Optimal Position for Transnasal Flexible Laryngoscopy

Flexed-Neck Flexible Nasolaryngoscopy for Evaluation of the Subglottis and Trachea in Children

OBJECTIVE

Determine if a flexed-neck posture during flexible nasolaryngoscopy (FNL) improves visualization of the subglottis.

STUDY DESIGN

Retrospective review of children undergoing FNL in the neutral (FNL) and flexed-neck (FN-FNL) positions.

SETTING

Tertiary children's hospital.

METHODS

FNL was performed with each child's head in neutral and flexed-neck positions. Videos in each posture were captured and randomized. The most distal view of the subglottis in each position was evaluated with 4 rating scales: (1) subjective view (SV); of the subglottis and trachea, (2) airway grade (AG); most distal anatomical structure visualized, (3) airway area (AA); percentage of the subglottis visualized; and (4) modified Cormack-Lehane grade.

RESULTS

Twenty children had 80 FNL views blindly evaluated by 5 pediatric otolaryngologists. The SV, AG, and AA were all significantly better with the neck flexed compared to a neutral position (7.3 vs 3.0, interquartile range [IQR]: 2.0-6.8, P < .001; 2.3 vs 1.5, IQR: 1.0-2.0, P < .001; 3.4 vs 1.7, IQR: 2.3-3.8, P = .001). There was no difference in the modified Cormack-Lehane grade between positions. Interrater reliability was excellent or strong (0.93-0.94, confidence interval: 0.91-0.93).

CONCLUSION

FN-FNL is a simple maneuver performed in children undergoing FNL that partially improves the subjective visualization of the subglottis.

Clinical and Anatomical Variation During Assessment of Maximum Glottic Angle

INTRODUCTION

Quantitative measurement and analysis of glottic abduction is used to assess laryngeal function and success of interventions; however, the consistency of measurement over time has not been established. This study assesses the consistency of glottic abduction measurements across visits in healthy patients and anatomic factors impacting these measurements.

METHODS

Review of patients with two sequential flexible stroboscopic exams over seven months from 2019-2022. Images of maximal glottic abduction were captured and uploaded into and measured with ImageJ. Cadaver heads were used to assess the impact of visualization angles on glottic measurements with a monofilament inserted into the supraglottis of each cadaver as a point of reference. Comparisons were done with a paired T-test, T-test, or Mann-Whitney U test as appropriate.

RESULTS

Fifty-nine patients and twenty-six cadaveric exams were included. Absolute change in maximum glottic abduction angle (MGAA) was 6.90° (95% CI [5.36°, 8.42°]; p < 0.05). There were no significant differences in change in MGAA by gender or age. Twenty percent of patients had a change of at least 25% in their MGAA between visits. Absolute differences in glottic angle between nasal side for cadaveric measurements was 4.77 ± 4.59° (p < 0.005)-2.22° less than the change in MGAA seen over time (p = 0.185).

CONCLUSION

Maximal glottic abduction angles varied significantly between visits. Factors considered to be contributing to the differences include different viewing windows between examinations due to the position and angulation of the laryngoscope and changes in patient positioning, intra- and inter-rater variations in measurement, and patient effort.

LEVEL OF EVIDENCE

N/a Laryngoscope, 134:2793-2798, 2024.

Optimization of Subglottic View During Flexible Laryngoscopy With Patient Positioning

OBJECTIVE

Determine the ideal head position to optimize visualization of the subglottis using flexible laryngoscopy.

STUDY DESIGN

Prospective cohort study.

SETTING

Outpatient multidisciplinary airway clinic at a tertiary care center.

METHODS

Patients presenting to a multidisciplinary airway clinic undergoing nasoendoscopic airway examination were enrolled. Three head positions were utilized to examine the subglottis during laryngoscopy: "sniffing," chin tuck, and stooping positions. In-office reviewers and blinded clinician participants evaluated views of the airway based on Cormack-Lehane (CL) scale, airway grade (AG), and visual analog scale (VAS). Demographic data were obtained. Statistical analysis compared head positions and demographic data using Student's t test, analysis of variance, and Tukey's post hoc analysis.

