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Flexible Fiberoptic Workshop: Advanced Course

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1 Flexible Fiberoptic Workshop: Advanced Course
April 26-28, 2013 New York-Presbyterian Hospital/Weill Cornell Medical Center Flexible Fiberoptic Workshop: Advanced Course Debra Munsell, DHSC, DFAAPA, PA-C Marie Gilbert, MPAS, DFAAPA, PA-C

2 Flexible Fiberoptic Workshop: Advanced Course
◄ Instruction ● Demonstration ● Practice ► Advanced instruction Clear demonstration with discussion of normal variants and abnormal findings Hands-on doing! Exchange of ideas Learn by Doing

3 Objectives Upon completion of this workshop, the participant will;
Improve fundamental knowledge of the normal anatomy, normal variants and abnormal findings visible via flexible fiberoptic nasopharyngoscopy. Have the understanding of the differences between flexible and rigid scope exams Perform flexible and rigid scope exams with appropriate technique Understand the appropriate use of flexible and rigid endoscope for specific pediatric and adult disorders.

4 Indications for Fiberoptic Endoscopy (FOE)
Dysphonia Presbylarynx VC paralysis VC Nodules LPR Neoplasms Dysphagia Cadidiasis Odynophagia Symptoms of aspiration Laryngomalecia Angioedema Strong gag reflex* Failed mirror exam* Nasal obstruction Foreign Body Septal deviation Adenoid hypertrophy Nasal mass Unilateral otitis media Polyps Sinusitis Chronic throat pain Chronic cough *Documentation of a strong gag reflex and failed mirror exam should be included in note to justify procedure for billing purposes.

5 Contraindications Epiglottitis (by inexperienced) Relative:
Coagulopathy Craniofacial trauma

6 Know Your Anatomy

7 Laryngeal Anatomy (Mirror*)
Images from 4. Aryepiglottic folds 5. Arytenoids 6. Pyriform sinuses 7. Base of Tongue True vocal cords False cords Epiglottis *Mirror Laryngoscopy, image is inverted.

8 Laryngeal Anatomy (FOE*)
True Vocal Cords abducted True Vocal Cords adducted *Fiberoptic endoscopy, image is true.

9 Review Tips For Starting the Exam
Patient informed of the procedure (obtain consent) Proper positioning Sniffing, head supported, use non-dominant hand to steady the pts. Head Choose the most patent of the nares Appropriate equipment Adult vs Pedi Decongestant/anesthetic Gloves Chair Photographic/video accessories Biopsy materials if needed Lubricant +/-

10 Photo Courtesy Bernadine Sonnier 2011
Preparation for FOE May want patient to blow nose. Assess most patent of nares. Antifogging solution. Apply topical decongestant 0.05% Oxymetazoline 0.25% -2 % Phenylephrine Apply topical anesthetic 4% Lidocaine Pontacaine Photo Courtesy Bernadine Sonnier 2011

11 Video Courtesy J. Mercado
Normal FOE Video Courtesy J. Mercado

12 Causes of Nasal Obstruction
Nasal Foreign Body Septal deviation Synechiae Turbinate hypertrophy Sinusitis Adenoid hypertropy Nasopharyngeal masses Nasal polyps

13 Septal Deviation/ Turbinate Hypertrophy
Septal deviation with evidence of septal spur and mild turbinate hypertrophy.

14 Synechiae Fused intranasal tissue is called an adhesion or synechiae.
Adhesions are a common, usually minor complication of nasal or sinus surgery and nasal packing. They also may develop because of trauma (nose-picking or cocaine use) and such conditions as syphilis, tuberculosis, lupus, or sarcoidosis.

15 Video Courtesy J. Mercado
Nasal Polyps Video Courtesy J. Mercado

16 Nasal Polyps Nasal polyps are common, noncancerous, teardrop-shaped growths that form in the nose or sinuses, usually around the area where the sinuses open into the nasal cavity. Mature nasal polyps look like seedless, peeled grapes Top image polyps viewed via nasal speculum. Bottom image polyps viewed via fiberoptic intranasal exam. Mercado 2011 © Image on left, transnasal view of nasal polyp. Image on right shows several nasal polyps.

