Flexible Nasendoscopy

This is an essential skill for any ENT surgeon. It's taught on many introductory courses and senior colleagues are usually happy to demonstrate and supervise.  Nasendoscopy is a diagnostic procedure.  It is the fundamental examination technique for the upper aerodigestive tract, for everything from nasal foreign body to malignancy. ENT surgeons rely heavily on this quick, inexpensive and relatively simple procedure.

This page is for reference, not instruction: you should be shown how to do this before attempting it on your own. 

Here are some good YouTube videos:

 

Equipment 

  • Flexible fibreoptic nasendoscope

  • Light source (can be portable)

  • Fibreoptic light lead (if required)

  • (Disposable sterile endoscopic sheath - if used in your department)

  • Personal protective equipment including non-sterile gloves; consider eye/mouth protection

  • Topical decongestant/anaesthetic spray (co-phenelcaine is widely used; lidocaine can sting in the nose)

  • Lubrication gel

  • Alcohol wipe

  • Tissues

  • Kidney dish

Take care not to drop or knock the nasendoscope, light lead or light source: these are sensitive pieces of equipment. Use a trolley if you are transporting the equipment elsewhere. 

 

Procedure

This procedure can be broken down into four stages.

 

Stage 1: Preparation

  • Clean the nasendoscope yourself or obtain a clean one, according to local policy

  • Apply the endoscopic sheath if using

  • Check the light source and lead

  • Talk to the patient -

    • Explain the procedure.

    • Risks: it is uncomfortable, like having their nose picked a bit too far back; it makes their eyes water and may make them sneeze; if used, the local anaesthetic spray tastes bitter; they cannot have food or drink until one hour later; rarely they may react to the topical spray

    • Benefits: it gives a lot of important information quickly

    • Obtain verbal consent

  • Position the patient -

    • Sit upright with head support and give them some tissues

  • Where indicated, use topical local anaesthetic spray

Many patients tolerate the scope without any spray. You can use the nasendoscope to look from the very front and note any oedema and mucus. Then you can use co-phenylcaine or xylometazoline (Otrivine) and allow a few minutes for it to work. The spray may help reduce nasal oedema.

 

Stage 2: Passing the nasendoscope

  • If you haven't already looked, get the patient to sniff and tell you which nasal passage they think is more patent.

  • For nasal conditions you will need to visualise both nasal passages. If you are more interested in the throat you can use only one side.

  • Lubricate the scope without getting any on the tip.

  • Touch the tip of the scope on the patient's tongue or use the alcohol wipe to reduce fogging.

  • Aim the scope so that the very centre of your view is the next air space into which you want to move. Try to avoid touching mucosa. In the nose, if you have to touch the sides, err on the side of the lateral nasal wall, as this is less sensitive.

  • When moving from nasopharynx to oropharynx, ask the patient to breathe through their nose - this opens up the soft palate.

 

Stage 3: Examination

  • Examine the nasal cavity, pharynx and larynx methodically (see the video links)

  • Perform manoeuvres to improve visibility:

    • Protruding the tongue allows examinination of the tongue base/valleculae

    • Blowing the cheeks out gives a clearer view of the pyriform fossae

    • Saying 'Eeeee' and turning the head left and right also help to visualise the pyriform fossae

    • Check vocal cord movements: 'Eeeee' or counting numbers should adduct both cords against each other in the midline; breathing in should abduct the cords equally

 

Stage 4: Communication

  • Describe and record your findings.

A drawing is a powerful and simple way of recording and communicating your findings. Some departments require a separate log of the procedure. If there is a cleaning/traceability sticker from the nasendoscope, stick it in the notes.

 

Post procedure instructions

  • Tell patient to refrain from eating or drinking until the anaesthetic wears off (about an hour).

  • If they feel faint, keep them seated.

  • At the end of the procedure, follow departmental endoscope sterilisation procedures.

  • Clean up after yourself.

 

DOPS

ENT surgeons are assessed on the following 10 points:

1.         Describes indications, anatomy, procedure and complications

2.         Obtains consent, after explaining procedure & possible comps.           

3.         Prepares for procedure according to an agreed protocol           

4.         Administers effective analgesia or safe sedation (if no anaesthetist)        

5.         Demonstrates good asepsis and safe use of instruments & sharps         

6.         Performs the technical aspects in line with the guidance notes

7.         Deals with any unexpected event or seeks help when appropriate         

8.         Completes required documentation (written or dictated)         

9.         Communicates clearly with patient & staff throughout the procedure    

10.        Demonstrates professional behaviour throughout the procedure

 

Link to ExR Virtual Reality: Nasendoscopy 

 

Page last reviewed: 9 December 2019