induced laryngeal obstruction in athletes treated with inspiratory muscle training

BackgroundExercise-induced laryngeal obstruction (EILO) is common in athletes and presents with dyspnoea, chest tightness, inspiratory stridor and sometimes panic reactions. The evidence for conservative treatment is weak, but case reports...

Optimal Position for Transnasal Flexible Laryngoscopy

Transnasal flexible laryngoscopy (TFL) is a simple, safe, and cost-effective procedure. TFL is routinely performed to awake patients in a sitting position but there is no a definite data about ideal head and neck position to be applied. The aim of this study is to determine which position is most appropriate to obtain the best laryngeal view during the TFL. The TFL videos of 132 randomized patients were evaluated by three blind observers experienced with laryngology. Three basic head positions; simple head extension (SHE), sniffing position (SP), and neutral position (NP) were performed during the TFL-Interobserver agreements for the grading system scores were assessed by using the kappa (k) statistic. For the SHE and SP, the numbers of patients constituting grade 1 were 127 (96.2%) and 126 (95.5%), respectively, while grade 2a were 5 (3.8%) and 6 (4.5%), respectively. In NP, the number of patients constituting grade 1 was 5 (3.8%), while grade 2a was 83 (62.9%), grade 2b was 37 (28%), and grade 3 was 7 (5.3%). The k score of the SHE was 0.826 (P < 0.001) between the ratings of observer 1 and observer 2, 0.905 (P < 0.001) between observer 1 and observer 3, and 0.919 (P < 0.001) between observer 2 and observer 3. These values denote nearly perfect agreement. A complete agreement was seen in 130 of the 132 (98.48%) videos. SHE and SP both provide a better glottic view than the NP and demonstrate the same success.

Office-based retrograde transtracheal application of mitomycin C

ObjectivesThe utility of topical mitomycin C (MMC) as an adjuvant treatment in the management of laryngeal and tracheal stenosis has been studied; however, the ideal timing of MMC application has not been fully elucidated. There is a paucity of studies evaluating the timing of MMC application after surgical airway intervention for stenosis. The purpose of this study is to describe a novel technique for MMC application that allows for delayed application in the unsedated, office-based setting, approximately one week following endoscopic airway dilation. MethodsA technique for retrograde transtracheal application of MMC was developed and utilized in 3 tracheostomy-dependent patients with subglottic stenosis and glottic stenosis with bilateral vocal fold immobility. After administration of topical anesthesia, a MMC (0.4 mg/ml) coated pledget was advanced via a transtracheal approach and directed to the area of stenosis in retrograde fashion using endoscopic frontal sinus instruments. Appropriate positioning of the pledget was confirmed via transnasal flexible fiberoptic laryngoscopy. ResultsAll 3 patients underwent successful in-office retrograde application of MMC onto the area of laryngeal stenosis 7–9 days after their preceding surgery. There were no complications. Two patients achieved decannulation while the third patient's management was interrupted due to cancer treatment. ConclusionsWe present a novel and well tolerated technique for delayed in-office application of MMC in tracheostomy-dependent patients with laryngeal stenosis. This approach can facilitate the study of the ideal timing of topical MMC use in airway stenosis.

A Grading System for Transnasal Flexible Laryngoscopy

Transnasal flexible laryngoscopy (TFL) is becoming more popular in laryngology clinical practice. There has not been any grading system for TFL to help the physician document and communicate the laryngeal view yet. In this study, we aimed to classify the laryngeal view based on the visualization of the glottic aperture with TFL performed on conscious patients. The TFL videos of 920 randomized patients were evaluated by three blind observers experienced with laryngology. The laryngeal view, consisting of the basic anatomic landmarks of the glottis, arytenoids, and epiglottis, was examined, and the glottic aperture was classified with a five-point grading system. Interobserver agreements for the grading system scores were assessed by using the kappa (k) statistic. Nine hundred and twenty subjects were enrolled in the study. Six hundred and thirty-eight (69.3%) were men, and 282 (30.6%) were women, and the mean age was 40.13 ± 15.08 (18-89 years). The number of patients constituting grade 1 was 737 (80.1%), while grade 2a was 122 (13.2%), grade 2b was 32 (3.4%), grade 3 was 24 (2.6%), and finally, grade 4 was only 5 (0.5%). The k score was 0.945 (P<0.001) between the ratings of observer 1 and observer 2, 0.933 (P<0.001) between observer 1 and observer 3, and 0.91 (P<0.001) between observer 2 and observer 3. This new grading system for the laryngeal view can help physicians assess the upper airways, and it can also help visualize how much of a glottic opening there is.

Steering Sheath for 2-Nostril Transnasal Office Laryngoscopy.

