Per-oral flexible laryngoscopy in awake neonates and infants: the ‘pacifier ’ technique P LOIZOU 1 , N HALOOB 1 , E EVGENIOU 2 1 Department of Otolaryngology and Head and Neck Surgery, The Lister Hospital, Stevenage, and 2 Department of Plastic Surgery, Wexham Park Hospital, Slough, UK Abstract Background: It is common for ENT specialists to be called to neonatal intensive care units to assess neonates with suspected laryngomalacia. At Addenbrooke’s Hospital, Cambridge, UK, it is standard practice to initially try to assess the larynx whilst the patient is awake. This can cause the patient to cry and become irritable, and can induce worry in the parents. A literature search revealed that numerous procedures have been successfully performed on neonates and infants whilst they were being pacified. Objectives: This paper describes various procedures where pacification has been used effectively. Furthermore, it reports a pacification technique developed for per-oral flexible laryngoscopy in awake neonates and infants. Key words: Laryngomalacia; Laryngoscopy; Neonatal Intensive Care Introduction Flexible laryngoscopy is now an indispensable tool in ENT practice. It has superseded direct and mirror laryngoscopy. This is because it allows the clinician to thoroughly assess the functional anatomy of the larynx in the awake patient, without the need for sedation or anaesthesia. Whilst this is true in adults, assessment of the paediatric airway still poses a challenge for clinicians. The most common indication for visualisation of the larynx in the neonate is stridor, of which laryngomalacia is the main cause. Per-oral flexible laryngoscopy in the neonate is well documented. This technique has replaced the more tradition- al method of rigid laryngoscopy under anaesthesia. It has been shown to be a safe and effective procedure; however, in practice it can cause distress to both the patient and parents, which can impede performance of the procedure. A number of techniques have been reported in the litera- ture that aim to reduce the pain and distress experienced by awake neonates during invasive procedures. We describe a novel pacifier technique for use during flexible laryngoscopy for assessment of the neonatal airway. Materials and methods The preparation for this technique is quick and easy. Specifically, a small hole of approximately 5 mm in diameter is cut from the tip of a sterile disposable bottle teat (available in most paediatric wards). The teat is then gently stroked along the corner of the child’s mouth eliciting the ‘rooting’ reflex, followed by the sucking reflex. This will pacify the patient. Once the flex- ible laryngoscope is ready, it can slowly be advanced through the hole created at the tip of the teat. This technique keeps the tip of the laryngoscope central, preventing the neonate from sucking and manipulating the laryngoscope tip with its tongue. The child usually remains calm, making the experience less distressing for both the patient and their parents if present (Figure 1). If manipulated gently, the gag reflex may be avoided, pro- vided that the laryngoscope does not make contact with the oropharyngeal wall. Another alternative is to spray some fla- voured topical anaesthetic agent such as benzocaine into the bottle teat before putting it in the patient’s mouth. The sucking also elicits swallowing and hence prevents accumu- lation of saliva in the hypopharynx, thereby enabling a better view of the hypopharynx and larynx. At this point of the procedure, the teat can be withdrawn from the patient’s mouth. This usually leads to phonation or crying, which enables a view of vocal fold movement and assessment of the epiglottis (and potential diagnosis of laryngomalacia) (Figure 2). The use of a video-laryngoscope allows better views (via a high-definition screen), and the recording of the footage enables slow-motion assessment. Discussion Assessment of the neonatal airway can be a challenge for the ENT clinician. The patient can cry, and become very restless and distressed. This can cause the parents, who are often present during the procedure, to worry. Hence, the clinician often has to battle between achieving a good view of the larynx and minimising distress. Currently, if flexible laryngoscopy is not tolerated by an awake neonate or infant, the patient will typically undergo rigid laryngoscopy under general anaesthesia. In such instances, the patient is subjected to a more invasive procedure and anaesthetic risks, causing further distress. This is associated with logistical challenges too, as the patient will need admitting to hospital, an operating theatre will be required, and the appro- priate staff team and paediatric anaesthetists will be needed. Accepted for publication 5 June 2013 First published online 4 February 2014 The Journal of Laryngology & Otology (2014), 128, 169–170. SHORT COMMUNICATION © JLO (1984) Limited, 2014 doi:10.1017/S002221511300340X