RESULTS

One hundred patients participated. No statistical differences existed among in-clinic or blinded reviewers for the CL score in any head position (p = .35, .5, respectively). For both AG and VAS, flexed and stooping positions were rated higher than the sniffing positions by both in-clinic and blinded reviewers (p < .01 for all analyses), but there was no statistical difference between these two positions (p = .28, .18, respectively). There was an inverse correlation between age and scores for AG and VAS in the flexed position for both sets of reviewers (p = .02, <.01 respectively), and a higher body mass index was significantly associated with the need to perform tracheoscopy for full airway evaluation (p < .01).

CONCLUSION

Both flexion and stoop postures can be implemented by an experienced endoscopist in awake, transnasal flexible laryngoscopy to enhance visualization of the subglottic airway.

A Predictor of Difficult Airway: The Tasli Classification in Transnasal Flexible Laryngoscopy

INTRODUCTION

Difficult airway is defined as difficulty or failure in one or more steps in upper airway management. Evaluation of the upper airway with physical examination methods and endoscopic devices is crucial in predicting difficult airway. The aim of this study was to evaluate bedside tests, Cormack Lehane (CL) and Tasli Classification (TC) scores of the patients and it was aimed to reveal the role of TC which will be performed preoperatively as a predictor of difficult tracheal intubation (DTI).

METHODS

The study included a total of 98 patients who underwent surgical treatment under general anesthesia. Demographic data, including age, gender, and body mass index (BMI), and bedside tests consisting Modified Mallampati Classification (MMC), thyromental (TD) and sternomental (SD) distances, neck circumference (NC), interincisor distance (IID), CL and TC were recorded.

RESULTS

Evaluation was made of 64 (65.3%) male and 34 (34.7%) female patients ranging in age from 18 to 84 years (mean age: 50.35 ± 0.47 years). The successfully intubated patients (SIP)  group comprised 68 (69.4%) patients, and the difficult intubation patients (DIP) group, 30 (30.6%). According to CL, the numbers of SIP and DIP constituting grade 1 was 29 (42.6%) and one (3.3%); grade 2a was 29 (42.6%) and one (3.3%); grade 2b was eight (11.8%) and three (10%); grade 3a was one (1.5%) and six (20%); grade 3b was one (1.5%) and 14 (46.7%) respectively. Grade 4 was only detected in the DIP group in 5 (16.7%) patients. According to TC, the numbers of SIP and DIP constituting grade 1 was 20 (29.4%) and 1 (3.3%); grade 2a was 37 (54.4%) and seven (23.3%); grade 2b was 10 (14.7%) and 18 (60%); grade 3 was one (1.5%) and two (6.7%) respectively. Grade 4 was only detected in the DIP group in two (6.7%) patients.

CONCLUSION

The TC, CL, NC and BMI scores were higher in the DIP group and higher TC scores (grade 2b, 3, and 4) can be a predictor of difficult airway. However, it may be more beneficial to use TC as a complementary diagnostic tool with bedside tests such as NC, SM, TM and MMC, rather than used alone.

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

Background

Since many years, office-based flexible transnasal laryngoscopy is a common routine procedure. The development of new technical equipment such as high-definition cameras and flexible tip-chip endoscopes nowadays allows for much more precise examination than a few years ago. In contrast to rigid laryngoscopy, it is possible to move the tip of the endoscope close to the vocal folds and to other structures of interest. Nevertheless, without professional handling of the equipment, one cannot benefit from the potential of the newest technology.

Method

Two easily performed and very helpful maneuvers in flexible endoscopy are described. The “dipping maneuver” enables a maximum magnification of the mucosal surfaces of the endolarynx as well as the examination of the subglottal region and the trachea by positioning the tip of the endoscope very close to the vocal folds or even in the upper trachea during long transnasal inspiration. During the “rotation laryngoscopy”, the tip of the endoscope is positioned in the posterior interarytenoid region by rotating the flexible endoscope by 180° and advancing it close to the glottis. This allows a close-up examination of the anterior commissure, the inferior aspect of the vocal folds and the inside of the Morgagni’s ventricle. Before performing transnasal flexible endoscopy, we routinely apply topical anesthesia sprayed intranasally.

Conclusion

The described techniques of flexible endoscopy are easily performed and allow a maximum magnification of the mucosal surfaces and otherwise not visible regions of the endolarynx.