1. Goal For The Day An introduction to performing and interpreting the results of Endoscopy, FNP, FEES procedures. We can add a bit about FEES, too, so that voice and swallowing overlap. Remember, you’re still looking at the larynx.

2. General Goal #1 Familiarity with equipment l endoscope(s), l camera l cabling l light source l video capabilities

3. General Goal #2 Recognition of anatomical landmarks l Examination of nasal passage and velopharyngeal port l Positioning the scope for nasal endoscopic exam l contrasting rigid and flexible endoscopy

4. General Goal #3 Gain knowledge of the risks and the contraindications of FNP l Topical anesthesia vs. decongestants: l Vasovagal response l Specific risks and contraindications l Liability

5. Endoscopy l Direct Vs. indirect laryngoscopy l Rigid oral endoscopy l Flexible nasopharyngoscopy l Endo: as in “endolymph”--scopy as in scope---endoscope

6. Direct Laryngoscopy l Requires general anesthesia l Requires hospital admission for an out- patient surgical procedure done by a physician l Often employed when a biopsy is needed l Used with a variety of surgical procedures

7. Rigid Oral Endoscopy l Hopkins Rod; 70 and 90 degree l increased fiberoptic cabling = better visual resolution l placed in the oral cavity; effectively eliminates examination of the dynamic aspects of speech movements l straight light or stroboscopic light source

9. Indirect Laryngoscopy l Mirror laryngoscopy: head mirror, light source, warmed dental mirror; no magnification or video-recording l Flexible nasopharyngoscopy: provides a controlled view of the vocal tract

10. Flexible Nasopharyngoscopy (FNP) Basic instrumentation: l light source is mandatory l camera* l VCR* l monitor* l time/date/character generator* (* means it’s not mandatory)

12. Adverse Reactions l Discomfort l Nose bleed l Allergic reaction/hypersensitivity to topical anesthesia or nasal spray l Laryngospasm l Vasovagal response

13. Topical Anesthesia l Lidocaine HC1 2%---amide family, not related to Novocain, cetacaine)---use 1- 2 ml (PDR=10 ml/100# body weight) ->allergic reaction is rare; limited to nasal mucosa, reaction mile including swelling and erythema (Lancet, 1971)

14. Decongestant(s) l Oxymetazoline HC1 0.05% as is usually found in Allerest, Dristan, Neosynepherine, Sinarest

15. Laryngospasm Strong, aversive, mechanical stimulation of laryngeal structures, or food, liquid, GER entering laryngeal vestibule--->VC adductor spasm Prevention: don’t touch the FVC, TVC or the arytenoids

16. Vasovagal Response l Mechanical stimulation of the upper airway (especially the nasal passage) l Sympathetic NS reaction to emotional stimuli (fear, anxiety) increases heart rate, BP--”fight of flight mechanism: l If no action, bradycardia-->syncope l other causes of syncope:cardiac conditions, BP meds

17. Preventing Vasovagal Response l Reassure the patient l If acute cardiac condition, either don’t do FNP/FEES or monitor BP and cardiac rhythm l Ask about history of fainting l Anesthetize the nasal passage

18. Adverse Reactions l Perforation of the mucosa; bleeding most common effect l Stimulation of the vagus causing laryngospasm l Allergic reastion to topicals l Infection, sinusitis (if endoscope is not properly cleaned

19. Adverse Reactions, cont. l Laceration of pharyngeal mucosa, esophageal or pharyngeal perforation, mediastinitis l Aspiration pneumonia, from aspirating food, liquid, or oropharyngeal secretions l Laryngitis from abrasion/irritation of the mucosa within the laryngeal vestibule

20. Summary l FNP can be done by SLPs to examine a biologic function: laryngeal valving, swallowing and its disorders l FNP/FEES requires knowledgeable, intuitive and competent examiners l Change in Liability l Managed care vs. NHS Models