NextGen Learning To Elevate Your Airway Practice

Meet the Expert

Lauren Brown MD

Lauren Brown is a faculty at PAC and an assistant Professor at Weill Cornell in the Dept of Otolaryngology-Head & Neck Surgery.

Indications

Nasopharyngoscopy does not need to be performed on every patient before intubation, but there are times when it is worth taking a look. Nasopharyngoscopy is indicated before intubation in situations where a thorough evaluation of the upper airway can help ensure a safe and effective airway management plan. Common indications include:

1. Suspected Airway Obstruction:
   • To assess for tumors, polyps, or structural anomalies in the nasal passages, pharynx, or larynx.
   • To identify obstructions caused by foreign bodies or edema.
2. Difficult Airway Anticipation:
   • In patients with a history of difficult intubation or prior airway surgery.
   • When physical examination (e.g., Mallampati score, limited neck mobility) suggests potential difficulty in airway access.
3. Evaluation of Vocal Cord Function:
   • To assess for vocal cord paralysis, dysfunction, or pathologies such as laryngeal stenosis or nodules that could complicate airway management.
4. Trauma Assessment:
   • In cases of maxillofacial trauma or suspected airway injury, to visualize structural integrity and determine the safest intubation approach.
5. Airway Masses or Infections:
   • For conditions like epiglottitis, abscesses, or cysts that could narrow the airway or complicate intubation.
6. Pre-Existing Airway Diseases:
   • For patients with conditions like subglottic stenosis, laryngomalacia, or tracheomalacia that require tailored intubation techniques.
7. Persistent Respiratory Symptoms:
   • Stridor of unclear origin, especially when intubation is planned.

Rapid Review

Topicalization

Basic Technique

90% of nasopharyngoscopy (NP) success is patient cooperation. To get that, you need to make them comfortable. Your ability to topicalize is the crucial first step in performing NP. Let’s go through it here.

1. Explain the Procedure: Inform the patient about the process, what they may feel, and the purpose of the numbing medication.
2. Position the Patient: Sit the patient upright comfortably with their head slightly tilted forward.
3. Gather Supplies:
   • Atomizer or spray device
   • Topical anesthetic (e.g., lidocaine 2-4%)
   • Decongestant (e.g., oxymetazoline or phenylephrine) to reduce nasal mucosal swelling

Tricks of the Trade

No pre-mixed drops? No problem!

1. Put 5-10 mL of 1-2% lidocaine into a new oxymetazoline spray bottle with a 25g needle.
2.  Insufflate the oxymetazoline spray bottle 2-3 times into the patient’s nose to atomize the anesthetic plus vasoconstrictive medication mixture.
3. Most people have excellent anesthesia in just a few minutes.  

See the full description of this hack here.

Anatomy

Basic Anatomy

Once you’ve started, it’s crucial to identify anatomy landmarks to find your way. This is very similar to laryngoscopy, except in this instance, you face the patient and have the extra task of traveling through the nasopharynx. So, let’s cover some basic anatomy to familiarize you with what you’ll see.

Clinical Anatomy

The Procedure

Rapid Review

Now, it’s time to perform the procedure. Play the rapid review a few times, particularly if you need a refresher. Then, dive into the full video below until you feel comfortable with the steps.

Full Procedure

Microskills

This poster has associated hands-on learning opporunities in our immersive and interactive physical space. If you’re with us in person, please make sure to visit the related station and use the self-guided resources here.

Practice tools

Curated MedEd

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