Pharyngoscopy: examination of the throat, indications

Pharyngoscopy is a targeted examination of the oropharynx and nasopharynx using a light source, a spatula, or an endoscope to diagnose inflammatory, tumorous, traumatic, and functional conditions of the throat. In outpatient practice, a standard examination with a disposable spatula and headlamp is most often used. In complex cases, flexible nasopharyngoscopy is used, allowing for safe assessment of the nasopharyngeal vault, the orifices of the auditory tubes, the soft palate, and the upper larynx. This step-by-step approach is described in current educational and reference materials on otolaryngology. [1]

Flexible nasopharyngoscopy complements classical pharyngoscopy when examination is limited by a pronounced gag reflex, anatomical peculiarities, or the need to assess the dynamics of the soft palate and airway during breathing and speech. Indications include dysphagia, unilateral sore throat, hoarseness, suspected peritonsillar abscess, foreign body, neoplasm, and complications following infection. The procedure is performed without general anesthesia; complications are rare and typically limited to short-term coughing, sneezing, gagging, or minor bleeding. [2]

Inpatient rigid pharyngoscopy is performed under general anesthesia, either as a standalone procedure or as part of a panendoscopy of the upper gastrointestinal tract, for example, to remove impacted objects or to examine suspected tumors. This approach provides direct visualization and the possibility of simultaneous interventions, but requires surgical conditions and consideration of anesthetic risks. Patient information materials from major ENT centers provide a realistic assessment of the benefits and risks, including the extremely low risk of dental damage. [3]

The choice of method determines sensitivity and comfort. In most outpatient situations, a spatula examination under good lighting with basic infection control measures is sufficient. In cases of atypical symptoms, suspected dangerous conditions, or unclear results of the basic examination, flexible endoscopy is used as a "second-line" assessment. This stepwise algorithm is consistent with modern clinical guidelines for the initial examination of ENT organs. [4]

Table 1. Types of pharyngoscopy: what, with what and when

Method	Tool and conditions	What can be seen best?	Typical indications
Basic pharyngoscopy	Disposable spatula, headlight	Tonsils, soft palate, posterior pharyngeal wall	Acute pain in the throat, plaque, mucosal injury. [5]
Flexible nasopharyngoscopy	Flexible endoscope, local anesthesia	Nasopharynx, openings of the auditory tubes, dynamics of the soft palate	Dysphagia, unilateral symptoms, suspicion of abscess or neoplasm. [6]
Rigid pharyngoscopy	Rigid endoscope under anesthesia	Direct visualization with interventional capabilities	Foreign bodies, biopsy, advanced diagnostics. [7]

Indications and clinical objectives

The most common reason for referral for pharyngoscopy is acute sore throat. The purpose of the examination is to differentiate viral from bacterial infections, promptly recognize complications, and determine whether further testing is needed. National guidelines for the management of acute sore throat emphasize that in most patients, the condition is self-limiting, antibiotics are not always required, and the decision should be based on a combination of symptoms and examination findings. Pharyngoscopy is a key element of clinical assessment here. [8]

Bacterial pharyngitis caused by group A beta-hemolytic streptococcus has characteristic features on examination: bright hyperemia, petechial hemorrhages on the soft palate, tenderness of the anterior cervical lymph nodes, plaque on the tonsils, and sudden onset of the disease. In the presence of these features, it is reasonable to consider rapid testing and, if necessary, laboratory confirmation, which is reflected in official clinical materials. [9]

Pharyngoscopy helps detect serious conditions: unilateral tonsil swelling with uvula deviation to the opposite side may indicate a peritonsillar abscess; dense infiltrates and atypical ulcers require the exclusion of a tumor; purulent discharge from the choanae and severe swelling of the posterior pharyngeal wall suggest nasopharyngeal inflammation or a retropharyngeal process. In such situations, flexible endoscopy expands the field of view and reduces the likelihood of diagnostic error. [10]

A separate group of indications includes dysphagia, a sensation of a "lump" in the throat, chronic cough of unknown origin, suspected soft palate dysfunction, and obstructed eustachian tube drainage. Flexible nasopharyngoscopy allows for the visualization of areas inaccessible to direct examination and prompt referral of the patient for additional imaging or endoscopic treatment. [11]

Table 2. Symptoms and what the doctor expects to see

Symptom	Possible findings during pharyngoscopy	The next step
Acute sore throat	Hyperemia, plaque, petechiae on the soft palate	Consider rapid streptococcal testing, symptomatic therapy. [12]
Unilateral pain and trismus	Asymmetry of the palatine arch, displacement of the uvula	Urgent evaluation for peritonsillar abscess, flexible endoscopy. [13]
Dysphagia, foreign body sensation	Edema of the posterior wall, the upper sections are not visible	Flexible nasopharyngoscopy, biopsy if indicated. [14]
Recurrent otitis in adults	Swelling of the auditory tube orifices	Search for the cause in the nasopharynx, endoscopy. [15]

