Evaluation of the larynx can be crucial in the diagnosis and management of common and life-threatening disorders. The approach to the patient with laryngeal dysfunction begins with obtaining a complete history. Symptoms may be related to any of the three primary functions of the larynx. These are protection of the lower airway from aspiration, a conduit of the airway, and phonation. Symptoms may include aspiration, cough, dysphagia, odynophagia, dyspnea, or hoarseness. Otalgia may be a referred symptom from the larynx and transmitted by a branch of the vagus nerve. Information regarding patient age, onset, duration, severity, and progressive nature of the process is necessary. Determine the patient’s past medical history including prior intubations, neck trauma, reflux esophagitis, similar previous episodes, and other systemic diseases. The social history, including smoking and alcohol usage, needs to be investigated. Medications, allergies, and over-the-counter drugs should be reviewed.
Perform a physical examination, including a complete head and neck examination, once the history has been obtained.1 Listen for stridor and watch for accessory muscle breathing. Consciously and critically evaluate the patient’s voice to hear breathiness, clarity, and volume. Inspect the ears, nose, oral cavity, oropharynx, and nasopharynx. Careful palpation of the neck is extremely important. Note any lymphadenopathy and neck masses. This must include their size, location, tenderness, and mobility. Palpate the larynx and note any crepitus. The lack of crepitus on lateral movement of the larynx over the vertebral bodies can be indicative of a laryngeal or hypopharyngeal mass. Note any movement with swallowing and asymmetry. This can help in determining the extent of a disease process.
Visualize the larynx after performing a complete history and physical examination with the exception of true airway emergencies. This allows the Emergency Physician to examine the larynx in context to the patient’s symptoms and other physical findings. It also allows a rapport to develop between the patient and Emergency Physician prior to undergoing a mildly invasive procedure.
There are four methods of performing indirect laryngoscopy: mirror laryngoscopy, nasal flexible fiberoptic laryngoscopy, oral flexible fiberoptic laryngoscopy, and rigid telescopic laryngoscopy. The following is a complete description of the procedure involved in performing each of these techniques. An excellent pictorial source for viewing normal and pathologic conditions of the larynx may be found in Bruce Benjamin’s publications.2,3 Table 206-1 reviews the advantages and disadvantages of each procedure. Each method allows visualization of the larynx with different degrees of distortion (Figure 206-1).
TABLE 206-1Summary of the Advantages and Disadvantages of the Different Techniques Used to Perform Indirect Laryngoscopy |Favorite Table|Download (.pdf) TABLE 206-1Summary of the Advantages and Disadvantages of the Different Techniques Used to Perform Indirect Laryngoscopy
| ||Hand-held mirror ||Per-oral flexible endoscopy ||Per-oral rigid endoscopy ||Nasal flexible endoscopy |
|Gag reflex ||Moderate ||Moderate ||Moderate ||Minimal |
|Visual clarity ||Good ||Good–distorted ||Superior ||Good–distorted |