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Examination of the Larynx and Pharynx

F. Christopher Holsinger, M.D., Merrill S. Kies, M.D., Y. Etan Weinstock, M.D.,
Jan S. Lewin, Ph.D., Shaheen Hajibashi, B.S., David D. Nolen, B.A.,
Randal Weber, M.D., and Ollivier Laccourreye, M.D.

From the Department of Head and Neck Visualization of the larynx and pharynx is an essential part of a complete head and
Surgery (F.C.H., Y.E.W., J.S.L., S.H., neck examination. Although the location of these structures often precludes direct
D.D.N., R.W.) and Thoracic–Head and
Neck Medical Oncology (M.S.K.), Uni- visualization, simple techniques can be used to evaluate them in the clinical setting.
versity of Texas M.D. Anderson Cancer Indirect laryngoscopy can be performed with either a simple dental mirror or a
Center, Houston; and the Department of flexible fiberoptic endoscope. The procedure can be performed when patients are
Otorhinolaryngology–Head and Neck Sur-
gery, Hôpital Européen Georges Pompi- awake, and it is usually well tolerated. Laryngoscopy can identify a wide variety of
dou, Assistance Publique–Hôpitaux de disorders — acute or chronic, benign or malignant.
Paris, Université René Descartes Paris V,
Paris (O.L.). Address reprint requests to
Dr. Holsinger at the Department of Head Indic at ions
and Neck Surgery, University of Texas M.D.
Anderson Cancer Center, 1515 Holcombe Common indications for laryngoscopy include chronic cough, laryngotracheal dys-
Blvd., Box 441, Houston, TX 77030-4009,
or at [email protected]. pnea, dysphonia, voice changes, chronic throat pain, persistent otalgia, swallowing
problems, dysphagia, and symptoms of aspiration. Laryngoscopy can be used to elu-
N Engl J Med 2008;358:e2. cidate the anatomic location of the problem and, in some cases, the cause.1
Copyright © 2008 Massachusetts Medical Society.
Patients who are at high risk for head and neck cancer benefit from screening
examinations with indirect mirror laryngoscopy or flexible endoscopic laryngosco-
py. Any adult patient with ear pain, hoarseness, or a sore throat that lasts longer than
2 weeks should have a complete laryngopharyngeal examination because of the pos-
sibility of cancer.2 Patients with a history of long-term tobacco and alcohol use merit
special attention and require careful examination.
Laryngoscopy is also important for evaluating patients with a difficult airway.
This examination can be performed in emergency departments when timely airway
control is imperative. Patients presenting with angioedema, uncontrolled epistaxis,
cervicofacial trauma, stridor, or suspected ingestion of a foreign body should be ex-
amined by laryngoscopy to evaluate the presenting problem and to rule out an air-
way compromise.
Finally, laryngoscopy may also be useful in the diagnosis of various diseases, such
as gastroesophageal reflux, tuberculosis, sarcoidosis, allergy, or neurologic diseases.3

C on t r a indic at ions

There are few, if any, contraindications to performing laryngoscopy with the fiber-
optic nasal laryngoscope. However, you should exercise great care when performing
laryngoscopy in a patient with impending airway compromise (e.g., epiglottitis). Only
a skilled operator should perform a laryngoscopic examination in this clinical sce-
nario. Inadvertent trauma to the laryngopharynx may exacerbate swelling and pre-
cipitate respiratory arrest.
Laryngoscopy can usually be performed in young children, although the patient’s
tolerance and compliance may limit the extent of the examination.4

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 Examination of the Larynx and Pharynx

Equipmen t
For mirror laryngoscopy, a curved dental mirror, an external light, a 4-by-4-in. gauze
pad, and antifogging solution are needed.
For a flexible laryngoscopic examination, you will need a standard flexible naso-
laryngoscope, gloves, a nasal speculum, surgical lubricant, antifogging solution,
decongestant spray, anesthetic spray, and a wall-suction setup with a Frazier-tip suc-
tion catheter. It is also useful to have tissues available. Decongestants, such as 0.05%
oxymetazoline or 0.1% to 1.0% phenylephrine, are used to elicit mucosal vasocon-
striction of the nasal passages, so that the endoscope can pass more comfortably.
Lidocaine (4.0%) is used to anesthetize the pharynx and larynx. The flexible en-
doscope has a thumb-dial control that allows the examiner to deflect the tip up or
down. When rotated 90 degrees, the thumb dial lets the examiner turn corners and
maneuver from side to side, as well as up and down.

