Can transnasal flexible fiberoptic laryngoscopy contribute to airway management decisions?

Abstract

Nasal endoscopic airway assessment is part of a common practice for otolaryngologists, especially those who are involved with head and neck oncology cases. Transnasal flexible fiberoptic laryngoscopy is a type of procedure that can be performed easily in an office environment under the combination of a topical anesthetic and a decongestant without resulting in any major patient discomfort (Fig. 1). Sawashima and Hirose developed today’s understanding of transnasal flexible fiberoptic endoscopy. Although it is named a laryngoscope, it actually provides excellent visual examination access to the nose, pharynx, posterior pharynx, epiglottis, and larynx, essentially all of the upper airway to the glottis. Pharyngeal and laryngeal functioning can be visualized easily in spontaneously breathing patients without much patient discomfort. Because it provides excellent access to the airway area of interest, transnasal flexible fiberoptic endoscopy has gained widespread acceptance among many types of medical specialists including otolaryngologists, emergency physicians, and speech-language pathologists. Currently, speech pathology specialists assess the swallowing process using a transnasal flexible fiberoptic laryngoscope. This procedure is called flexible endoscopic evaluation of swallowing, and it is the “gold standard” for the functional assessment of swallowing. Despite its well-established role in assessing the airway and swallowing, however, transnasal flexible fiberoptic laryngoscopy is not a frequently used airway assessment technique by anesthesiologists. As anesthesiologists, we continually deal with expected and unexpected difficult airways. Transnasal flexible fiberoptic laryngoscopy is one of the tools that we have recently started to use in patients in remote (outside the operating room [OR]) locations in collaboration with our otolaryngologist colleagues. We sometimes use the transnasal flexible fiberoptic laryngoscopy technique in conjunction with our otolaryngology colleagues in the emergency room, at other times in the ear-nose-throat clinic, and rarely in the preoperative holding area. This easy-to-use fiberoptic laryngoscopic technique helps us to make definitive management plans in potentially difficult airway cases including traumatized airway cases and airway malignancies. In this month’s issue of Anesthesia & Analgesia, Dr. Rosenblatt et al. present a very interesting airway article. The investigators used this technique to guide their airway assessment and anesthesia induction plans. They sought to determine whether preoperative (nasal) endoscopic airway evaluation (PEAE) affected airway management in patients with known upper airway pathology. The authors used transnasal flexible fiberoptic laryngoscopy to assess the upper airway down to the glottis, and concluded that PEAE affected their airway management in 26% of the patients. In a great majority of patients, PEAE supported decreased use of awake fiberoptic intubation, which possibly decreased anesthesia care time, increased patient comfort, and overall diminished the level of invasiveness. In a smaller percentage, PEAE emphasized the need for awake fiberoptic intubation, although the initial plan called for direct laryngoscopy after induction of general anesthesia. In addition to bringing the practical use of transnasal flexible fiberoptic laryngoscopy to our preoperative holding area, Dr. Rosenblatt et al. relayed a very important message in their article: transnasal fiberoptic laryngoscopy improves the safety of managing both our known and unpredictably difficult airway patients. We thus recommend that the reader focus more on the patient safety outcome obtained in the 8 patients in whom an awake tracheal intubation was not planned initially (false negatives), but who underwent awake intubation after PEAE. We believe that this benefit has a higher priority outcome compared with the potential benefit of improved patient comfort achieved from canceling awake intubation plans in 28 cases after PEAE (false positives). As the difficult airway team instructors, we believe that awake intubation is probably one of the most important skills that an anesthesiologist needs to master. The fear of potential patient discomfort (associated with awake fiberoptic attempts) should not supersede the critical safety measure gained by From the *Department of Anesthesiology & Perioperative Medicine, Neuroscience Intensive Care Unit, University of Louisville, Louisville, Kentucky; and †Outcomes Research Consortium.

DOI: 10.1213/ANE.0b013e31820a146d

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Cite this paper

@article{Aka2011CanTF, title={Can transnasal flexible fiberoptic laryngoscopy contribute to airway management decisions?}, author={Ozan Akça and Rainer Lenhardt and Michael F Heine}, journal={Anesthesia and analgesia}, year={2011}, volume={112 3}, pages={519-20} }