17 Video Courtesy J. Mercado
Sinusitis 27 year old female, 32 weeks pregnant with a 4 week history of facial pressure. Video Courtesy J. Mercado

18 Sinusitis Sinusitis is diagnoses by history and physical examination.
Fiberoptic endoscopy (flexible or rigid) is ideal for evaluating the osteomeatal complex Image of fungal sinusitis. Note thick debris vs purulent secretions in previous video.

19 Video Courtesy J. Mercado
Adenoid Hypertrophy Examination of nasal obstruction in a 7 year old female with complaints of snoring. Copious nasal secretions make examination difficult. End of scope is brushed against nasopharynx when it becomes too foggy to see to clear scope. Note amount of nasal obstruction in terms of percentage. Roughly 70% obstruction. Patient was started on topical nasal steroid spray as well as environmental control measures for dust and mold avoidance with excellent improvement of symptoms. Video Courtesy J. Mercado

20 Adenoid Hypertrophy Adenoids are described based on % of obstruction
No obstruction Partial (percentage) obstruction Complete obstruction Endoscopic view of the nasopharynx showing adenoidal obstruction of the choana. Mercado 2011 ©

21 Video Courtesy J. Mercado
Angiofibroma Video Courtesy J. Mercado

22 Juvenile Angiofibroma
Juvenile angiofibroma – benign, highly vascular invasive mass that occurs in the posterior nasal cavity in less than 0.5% of head and neck tumors. Almost always found in adolescent boys. Presents with epistaxis and nasal congestion or both. CT Scan w/contrast confirmed nasopharyngeal mass measuring 4.0 cm x 3.8 cm consistent with a juvenile angiofibroma. 15 year old hispanic male with c/o of epistaxis, nasal congestion and difficulty breathing x 4 years. Born full term NSVD without complications. No pets at home and not exposed to second hand smoke.

23 Tornwaldt Cyst A Tornwaldt cyst is a midline pouch within the posterior roof of the nasopharnx which is caused by an adherence of the notochord to the pharyngeal ectoderm during development, resulting in the outpouching of ectoderm into the pharyngobasilar fascia. They are typically asymptomatic but may present with middle ear symptoms (eustachian tube obstruction), halitosis (when associated with a leaking sinus tract), foul taste in mouth, and, rarely, occipital headaches. These lesions will demonstrate low to increased signal on T1-weighted images depending on the protein content of the mucus. They will be high signal on T2-weighted images and will not enhance.

24 Unilateral Otitis Media
Unilateral Otitis Media in adults should raise suspicion of Nasopharyngeal mass blocking Eustachian Tube orifice which can cause unilateral middle ear effusion. 1.5:100,000 patients, more common in Asian and Alaskan people 20:100,000 Top image normal Torus Tubarius Bottom image opening covered with mucosal tissue (squamous cell carcinoma). Mercado 2011 © Bottom image was a 65 year old Asian female with a 6 week history of left, unilateral otitis media that failed to resolved with oral antibiotics. She complained of clogged sensation with hearing loss. Fiberoptic nasal endoscopy revealed left torus tubarius was blocked with mucosal tissue. Biopsy confirmed squamous cell carcinoma. Mercado 2011 ©

25 Voice Change Voice overuse/misuse Vocal cord nodules/polyps Layngopharyngeal Reflux Vocal Cord Paralys Presbylarynx Laryngeal neoplasms

26 Video Courtesy M. Mitrani
Vocal Cord Paralysis Video Courtesy M. Mitrani

27 Video Courtesy J. Mercado
Vocal Cord Nodules, LPR Video Courtesy J. Mercado

28 Video Courtesy J. Mercado
Laryngeal Cancer 49 year old male that presented with clogged left ear. Initial impression was hoarseness of voice. Heavy smoker. Cerumen impaction cleared and fiberoptic laryngoscopy revealed large pendunculated left vocal cord exophytic lesion. Biospsy confirmed poorly differentiated squamous cell carcinoma. Video Courtesy J. Mercado

29 Adult Mannequin Place marker, actual picture forthcoming. Pearls for performing flexible fiberoptic exam on infants and children. Practice mannequins available to practice flexible fiberoptic endoscopy technique.

