2 Flexible Fiberoptic Workshop: Advanced Course ◄ Instruction ● Demonstration ● Practice ►Advanced instructionClear demonstration with discussion of normal variants and abnormal findingsHands-on doing!Exchange of ideasLearn 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 examsPerform flexible and rigid scope exams with appropriate techniqueUnderstand the appropriate use of flexible and rigid endoscope for specific pediatric and adult disorders.
4 Indications for Fiberoptic Endoscopy (FOE) DysphoniaPresbylarynxVC paralysisVC NodulesLPRNeoplasmsDysphagiaCadidiasisOdynophagiaSymptoms of aspirationLaryngomaleciaAngioedemaStrong gag reflex*Failed mirror exam*Nasal obstructionForeign BodySeptal deviationAdenoid hypertrophyNasal massUnilateral otitis mediaPolypsSinusitisChronic throat painChronic cough*Documentation of a strong gag reflex and failed mirror exam should be included in note to justify procedure for billing purposes.
9 Review Tips For Starting the Exam Patient informed of the procedure (obtain consent)Proper positioningSniffing, head supported, use non-dominant hand to steady the pts. HeadChoose the most patent of the naresAppropriate equipmentAdult vs PediDecongestant/anestheticGlovesChairPhotographic/video accessoriesBiopsy materials if neededLubricant +/-
10 Photo Courtesy Bernadine Sonnier 2011 Preparation for FOEMay want patient to blow nose.Assess most patent of nares.Antifogging solution.Apply topical decongestant0.05% Oxymetazoline0.25% -2 % PhenylephrineApply topical anesthetic4% LidocainePontacainePhoto Courtesy Bernadine Sonnier 2011
11 Video Courtesy J. Mercado Normal FOEVideo 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 PolypsVideo Courtesy J. Mercado
17 Video Courtesy J. Mercado Sinusitis27 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 complexImage of fungal sinusitis. Note thick debris vs purulent secretions in previous video.
19 Video Courtesy J. Mercado Adenoid HypertrophyExamination 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
21 Video Courtesy J. Mercado AngiofibromaVideo 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 CystA 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.
26 Video Courtesy M. Mitrani Vocal Cord ParalysisVideo Courtesy M. Mitrani
27 Video Courtesy J. Mercado Vocal Cord Nodules, LPRVideo Courtesy J. Mercado
28 Video Courtesy J. Mercado Laryngeal Cancer49 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 MannequinPlace 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 ChildrenMust rule out foreign body aspirationLaryngomaleciaSubglotticstenosisAdultsAngioedema
31 Flexible fiberoptic exam on infants and children. Secure patient cradle vs papoose
32 Video Courtesy J. Mercado Laryngomalacia4 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
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 IClass IIClass 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.
38 Rigid ScopeMarie 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 ScopeThe 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.
41 Rhinosinusitis, Fifth Edition Nasal CulturesNasal cultures are not routinely indicated in first- line management of Acute RhinosinusitisEndoscopically 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 TurbinateMicroswabRhinosinusitis : CulturesPhoto 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.ReferencesBenninger 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
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. ComplicationsTearingEpistaxisCoughingLaryngospasm – rareBleedingAdvise patient not to eat or drink anything 1 hour after procedure.
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 PrintLaryngeal Evaluation by Kendall & LeonardPublication Date: August pp, 309 illustrations hardcover & video ISBN (Americas): ISBN (EUR, Asia, Africa, AUS):