How is nasopharyngeal endoscopy performed in adults and children?
Nasopharyngeal endoscopy is an outpatient procedure performed with a flexible or rigid endoscope through the nasal cavity; in adults and children it differs in the choice of instrument, preparation, positioning and the need for anesthesia. The technique for both age groups is summarized below.
I. Types of endoscopes and choice of instrument
| Parameter | Flexible fiberoptic endoscope | Rigid endoscope |
|---|---|---|
| Diameter | 2.2–3.2 mm (children); 3.4–4.0 mm (adults) | 2.7 mm or 4.0 mm |
| Viewing angle | Steerable tip (up to 180°) | Fixed: 0°, 30°, 45°, 70° |
| Image quality | Good (distal chip — HD); lower with fiberoptics | Excellent (Hopkins optics) |
| Patient comfort | Higher (thinner, more flexible) | Lower (stiff, thicker) |
| Access to the nasopharynx | Excellent — passes beyond the choanae | Limited by anatomy; better for the middle meatus |
| Main use | Children, narrow nasal passages, assessment of the nasopharynx/larynx | Detailed assessment of the ostiomeatal complex, pre-operative assessment |
The AAO-HNS recommends using smaller-diameter and flexible endoscopes in children and patients with complex nasal anatomy. [1]
II. Technique in adults: three-pass endoscopy
Preparing the nasal cavity
A topical decongestant and anesthetic are applied before the examination. The Cochrane review by Sunkaraneni & Jones (2011, 8 RCTs, n=746) showed that 5 of 8 studies found no advantage of topical anesthesia over placebo in reducing pain during flexible nasopharyngoscopy; one study showed that xylometazoline (a decongestant) reduces the overall “unpleasantness” of the procedure. The review by Hale et al. (2024) confirmed that there is no consensus on optimal preparation, although most rhinologists still use a combination of anesthetic and decongestant. [7][8]
The most common preparation regimens:
- Packing: cotton pledgets soaked in 4% lidocaine + 0.05% oxymetazoline (or 0.1% xylometazoline) are placed for 5–10 minutes — this gives better visualization and less discomfort [8][9]
- Spray: 10% lidocaine spray + a decongestant spray — faster but less effective [8][10]
- The RCT by Gaviola et al. (2013, n=99) found no differences between 2% tetracaine and 4% lidocaine; tetracaine may be preferable in older patients [10]
- Buffered lidocaine (with bicarbonate) showed no advantage over plain lidocaine and caused more side effects (burning, throat discomfort) [11]
Systematic three-pass examination
According to the AAO-HNS, the endoscopic examination is performed systematically in 3 passes (if the anatomy allows): [1]
- Pass 1 — lower (along the floor of the nasal cavity) — The endoscope is passed along the floor of the nasal cavity. Visualized: the floor of the nasal cavity → inferior turbinate → inferior meatus → Hasner’s valve (nasolacrimal duct opening, sometimes) → Eustachian tube opening → posterior wall of the nasopharynx. Assessed: the condition of the mucosa, the nature of the discharge, adenoid tissue (in children), nasopharyngeal masses
- Pass 2 — middle — The endoscope is directed medial to the middle turbinate. Visualized: middle turbinate → olfactory cleft → sphenoethmoidal recess → superior turbinate → sometimes the sphenoid sinus ostium. Assessed: polyps, purulent discharge, swelling
- Pass 3 — upper (lateral wall) — The endoscope is directed towards the nasal vault and the lateral wall. Visualized: attachment of the middle turbinate to the lateral wall → ostiomeatal complex → uncinate process → hiatus semilunaris → anterior ethmoid bulla. Assessed: patency of the ostiomeatal complex, anatomical variants (concha bullosa, septal deviation, spurs) [1]
The study by Babahoji et al. (2024) involving 19 expert rhinologists showed that the most important structures to assess depend on the clinical situation: for postnasal drip — the middle meatus (NAS 0.73), focusing on the nature of the mucus (purulent or not); for nasal obstruction — the septum and turbinates; for polyposis — the middle meatus and the olfactory cleft. [12]
III. Technique in children: specifics
Choice of endoscope
In children, small-diameter flexible endoscopes of 2.2–2.7 mm are used. Torretta et al. (2013, n=191, mean age 5.6 years) used a 2.7 mm flexible endoscope without anesthesia or decongestants; Chadha et al. (JAMA Otolaryngology, 2013, n=69) used 2.4 mm; Isaac et al. (JAMA Otolaryngology, 2015) used 2.2 mm. If a more detailed assessment is needed in older children, a 2.7 mm rigid endoscope may be used. [2][13][14][15]