Preparation and technique: how to make the examination informative and safe

Before the examination, it is important to explain the purpose and sequence of procedures to the patient, ask them to remove removable dentures, provide good lighting, and observe hygiene measures. The doctor puts on gloves, uses a disposable tongue depressor, and asks the patient to protrude their tongue, making the sound "ah" to lift the soft palate and open the view. The examination includes the tonsils, arches, uvula, posterior pharyngeal wall, and soft palate. This systematic approach is described in clinical guidelines for basic ENT examinations. [16]

If a pronounced gag reflex is present or the nasopharyngeal vault needs to be examined, local anesthesia with lidocaine spray and a vasoconstrictor nasal spray are used, followed by flexible nasopharyngoscopy through the lower or middle nasal meatus. The examination is performed delicately, avoiding trauma to the mucous membrane and prolonged contact with the septum and turbinates, which contain numerous vessels. Detailed step-by-step instructions emphasize the need to monitor the patient's response and be prepared to discontinue the procedure if significant discomfort occurs. [17]

To improve quality, assess the structures statically and dynamically: ask the patient to breathe through the nose and mouth, pronounce "i" and "k" to assess the soft palate's elevation, and ask them to swallow water to monitor conductivity. If pathology of the auditory tube orifices is suspected, assess their opening during swallowing. This functional component allows for the detection of soft palate relaxation, dyskinesia, and underlying disorders. [18]

At the end of the examination, the physician documents findings, takes photos or videos during the endoscopy, and notes tolerance and possible reactions. If a specific infection or tumor is suspected, a further investigation plan is developed: a throat swab for group A beta-hemolytic streptococcus, rapid tests, biopsy, neck ultrasound, or imaging as indicated. Decision-making algorithms link the clinical picture and examination results. [19]

Table 3.

Step	Action	For what
Preparation	Explain the procedure, remove the dentures, put on gloves, prepare the spatula and light	Reduced anxiety, safety. [20]
Basic examination	Press the tongue with a spatula, examine the tonsils, soft palate, and back wall	Initial assessment of inflammation and complications. [21]
Addition	Local anesthesia, flexible endoscopy through the nose	Expanding the view to the nasopharynx and dynamics. [22]
Conclusion	Documentation, test or treatment plan	Relationship of findings with tactics. [23]

Contraindications and precautions

There are virtually no absolute contraindications for basic pharyngoscopy, but if there are signs of impending airway obstruction, significant epiglottic edema, progressive dyspnea, or stridor, the primary goal is to ensure airway patency rather than a more in-depth examination. In such situations, the decision is made by a team involving an anesthesiologist and surgeon. Guidelines for performing flexible ENT procedures emphasize respiratory safety as a priority. [24]

Relative limitations include uncorrected coagulopathy, recent bleeding, severe unstable angina, and marked hyperreactivity of the cough and gag reflexes. If necessary, the examination is postponed, performed under local anesthesia, or in an operating room. Brief clinical indicators for endoscopy emphasize the importance of post-procedural observation in the presence of risk factors. [25]

Dental risks are typical for rigid procedures under general anesthesia. Patient information notes a minimal, but not zero, risk of damage to lips, teeth, or fillings, especially in the presence of loose teeth and crowns. A preliminary dental examination and recording of protective measures is mandatory. [26]

With any type of examination, it is important to discuss allergies to local anesthetics and concomitant medical conditions in advance, assess the patient's anxiety level, and promptly discontinue the procedure if their condition worsens. This reduces the likelihood of vasovagal reactions, laryngospasm, and mucosal trauma, which are warned about in professional guidelines. [27]

Table 4. Contraindications and how to proceed

Situation	Risk	What to do
Signs of a respiratory threat	Obstruction and hypoxia	Immediately address the issue of airway patency and postpone a detailed examination. [28]
Coagulopathy	Bleeding during endoscopy	Coagulation correction, soft technique or transfer. [29]
Unstable heart	Vasovagal reactions	Monitoring and minimizing irritants. [30]
Loose teeth, crowns	Dental damage	Prevent, protect, take into account rigid methods. [31]

Findings and Interpretations: From Red Throat to Red Flags

Viral pharyngitis typically shows diffuse mucosal hyperemia without purulent plaque, moderate granularity of the posterior wall, and enlarged lymphoid tissue follicles. Dense exudative plaque, severe tenderness of the anterior cervical lymph nodes, petechiae on the soft palate, and high fever suggest a bacterial origin. These signs are correlated with testing and treatment decisions based on clinical guidelines. [32]

Lateral displacement of the uvula, asymmetrical protrusion of the soft palate, hyperemia, and severe pain usually indicate a peritonsillar abscess. Flexible endoscopy helps confirm the diagnosis and assess the extent of the process in the maxillary pharyngeal space. Timely recognition helps prevent the spread of infection and the risk to the airway. [33]

Chronic changes such as hypertrophy of the palatine tonsils, cryptorchidism, and granular pharyngitis often accompany gastroesophageal reflux or exposure to irritants. In these cases, a description of the shape, size, and symmetry, photographic documentation, and dynamic observation are important. In cases of persistent unilateral changes, a biopsy is indicated to rule out neoplasia. [34]

