Flexible Nasopharyngolaryngoscopy

OVERVIEW

Flexible Nasopharyngolaryngoscopy is a rapid bedside assessment of the upper airway that can be used in critical care settings to clarify the cause of stridor, dysphonia, secretion clearance problems, and dysphagia, and as a decision tool for airway management.

The procedure is more conveniently known as flexible nasoendoscopy (FNE) or nasopharyngoscopy

USES

Main indications in critical care settings are:

• Airway planning (especially if neck mass and/or stridor) to idenitfy pathology that may:
  • impair face mask ventilation (e.g., supraglottic oedema)
  • prevent direct laryngoscopy (e.g., base‑of‑tongue tumour)
  • obstruct tracheal tube passage (e.g., mass, lateralised larynx)
• Suspected airway burns
• Suspected foreign body (may be able to remove under direct vision)
• Stridor/ partial upper airway obstruction
  • Post‑extubation stridor: oedema, immobility, or supraglottic collapse
  • Suspected angioedema (only if it won’t delay airway control)
  • Suspected supraglottitis/epiglottitis
• Dysphonia
  • Post‑intubation hoarseness
  • Suspected vocal fold paresis/paralysis
  • Suspected paradoxical vocal cord motion (PVCM)
• Secretion burden / poor airway protection
  • Pooling in valleculae/piriform fossae
  • Weak cough closure
  • Suspected reduced laryngeal sensation
• Dysphagia / aspiration risk
  • Failed swallow after extubation, tracheostomy, stroke, neuromuscular disease
  • To facilitate FEES
• Epistaxis / nasal pathology
  • Persistent or recurrent epistaxis
  • Suspected posterior bleed
  • Exclude a “coroner’s clot” prior to extubation

CONTRA-INDICATIONS

Absolute (if they delay airway control)

• Rapidly progressive obstruction
• Exhaustion, hypoxaemia, hypercapnia
• Impending arrest

Relative

• Suspected basilar skull fracture / unstable midface trauma
• Significant bleeding diathesis/ coagulopathy
• Agitation where sedation risks airway compromise
• Marked nasal obstruction or recent nasal surgery

Stop the procedure early if:

• Resistance to passage
• Bleeding obscures view
• Cardiorespiratory compromise (e.g. hypoxia, respiratory distress, bradycardia, hypotension)

DESCRIPTION

Nasoendoscopy uses a flexible fibreoptic or video endoscope passed via the nose to visualise:

• Nasal cavity and nasopharynx
• Oropharynx and hypopharynx
• Supraglottis and glottis (vocal fold mobility, oedema, secretions)

It is distinct from:

• Bronchoscopy, where the scope passes beyond the vocal cords
• Flexible endoscopic evaluation of swallow (FEES), which involves a structured swallow assessment performed by ENT or SLT

Equipment needed:

• Flexible nasendoscope
  • Diameter: 2.8–4.0 mm (ICU/ED often 3.0–3.5 mm)
  • Working length: ~300–350 mm
  • Field of view: 80–110°
  • Tip deflection: ≥130° up / ≥130° down
  • Features: portable video chip‑on‑tip preferred; suction channel optional but not essential for bedside use
• Light source / battery pack — portable, fully charged
• Suction setup — Yankauer, fine catheter
• Vasoconstrictor spray — oxymetazoline or phenylephrine
• Lidocaine spray/gel — minimal effective dose
• Pledgets — cotton tips or patties for targeted topicalisation
• Lubricant gel — for scope tip and nasal floor
• Anti‑fog solution — or warm water
• PPE — gloves, mask, eye protection
• Oxygen delivery device — nasal prongs ± facemask
• Monitoring — SpO₂, ECG, BP
• Gauze/tissues — for minor epistaxis
• Waste bag / sharps — safe disposal
• Scope cleaning kit (unless disposable scope used)
• Airway bag/ trolley (backup for airway management)

