Office‐based laryngology: Technical and visual optimization by patient‐positioning maneuvers

Abstract

Objective/Hypothesis To qualitatively and quantitatively assess the effect of discrete head postures/maneuvers during flexible laryngoscopy on visualization of specific anatomical structures within the laryngopharynx. Study Design Prospective, observational study. Methods Flexible laryngoscopy was performed on 18 sequential patients. Videos of the laryngopharynx were captured during the neutral head position and five discrete maneuvers: maximal sniffing, head extension, right turn, left turn, and chin down. Images were analyzed using ImageJ, and differences in the (normalized) anatomical areas of interest were examined with each maneuver (paired t test]. Covariates for surgeon, nostril, and gender were evaluated. Results There was a significantly increased (P = 0.009) area of view of the anterior space (petiole of epiglottis/anterior laryngeal vestibule) with head extension. Right head turn led to a significantly increased view of the left pyriform sinus (P = 0.00001), whereas left head turn yielded an increased view of the right pyriform sinus (P = 0.0001). The right and left vocal fold/ventricle were better visualized during right head turn (with the scope traversing the right nostril) and left head turn (with the scope traversing the left nostril), respectively. Chin‐down posture achieved a more distal view of the airway more frequently than the other maneuvers. Conclusion The anterior space (supraglottic larynx) may be best visualized and accessed with head extension. Right and left head turn improve visualization of the contralateral piriform sinus. Chin down provides improved airway visualization in a plurality of patients. Future studies examining maneuvers are warranted to create a catalog of validated techniques to optimize the efficacy of the office‐based proceduralist. Level of Evidence 2 Laryngoscope, 129:330–334, 2019

Optimization of Subglottic View During Flexible Laryngoscopy With Patient Positioning

“…While a variety of patient postures for awake transnasal flexible laryngoscopy exist in order to view the hypopharynx, glottis, esophageal inlet 4,5,12‐14 and more distal views, 6,7 the ability to adequately visualize the subglottis and proximal trachea in clinical practice is limited. This is the first single‐blinded prospective trial to evaluate the effect of patient posture on visualization of the subglottic and tracheal airways for in‐clinic laryngoscopy.…”

“…Several studies have shown that simple forward head extension, or "sniffing" position, optimizes the view of the supraglottic and glottic structures. 4,5 Two studies describe the use of a flexed or "chin-tuck" head position to improve visualization of the distal airway in the awake patient. 4,6 Lastly, the laryngeal distraction or "stooping" maneuver, or chin tuck with head turn, has been implemented to obtain views of the subglottis and proximal trachea without the need for topical anesthetic administration.…”

“…Maneuvers aimed to enhance visualization of the aerodigestive tract in the awake patient during flexible laryngoscopy have been developed as more sophisticated technologies have allowed. Several studies have shown that simple forward head extension, or “sniffing” position, optimizes the view of the supraglottic and glottic structures 4,5 . Two studies describe the use of a flexed or “chin‐tuck” head position to improve visualization of the distal airway in the awake patient 4,6 .…”

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

“…Office-based flexible transnasal laryngoscopy is a common routine procedure since many years. The development of new technical equipment such as flexible high-definition endoscopes allows for very precise examination [1][2][3][4][5][6][7][8][9]. The basic principle for getting optimal magnification in laryngoscopy is to decrease the distance of the lens to the target, i.e., the nearer one gets to the vocal fold, the more details one can see.…”