Great, hello there. Today we'll be showing you how to perform a flexible nasal endoscopy. This is a procedure really used as an extension of your examination when you're assessing someone in an ENT clinic or an acute. setting to see how their larynx look like and hopefully we can teach you to make it a little bit easier for yourself and for the patients by a few tips and then we've got a stack here which as we do the procedure on Dr Ringrose we can have a look at the different structures and what to look out for. So obviously it's always important to introduce yourself which I'm sure you always do.
It's important to adhere to your local protocol as this is an aerosol generating procedure and currently we're operating during the pandemic's time so it's important to know what the local policy is when you're performing this procedure in some way. with safe for yourself and for the patient. So I'm just going to go ahead and introduce myself Hi Dr Rigos, Rosario, one of the ENT doctors, thanks very much for coming.
What we're going to do today is we'd like to have a look at your vocal cord, that's your voice box, which generates sound and also acts as a gateway to your airway, really your air pipe. So just to find out a little bit more why you've been suffering with symptoms that you have. Would that be alright with you? That's fine. Great.
Have you ever had this procedure before? I've not before, no. Great. I'm going to take you step-by-step through what we're doing.
If you have any questions at any point, please do ask me and we'll take it further. Great. So broadly, we're going to use this camera here. It looks a little bit long, but that's just to make it easier for me to use.
I'm going to use not very much of this camera at all. It's a fibre optic camera, and it's got a light source hit, so it just allows me to have a look at the TV there, so we can see what's going on. Would that be all right with you? That's fine. Fantastic.
In every patient, when you're performing a flexible nasoendoscopy, you should always discuss or ask them whether they would like to have a nasoendoscopy. have the local anaesthetic. We tend to use the combination of phenylephrine and lidocaine.
And the two aspects of this is, first of all, we do local anaesthetic, making the procedure a little bit easier for the patient, more tolerable. And also it's got some phenylephrine which essentially acts as a decongestant. So it makes the first part of the procedure, which is going through the nose, a little bit easier for the patient.
So the tissue are slightly reduced in size and not identified. So, do you have any allergies to anything, sir? Not that I know of. Right, so I'm just going to use this solution. I'm afraid it doesn't taste very nice.
Yeah. If you swallow it, that's okay. you want to spit it out that's fine as well. We can provide you with some tissue and a bit of bollocks so you can do that.
How are you breathing through your nose? Do you have any difficulty breathing through one side or the other? Sometimes a bit blocked on the nose.
Is it blocked today? It was okay today. Great, fine.
Can you take a nice dip of that through your nose? That's all nice and open. So I'm just going to spray this solution into your nose and forgive me if it doesn't taste very nice. I'm just making sure that this is easier for you. So what I usually do, I place my hands on the patient's head and lift the tip of the nose so you can see the intruder's nose on each side and then you can just spray.
under the solution on both sides. Great, thank you very much Dr. Lewis. If you could just do a little bit of a snip of whatever comfort tissues you need to use it. Fantastic.
As we're looking inside your nose, it shouldn't be uncomfortable. If it is uncomfortable at any time, you just put your hands up and I'll stop. Yeah, sure.
You'll be good. And what I would like you to do is to keep your neck still and look straight ahead and bring your head down a little bit. Great. And you can look at the screen and see the... Nice deep breaths in and the more you breathe through your nose the easier job is for me to have a look because the air allows me to go in a little bit easier.
First of all if you stick your tongue out I'm going to warm up the tip of my scope so it doesn't... I'm not asking too much as we look inside. That's great, thank you.
Lovely. And if you take a nice deep breath in, we'll just have a look, and then again, don't forget to ask me to stop if I'm causing discomfort. Okay, right. So I'm looking from the right side. As you can see at the top of the picture, you've got the inferior turbinate.
