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1.How to get a good view of larynx during clinical examination

The technique of examination is very important as well the patient's cooperation.  Most of the patient can tolerate the examination without having the throat sprayed with local anaesthetic.


Make sure the patient sits properly with the chest forward and the head flexed at neck and extended at atlantoaxial joint (turtle's neck).

Ask the patient to open the mouth moderately wide and stick out the tongue.


Hold the tongue tip gently with slight pull (Do not overpulled- this may cause pain!!!).


Pre-warm the laryngeal mirror or dips once into demisting solution.


Introduce the laryngeal mirror slowly and gently lean against the soft palate and uvula while pushing is gently posteriorly (limited by posterior pharyngeal wall).

Ask the patient to say the word "eeeeee" moderately loud and assessed the base of tongue, hypopharyngeal, and the larynx in a systematic manner.

If 70 degrees endoscope being used, its holding stability can be gained further by leaning it against the upper incisors of the patient or against the examiner's own thumb to act as a support and axis of scope movements.

White balance need to be set unless automatically determined.  Focus to an object or white gauze (good for both purposes) at a distance of about 3-4 cm.  The final focusing is during the examination itself unless automatically determined.

If transoral examination failed due to overly sensitive or painful throat conditions, we can resort to transnasal flexible laryngoscopic technique.  The nostrils and throat of the patient will have to be sprayed with local anaesthetics prior to examinaton.

Avoid making too many attempts on indirect or rigid transoral laryngoscopy (Limit to 3 times is sensible)


 See video Examination of Larynx and Pharynx @ YouTube


See video Tips for Great Laryngoscopy @ YouTube


Hope for a better look next time.  Good Luck

Head Mirror- An example

Traditionally head mirror provides a focus light beam to the area intended to be examined. For indirect laryngeal examination, the light is reflected onto the examination mirror to enable the laryngeal inlet view to be seen while the patient's tongue be held gently.  It is an inexpensive technique and still very useful especially when the endoscope in unavailabe for any reason.  On the other hand, endoscopic examination provides a superior view and better tolerated by the patient and is recommended for detail examination these days.

2.Do know that you can get shoulder and scapular pain when performing laryngeal surgery?

Surgeon's malposture, poorly adjusted height, hanging elbow and forearm without proper support are few important aspects that need to be considered and corrected.  The axis of movements has to be at wrist, while the elbow well supported by using commercialized surgeon's stool with arm rest or simply by resting on adjusted Mayo's table.  Surgeon should optimize using both hands during surgery.  

The after-effects of malposture varies with frequency of operation and length of surgery.  Although the procedure or surgery can be of short duration the effects can be cumulative over times. 


So, prevent harmful effect and start performing surgery in a optimal posture

3.How to get further view into subglottis and upper trachea during office endoscopic examination?

The tip of the flexible scope is brought as near to the glottic opening without touching its mucosa.  Similarly, the closest and best angle is taken when 70 degrees rigid scope is being used.  Ask the patient to breath slowly and steadily at the beginning.  As deeper view is needed, the patient is then instructed to breathe in deeply and forcibly as long as he can.  This causes the vocal folds to abduct further and sustain its position until subsequent exhalation.  During this action, the sublottis and upper trachea can be seen further down up to mid-cervical level.

Throat spray with local anaesthetic and lidocaine drip to the laryngeal inlet is ideal.  Beware the risk of laryngeal spasms; this should not be done in stidorous patient unless performed in the operation theathre where tracheostomy facility is avilable.  Good view is not possible when the vocal folds are in median/paramedian position as found in abductor vocal cord palsy, arytenoid ankylosis/dislocation, and an pathology causing supraglottic and glottic stenosis.