Question: Should an allergist who is treating children consider using the rhinoscope as a diagnostic tool in young children?

Answer by the collected wisdom of the ACAAI Rhinitis/Sinusitis/Ocular Committee members:
Rhinoscopy is a useful tool for examining the upper airways of school-age children and even infants. In fact, infants held in the mother’s arms may be relatively easy to scope, e.g., to access adenoid size. Preschool children can be a little more challenging as they tend to be much more active. However, many experienced allergists complete rhinoscopy on children pre-school and school aged, as long as they are cooperative and can tolerate the procedure. Rhinoscopy is particularly useful for looking at adenoids, as part of making a diagnosis of chronic rhinosinusitis, and for obtaining a directed culture when the child has a resistant sinus infection.  Some school-age children can also tolerate laryngeal area examination with the rhinoscope, useful for evaluating laryngeal diseases and diagnosing laryngeal pharyngeal reflux disease and gastroesophageal reflux disease.

Most allergists who scope children use the 2.5 or 2.7 mm flexible scope also referred to as the pediatric rhinoscope. In fact, many allergists find that this is useful for adults who have narrow nasal cavities due to nasal septal perforation and for accessing the sphenoethmoidal recess and superior meatus in all adults and children. With the added maneuverability and patient comfort, it is perhaps the best all-around option for everyone. While the pediatric scope may be a little more expensive, if you must choose just one scope for your practice to use on both adults and children, consider purchasing the 2.5 or 2.7 mm scope.

While some pediatric otolaryngologist will use an Olympia Papoose system to stabilize the child, we are not aware of any allergists that have utilized this immobilization device. If completing the rhinoscopy becomes that difficult, most allergists would likely be referring to an otolaryngologist.

Question:  I have not performed rhinoscopies for a number of years. My current Welch Allen rhinoscope is no longer manufactured.  Can you provide me with detailed instructions on how to clean a flexible non-channel rhinolarynoscope? 

Dr. Dana V. Wallace, Associate Professor, Nova Southeastern Allopathic Medical School, Davie Florida
Answer: Most rhinolarynoscope manufacturers will have their own set of cleaning AKA "reprocessing" instructions and it would be best to review their recommended method, when this is available. While non-channel rhinolarynoscopes are easier to reprocess than those with a channel, similar cleaning/disinfecting procedures are recommended for both. New products continue to be developed, e.g., Aldahol 1.8 high-level disinfectant and FlexClean 895 detergent, as featured on the Olympus website. 
http://medical.olympusamerica.com/customer-resources/cleaning-disinfection-sterilization/reprocessing-products

When one looks at published studies on reprocessing of flexible laryngoscopes, simple pre-cleaning with soap and water, use of alcohol wipes, and brief submersion in a high-level disinfectant all seem to be effective. However, the authors do suggest using two or more steps in the disinfectant process. (ARCH Otolaryngol Head Neck Surg/Vol 138 (NO.2), Feb 2012 "Disinfection of Flexible Fiberoptic Laryngoscopes..." article attached.)

Cidex OPA is recommended over glutaraldehyde which is more of an irritant, thereby introducing increased risk for staff performing the disinfectant process. Cidex OPA has excellent stability over a wide pH range (pH 3-9), is not a known irritant to the eyes and nasal passages, does not require exposure monitoring, has a barely perceptible odor, and requires no activation. (For more details see https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html)

In 2004, the manufacturers of Cidex OPA reported anaphylaxis-like reaction after cystoscopy with a scope that had been reprocessed using Cidex OPA. Of approximately 1 million urologic procedures performed using instruments reprocessed using OPA, 24 cases have been reported.  Most of these reactions were in patients with bladder cancer who had had multiple urological procedures. The author is not aware of any published reports of anaphylaxis following the use of a rhinolaryngoscope reprocessed using Cidex OPA. However, there have been isolated reports of contact dermatitis and asthma in healthcare workers when exposed to Cidex OPA.

A tertiary amine compound (TAC), e.g., Sencron2®, manufactured in Turkey and commonly used in Europe, seems to be a good alternative disinfectant requiring a relatively short disinfectant exposure time and is more cost effective than Cidex OPA. However, this product is not widely used in the United States. 

The following protocol is one that the author has used for reprocessing but there are certainly others that could be adopted. 

Reprocessing of scope uses cleaning, followed by soaking in a high-level disinfectant, e.g., Cidex OPA Solution (Johnson & Johnson product) or equivalent product. Cidex OPA Solution contains 0.55% ortho-phthalaldehyde

The personnel performing the cleaning of the instrument should wear personal protective equipment, e.g., gloves, eye protection, mouth protection, and fluid-repellent gown. Cidex OPA can stain clothing, countertops, and floors. Cidex OPA may discolor skin.  If there is accidental skin contact, wash with soap and water. Skin discoloration will usually resolve after 1-2 days.  

1. Scrub instrument with anti-bacterial soap and water for 30 seconds.  
2. Complete a 30 second scrub with 70% isopropyl alcohol. 
3. Thoroughly rinse scope with water and dry instrument
4. Pour Cidex OPA (full-strength) into an appropriate disinfectant tray and fully immerse non-channel endoscope in tray. It is recommended to use a Cidex Solution Test strip each time an instrument is cleaned to confirm that the solution has the Minimal Effective Concentration (MEC) for proper disinfecting. Cover tray with secure lid. 
5. Soak for 12 minutes at 68 degrees F (per US labeling instructions)
6. Rinse thoroughly in disinfectant tray with water for 3 rinses, with each rinse lasting one minute and using a minimum of 2 gallons of water/rinse
7. Dry instrument and return to storage case

Note: Unopened, Cidex OPA Solution has a shelf life of 2 years. Once opened, it must be discarded in 75 days. When present in the disinfecting tray, it may be reused for 14 days and then should be discarded. 
 

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