Flexible fiberoptic laryngoscopy in children: effect of sitting versus supine position

Currently no standard exists as to the exact technique of flexible fiberoptic laryngoscopy (FFL) for children. Our objective was to determine the effects of examination in the sitting versus supine position on upper airway findings during FFL in children using a standardized technique and a grading system. In this prospective study, each child acted as his or her own control. Thirty children underwent FFL at a tertiary care children's hospital (mean age 4.5 years). FFL was performed during spontaneous ventilation in both positions, using a standardized sedation technique administered by a single paediatric anaesthesiologist. The findings of inspiratory prolapse of the base of tongue, epiglottis, aryepiglottic folds and arytenoids, and presence of retractions were graded. The results indicated no differences in laryngeal findings between the two positions in 19 (63%) out of 30 children. Differences were observed in 11 (37%) children (p<0.01), but were of small magnitude (one grade) in 10 (91%) of 11 children. Only one child (9%) with severe hypotonia had a difference of two grades. For children with positional differences, 6 (55%) had more obstruction in the supine position, while 5 (45%) had more obstruction in the sitting position. We conclude that although sitting versus supine position statistically significantly affects upper airway findings during FFL in children, examination in either position is usually acceptable. Examination in both positions may detect small differences in approximately one third of children, but we believe this would usually not alter management. Investigators are encouraged to adopt standardized techniques for FFL and grading systems that will allow meaningful comparisons between patients, techniques, and centers.