Direct Laryngoscopy

This test allows visualization of the larynx by the use of a fiber-optic endoscope or laryngoscope passed through the mouth and pharynx to the larynx. It's indicated for children, patients with strong gag reflexes due to anatomic abnormalities, and those who have had no response to short-term therapy for symptoms of pharyngeal or laryngeal disease, such as stridor and hemoptysis. Secretions or tissue may be removed during this procedure for further study. The test is usually contraindicated in patients with epiglottitis but may be performed on them in an operating room with resuscitative equipment available.

Purpose

• To detect lesions or strictures and to remove benign lesions or foreign bodies from the larynx
• To aid diagnosis of laryngeal cancer
• To examine the larynx when indirect laryngoscopy is inadequate

Patient preparation

• Explain to the patient that this test is used to detect laryngeal abnormalities.
• Instruct the patient to fast for 6 to 8 hours before the test.
• Tell him who will perform the procedure and where it will be performed.
• Inform the patient that he'll receive a sedative to help him relax, medication to reduce secretions and, during the procedure, a general or local anesthetic. Reassure him that this procedure won't obstruct his airway.
• Make sure the patient or a responsible family member has signed an informed consent form.
• Check the patient's history for hypersensitivity to the anesthetic.
• Obtain baseline vital signs.
• Administer the sedative and other medication (usually 30 minutes to 1 hour before the test).
• Before the patient receives the sedative, instruct him to remove dentures, contact lenses, and jewelry and ask him to void.

Equipment

Laryngoscope, sedative, atropine, local anesthetic (spray or jelly) or general anesthetic, sterile container for microbiology specimen, sterile gloves, Coplin jar with 95% ethyl alcohol for cytology smears, container with 10% formaldehyde solution for histology specimen, forceps for biopsy, emesis basin, suction and resuscitation equipment

Procedure and posttest care

• Place the patient in the supine position.
• Encourage him to breathe through his nose and to relax with his arms at his sides.
• A general anesthetic is administered, or the patient's mouth and throat are sprayed with a local anesthetic.
• A laryngoscope is introduced through the patient's mouth, the larynx is examined for abnormalities, and a specimen or secretions may be removed for further study; minor surgery, such as removal of polyps or nodules, may be performed at this time.
• Place the specimens in their respective containers.
• Place the conscious patient in semi-Fowler's position; place the unconscious patient on his side with his head slightly elevated to prevent aspiration.
• Check vital signs every 15 minutes until the patient is stable and then every 30 minutes for 4 hours, every hour for the next 4 hours, and then every 4 hours for 24 hours. Immediately report to the doctor any adverse reaction to the anesthetic or sedative.
• Apply an ice collar to minimize laryngeal edema.
• Provide an emesis basin, and instruct the patient to spit out saliva rather than swallow it. Observe sputum for blood, and report excessive bleeding immediately.
• Instruct the patient to refrain from clearing his throat and coughing to prevent hemorrhaging at the biopsy site.
• Advise the patient to avoid smoking until vital signs are stable and there is no evidence of complications.
• Immediately report subcutaneous crepitus around the patient's face and neck, which may indicate tracheal perforation.
• Listen to the patient's neck with a stethescope for signs of stridor and airway obstruction.

Clinical Alert: Observe the patient with epiglottitis for signs of airway obstruction, and immediately report signs of respiratory difficulty. Keep emergency resuscitation equipment available; keep a tracheotomy tray nearby for 24 hours.

• Restrict food and fluids to avoid aspiration until the gag reflex returns (usually within 2 hours). Then the patient may resume his usual diet, beginning with sips of water.
• Reassure the patient that voice loss, hoarseness, and sore throat are temporary. Provide throat lozenges or a soothing liquid gargle when his gag reflex returns. .

Precautions

• Send the specimens to the laboratory immediately.

Normal Findings

A normal larynx shows no evidence of inflammation, lesions, strictures, or foreign bodies.

Abnormal findings

Indirect laryngoscopy may reveal inflammation, lesions, or polyps. The combined results of direct laryngoscopy, biopsy, and radiography may indicate laryngeal carcinoma. Direct laryngoscopy also may show benign lesions, strictures, congenital abnormalities, and foreign bodies.

Interfering factors

• Failure to place the specimens in appropriate containers or to send them to the laboratory immediately
• Patient's inability to cooperate with the procedure