How to perform a flexible video nasopharyngeal laryngoscopy (FVNL) in a patient with suspected epiglottitis and a history of bleeding disorders or anticoagulant use?

Performing Flexible Video Nasopharyngeal Laryngoscopy in Suspected Epiglottitis with Bleeding Disorders/Anticoagulation

In patients with suspected epiglottitis and bleeding disorders or anticoagulant use, flexible nasopharyngeal laryngoscopy should be performed with extreme caution in a controlled environment with immediate airway management capabilities, as the procedure itself carries minimal bleeding risk but the underlying epiglottitis represents a life-threatening emergency requiring immediate diagnosis and potential intubation. 1, 2, 3

Pre-Procedure Risk Assessment and Environment

Critical Safety Requirements:

• Perform the procedure only in an operating room or intensive care setting with difficult airway equipment immediately available, including fiberoptic bronchoscope, videolaryngoscope, laryngeal mask airway, and surgical tracheostomy setup ready for immediate use 2, 3
• Document all bleeding risk factors including specific anticoagulant/antiplatelet medications, bleeding disorder type, and coagulation parameters 4
• Do not delay diagnostic laryngoscopy due to anticoagulation status alone, as failure to diagnose epiglottitis carries 7% mortality in adults versus minimal bleeding risk from nasal endoscopy 1, 3

Procedural Technique Modifications for Bleeding Risk

Topical Preparation:

• Apply topical vasoconstrictor (oxymetazoline or phenylephrine) to both nasal passages 10-15 minutes before the procedure to minimize mucosal trauma and bleeding risk 5, 6
• Use topical anesthetic (lidocaine spray or gel) liberally to reduce patient discomfort and movement that could cause trauma 4

Scope Selection and Passage:

• Use the smallest diameter flexible laryngoscope available (typically 3.0-3.5mm) to minimize mucosal contact 4
• Choose the more patent nasal passage after vasoconstrictor application to reduce trauma 4
• Advance the scope gently along the nasal floor, avoiding contact with the septum and turbinates where bleeding is most likely 4

Critical Examination Technique:

• Maintain the scope in the midline without touching inflamed supraglottic structures, as direct contact with the swollen epiglottis can precipitate complete airway obstruction 1, 2, 3
• Visualize the characteristic "cherry-red" swollen epiglottis from a safe distance without attempting to manipulate or touch it 2, 3
• Perform the examination quickly (under 30 seconds if possible) to minimize patient distress and risk of laryngospasm 3, 7

Specific Considerations for Anticoagulated Patients

Pre-Procedure Management:

• Do not reverse anticoagulation or withdraw antiplatelet medications before diagnostic laryngoscopy, as the bleeding risk from nasal endoscopy is minimal compared to the thromboembolic risk of medication reversal 4
• Contact the prescribing clinician to document anticoagulation indication, but proceed with examination as this is a life-threatening emergency 8, 5

If Nasal Bleeding Occurs:

• Apply firm sustained compression to the lower third of the nose for minimum 5 minutes without interruption 4, 6
• Use resorbable packing materials (not non-resorbable packing) if bleeding cannot be controlled with compression alone 4
• Avoid nasal cautery in anticoagulated patients unless absolutely necessary, as this increases risk of rebleeding 5

Post-Procedure Monitoring and Documentation

Immediate Post-Procedure:

• Keep patient upright in sitting position with continuous pulse oximetry and visual monitoring for signs of airway compromise 1, 3
• Inspect nasal passages for active bleeding after scope removal 4, 8
• Document vocal fold mobility findings, degree of supraglottic edema, and any procedural complications 4, 8

Documentation Requirements:

• Record all bleeding risk factors including specific medications and dosages 4, 8
• Document the indication for examination despite bleeding risk (suspected epiglottitis is life-threatening) 8, 1
• Note whether resorbable packing was used and patient education provided if bleeding occurred 4

Critical Pitfalls to Avoid

• Never perform this examination in an office setting or without immediate airway management capabilities, as epiglottitis can progress to complete obstruction within minutes 1, 2, 3
• Never attempt to manipulate or touch the epiglottis with the scope, as this can precipitate sudden complete airway obstruction 2, 3
• Never delay the examination to "optimize" coagulation parameters, as the 7% mortality from undiagnosed epiglottitis far exceeds the minimal bleeding risk from flexible laryngoscopy 1, 3
• Do not rely on indirect mirror laryngoscopy in suspected epiglottitis, as flexible laryngoscopy provides superior visualization and allows examination without tongue manipulation that could trigger obstruction 4, 3

When Intubation Becomes Necessary

If the examination confirms severe epiglottitis with impending airway compromise:

• Videolaryngoscopy is superior to direct laryngoscopy for intubating through the distorted, swollen anatomy 2
• Use the smallest endotracheal tube that will pass (often 5.0-6.0mm) through the narrowed glottic opening 2
• Have surgical airway immediately available as backup, as intubation may be extremely difficult or impossible 2, 3, 7