Flexible endoscopy is possible even in newborns using ultrathin fiberscopes. [16]
Positioning
- The child sits on a parent’s lap (younger children) or in the chair on their own (older children)
- An assistant or parent gently holds the head from both sides to prevent sudden movements
- The child is offered a choice — to sit alone or on a parent’s lap [14]
Preparation and anesthesia
The RCT by Chadha et al. (JAMA Otolaryngology, 2013, n=69, children aged 3–12), the only double-blind placebo-controlled study in children, compared three groups: placebo (saline), decongestant (0.05% xylometazoline), decongestant + 1% lidocaine. Result: no statistically significant differences in pain between the groups (mean Wong-Baker score: 2.4 vs 1.8 vs 2.2; p=0.45). The decongestant showed a trend towards the least discomfort and the least difficulty of the procedure for the doctor, but the differences did not reach significance. [14]
“This study revealed no statistically significant difference in the discomfort experienced by children undergoing flexible nasendoscopy after placebo, decongestant, or TLA with decongestant”. — Neil K. Chadha, MBChB(Hons), MPHe BSc(Hons), FRCS(ORL-HNS), et al., Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada and other institutions. Intranasal Topical Local Anesthetic and Decongestant for Flexible Nasendoscopy in Children: A Randomized, Double-blind, Placebo-Controlled Trial. JAMA Otolaryngol Head Neck Surg. December 1, 2013. Content used under license from the JAMA Network® © American Medical Association. [14]
Torretta et al. (2013, n=191) performed endoscopy in children entirely without anesthesia, decongestants or sedation — the procedure succeeded in all patients over 2 years of age, with a mean discomfort VAS of 2.06 out of 10. Restraint was needed significantly more often in younger children (p<0.001), and tolerance improved with age. [13]
Psychological preparation of the child
The protocol by Chadha et al. includes important elements of adaptation: [14]
- The doctor explains the procedure to the child and the parent
- The child is shown the equipment and invited to touch the tip of the endoscope
- An image of the child’s finger and face is shown on the monitor — the child sees how the camera works
- During the procedure the image is shown on the monitor — the child, the parent and the doctor watch together
IV. Comparison table: adults vs children
| Parameter | Adults | Children |
|---|---|---|
| Endoscope | Rigid 4 mm (preferred) or flexible 3.4–4 mm | Flexible 2.2–2.7 mm (preferred) |
| Topical anesthesia | Standard (4% lidocaine + decongestant), although evidence of benefit is mixed | Not required; no proven advantage over placebo |
| Decongestant | Recommended to improve visualization | May be used; a trend towards improvement, but not significant |
| Positioning | Sitting in a chair, head upright | On a parent’s lap or in a chair; head held by an assistant |
| Sedation | Not required | Not required (with an experienced specialist); possible in children under 2 |
| Examination technique | 3 systematic passes | Usually 1 pass along the floor to the nasopharynx; more if needed |
| Duration | 1–3 minutes | 30 seconds – 1 minute |
| Tolerance | Good (VAS ~2/10) | Good in children over 2 (VAS ~2/10); worse in younger children |
| Complications | Extremely rare (nosebleed, vasovagal reaction) | None reported in large series |
V. Indications for nasopharyngeal endoscopy
Fiberoptic nasopharyngoscopy is the gold standard for diagnosing the following conditions: [5][17][18]
- Adenoid hypertrophy — assessing the degree of choanal obstruction (children)
- CRS with/without polyps — first-line confirmatory test
- Nasal obstruction — septal deviation, turbinate hypertrophy, nasal valve collapse
- Nasopharyngeal masses — juvenile angiofibroma, nasopharyngeal carcinoma
- Eustachian tube dysfunction — visualizing the opening and its movement during swallowing
- CSF leak — finding the source of the leak
- Foreign bodies — especially in children
- Pre-operative assessment before FESS, adenoidectomy, septoplasty
Gardiner et al. (2023, n=346) showed that rigid endoscopy reveals findings not visible on anterior rhinoscopy in 23.7% of patients and changes the surgical plan in 7.5%. [19]
Sources
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- 2.Assessment of Vibratory Characteristics in Children Following Airway Reconstruction Using Flexible and Rigid Endoscopy and Stroboscopy — JAMA Otolaryngology–Head & Neck Surgery, 2015. Zacharias SR, Weinrich B, Brehm SB, et al.