30 Respiratory Complications
Children Must rule out foreign body aspiration Laryngomalecia Subglotticstenosis Adults Angioedema

31 Flexible fiberoptic exam on infants and children.
Secure patient cradle vs papoose

32 Video Courtesy J. Mercado
Laryngomalacia 4 month old female with inspiratory stridor and noisy respirations. No shortness of breathe or cyanosis. On Nutramagen formula with mild reflux eating 4-5oz every 2 to 3 hours. Video Courtesy J. Mercado

33 Laryngomalacia Most common congenital abnormality of the larynx.
Most prominent SX – inspiratory stridor. Immature development results in soft laryngeal walls that close airway. Child outgrows, Usually, No treatment necessary, Omega Shaped epliglottis Mercado 2011 ©

34 Subglottic Stenosis Class I Class II Class III
Narrowing of subglottis can be congenital or acquired in etiology. Its nature can be membranous, cartilaginous, or mixed, with or without combination of glottic or upper tracheal stenosis. The lower limit of normal subglottis dimension in full term infant is 4.0 mm and in premature infant 3.5 mm. Circumferential edema of 1mm reduces its cross-sectional area by 60%. Myer-Cotton grading system is a useful classification for mature circumferential subglottic stenosis. It is divided into 4 grade as below:: Grade I - Obstruction of 0-50% of the lumen obstruction Grade II - Obstruction of 51-70% of the lumen Grade III - Obstruction of 71-99% of the lumen Grade IV - Obstruction of 100% of the lumen (ie, no detectable lumen) Class I Class II Class III

35 Infant/Child Mannequin
Place marker, actual picture forthcoming. Pearls for performing flexible fiberoptic exam on infants and children. Practice mannequins available to practice flexible fiberoptic endoscopy technique.

36 Angioedema Vascular leakage beneath the dermis and subcutanis. Response is mediated by vasoactive mediators, i.e., histamine, serotonin, and kinins (eg, bradykinins), which cause the arterioles to dilate while inducing a brief episode of vascular leakage in the venules, where the junction between the endothelial cells appears looser than in the capillaries and arterioles. Angioedema with or without urticaria, is classified as allergic, hereditary, or idiopathic. Complications range from dysphonia or dysphagia to respiratory distress, complete airway obstruction, and death. Symptoms - Severe facial/oral edema, Urticaria – (hives) food allergy, erythema. Most common cause - ACE Inhibitor sensitivity, Food allergies such as fresh berries, shellfish, fish, nuts, tomatoes, eggs, milk, chocolate, food additives, and preservatives Treatment - H 1, antihistamine, H 2, antacid, Steroids. Protect airway. Mercado 2011 © Patient on top was admitted with chest pain and elevated blood pressure. He developed dysphagia and lip swelling 2 days after starting lisinopril. Patient on bottom suffers from hereditary angioedema and has recurrent episodes. Hereditary angioedema (HAE) is caused by low levels or improper function of a protein called C1 inhibitor. Mercado 2011 ©

37 Angioedema Edema uvula Edema floor of mouth Edema arytenoid
Mercado 2011 © Edema uvula Edema floor of mouth Slide from Henry Ford from “Laryngoscopy 101” by Mausumi Syamal, MD, MS, Glendon Gardner, MD, Bob Standring, MD, and Werner Roennecke, MD from Henry Ford Health Systems. Patient on right was seen in ER with a 3 week history of sore throat that got worse over last 6 days. He had been started on accupril 1 week ago. Edema arytenoid Edema epiglottis

38 Rigid Scope Marie is awesome and was able to get some rigid scopes for us to use during advanced course. The goal here is to provide familiarization of the rigid scope and discuss two specific uses; obtaining culture from sinuses and post operative FESS debridement. Attendees will have to practice on mannequins NOT each other.