Comparing findings with complaints and systemic signs helps select appropriate tests. If a streptococcal infection is suspected, rapid tests described in diagnostic guidelines are appropriate. If the findings are atypical or contain red flags, a decision is made regarding neck imaging, endoscopic intervention, or referral to a specialized center. [35]

Table 5. Red flags during pharyngoscopy

Sign	What is dangerous?	What to do
Unilateral soft palate deformity	Abscess, tumor	Urgent endoscopy, possible drainage and biopsy. [36]
Drooling, stridor, difficulty breathing	Threat of obstruction	Immediate airway assessment.[37]
Persistent unilateral ulcers or infiltrates	Neoplasia	Biopsy and routing. [38]
Hemoptysis, fresh blood	Trauma, ulcers, vascular anomaly	Stopping bleeding, observation, cause. [39]

Infection control and equipment reprocessing

Gloves and a disposable spatula are required for the basic examination. This reduces the risk of cross-transmission of infection and is consistent with the principles of safe primary examination practice. The use of disposable spatulas is preferred for reasons of hygiene and convenience. [40]

Flexible nasopharyngoscopes are considered semi-critical devices and require high-level disinfection with strict adherence to the following steps: pre-cleaning, manual or automated reprocessing with approved agents, rinsing, drying, and storage under conditions that prevent recontamination. Guidance documents for reprocessing emphasize the role of personnel training, personal protective equipment, and documentation. [41]

Modern ENT services are implementing solutions to improve efficiency and environmental sustainability, including ultraviolet (UV) treatment as a component of a validated reprocessing process. Publications from professional societies indicate that UVC, when properly validated, can provide comparable microbial reduction compared to automated washer-disinfectors, while reducing resource consumption. Specific technologies are selected at the facility level. [42]

During examinations, it is important to minimize aerosol generation, especially when coughing and sneezing, ensure adequate ventilation, and use protective equipment as indicated. Experience with outpatient ENT patients in high-risk infection settings confirms that adherence to protocols allows for the safe performance of endoscopic procedures. [43]

Table 6. Reprocessing of flexible nasopharyngoscopes

Stage	Content	Comment
Pre-cleaning	Immediate removal of biomaterial after the procedure	Reduces bioburden. [44]
High-level disinfection	Manual solutions or automated systems	Selection by resources and validation. [45]
Alternative technologies	Ultraviolet class C as part of a validated process	Comparable efficiency, lower carbon footprint. [46]
Drying and storage	Complete drying, clean cabinets, protection from re-contamination	The Key to Patient Safety. [47]

Complications and safety

Basic pharyngoscopy is characterized by mild and short-lived reactions: gagging, coughing, sneezing, and a scratchy sensation in the throat. With flexible endoscopy, minor nosebleeds, vasovagal reactions, episodes of laryngospasm, and transient discomfort are rare. The physician must warn the patient in advance and be prepared to terminate the procedure. Professional guidelines and training materials list these risks and preventative measures. [48]

Serious complications are extremely rare. A small risk of dental trauma and oral soft tissue damage following rigid procedures under general anesthesia has been described in the literature, and this is reflected in hospital patient information sheets. Adherence to proper instrument insertion technique and a preliminary assessment of dental status minimize these risks. [49]

Following endoscopy, brief observation is advisable: assess for the presence of bloody discharge, increasing pain, and difficulty breathing. If fresh blood appears from the nose or mouth, or if pain increases or shortness of breath occurs, the patient is advised to immediately notify the doctor. A checklist for post-procedural observation is provided in the clinical indicators. [50]

A personalized pain management plan and fluid recommendations after local anesthesia improve comfort and reduce anxiety. Patients can typically return to normal activities within a short time, unless sedation or general anesthesia was administered. This is consistent with practical guidelines for flexible ENT procedures. [51]

Table 7. Complications and physician actions

Complication	How to recognize	What to do
Short-term cough, sneezing, gagging	Occur during examination	Stop the irritation, give a break, repeat if necessary. [52]
Nosebleed	Bleeding from the nostril after endoscopy	Tamponade, cold, observation, hemostasis if necessary. [53]
Vasovagal reaction	Dizziness, pallor, sweating	Lying position, observation, pressure control. [54]
Laryngospasm	Stridor, difficulty breathing	Stop manipulation, oxygen, drug assistance according to protocol. [55]

Short answers to frequently asked questions

Is any preparation necessary before pharyngoscopy? No special preparation is required. Oral hygiene, removal of dentures, and informing the patient about possible discomfort are sufficient. For flexible endoscopy, local anesthesia spray is used. [56]

Who should undergo rapid testing for pharyngitis? For clinical presentations typical for group A beta-hemolytic streptococcus, rapid antigen testing is appropriate, based on clinical guidelines and national recommendations for the management of acute sore throat. [57]

How common are complications? With flexible nasopharyngoscopy, complications are rare and usually mild: brief coughing, sneezing, gagging, minor bleeding. Serious events are extremely rare with proper technique and monitoring. [58]

How are endoscopes reprocessed to prevent infection? High-level disinfection is used according to validated protocols, with mandatory pre-cleaning, drying, and proper storage. Alternative solutions are also possible, such as ultraviolet treatment as part of a validated process. [59]