- 3.Video Nasopharyngoscopy: A Comparison of Fiberscopic, Telescopic, and Microscopic Documentation — Ann Otol Rhinol Laryngol, 1989. Yanagisawa E, Isaacson G, Kmucha ST, Hirokawa R.
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- 7.Topical Anaesthetic or Vasoconstrictor Preparations for Flexible Fibre-Optic Nasal Pharyngoscopy and Laryngoscopy — Cochrane, 2011. Sunkaraneni VS, Jones SE.
- 8.Topical Anaesthesia and Decongestion in Rhinology — Rhinology, 2024. Hale SJM, Kim R, Douglas RG.
- 9.Topical Anesthesia for Endoscopic Office-Based Procedures of the Upper Aerodigestive Tract — J Voice, 2019. Wellenstein DJ, van der Wal RAB, Schutte HW, et al.
- 10.A Prospective, Randomized, Double-Blind Study Comparing the Efficacy of Topical Anesthetics in Nasal Endoscopy — Laryngoscope, 2013. Gaviola GC, Chen V, Chia SH.
- 11.Buffered Lidocaine for Topical Nasal Anesthesia: A Double-Blind Randomized Controlled Trial — J Voice, 2025. Siag K, Paker M, Gutkovich YE, Mazzawi S.
- 12.Features of Importance in Nasal Endoscopy: Deriving a Meaningful Framework — Otolaryngology–Head and Neck Surgery, 2024. Babahaji LM, Ganeshan V, Nguyen TS, et al.
- 13.Nasopharyngeal Fiberendoscopy in Children: A Diagnostic Challenge in Current Clinical Practice — Int J Pediatr Otorhinolaryngol, 2013. Torretta S, Marchisio P, Cappadona M, Baggi E, Pignataro L.
- 14.Intranasal Topical Local Anesthetic and Decongestant for Flexible Nasendoscopy in Children: A Randomized, Double-blind, Placebo-Controlled Trial — JAMA Otolaryngology–Head & Neck Surgery, 2013. Chadha NK, Lam GO, Ludemann JP, Kozak FK.
- 15.Correlations Between Acoustic Rhinometry, Subjective Symptoms, and Endoscopic Findings in Symptomatic Children With Nasal Obstruction — JAMA Otolaryngology–Head & Neck Surgery, 2015. Isaac A, Major M, Witmans M, et al.
- 16.Anatomy and Assessment of the Pediatric Airway — Paediatric Anaesthesia, 2009. Adewale L.
- 17.Clinical Practice Guideline: Adult Sinusitis Update — Otolaryngology–Head and Neck Surgery, 2025. Payne SC, McKenna M, Buckley J, et al.
- 18.Rhinitis 2020: A Practice Parameter Update — J Allergy Clin Immunol, 2020. Dykewicz MS, Wallace DV, Amrol DJ, et al.
- 19.The Role of Nasal Endoscopy in the Preoperative Evaluation of Nasal Airway Obstruction — Otolaryngology–Head and Neck Surgery, 2023. Gardiner LA, Goyal LK, McCoy JL, Gillman GS.
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