METHOD OF USE/ PROCEDURE

Preparation

• Check equipment
• Full monitoring
• Suction ready
• Oxygenation strategy with rapid escalation
• Pre‑briefed airway plan (e.g. airway assessment, roles, equipment, plan ABCD, notifications (e.g. anaesthesia & ENT)

Topicalisation 

• Goal is to improve comfort and passage without compromising airway reflexes.
• Vasoconstrictor
  • Purpose: reduce bleeding, shrink turbinates, improve passage
  • Agents:
    • Oxymetazoline 0.05% spray, or
    • Phenylephrine 0.5% spray
  • Technique:
    • 1–2 sprays into the chosen nostril
    • Alternatively, a soaked cotton pledget placed for 1–2 minutes
  • Vasoconstrictor alone is often enough in cooperative patients.
• Local Anaesthetic (LA)
  • Purpose: improve tolerance of nasal passage and pharyngeal contact
  • Agents:
    • Lidocaine 2–4% spray
    • Lidocaine gel (2%) applied to the scope or nasal floor
  • Technique:
    • Apply minimal effective dose to each nostril
    • Avoid excess LA or spraying directly onto the cords
      • blunts laryngeal sensation, increasing aspiration risk
      • can worsen secretion retention
      • can trigger coughing, paradoxically worsening the view
      • In stridor or borderline obstruction, may reduce airway tone
    • Avoid LA if:
      • severe airway obstruction where any delay in securing airway is unsafe
      • high aspiration risk
      • known LA allergy
• Sedation
  • Avoid if possible, if required treat as high‑risk procedural sedation
  • Sedatives may worsen obstruction by reducing tone
  • Intubated patients: deepen sedation only as needed

Technique

• Position: sitting up (awake) or head‑up (intubated)
• Stabilise distal hand holding the flexiscope on the patient’s face/nose
• Choose the most patent nostril
• Advance along the floor of the nose
• Smooth, continuous movement
• Perform a systematic sweep
• Nasal cavity (floor, middle meatus, superior/ posterior cavity → nasopharynx → oropharynx/hypopharynx (base of tongue) → supraglottis → glottis
• Ask patient to perform maneuvers:
  • “Sniff” — opens the nasopharynx allowing scope to pass (saying “mmm” may also help) and the vocal cords.
  • “Tongue out” — exposes the valleculae and base of tongue 
  • “Blow cheeks out” or “turn head” — opens the piriform fossae to reveal pooling or masses.
  • “Say eeee” or count aloud — assess phonation and abducts the vocal cords; inspiration should abduct symmetrically.
  • “Swallow” – assesses swallow (if appropriate)

Troubleshooting

• Fogging: warm scope, anti‑fog
• Gag/cough: withdraw slightly, re‑approach smoothly
• Secretions: suction early and often
• If you only see “pink” (tip against tissue), withdraw scope until you can see a dark passage centre screen and reorientate before advancing

Documentation

• Vocal fold mobility
• Oedema: location + severity
• Secretions/pooling
• Lesions/trauma/granulation
• Tolerance, complications, topical agents used

ANATOMY AND KEY FINDINGS

Nasal Cavity – three‑pass inspection assessing the floor, middle meatus, and superior/posterior cavity.

• Septum — deviation, bony spurs, perforations
• Turbinates — hypertrophy, mucosal oedema, contact points
• Nasal valves — collapse, stenosis
• Mucosa — purulence, crusting, polyps, adhesions
• Bleeding points — Kiesselbach’s plexus, posterior sources
• Red flags: unilateral polyps, destructive lesions, persistent purulence

Posterior Nasal Space – inspection of the Eustachian tube orifices, fossa of Rosenmüller (pharyngeal recess superior and posterior to the eustachian tube), and adenoidal pad.

• Adenoids (should regress in adults)
• Masses — especially in the fossa of Rosenmüller (common site for nasopharyngeal carcinoma)
• Eustachian tubes — patency, oedema, asymmetry

Base of Tongue and Valleculae

• Lingual tonsils — often irregular but symmetrical
• Valleculae — cysts, masses, pooling
• Red flags: unilateral fullness, ulceration, firm mass (common site for oropharyngeal malignancy)

Epiglottis

• Epiglottic shape — omega‑shaped epiglottis or prolapsing aryepiglottic folds in laryngomalacia
• Epiglottitis — swollen, cherry‑red epiglottis; contraindication to routine scoping unless in a controlled airway environment
• Other findings: cysts, scarring, trauma

Piriform Fossae – important for silent aspiration and hypopharyngeal pathology.

