https://orcid.org/0000-0001-5132-9832
In this month’s issue of Journal of Investigative Surgery, Önal et al. investigated the quality of a clinician’s field of view during flexible nasopharyngeal laryngoscopy (NPL) under different intranasal applications—hypertonic saline, lidocaine, xylometazoline and isotonic saline. In addition, they wanted to determine patient anxiety, pain and discomfort levels with each application using a visual analog scale. The authors concluded that saline provides superior visualization, however, at the cost of patient anxiety, pain and discomfort compared to lidocaine and xylometazoline [Citation1].
NPL is an essential tool used often by a number of healthcare professionals, namely otolaryngologists. Due to its frequent use, it is paramount that the procedure maximizes efficiency and accuracy while minimizing discomfort for patients. Historically, many different topical agents have been used to achieve thorough examinations with variations in patient comfort [Citation2].
The use of topical agents during upper airway visualization has been called into question over the years as numerous studies suggest that their use is not efficacious and may actually contribute to patient discomfortCitation2 .When comparing routinely used topical agents, it has been found that there is little difference in their effectiveness and the side effects of lidocaine make it less appealing when assessing patient comfort [Citation3]. Alternative methods such as visual distractions have shown to be significantly more pleasant for patients than lidocaineCitation4 .However, other studies suggest that lidocaine is effective at decreasing patient discomfort and can be used to avoid general anesthesia [Citation5]. From a physician’s perspective, the use of anesthetic has proven advantageous in both ease and quality of examination when compared to a placeboCitation6 .Different maneuvers used by more experienced physicians can also allow for increased visualization that may otherwise not be attainedCitation7 .Topical decongestants may be used in combination with other methods to maximize the efficiency of upper airway procedures and patient comfort. For example, the use of xylometazoline and oxymetazoline has shown to produce less patient discomfort and a subsequent shorter duration of examination [Citation8], especially when combined with a topical anesthetic [Citation9].
It is evident that multiple factors contribute to the outcome of an NPL that ultimately affects the endoscopist’s ability to perform the procedure and the patient’s experience. Patient variables during anesthetic use such as mean blood pressure or pulse rate have not been proven to be clinically significantCitation9 .Although route of administration has not been shown to have a significant impact on patient comfort, it is something to consider when analyzing the cost of treatment [Citation10]. Most studies exclude patients that have had NPL previously and an inclusion of these patients may affect results, especially since this is a procedure that may be used more than once on a patient [Citation1, Citation10].
In conclusion, physicians might achieve superior visualization using hypertonic saline while performing an NPL. This could potentially allow for shorter procedural times by making an expedited diagnosis. However, patients should be counseled that they may experience increased anxiety, pain and discomfort with hypertonic saline compared to topical decongestants or anesthetics.
Disclosure statement
The authors report no conflicts of interest.
References
- Önal M, Keles B, Erdur Ö, Alatas N, Önal Ö. Effect of hypertonic saline during flexible nasopharyngeal laryngoscopy: a double-blinded, randomized, controlled trial. J Invest Surg. 2020; In press.
- Frosh AC, Jayaraj S, Porter G, Almeyda J. Is local anaesthesia actually beneficial in flexible fibreoptic nasendoscopy? Clin Otolaryngol Allied Sci. 1998;23(3):259–262. doi:https://doi.org/10.1046/j.1365-2273.1998.00149.x.
- McCluney NA, Eng CY, Lee MS, McClymont LG. A comparison of xylometazoline (Otrivine) and phenylephrine/lignocaine mixture (Cophenylcaine) for the purposes of rigid nasendoscopy: a prospective, double-blind, randomised trial. J Laryngol Otol. 2009;123(6):626–630. doi:https://doi.org/10.1017/S0022215108003666.
- Biggs TC, Henderson A, Shelton F, Patel NN. The use of visual distraction to improve the tolerability of flexible laryngoscopy. J Laryngol Otol. 2018;132(8):739–741. doi:https://doi.org/10.1017/S0022215118001093.
- Wellenstein DJ, van der Wal RAB, Schutte HW, et al. Topical anesthesia for endoscopic office-based procedures of the upper aerodigestive tract. J Voice. 2019;33(5):732–746. doi:https://doi.org/10.1016/j.jvoice.2018.02.006.
- Javed F, Parmar A, Hussain A, Hajioff D, Pinder D. A randomised controlled trial assessing the efficacy of co-phenylcaine nasal spray in flexible transnasal pharyngolaryngoscopy. Ann R Coll Surg Engl. 2017;99(4):313–318. doi:https://doi.org/10.1308/rcsann.2016.0336.
- Fleischer S, Pflug C, Hess M. Dipping and rotating: two maneuvers to achieve maximum magnification during indirect transnasal laryngoscopy. Eur Arch Otorhinolaryngol. 2020;277(5):1545–1549. doi:https://doi.org/10.1007/s00405-020-05862-7.
- Eccles R, Eriksson M, Garreffa S, Chen SC. The nasal decongestant effect of xylometazoline in the common cold. Am J Rhinol. 2008;22(5):491–496. doi:https://doi.org/10.2500/ajr.2008.22.3202.
- Şahin Mİ, Kökoğlu K, Güleç Ş, Ketenci İ, Ünlü Y. Premedication methods in nasal endoscopy: a prospective, randomized, double-blind study. Clin Exp Otorhinolaryngol. 2017;10(2):158–163. doi:https://doi.org/10.21053/ceo.2016.00563.
- Young VN, Smith LJ, Rosen CA. Comparison of tolerance and cost-effectiveness of two nasal anesthesia techniques for transnasal flexible laryngoscopy. Otolaryngol Head Neck Surg. 2014;150(4):582–586. doi:https://doi.org/10.1177/0194599813519952.