Mir ror L a r y ng os c opy

During mirror laryngoscopy, the patient should sit opposite and slightly elevated
relative to the examiner. The patient’s legs should be uncrossed, and the patient
should lean forward slightly, with mouth wide open and tongue protruding. To pre-
vent fogging of the mirror, warm it to just above body temperature or coat it with
an antifogging solution.
Gently grasp the anterior portion of the patient’s tongue with a sterile, 4-by-4-in.
cotton gauze pad and hold it just outside the mouth. Ask the patient to take slow,
deep breaths through the mouth. Keep the light source focused on the patient’s
oropharynx while performing the exam. To avoid a gag reflex, pass the mirror into
the patient’s oropharynx without touching the mucosa of the oral cavity, soft palate,
or posterior oropharyngeal wall. Gently angle the mirror downward until you can
see the mucosal surfaces of the larynx and hypopharynx. Note that in mirror laryn-
goscopy, the image is inverted: the right vocal cord appears on the left side of the
mirror and the left cord appears on the right side of the mirror. Ask the patient to
say “e” (as in “eel”) and observe the dynamic motion of the true vocal cords and ary-
tenoid cartilages. The vocal cords will lengthen and adduct along the midline. The
anterior aspect of the larynx can be seen by asking the patient to say “e” in a higher
register. This maneuver fully exposes the anterior commissure, permitting complete
visualization (Fig. 1). To increase visualization, ask the patient to stand when you
Figure 1. The True Vocal Cords.
are seated and vice versa while performing the examination. The oropharyngeal val-
High-resolution freeze-frame digital
lecula and base of the tongue, as well as the hypopharynx (pyriform sinuses and laryngoscopy reveals the normal anat-
posterior pharyngeal wall), can also be seen with the mirror. Inspect these structures omy of the true vocal cords during
for symmetry and any potential mucosal abnormalities. phonation. In this image, anterior is
toward the bottom.
Fl e x ibl e L a r y ng os c opy

Preparation and Positioning

Setup for this exam is quick and easy. Before you begin, explain the procedure to
the patient and obtain consent. At the very least, the patient should provide verbal
consent, but increasingly, the use of written informed consent is recommended. As-
certain whether the patient has any allergies to medication or medical contraindi-
cations before performing the procedure. Prepare the patient’s nose by applying a
decongestant and an anesthetic agent to the nasal mucosa. Any delivery method,
whether by an atomized spray device or a plain syringe, is acceptable.
Administer the medication by opening the patient’s nose with a nasal speculum.

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The New England Journal of Medicine

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 The n e w e ng l a n d j o u r na l of m e dic i n e

Ask the patient to hold his or her breath during spraying to avoid inhalation of the
agents. Once the nose is adequately prepared, position the chair so that the patient’s
face is at eye level with yours. Then have the patient lean slightly forward, with
hands placed on the knees.

