OTORHINOLARINGOLOGY

ENT ENDOSCOPY & APPLIED PHYSIOLOGY

Joel Aclan Romualdez, MD
First Shift: August 22, 2018

• Examination of the Larynx

• Indirect Laryngoscopy – mirror is directed downwards. Gauze
is needed to retract the tongue. Place the mirror at the space
Table of Contents within the oropharynx.
• Mirror Laryngoscopy
• Endoscopy
I. Overview .................................................................................1 • Nasal Endoscopy
II. Nose .......................................................................................1 • Indirect Laryngoscopy
A. Nasal Sinuses ................................................................1 o Rigid Telescopic Laryngoscopy
1. Sinusitis ......................................................................1 • Direct Laryngoscopy
• Flexible Nasopharyngolaryngoscopy
a. Acute Sinusitis ......................................................1
• Video Otoscopy – small tube connected to a very large
b. Chronic Sinusitis ...................................................1 monitor
c. Severe Sinusitis ....................................................1
2. Function......................................................................1 II. Nose
a. 3 Meatus ...............................................................1
A. Nasal Sinuses
i. Inferior Meatus ..................................................1
ii. Middle Meatus ..................................................1 • Interconnected hallow spaces in the skull
iii. Superior Meatus ..............................................2 • Walls are lined by mucus secreting membranes which may
become infected or inflamed because of cold or allergies and
B. Nose and the Lateral Nasal Wall ..................................2 block the nasal passages so that the fluid in the sinuses can’t
a. Nasal Cycle ...........................................................2 drain
b. Mucociliary Clearance ..........................................2
1. Sinusitis
i. Function .............................................................2
ii. Components .....................................................2 o Result of fluid in the sinuses which causes pressure and
pain
C. Examination of the Nose ...............................................2
1. Anterior Rhinoscopy ..................................................2 a. Acute Sinusitis
2. Posterior Rhinoscopy ................................................2 ▪ Less than 12 weeks
III. Larynx....................................................................................3 b. Chronic Sinusitis
A. Examination of the Larynx .............................................3
o More than 12 weeks
1. Mirror Laryngoscopy..................................................3
2. Endoscopy .................................................................3 c. Severe Sinusitis
3. Nasal Endoscopy .......................................................3 o May require surgical opening of the passage way
4. Rigid Telescopic Laryngoscopy ................................4 Two Methods to Relieve Sinus Pain
5. Flexible Nasopharyngeal Laryngoscopy ..................4 o Destruction of Ethmoid Sinus
6. Direct Laryngoscopy..................................................4 ▪ Since you have a sinus inflammation, it becomes like
an abscess, so you have to do incision and drainage.
IV. Ear.........................................................................................4 However, since it is the face, you cannot do this.
V. Conclusion .............................................................................5 o Balloon Sinuplasty
▪ Insert a non-inflated balloon in the sinus and then
inflate it so there can be drainage
▪ Problem: after several days, the sinus can close again
REMEMBER TEXTBOOK EDITOR PREVIOUS TRANS
2. Function
   
o Breathing/Ventilation
o Immune Defense
This trans follows the content and format of the ppt supplemented
o Mucociliary Clearance
by Doc Romualdez.
o Nonspecific/Specific Immunity (enzymes, interferons,
lymphocytes, immunoglobulin)
I. Overview o Temperature regulation and humidification
▪ Ex: If you are living in the desert or in the north or south
• It is important to know when to require endoscopy and when pole, without the nose your lungs could dry up and burn
to require physical examination. or freeze.
For the ear:
1. Inspection – Inspect everything around the area a. 3 Meatus
2. Palpation i. Inferior Meatus
3. Auscultation – performed in certain diseases  Nasolacrimal duct drains here. Sometimes you feel like
e.g. tinnitus – you have to basically hear where the sound you have colds because it is basically the tears going
is coming from a certain source down the duct
• Examination of the Nose
o Anterior Rhinoscopy ii. Middle Meatus
o Posterior Rhinoscopy – you need a smaller mirror directed  Frontal, maxillary, anterior ethmoid sinuses drain here
upward