• Pooling — saliva or secretions (impaired airway protection)
• Fullness or mass — requires prompt ENT evaluation
• Asymmetry — concerning for malignancy or extrinsic compression

Larynx – paramount importance for airway management

• Arytenoids
  • Oedema — common in post‑extubation stridor
  • Subluxation — post‑intubation trauma
  • Granulation — prolonged intubation
• Vocal Folds
  • Mobility — abduction/adduction, symmetry
  • Paresis/paralysis — aspiration risk, stridor if bilateral
  • Oedema — glottic narrowing
  • Masses — polyps, cysts, papillomas, malignancy
  • Mucosal changes — ulceration, granuloma, leukoplakia
• Airway Protection
  • Cough closure — weak or absent
  • Secretions — pooling, silent aspiration
  • Dynamic collapse — laryngomalacia, fatigue, neuromuscular disease

COMPLICATIONS

• Epistaxis (most common)
• Hypoxaemia from cough/distress
• Bronchospasm/laryngospasm (rare)
• Vasovagal episodes
• Aspiration risk with excessive topical anaesthetic
• Laryngospasm (rare)
• Equipment failure or damage

OTHER

Tips

• Have a head rest behind the patient so they cannot pull away
• Provide patient with eye protection during procedure
• Nasoendoscopy can also be performed by standing behind the patient (Di Maio et al, 2020)

Pitfalls

• Avoid over‑topicalising the larynx or using sedation due to risk of airway compromise
• Never force the scope!
• When used for airway planning remember:
  • Anaesthesia changes anatomy — loss of tone alters pharyngeal view; FNE findings in awake patient may not match post‑induction view.
  • If there is dynamic collapse, reduced tone may worsen obstruction.

VIDEOS

Walkthrough of flexible nasal endoscopy by ENT Academy:

ENT surgeon describes technique and anatomy while performing self-nasoendoscopy:

Detailed identification of nasal structures on endoscopy:

Protected Airway Collaboration video demonstrating nasopharyngoscopy for airway assessment:

The MiniEM approach to nasopharyngoscopy in the ED:

REFERENCES

Journal articles

1. Bentsianov BL, Parhiscar A, Azer M, Har-El G. The role of fiberoptic nasopharyngoscopy in the management of the acute airway in angioneurotic edema. Laryngoscope. 2000 Dec;110(12):2016-9. doi: 10.1097/00005537-200012000-00007. PMID: 11129012.
2. Di Maio P, Traverso D, Iocca O, De Virgilio A, Spriano G, Giudice M. Endoscopic nasopharyngoscopy and ENT specialist safety in the COVID 19 era: the back endoscopy approach to the patient. Eur Arch Otorhinolaryngol. 2020 Sep;277(9):2647-2648. doi: 10.1007/s00405-020-06093-6. Epub 2020 Jun 4. PMID: 32500327; PMCID: PMC7271825.
3. Cox GJ, Bates GJ, Drake-Lee AB, Watson DJ. The use of flexible nasoendoscopy in adults with acute epiglottitis. Ann R Coll Surg Engl. 1988 Nov;70(6):361-2. PMID: 3207326; PMCID: PMC2498607.
4. Kramer A, Kohnen W, Israel S, Ryll S, Hübner NO, Luckhaupt H, Hosemann W. Principles of infection prevention and reprocessing in ENT endoscopy. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2015 Dec 22;14:Doc10. doi: 10.3205/cto000125. PMID: 26770284; PMCID: PMC4702059
5. O’Carroll J, Endlich Y, Ahmad I. Advanced airway assessment techniques. BJA Education, 2021; 21, 336-342 [article]