The Procedure
Place the tip of the laryngoscope into the nostril and slowly advance it lateral to the
septum and medial to the inferior turbinate. Visualize the inferior meatus and fol-
low along the inferior turbinate. Advance the scope posteriorly into the nose beyond
the middle turbinate along the nasal floor. Visualize the eustachian tube orifice (“the
torus tubarius”) lateral to the entrance of the nasopharynx. Visualize the adenoid
or the central lymphoid tissue of Waldeyer’s ring. Immediately posterior to the eu-
stachian tube opening is a shallow depression called Rosenmüller’s fossa. Because
nasopharyngeal carcinoma may arise from these recesses, this part of the exam
merits especially careful evaluation. Any bleeding when the mucosa is touched with
the tip of the laryngoscope should alert you to the possibility of nasopharyngeal
carcinoma.
Examine the posterior nasal septum and the nasopharyngeal aspect of the soft
palate. Ask the patient to breathe through the nose; this will separate the palate
from the posterior nasal wall and allow passage of the scope into the oropharynx.
From this location, the scope shows a panoramic view of the oropharynx below.
Continue to pass the scope inferiorly until you can easily visualize the larynx. The
true vocal cords should appear clean, white, and taut. Note any changes in the color
of the mucosa or any superficial irregularities. When the patient is breathing deep-
ly, the glottis remains wide open, with the vocal cords abducted. Some portion of
the subglottic larynx can usually be seen. The anterior ring of the cricoid cartilage
is often visible just below the true vocal cords. However, the laryngoscope should
not be passed through the true vocal cords, since contact can elicit laryngospasm.
Ask the patient to sniff or to inspire deeply through the nose. This causes maximal
vocal cord abduction, permitting optimal assessment of the larynx.5 Then, ask the
patient to say “e” or “ah” to assess the function and movement of the vocal cords and
arytenoid cartilages. Examine the epiglottis, arytenoids, aryepiglottic folds, false vocal
folds, true vocal cords, and subglottic region, or cricoid shelf.
Videostroboscopy can be performed to evaluate the patient’s speech. During hu-
man speech, a vibratory wave is formed as the vocal cords produce sound. Strobo-
scopic illumination of the larynx can reveal subtle alterations of vocal-fold vibration
that are not visible with standard laryngoscopy.6
The hypopharyngeal anatomy should be distinguished from both the larynx and
the oropharynx, using the boundaries of the aryepiglottic and pharyngoepiglottic
folds, respectively (Fig. 2). For all portions of this examination, advance the endo-
Figure 2. The Division between the scope as close to the tissue being examined as possible without making contact.
Larynx and Pharynx.
Touching the mucosa may elicit a gag reflex.
The oropharynx, supraglottic larynx,
The paired pyriform sinuses are visible on either side of the larynx. Ask the pa-
and hypopharynx converge on the
threefold region (pink, center). The tient to puff out the cheeks and hold them; this will push out the walls of the hy-
vocal cords are found below the popharynx, allowing for an easier and more complete view. Rotate the head from
supraglottic larynx and are not one side to the other to maximize visualization of lateral structures.
shown.

T ips a nd T roubl e sho o t ing

Occasionally, patients may not tolerate the mirror laryngoscopic examination be-
cause of a prominent gag reflex, apprehension, or discomfort. In these circumstances,
apply a mild topical anesthetic to the throat and allow sufficient time for the medica-

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 Examination of the Larynx and Pharynx

tion to take effect before reattempting the examination. Sometimes the procedure References
1. Laccourreye H. How do I study laryn-
simply cannot be performed; flexible laryngoscopy should be attempted in such geal mobility? Ann Otolaryngol Chir Cer-
cases. vicofac 1993;110:234-6. (In French.)
2. Diagnostic procedures and documen-
tation. In: Kleinsasser O. Tumors of the
A f terc a r e a nd C ompl ic at ions larynx and hypopharynx. New York:
Thieme, 1988:124-8.
Since laryngoscopy is generally painless, no postprocedure analgesia is necessary. 3. Ridley MB, Kelly JH, Marsh BR, Roa
A. Office diagnostic techniques: the adult
Patients should be advised to avoid eating and drinking for 1 hour after the applica- patient. In: Fried MP, ed. The larynx: a mul-
tion of lidocaine. Until mucosal anesthesia resolves, reduced laryngopharyngeal sen- tidisciplinary approach. 2nd ed. St. Louis:
sation might predispose the patient to aspiration. Otherwise, there are few compli- Mosby, 1996:57-64.
4. Hartnick CJ, Zeitels SM. Pediatric
cations associated with laryngoscopy. Epistaxis and hemoptysis are uncommon. video laryngo-stroboscopy. Int J Pediatr
Otorhinolaryngol 2005;69:215-9.
5. Poletto CJ, Verdun LP, Strominger R,
C onclusions Ludlow CL. Correspondence between la-
ryngeal vocal fold movement and muscle
Evaluation of the larynx and pharynx is an important part of a complete physical activity during speech and nonspeech
examination. Laryngoscopy by mirror or by flexible fiberoptic exam can be safely per- gestures. J Appl Physiol 2004;97:858-66.
6. Zeitels SM. Atlas of phonomicrosur-
formed in adults and children for benign or malignant conditions. With the advent gery and other endolaryngeal procedures
of multidisciplinary care for head and neck cancer, knowledge of laryngoscopy and for benign and malignant disease. San
laryngopharyngeal anatomy is important in an increasing number of medical spe- Diego, CA: Singular, 2001.
Copyright © 2008 Massachusetts Medical Society.
cialties.
No potential conflict of interest relevant to this article was reported.

n engl j med 358;3 www.nejm.org january 17, 2008

The New England Journal of Medicine

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Copyright © 2008 Massachusetts Medical Society. All rights reserved.