EN3.3 | Rigid Flexible Laryngoscopy — Summary & Reflection

KEY TAKEAWAYS

Laryngoscopy is the definitive examination for any laryngeal complaint. The critical rule: hoarseness >3 weeks = laryngoscopy to exclude laryngeal carcinoma — no exceptions. Three instruments: flexible nasopharyngolaryngoscope (4 mm, nasal route, awake patient, outpatient gold standard for diagnostic laryngeal assessment including cord mobility); rigid 70° Hopkins rod (transoral, high-resolution, used for glottic detail and stroboscopy, requires cooperative patient without gag reflex); rigid direct laryngoscope under GA (Mackintosh/Lindholm blade, supine patient, operating theatre — for biopsy and microlaryngoscopic surgery). Flexible technique: decongestant + LA → inferior meatus → nasopharynx → oropharynx → laryngeal inlet survey (epiglottis, aryepiglottic folds, false cords, true cords, rima glottidis, arytenoids) → phonation ('E') for adduction → inspiration for abduction. Key findings: normal = pearly white cords, symmetric abduction/adduction; left cord palsy = paramedian position, no movement, image entire vagal course from skull base to aortic arch (left RLN loops under aortic arch); glottic carcinoma = irregular cord mass, early hoarseness, cord mobile (T1) or fixed (T3+), good prognosis if caught early; supraglottic = epiglottis/aryepiglottic fold mass, late hoarseness, early bilateral nodes, poorer prognosis; Reinke's oedema = bilateral gelatinous cord swelling, smoker, pitch dropped — smoking cessation first; vocal nodules = bilateral at anterior 1/3–posterior 2/3 junction, voice abuse — voice therapy first.

REFLECT

The three-week hoarseness rule is a simple, evidence-based threshold, but its consistent application in primary care is poor. Reflect on the system-level factors that contribute to delayed laryngoscopy referral: patient reluctance to present early, GP attribution of hoarseness to common benign causes, limited access to ENT in rural India, and the absence of a 'symptoms that mandate referral' pathway in many primary care settings. As a future MBBS clinician, what personal practice standard would you set for yourself — what would be your personal threshold for referring a patient with hoarseness for laryngoscopy? Write two sentences in your reflective journal.