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CONCEPCION | ALER • ALINSAÑGAN • AZUCENA • CAMACHO • CHAN
 ENT ENDOSCOPY & APPLIED
PHYSIOLOGY
iii. Superior Meatus ▪ Ciliated because there is a mechanism for it to clean
 Drainage of sphenoid and posterior ethmoid sinuses itself
▪ Mucociliary flow is going posterior
If you see a discharge from a certain meatus, you will know
where the sinusitis is. For example, you have a superior meatus i. Function
discharge, this can only come from sphenoid and posterior  Humidification
ethmoids  Cleaning of inspired air
 Eliminate debris
B. Nose and the Lateral Nasal Wall
ii. Components
• Turbinates  Ciliated, pseudostratified columnar epithelium
o Lateral bony  Goblet cells – produce mucus that forms a layer to trap
protrusions covered foreign materials
by ciliated columnar  Cilia – mobilizes the mucus layer removing the foreign
epithelium matter and prevents it from entering the lungs
 Mucus
How to Differentiate  Gel Phase: Superficial, more viscous
Nasal Polyp and  Sol Phase: deep, less viscous
Turbinate:
 Composition of mucus
o Perform anterior
 Water (95%)
rhinoscopy  Glycoproteins (3 %)
o Nasal polyp –
 Electrolytes (1-2%)
whitish glistening Figure 1| Lateral Wall of Nasal Cavity
kaong-like material C. Examination of the Nose
o Decongest the patient using oxymetazoline which will shrink
1. Anterior Rhinoscopy
the nasal turbinate. If it is polyp, it won’t decongest.
o Turbinate: very painful when touched; bleeds easily once
you touch it.
o Polyp: No sensation of pain when touched; less bloody
These are the reasons why when performing the anterior
rhinoscopy, we have to do it first without decongestion then
with decongestion to see the effect of the decongestant.
o Rhinitis medicamentosa – rebound nasal congestion
caused by using decongestant more than 5-7 days
o Too much medication in the nose give instant relief but after
Figure 3| Anterior rhinoscopy
sometime it becomes more congested
o Vick’s inhalers – the feeling of decongestion is due to
o Indications:
menthol receptors in the trigeminal nerves but in reality the
▪ Used to examine most of the pathologies in the nose |
size of the sinuses are still the same
▪ Evaluation of nasopharynx & posterior choanae
a. Nasal Cycle ▪ Minor procedures
▪ Nasal packing
▪ Gives the turbinates more time to clean themselves ▪ Foreign body removal | 
▪ Physiologic  Decongestion is the most important procedure prior
▪ Alternating congestion/decongestion of turbinates to foreign body removal | 
▪ Regulated by autonomic nervous system ▪ Polypectomy
 Parasympathetic: dominates over sympathetic; more o Cannot be used to adequately assess the middle meatus,
discharge, more congestion middle turbinate, posterior portions of the nasal cavity and
 Sympathetic: dry nose, less congestion the nasopharynx | 
▪ Can also be caused by medication: e.g. patient taking
anti-HTN medication – they will also have congestion 2. Posterior Rhinoscopy
▪ Every 2-7 hours depending on the individual
b. Mucociliary Clearance

Figure 4| Technique for inspecting the nasal cavity

o Technique:
▪ You need a smaller mirror directed upward
▪ Tongue depressed with blade. Small mirror introduced
Figure 2| Mucociliary Cearance between soft palate and posterior pharyngeal wall
o Indications:
▪ Respiratory epithelium – ciliated pseudostratified
columnar epithelium with goblet cells

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 ENT ENDOSCOPY & APPLIED
PHYSIOLOGY
▪ Examination of the nasopharynx and posterior choanae
(formerly, now obsolete with the establishment of
endoscopy) | 
3. Nasal Endoscopy
o To examine nasal pathologies
that are difficult to visualize
E.g. Small polyps in the
osteomeatal unit | 
o To examine nasal pathologies
Uses:
 Nasal obstruction
 Epistaxis
 Anosmia/Hyposmia
 Foul-smelling discharge
 First Pass Figure 6| Microanatomy of the Vocal Fold
▪ Nasal floor
▪ Nasolacrimal Duct A. Examination of the Larynx
▪ Nasopharynx