The aim was to study the feasibility of performing office-based laryngeal procedures employing a flexible hollow steerable sheath placed contralateral to the nostril through which a standard flexible video endoscope is placed. The study design included simulation of transnasal endoscopic laryngeal procedures evaluating the use of a flexible steering sheath in laboratory and clinic settings. Transnasal laryngeal procedures were performed in an otolaryngology office setting employing an airway-management-trainer mannequin and then repeated in a human cadaver lab with standard transnasal flexible video laryngoscopy. Video documentation assessed use of a lever-manipulated deflecting ureteral access sheath with an inner diameter of 2.97 mm, an outer diameter of 4.95 mm, and a length of 45 cm. Simulated transnasal laryngoscopy procedures deployed devices through the deflecting sheath to mimic vocal fold needle injection, biopsy with forceps, balloon dilation, and laser treatment to identify strengths and shortcomings to the technology and technique. Simulation was successful in appropriately directing instrumentation for all procedures tested. Shortcomings included limitations in steering capacity, greater length to the sheath than desirable for laryngeal procedures, and the need for additional assistants to perform procedures. Steering sheath technology is applicable to enhance in-office transnasal laryngoscopy procedures.

Optimal positioning to image the subglottis during transnasal flexible laryngoscopy

Optimal positioning to image the subglottis during transnasal flexible laryngoscopy

The Benefits and Limitations of Targeted Training in Flexible Transnasal Laryngoscopy Diagnosis

Targeted laryngoscopy training can be used successfully in de novo learners. To determine the value of targeted laryngoscopy education in interns. This prospective study of fiberoptic laryngoscopy interpretations enrolled 13 participants in an academic hospital setting from August 1 to December 31, 2015. Participants included 10 postgraduate year 1 emergency and otolaryngology interns and 3 board-certified otolaryngology attending physicians. Participants viewed 25 selected and digitally recorded fiberoptic laryngoscopies and were asked to rate 13 items relating to abnormalities in the pharynx, hypopharynx, larynx, and subglottis; the level of concern; and confidence with the diagnosis. A laryngoscopy teaching video was then administered to the interns before rating a second set of 25 videos. Improvement in diagnosis and intraclass correlation coefficients (ICC) were calculated for each question and compared between the first and second administration. Improvement in correct diagnosis of abnormalities in recorded laryngoscopies. All 13 participants completed the interventions. The ICCs for all questions were generally low for the intern groups and higher for the attending group. For vocal cord mobility, a preintervention ICC of 0.25 (95% CI, 0.16-0.37) improved to 0.47 (95% CI, 0.36-0.59) among interns after the intervention. The ICCs for vocal cord mobility were higher among attendings for the preintervention (0.89; 95% CI, 0.84-0.93) and postintervention (0.89; 95% CI, 0.83-0.93) assessments. Minimal improvement was observed in intern scores for base of tongue abnormalities, subglottic stenosis, vocal cord abnormalities, level of comfort, level of concern, pharyngeal abnormalities, or laryngeal, pharyngeal, and hypopharyngeal masses. Learning of flexible laryngoscopy can be improved with the use of a teaching video; however, additional interventions are needed to attain competence in accurately diagnosing upper airway lesions. Clinicians who seek to perform flexible laryngoscopy require robust training.

The Accuracy of the Laryngopharyngeal Reflux Diagnosis: Utility of the Stroboscopic Exam.

To determine the prevalence and also accuracy of the laryngopharyngeal reflux (LPR) referring diagnosis and to determine the most useful clinical tool in arriving at the final diagnosis in a tertiary laryngology practice. Case series with planned data collection. Six tertiary academic laryngology practices. We collected referring diagnosis and demographic information, including age, sex, ethnicity, referring physician, and whether or not patients had prior flexible laryngoscopy for 1077 patients presenting with laryngologic complaints from January 2010 and June 2013. Final diagnosis after the referred laryngologist's examination and the key diagnostic test used was then recorded. Of 1077 patients, 132 had a singular referring diagnosis of LPR. Only 47 of 132 patients (35.6%) had LPR confirmed on final primary diagnosis. Transnasal flexible laryngoscopy confirmed this in 27 of 47 (57.4%) patients. Eighty-five of 132 (64.4%) had a different final diagnosis than LPR. Sixty-five of 85 (76.5%) of these alternative pathologies were diagnosed with the aid of laryngeal stroboscopy. LPR appears to be an overused diagnosis for laryngologic complaints. For patients who have already had transnasal flexible laryngoscopic exams prior to their referral, laryngeal stroboscopy is the key diagnostic tool in arriving at the correct diagnosis.