39 Rigid Scope The rigid endoscope provides superior image clarity, facilitates culture and tissue sampling, controls epistaxis, and affords the endoscopist the ability to perform surgery. Rigid endoscopes for the nose come in diameters of mm and have tips of different angles (generally 0-70º), allowing the clinician to visualize various sinuses and areas within the nasal cavity. This facilitates culture of the sinuses and dedribement postoperatively.

40 Rhinosinusitis, Fifth Edition
Rigid Scope Nasal Septum Endoscopic Nasal Examination and Obtaining Culture for Diagnosis The most common symptoms associated with bacterial RS include nasal congestion and the production of a thick postnasal discharge. Facial pressure and pain commonly bring the patient to the physician’s office. The site of pain and pressure may localize the infection to a specific paranasal sinus. Other common symptoms include nasal obstruction and headache. Alteration in sense of smell, cough, fever, halitosis, fatigue, dental pain, pharyngitis, and otologic symptoms (ear fullness and clicking) also may be present. Symptoms based on specific sinuses. Upper-teeth or gum pain is highly specific for maxillary RS. Tenderness over the lacrimal region, with referred tenderness to the periorbital and temporal regions, usually accompanies ethmoid RS. Frontal RS is usually characterized by severe headache localized to the forehead over the orbits, with tenderness produced by pressure on the floor of the frontal sinus. A sign of acute sphenoidal RS is headache described as a chronic dull ache in the back of the head, specifically over the occiput with radiation to the frontal and retro-orbital regions. Chronic RS is more subtle; facial pain and pressure are less common, and nasal congestion and obstruction with thickened nasal secretions are the most reported symptoms. Physical examination. Acute RS is characterized by hyperemia of the nasal mucosa and edema. Anterior rhinoscopy, performed with a nasal speculum under good illumination, is helpful in visualizing the nasal passages for septal deviation, obstruction, nasal polyps, and the nasal turbinates. Topical nasal decongestants with alpha-agonists such as phenylephrine hydrochloride may improve the congestion and aid in visualizing the nasal cavity. References Benninger M, Appelbaum, Denneny J, Osguthorpe JD. Maxillary Sinus Puncture and Culture in the Diagnosis of Acute Rhinosinusitis: The Case for Pursuing Alternative Culture. Otolaryngol Head Neck Surg 2002;127:7-12. Hadley JA, Schaefer SD. Clinical evaluation of rhinosinusitis: History and physical examination. Otolaryngol Head Neck Surg 1997;117 (suppl 3):S8-S11. Kaliner M, Osguthorpe JD, Fireman P, Anon J, Georgitis J, Davis M, Naclerio R, Kennedy D. Sinusitis: Bench to Bedside. Otolaryngol Head Neck Surg 1997;116(suppl 6):S1-S20. Lanza DC, Kennedy DW. Adult rhinosinusitis. Otolaryngol Head Neck Surg 1997;117 (suppl 3):S1-S7. Inferior Turbinate Mercado 2011 © Nasal endoscopic examination and culture for definitive diagnosis best accomplished with rigid scope. Small culturette used to obtain mucous & pus sample from hiatus semilunaris. Be sure not to touch other tissue as this may contaminate specimen. Copyright 2006 The American Academy of Otolaryngology--Head and Neck Surgery Foundation