 Second Pass Figure 5| Nasal Endoscopy

▪ Middle meatus
▪ Osteomeatal Complex
▪ Sphenoethmoid recess
 Third Pass
▪ Frontal recess
• Technique:
D. Swallowing o Patient’s tongue pulled
• Phases of swallowing: forward using gauze
o Long finger retract patient’s
o Oral Phase
upper lip
▪ Oral Preparatory – chewing food so that it will
o Warm mirror elevates uvula
become bolus
o Patient is asked to phonate
▪ Oral Propulsive – bolus will go to the base of tongue
and trigger swallowing reflex. o Strobe light in stroboscopy
▪ Used to view the vocal cords so in a way it will be
moving in slow motion but in reality it is moving in a
This is why we have to chew food properly because even if
very fast motion that our naked eye cannot see
food is still whole but once it reached the base of the
o Vocal folds
tongue and triggers the reflex, you would have no choice
▪ During inhalation/exhalation, vocal cords are open and
but to swallow it.
abducted
▪ High notes – vocal folds are stretched by virtue of
o Pharyngeal Phase
cricothyroid muscle. Cricothyroid muscle will contract
▪ Most complicated
and will move the cricothyroid joint and this movement
▪ Nasopharynx has to be closed.
▪ Soft palate will move towards posterior pharyngeal will stretch the true vocal folds.
wall. 1. Mirror Laryngoscopy
▪ Patients with cleft palate – nasal regurgitation
▪ Protect airways – close vocal folds. Epiglottis will
move up and prevent bolus from entering.

Patients with neurological problems such as stroke (no

proper coordination) could lead to aspiration and even
death.

o Esophageal Phase
2 ways food is propelled through the esophagus:
▪ Esophageal peristalsis
▪ Gravity

III. Larynx 2. Endoscopy

• Function: o Structural Assessment
o Airway protection – most primitive o Functional Assessment
o Respiration o Benefits:
o Phonation – sound and speech 1. Provide close-up
• Microanatomy of the Vocal Fold views of small spaces
o Loose and pliable superficial mucosal layers vibrate freely 2. Screening and early
over the stiffer structural underlayers detection
3. Avoids skin incisions
and scars in procedures/surgeries

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 ENT ENDOSCOPY & APPLIED
PHYSIOLOGY
o Equipment:
▪ Rigid Endoscopes
 Diameter: 2.8
(children), 4mm,
6mm, 8mm
 Angle: 0, 30, 70, 90
degrees
▪ Flexible Endoscopes
 Outer diameter: 3-4mm
o Preparation:
▪ Decongestion of nasal mucosa using oxymetazoline
▪ Topical anesthetic should be applied (Lidocaine)
3. Rigid Telescopic Laryngoscopy
o Dysphonia/Hoarseness
o Dysphagia
o Chronic cough
o Foreign body

