Hi, very interesting topic because the nasendoscopy could drive your future decision on airway management. To my knowledge only Rosenblatt included nasendoscopy as part of airway assessment in ENT surgery. Rosenblatt also built an algorithm including this technique as decisional rule.

My own view is that nasendoscopy is an invasive procedure not without risk. Using standard clinical methods, it is easy to identify patients in whom intubation will be straight forward. In those that you think 'might' be difficult based on clinical assessment, I can see the value of adding something extra. However, I'm not sure whether examination findings on nasendoscopy are any better at identifying the difficult airway than standard clinical assessment. If in doubt, you are still going to opt for AFOI. So in summary, i can't see fibre optic nasendoscopy adding much to my clincial assessment at the moment - though it is interesting what Dr Caldiroli says about Rosenblatt's algorithm. Do you have a reference for this?

May I ask what would the advantages of nasendoscopy be over the fibre-optic devices that we are currently using?

The nasendoscopy is a different device. It is very thin and usually similar to a pharyngoscope to study the swallowing and the vocal cord movement. The lenght is about 30 cm and there is no the aspiration channel. The diameter is about 2 mm. Even if in the adult pt the procedure is well tolerated I agree with dr Griffith that nasendoscopy should be addressed to those pts in which there is a suspected distortion of pharyngeal o laryngeal anatomy. The nasendoscopy is a decisional tool and it is not aimed to intubate the pt. during the procedure. To assess the difficult airway and reduce the unexpected difficult intubation we use El Ganzouri risk index combined with routine Glidescope. The algorithm is published on Minerva Anestesiologica 2011. I will post later the ref of Rosenblatt.

Well well, hadn't even thought about this possible use.. I guess since it's slender it would be more tolerated by the patient.. but sorry, I have not seen any article / anyone using it for this purpose.

Look at these links (both are on use of naso-endoscopy for airway assessment):

1. http://journals.lww.com/ejanaesthesiology/Fulltext/2011/06001/Routine_use_of_fibreoptic_nasendoscopy_for.725.aspx

2. http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2000.01479-14.x/full

Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation.

Rosenblatt W, et al.

Anesth Analg. 2011 Mar;112(3):602-7. doi: 10.1213/ANE.0b013e3181fdfc1c. Epub 2010 Nov 16.

This paper provides us evidence of the usefulness of pharyngoscopy as a decision tool.

Very impressive article. Nice idea but as the authors have mentioned it should initially be considered for those with airway pathologies. I suppose it would be difficult for a patient diagnosed with an airway difficulty to undergo both procedures. I mean, after the difficulty is diagnosed via endoscopy, the patient has to tolerate another awake FO procedure.

Yes, it could be exactely as you suppose.

However my opinion is that paper from Rosenblatt provides to all of us an important decisional tool which allows us to make the right decision on how to best manage the airway for every single patient. After the diagnosis you can go to the fibers, awake video laryngoscopy or also to a simply direct laryngoscopy while asleep or awake trach or what technique you are familiar with.

I am using oral as a routine use under GA but nasal approach usually used during awake fiberoptic only by me

We just used the Rosemblatt approach twice in a week as decisional tool in a couple a pts w

with previous pharyngo - laryngeal operation to be undergoing spine surgey.

We use the smallest and thin fiberscope we usually use for swallowing disorders.

No sedation, only lidocaine spray. After the diagnosis of normal anatomy

and space and no mucosal bleeding we decided to go to induction e NMB.

Cormack 1 in both cases with glidescope

The nasalendoscopy is very well tolerated as long as you do a minimal prep: vasoconstrictor and a little topical lidocaine (20-50mg). No sedation or monitoring needed. I typically use a 3.2mm fiberscope (not unusual in the OR). If the determination is that the patient should have an awake intubation, patients typically dont mind the second scoping. In part this is because the reason for the PEAE was explained to them. Someone above mentioned that it seems to be invasive. Not nearly as invasive as doing an awake intubation when one is not needed, or a routine or RSI induction in a patient who has true pathology. On PEAE I look for 3 things 1) is there a single plane access to the airway (e.g. no obstruction) 2) is there a any obstruction that would prevent the seating or use of an SGA (if I should need one ) 3) is there any anterior lesion which might be damaged by a blade type laryngoscopy (if I induce the patient and find I emergently need DL or VL, will I cause a bleed ? ). As noted in the paper PEAE actually reduced the number of awake intubations. That is, a difficult appearing patient had no obstruction/issue once you looked passed the tongue.

Article Preoperative Endoscopic Airway Examination (PEAE) Provides S...

I've just started a study on this matter-

Fiberscope naso-tracheal intubation in conscious sedation and topical anaesthesia in the case of Oro and Hypo-pharynx tumours: patient comfort and safety

I think the nasendoscope is a perfect tool for airway assessment , especially in head&neck pathology anesthesia but also a very reliable tool for awake intubation. Dr Rosenblatt article is a very good one in my opinion ( I could use a copy and cite it in my study if possible). I attache a small movie with an awake naso-tracheal intubation with a nasendoscope of 2.8 mm diameter of a patient with pyriform sinus tumor. All I can say so far after 13 patients included in study is that we did not have any complications, the patients were calm and cooperative and declared high satisfactions scores. We used the sitting position for patients with nebulized lidocaine in preoperative room for 10 minutes and the topical anesthesia(gargling and instilation) and light sedation with midazolam-fentanyl -droperidol (not exceeding 2.5 mg).

I've just started a study on this matter-

Fiberscope naso-tracheal intubation in conscious sedation and topical anaesthesia in the case of Oro and Hypo-pharynx tumours: patient comfort and safety

I think the nasendoscope is a perfect tool for airway assessment , especially in head&neck pathology anesthesia but also a very reliable tool for awake intubation. Dr Rosenblatt article is a very good one in my opinion ( I could use a copy and cite it in my study if possible). I attache a small movie with an awake naso-tracheal intubation with a nasendoscope of 2.8 mm diameter of a patient with pyriform sinus tumor. All I can say so far after 13 patients included in study is that we did not have any complications, the patients were calm and cooperative and declared high satisfactions scores. We used the sitting position for patients with nebulized lidocaine in preoperative room for 10 minutes and the topical anesthesia(gargling and instilation) and light sedation with midazolam-fentanyl -droperidol (not exceeding 2.5 mg).