41 Rhinosinusitis, Fifth Edition
Nasal Cultures Nasal cultures are not routinely indicated in first- line management of Acute Rhinosinusitis Endoscopically guided microswab or suction aspiration culture of a draining sinus ostium are a strong consideration in Chronic Rhinosinusitis, especially when poorly responsive to prior antibiotics. Middle Turbinate Microswab Rhinosinusitis : Cultures Photo depicts a “microswab” obtaining a specimen from the middle meatus under direct vision via nasal endoscopy. Such culture, in the presence of visible pus draining into the hiatus semilunaris and then into the nasal cavity, yields organism(s) that correspond to those cultured directly from the affected sinus (e.g., from the maxillary sinus via direct needle puncture) about 75-85% of the time. Culture is not indicated for the average community acquired acute RS, or even some cases of CRS. However, for severe RS cases, those not responding per expectation to antibiotics, or when the patient is immunocompromised or has been on multiple prior courses of antibiotics, culture is prudent. References Benninger M, Appelbaum, Denneny J, Osguthorpe JD. Maxillary Sinus Puncture and Culture in the Diagnosis of Acute Rhinosinusitis: The Case for Pursuing Alternative Culture. Otolaryngol Head Neck Surg 2002;127:7-12. Benninger M, Ferguson B, Hadley J, Hamilos D, Jacobs M, Kennedy D, Lanza D, Marple B, Osguthorpe J, Stankiewicz J, Anon J, Denneny J, Emanuel I, Levine H. Adult Chronic Rhinosinusitis: Definitions, Diagnosis, Epidemiology, and Pathophysiology. Otolaryngol Head Neck Surg 2003;129(suppl 3) S1-32. Copyright 2006 The American Academy of Otolaryngology--Head and Neck Surgery Foundation

42 Dr. Kevin Kavanaugh ©
FOE After FESS Mercado 2011 © Dr. Kevin Kavanaugh © Post operative debridement following FESS is best accomplished with rigid scope. Rigid scope allows clinician to visualize area and suction or use forceps.

43 Rigid Scope Practice Practice FESS Debridement
Practice C/S swab with rigid scope. Place marker, actual picture forthcoming. Practice mannequins available to practice rigid fiberoptic endoscopy technique.

44 Advise patient not to eat or drink anything 1 hour after procedure.
Complications Tearing Epistaxis Coughing Laryngospasm – rare Bleeding Advise patient not to eat or drink anything 1 hour after procedure.

45 Care of Scope

46 Pull endosheath from distal end
Endosheaths Loosen endosheath Pull endosheath from distal end To remove endosheath, loosen from tip and pull from distal end. Do not push from hub adapter as sheath will become wedged and may damage scope. Mercado 2011 © Mercado 2011 ©

47 Cold Sterilization Flexible scopes are non-autoclavable.
Clean length of flexible scope with an enzymatic detergent solution like ENZOL® to remove debris and reduce bacterial burden before instruments are disinfected or sterilized. Soak flexible scope in a glutaraldehyde solution like Cidex ® which provides quick high-level disinfection. Noncorrosive solution reduces instrument damage and associated repair costs. Soaking times vary by product. Mercado 2011 ©

48 Leak Testing Routine leak testing in accordance with specific manufacture depending on volume of use. Introduce air pressure via attached bulb (DO NOT overinflate) and submerge looking for leaks. Leaks can slowly damage fiberoptics and internal parts causing expensive yet preventable damage. Mercado 2011 © Mercado 2011 © Mercado 2011 ©

49 Review of Scope Care Avoid bending scope in tight angles.
Clean lens with lens cleaner/paper. Pre-clean with enzymatic cleaner. Soak only for required period depending on brand and manufacture. Store in dry safe place. Perform regular leak testing to avoid damage.

50 Resources Excellent pictures and videos by Dr. Kevin Kavenaugh
Dr Rahmat Omar, Direct Laryngoscopy video

51 Laryngeal Evaluation by Kendall & Leonard
Resources Print Laryngeal Evaluation by Kendall & Leonard Publication Date: August pp, 309 illustrations hardcover & video ISBN (Americas): ISBN (EUR, Asia, Africa, AUS):

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