FNE - Fibreoptic Nasendoscopy

Nasendoscopy is a diagnostic procedure. It can help to investigate the upper aerodigestive tract for everything from nasal foreign body through to malignancy. The ability to perform a FNE is an essential skill for ENT surgeons, who often rely heavily on this quick, inexpensive and relatively simple/safe procedure.

During the procedure a small flexible endoscope is used to visualise and examine the nasal cavity, the nasoparhynx, the oropharynx and the laryngo-pharynx. The area to be examined is illuminated by light from fibreoptic cables within the scope, and images transmitted to either a viewing port on the end of the scope or to a monitor. Video or photographs of the examination can be made.

 Common indications

  •   Nasal Cavity

    • Recurrent epistaxis

    • Chronic sinusitis 

    • Suspected nasal polyps

    • Suspected malignancy

  • Nasopharynx

    • Suspected malignancy

  • Oropharynx/Laryngopharynx

    • Foreign body ingestion (e.g. fishbone)

    • Dysphonia/Hoarseness

    • Dysphagia/Odynophagia

    • Lingual/pharyngeal tonsil pathology

    • Laryngomalacia

    • Obstructive sleep apnoea

  • Miscellaneous

    • Pre-operative vocal cord check prior to thyroidectomy

    • Post-operative assessment of pharyngeal grafts/FESS patients

    • Difficult/complicated NG tube insertion (e.g. laryngectomy patients)

Relative contraindications:

  • Craniofacial trauma:

    • Discuss with ENT SpR/Senior – weigh benefits against risk of potential exacerbation of nasopharyngeal injuries

  • Coagulopathies:

    • Discuss with ENT SpR/Senior - increased risk of bleeding with minor trauma during the procedure

Contraindications:

  • Epiglotitis:

    • Only to be performed by SpR/Consultant/ Experienced personnel due to risk of inducing laryngospasm/ further airway compromise

  • Croup/paraglottic disease:

    • Discuss with SpR/senior – only to be performed if symptoms suggest anatomic or congenital abnormalities

Equipment

  1. Flexible fibreoptic nasendoscope

  2. Light source

  3. Camera and video screen (if applicable) 

  4. Personal protective equipment (non-sterile gloves + consider eye/mouth protection)

  5. Topical decongestant/anaesthetic spray (Co-Phenylcaine)

  6. Lubrication gel

  7. Alcohol wipe

  8. Tissues

  9. Kidney dish

  10. Trolley

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

Procedure

 

The procedure can be broken down into four stages, preparation, passing the nasendoscopy, examination and recording of findings.

 

Stage 1: Preparation

 

  • 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 local anaesthetic spray is used warn them it tastes bitter AND they cannot have food or drink for one to two hours after; rarely they may react to the topical spray

    • Benefits: It gives a lot of important information quickly

    • Obtain informed verbal consent

  • Obtain equipment as listed above 

  • Check the light source, then connect the scope to the light source/screen ⱡ*

  • Position the patient: -

    • Sit upright, head slightly flexed and resting on a support

    • Give them some tissues and a bowl

  • Squirt some lubricant jelly on tissues

  • Where indicated use topical anaesthetic spray into one or both nostrils

    • Note: The majority of patients tolerate the scope without any spray

    • If there is a lot of nasal oedema and mucus on initial inspection Co-Phenylcaine or Xylometazoline (OtrivineTM) spray may help reduce this after a few minutes

 

Stage 2: Passing the nasendoscope

 

  • Get the patient to sniff and tell you which nasal passage they think is more patent 

  • Put on non-sterile gloves

  • Examine and assess the patency of each nostril and determine which would be easier to attempt

    • For nasal conditions, you will need to visualise both nasal passages. For examination of the throat, you can use only one side

  • Hold the scope in your dominant hand 

    • Movement of the tip is approximately 90 degrees about the vertical plane only

    • The mechanism can be operated with either the thumb or index finger. Either is acceptable and is entirely user dependent  

 

 

 

 

 

 

 

 

 

 

 

  • Check orientation and white balance 

    • Using something with writing is easiest for this e.g. the back of the white lubricant jelly sachet

  • Apply a small amount of lubricant jelly to the end of the scope (about 2cms away from the tip so as not to obscure the camera)

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

  • Ask the patient to breathe deeply through their nose when moving from nasopharynx to oropharynx as this opens up their soft palate.

