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Flexible Nasal Endoscopy (FNE) by Emergency Physicians

Three Part Question

In [patients requiring flexible nasal endoscopy, FNE] are [emergency physicians] capable of [conducting FNE and interpreting non-inferiorly to ENT doctors Clinical Scenario You are an Emergency Medicine (EM) Registrar seeing a patient with a sore throat and have a plan to discharge home without formal follow-up arranged. However, you wish to rule out supraglottitis as a differential. It’s changeover day and the current Ear, Nose and Throat (ENT) junior doctor hasn’t been trained in Flexible Nasal Endoscopy (FNE) and there is no senior support on site. FNE is not in your current or previous skillset.

A new EM junior doctor, having just rotated from ENT, offers to assist in performing FNE. Whilst taking them up on the offer, you wonder if FNE should be part of the skill set of an EM Registrar?

Search Strategy

EMBASE, PubMed and CINAHL were searched, with no limitation on date or language, via the NICE Healthcare Databases Advanced Search (HDAS) portal (Search strategy 446255).
"(((em* OR er) AND (doctor OR physician OR resident OR fellow OR practitioner OR nurse OR registrar OR consultant OR PA OR physician assistant)).ti,ab AND (((flex* AND nas*) AND endoscop*).ti,ab OR (flex* AND nasendoscop*).ti,ab OR (fib* AND nasendoscop*).ti,ab OR ((fib* AND nas*) AND endoscop*).ti,ab OR (fib* AND laryng*).ti,ab OR (flex* AND laryng*).ti,ab OR (indirect AND laryngo*).ti,ab OR (FNE).ti,ab OR ENT OR otorhinolaryn* OR glottitis).ti,ab) AND (train* OR exp* OR skill OR educat* OR teach* OR curriculum OR competenc* OR accredit* OR induc*).ti,ab"

Search Outcome

CINAHL: 66 results
EMBASE: 254 results
PubMed: 133 results

Of these 453 entries (11th June 2018), 24 had duplicates, after removal, 428 unique entries remain. Entries then screened based on title (309 excluded), then abstract (102 excluded), with regard to the three part question using the Rayyan platform(1), with 17 entries of interest in relation to the three part question, such as discussing FNE, induction to and maintenance of knowledge, skills and attributes of non-ENT doctors in a ENT rotation and the format and duration of such training at induction and in clinics.

None of these entries directly related to the proposed three part question or clinical vignette. Review of references yielded papers of interest but not directly relevant.


Most Emergency Medicine SpRs in the United Kingdom currently undertake the Acute Care Common Stem (ACCS) training programme for their first two years of post-foundation training. These rotations include acquisition of the Initial Assessment of Competencies (IAC) as stipulated in the Royal College of Emergency Medicine (RCEM) (2)and Royal College of Anaesthetists (RCoA) curriculum(3). After this, trainees join the ST3 tier, with training in Paediatric EM and often with a focus on ‘minors’ and musculoskeletal presentations. There is no mandatory training in ENT required in UK undergraduate curricula or the Foundation Programme. However, Foundation programme, Core Surgical Training (CST) and General Practice Vocational Training Scheme (GP-VTS) trainees form the large majority of ENT junior post holders, and are often the first port of call for the skill of FNE. Given that EM trainees must practice and train in an ED approved for training, that these are type 1 EDs likely to be based in a hospital with an ENT service (not exclusively inpatient or same site); and that ENT juniors in some deaneries are given training in basic skills such as FNE and indirect laryngoscopy(4)(5)(6)(7) (often per rotation if not annually), there is potential for this to be open to EM trainees. This could form part of their ST3 training or ACCS (EM rotation) training, and be in the form of day-release or study leave to join onto existing training occurring for ENT juniors. This can then be reinforced through attendance in ENT clinics to have further supervised training and assessment, with a blueprint already present in the Intercollegiate Surgical Curriculum Programme (ICSP)(8). Clinical note keeping, peer or supervisor review and logbooks are highly likely to be supported by the use of enhanced imaging capabilities from FNE, and even the use of smartphone adapters(9).

Clinical Bottom Line

Whilst not currently part of the EM training curriculum, the skill of FNE is easily acquired and practiced by other non ENT junior doctors, and has a role to play in the evaluation of EM patients outside of airway management indications. There is scope for attaining this skill in order to improve the familiarity of EM clinicians to the normal and abnormal appearances on FNE as well as expediting clinical care and reducing the duration of patient stay in the ED and associated ‘double clerking’ when referring to ENT for an opinion regarding safe discharge in particular presentations. References 1. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev [Internet]. 2016;5(1):1–10. Available from: 2. Royal College of Emergency Medicine. THE ROYAL COLLEGE OF EMERGENCY MEDICINE Curriculum and Assessment Systems For Training in Emergency Medicine. 2016;(August 2015). Available from: 3. The Royal College of Anaesthetists. CCT in Anaesthetics. Higher Level Training (Annex D). 2010; Available from: 4. Smith ME, Trinidade A, Tysome JR. The ENT boot camp: an effective training method for ENT induction. Clin Otolaryngol [Internet]. 2016;41(4):421–4. Available from: 5. Coulter CA, Powell J, Wilson J. UK ENT emergency service provision: 4 Steps to improve your emergency service. Otorhinolaryngologist. 2012;5(1):47–9. 6. The Royal College of Emergency Medicine. Ultrasound Training [Internet]. [cited 2017 Aug 1]. Available from: 7. Swords C, Smith ME, Wasson JD, Qayyum A, Tysome JR. Validation of a new ENT emergencies course for first-on-call doctors. J Laryngol Otol. 2017;131(2):106–12. 8. Joint Committee on Surgical Training. The Intercollegiate Surgical Curriculum Educating the surgeons of the future. 2013;(October):1–360. Available from: 9. Quimby AE, Kohlert S, Caulley L, Bromwich M. Smartphone adapters for flexible Nasolaryngoscopy: A systematic review. J Otolaryngol - Head Neck Surg. 2018;47(1).