Overcoming the epiglottis when a good examination is critical.

A 53-year-old woman, a professional singer, related a history of intermittent episodes of debilitating hoarseness that resolved with prolonged voice rest. Examination was performed with a distal-chip flexible laryngoscope and a rigid laryngeal 70[degrees] telescope. The flexible scope identified ectasias and an indistinct left mass (figure 1).

[FIGURE 1 OMITTED]

Examination with the rigid scope was conducted initially with minimal topical anesthesia because the patient was scheduled to perform the following evening and she did not want to be anesthetized heavily, fearing chemical irritation. However, because the epiglottis was retroflexed, the full glottis was not visualized consistently. The left mass was more visible through the rigid scope, but it was still not clearly defined (figure 2). At this point, the patient was reassured that anesthesia would not compromise her upcoming performance, and additional topical anesthesia was applied. The rigid scope was then inserted from the side of the mouth, and the telescope shaft was used to retract the epiglottis. The camera was rotated so that the glottis was oriented vertically on the screen.

[FIGURE 2 OMITTED]

Because the lens was so much closer to the vocal folds, an assistant had to continuously focus the camera. Light is often too bright when the distance between the telescope and the vocal fold is so short. If a lighting device does not have an aperture control, the amount of light can be reduced by connecting a light-control adapter to the light cord. Alternatively, the amount of light can be reduced by partially removing the endoscope light cord from the light source, thereby increasing the distance between the bulb and the cord.

With the reduction in the amount of light, it became clear that the mass on the left vocal fold was fibrotic. There was an indented, right-sided mass, which appeared to be fluid-filled and was likely reactive (figure 3). Further, the subtle scarring under the right mass became more apparent, which allowed for more accurate patient counseling regarding the degree to which the patient's voice could be rehabilitated.

In summary, excellent visualization is critical to making a correct diagnosis. When a view is obstructed by the epiglottis, visualization can be facilitated by:

* gaining the patient's confidence and helping him or her relax

* administering an adequate amount of pharyngeal anesthesia and correctly positioning the patient

* inserting the telescope from the side and retracting the epiglottis forward

* placing the lens of the scope close to the vocal folds

* adjusting the camera angle, amount of light, and focus for optimal results

* bringing the vocal folds into better view with external laryngeal pressure, in some cases

[FIGURE 3 OMITTED]

Robert Eller, MD; Mary Hawkshaw, BSN, RN, CORLN; Robert T. Sataloff, MD, DMA

From the American Institute for Voice and Ear Research (Dr. Eller and Ms. Hawkshaw) and the Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine and Graduate Hospital (Dr. Sataloff), Philadelphia.