4. Flexible Nasopharyngeal Laryngoscopy Figure 8|

Figure 7|
o Place the scope into the nose going to the nasopharynx
then oropharynx until you reach the laryngopharynx where
you visualize the different parts of the pharynx including the Figure 9| Images with different exams
vocal folds. You can perform this with the patient under
local anesthesia (e.g. lidocaine spray) o Indirect – left becomes right; right becomes left, but anterior
Table 1| Rigid vs Flexible |  and posterior remains the same.
RIGID FLEXIBLE o Telescopic/Fiber optic – posterior and anterior exchanged
ADVANTAGES 1. High 1. Dynamic evaluation of o Direct – no mirroring
resolution larynx
2. Image 2. Permit examination of IV. Ear
more nasal cavity in same • Right ear – angle of malleus situated at 1o’clock
magnified setting • Left ear – angle of malleus situated at 11 o’clock
3. One hand Good for patients with • Tuning fork exams
use hypergag reflex |  o Rinne – bone conduction vs air conduction
DISADVANTAGES 1. Limited 1. Weak light intensity ▪ Bone conduction
phonation 2. Poorer resolution  Tuning fork placed on the mastoid would
2. Problems 3. Two-hand use! directly stimulate the cochlea. From the inner
with gag ear, by-passing the outer and middle ear.
relex |  From their it would move the cochlear fluids
and there will be a stimulation of the nerve
5. Direct Laryngoscopy going to the temporal lobe.
▪ Air conduction – usual pathway of the ear
o Place the laryngoscope in the upper airways to visualize the o Weber – lateralization
larynx ▪ Used for unilateral hearing loss. It would be
o Provides direct view into larynx confusing if used with bilateral hearing loss
o General anesthesia o Conductive hearing loss | 
o May use microscope for detailed examination ▪ Bone conduction > Air conduction
o Laser delivery systems for therapeutic applications ▪ Sound will be heard better in the pathologic ear.
Patients come to the clinic complaining of hearing
Suspension laryngoscopy/direct laryngoscopy is under loss with low voice volume because they can hear
general anesthesia. It can be used to take out nodules, do themselves.
biopsies. Can use both hands to handle patients unlike o Sensorineural hearing loss | 
flexible and rigid only one hand. ▪ Air conduction > Bone conduction
▪ Sound will be better in the good ear. Patients come
to the clinic complaining with a loud voice because
they can’t hear themselves.
o Video otoscopy

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PHYSIOLOGY
▪ ask the patient to close nose and do Valsalva
maneuver, or to swallow (Toynbee maneuver). It
will cause increase pressure to the eardrum causing REFERENCES
movement.
• Lecture
• Tympanagram | 
o Bell-shaped (Type A) – normal. Pressure within +/- 100
DPa (decaPascals)
o Flat tympanagram (Type B) – no movement of tympanic
membrane may be due to problem with external
auditory canal, perforated tympanic membrane, fluids in
the middle ear.
o Type C (bell shifted to the left) – may be due to
Eustachian tube dysfunction such as during colds, acute
viral rhinitis. More negative middle ear pressure. That
is why when you have colds, you will also have difficulty
hearing.

V. Conclusion
• Thorough examination of the Ear, Nose, and Throat is vital
in the evaluation of diseases in the field of Otolaryngology
Head and Neck Surgery
• Endoscopy can aid in the extensive examination of patients
with ENT disorders; playing role in the accurate diagnosis
and complete management of patients
VI. Pre-Test
1. On fiberoptic laryngoscopy, which figure below will show the
proper orientation of the larynx?

2. A 46/F known asthmatic, consulted due to a 3–month history

of bilateral nasal obstruction. She has frequent colds and
sneezing since childhood. Upon anterior rhinoscopy,
bilateral glistening masses were seen. What is the most
likely diagnosis? Polyp
3. A 50/F consulted due to a 3-month history of unilateral nasal
obstruction, anosmia and headache. What endoscopic
procedure would be most appropriate to perform? Nasal
endoscopy
4. A 20/M complains of daily nasal congestion upon waking up
in the morning that alternates in both sides of the nasal cavity
lasting several hours. Anterior rhinoscopy revealed pinkish
normal-sized turbinates bilaterally, septum midline with no
mass and no abnormal discharge appreciated. What can
explain the patient’s symptoms? Nasal cycle
5. A 28/F call center agent consulted for hoarseness of 2-week
duration. She denied having cough, colds, and fever. She
does not smoke nor drink alcoholic beverages. She is also a
member of the church choir and joins singing contests.
Given the laryngoscopy findings below, what is your most
likely diagnosis? Nodule

VII. Post-Test

1. What endoscopic procedure would be the most probably be

performed with a 3 month history of facial pain, purulent
discharge and anosmia? Nasal Endoscopy

2. What endoscopic procedure would be most appropriate to

enable a dynamic evaluation of laryngeal movement exam
on a patient? Flexible Nasopharyngeal Laryngoscopy

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