To the right of the picture is the septum, and the left side, you've got the lateral aspect of the nose. What I'm trying to do... is just to go through this gap here without touching any tissue because it's going to be uncomfortable for Dr. Ringrose and gently pass it through and sticking to the floor of the nose without touching it and as you can see I'm not touching the scalp at all at this point I'm just going straight back this is the porcelain nose of the space here and what I'm doing now I'm just rotating my camera without touching anything and we're trying to take a look at the Rosenmüller Fosse which is further up so it's top left of the picture and also the opening of the station chief on demand. So once we've done that, now I'm going to start to gently look down. So nice deep breath in, Dr. Rene.
We're just going to go slightly in again. If it's uncomfortable, you let me know and we'll stop. Right, so our view starts to change a little bit. So what you can see here at the bottom of the picture...
This is the tongue base and the follicular and that is the epiglottis. This is the middle of the picture as you can see this cartilaginous structure and it's just. Light in the middle of the picture for me here.
So as you can see, the vocal cords are moving there. And just to orientate ourselves, bottom of the picture is anterior to the patient. So what that means is that this picture is now lateral. inverted so the right of the picture is left of the patient and the left of the screen is right of the patient.
Alright nice deep breath. Great. So as you can see the vocal cords are moving.
Can you bring... your jaw forward Tom. So do you see it kind of easily opens the superior glottis, it gives you better view of the reamer glottis. So the gap between the two vocal cords are called reamer glottis and that's your rest of the airway there. And the bottom of the picture that's your anterior commissure so as you see it looks like a triangle, the head of the triangle is just the bottom of the glottis.
there and retinoids they are on the top of the picture the two blobby things that you can see those are the coniform and corniculate cartilages and there is a structure that runs between the retinoids And the epiglottis, and that's the areopiglottic folds. Alright, so can you say ee? Ee. So as you see, we're now testing adduction.
The chords are coming together quite nicely. Can you cough, Tom? Great. And can you say hey, hey, hey? Hey, hey, hey.
Great. And can you count one to five? One, two, three, four. Wonderful. Can you stick your tongue out?
So we're going to try to get a better view of the tongue base and see whether you can see anything here. So as you can see on the left side, here that looks like a retention cyst. These are the tonsils.
So that's the left tonsil. This is the right tonsil, just under here. Alright.
Nice deep breath in again. That's it. Brilliant. And you can always refocus and adjust how far you can go down. I'm not going to touch any tissues there because it will stimulate the cough reflex and we don't want to do that.
Tom, if you rotate your neck to your left... All the way and as you can see we are opening up the right hand side and there's two channels here called the piriforme fossa where food goes down, it channels down and these are the areas that sometimes you can get new plastic changes and if you look the other side, so it's quite important to check both sides when you're testing someone. Alright, so we're just going to go down and try not to touch things too much.
Get the view off that. So, just going to move it down a little bit. Try to evade the tonsil. And Nick, back in the middle.
Alright, that's well done Tom. That's great. Alright. So, when you assess someone's larynx, or the essentially supraglottis, glottis and subglottis, and you're interested in two things, function, which we just tested, and anatomy. So you're looking at structure to see whether you can see...
any abnormal features. We'll go a little bit down and I think we can stop hurting Dr. Ringwood. I'm sure it's not very comfortable. Great.
On either side of the white band, which is the true vocal cord. you've got the false cords again we usually look for abnormal growth abnormal changes the vocal cord nodules they're usually present anterior two-thirds and knowing the anterior is down to the bottom of the picture and things like infection causes pus around this area so that's something that you might need to have a look and research someone who's got stridal if the cords are not moving and whether there's a big old shiver in the way, and that might sometimes be the problem. Alright, and now I'm going to gently withdraw, so we have completed this examination, we saw what we wanted to see.
We can also turn around a little bit and look on the right side, look at the rosin molar fossa, and also looking at the station tube and then we're gently going to come back and as I withdraw I continue to look at the nose make sure I'm not damaging anything. Great thank you very much Dr McGrath. Are you all right? I'm fine. Brilliant.
I'm just going to put my equipment down and then just discuss with you what we saw and what we ought to do. All right, do you have any questions for me? Nothing at the moment. That's wonderful, thank you very much.
I hope that was a little bit useful and you find some tips that might help you in your clinical practice. Thanks very much.