Stage 3: Examination

 

  • With your non-dominant hand, hold the end of the scope (just proximal to where you have applied the lubricant jelly) between your thumb and index finger.

             Technique varies so find what suites you best.

  • Gently guide the tip of the scope through the chosen nostril, resting your middle and or ring finger of your non-dominant hand on the patient's nose/cheek

  • Advance the scope under direct visualisation in a horizontal direction along the nasal floor 

    • Following the junction between the nasal septum and floor is the easiest path

    • Stay below the inferior turbinate to ensure correct placement 

    • Assess and observe for any abnormal anatomy or pathology – take pictures ⱡ if appropriate

  • The first resistance you should meet is the posterior pharyngeal wall  

  • Angle/direct the tip of the scope downwards (and slightly medially) using the switch

    • If fogging occurs, gently touch the tip of the scope to the posterior pharyngeal wall OR ask the patient to swallow

  • Slowly advance the scope forward until the larynx come into full view

    • Assess and observe for any abnormal anatomy/pathology -– take pictures ⱡ if appropriate

  • Observe for movement of the vocal cords and airway patency with breathing and phonation 

  • Perform the following manoeuvres to improve visibility:

    • Asking the patient to protrude their tongue allows examination of the tongue base/valleculae

    • Asking the patient to blow their cheeks out gives a clearer view of the pyriform fossae

    • Asking the patient to say “eeeeee” or counting numbers allows assessment of the vocal cords – they should symmetrically ADduct against each other in the midline; breathing ABduct the cords equally

  • Examine for: 

    • Asymmetry; Abnormal growths; Increased erythema/hyperaemia; Ulceration.

    • Take pictures +/- video if appropriate 

  • Once happy, slowly withdraw the scope under direct vision, and once again examine for abnormal anatomy/pathology on the way out

Stage 4: Record your findings

 

  • Document the procedure and any findings in the patient’s notes (it is usually advised to add a visualised sketch to the notes, identifying all the major structures mentioned above

  • If pictures were taken, these should be printed and attached to the patient’s notes with a patient sticker (see the following section for details)

 

  • Comment on the following when documenting:

  1. Entry: Easy or difficult

  2. Presence of any septal abnormalities 

  3. Presence of any polyps (grade I-III)

  4. Comment on the tongue base

  5. The epiglottis i.e. presence of oedema/erythema/epiglottitis 

  6. The vocal cords: 

    1. Position and whether movement occurs symmetrically or asymmetrically 

    2. Presence of nodules? (bilateral nodules are usually benign i.e. singer’s nodules

    3. Presence of cord swelling? i.e. Reinke’s oedema 

    4. Presence of any plaques or candidiasis 

  7. The vallecula

  8. The arytenoids (inflamed in GORD)

  9. Folds: Vestibular fold, vocal fold and aryepiglottic fold

  • Abnormalities should be reviewed by a senior

  • Arrangements should be made for formal microlaryngoscopy/ panendoscopy +/- biopsy where an abnormality is detected

  • Note: When using the portable scopes from theatre, complete the two self-explanatory sheets with patient labels (one to stay in the notes, the other to return with the scope)

  • Note: When using SDMU/Ward scope, a cleaning traceability sticker should also be kept in the patient’s notes

 

Post Procedure

 

  • If local anaesthetic spray used, warn the patient not to eat and drink for one to two hours until the local anaesthetic wears off

  • If the patient feels faint, lie them backwards and raise their legs