Short Scientific CommunicationGeneral Otolaryngology
Otolaryngology
Microbiological Sampling of the Forgotten
Components of a Flexible Fiberoptic
Laryngoscope: What Lessons Can We
Learn?
Jay M. Bhatt, MD1, Ellena M. Peterson, PhD2, and
Sunil P. Verma, MD1
Sponsorships or competing interests that may be relevant to content are dis-
closed at the end of this article.
Abstract
The effectiveness of a Cidex-based decontamination proto-
col was analyzed for its effectiveness in cleaning various
components of a flexible fiberoptic laryngoscope (FFL),
including the handle, eyepiece, and detachable light cable. A
random microbiological sampling and aerobic bacterial cul-
ture analysis of 6 FFL eyepieces, 6 FFL driver handles, and 5
light cables prior to patient use was performed. Of 17 sam-
ples collected, 7 (41%) were contaminated with bacterial
organisms. Organisms recovered represented both environ-
mental organisms from skin and oral flora origin. This study
demonstrates that potential contaminants may be present
on FFL eyepieces and light cables, which are commonly
overlooked in the cleaning protocols of a standard otolaryn-
gology clinic.
Keywords
flexible fiberoptic laryngoscope, contamination, safety
Received June 30, 2013; revised October 21, 2013; accepted October
29, 2013.
D
ue to a recent increase in safety awareness in health
care, the flexible fiberoptic laryngoscope (FFL) has
received considerable attention. Since the shaft of a
FFL comes in contact with patients mucous membranes, it
is considered a semi-critical instrument in the Spaulding
Classification, thus requiring high-level disinfection.1
There are numerous protocols for disinfection, but the
most common disinfection technique addresses only the
shaft of the laryngoscope.2 There has been limited discus-
sion on cleaning the noncritical portions of the flexible lar-
yngoscope, including the eyepiece, handle, and light cord.
Therefore, an investigation was performed to see if the non-
critical portions of a laryngoscope could harbor organisms
that represented clinical bacterial isolates.
Head and Neck Surgery
2014, Vol. 150(2) 235236
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2013
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599813513424
http://otojournal.org
Materials and Methods
The University of California at Irvine Medical Center
review board found this work to be exempt, as it fit in the
category of nonhuman subjects research.
Samples were obtained during a busy outpatient otolaryn-
gology clinic of a general adult outpatient clinic at a tertiary
teaching hospital. Samples were taken of 6 random FFLs
from the eyepiece and driver handle prior to use, as well as
from the proximal and distal ends of 5 light cables. All
FFLs underwent the clinics cleaning protocol: debridement
with an enzymatic sponge of the shaft and body, tap water
rinse, and immersion of the shaft in Cidex (2.5% glutaralde-
hyde; Metrex Research Corporation, Romulis, Michigan),
followed by air drying.
Samples were obtained using culture swabs (BBL
CultureSwab Plus Collection & Transport System; Becton
Dickinson, Franklin Lakes, New Jersey) that were mois-
tened with nonbacteriostatic saline.
Samples were delivered within 1 hour of collection to the
UC Irvine Medical Microbiology laboratory, cultured onto
5% sheep blood agar (BBL), and incubated overnight at
35C in 5% CO2. Colonies were enumerated if \10/plate,
and if .20 per plate, they were rated as 11 to 41.
Results
From the 17 samples collected, there was bacterial growth
in 7 (41%). The growth was low level, with 1 to 4 colonies
recovered from 5 samples (see Table 1). There was 11
1
University Voice and Swallowing Center, Department of Otolaryngology
Head and Neck Surgery, University of California at Irvine Medical Center,
Irvine, California, USA
2
Department of Medical Microbiology, Pathology, University of California at
Irvine Medical Center, Irvine, California, USA
This article was presented as a poster at the 2013 AAO-HNSF Annual
Meeting & OTO EXPO; September 29 to October 3, 2013; Vancouver,
British Columbia, Canada.
Corresponding Author:
Sunil P. Verma, MD, University Voice and Swallowing Center, Department of
OtolaryngologyHead and Neck Surgery, University of California at Irvine
Medical Center, 62 Corporate Park, Ste 115, Irvine, CA 92868, USA.
Email: verma@uci.edu
236
Table 1. Number of positive cultures (and percentage of site total) by each site sampled.
Source No. of Scopes Sampled
Light cable 5 3 (60)
Driver 6 1 (17)
Eyepiece 6 3 (50)
Totals 17
growth from 2 samples: 1 from the FFL eyepiece (normal oral
flora) and the light handle (Corynebacterium). Other isolates
recovered included a coagulase-negative Staphylococcus,
Bacillus species, and a nonfermenting Gram-negative bacillus.
Discussion
Otolaryngology is a unique medical discipline in which
mucosal barriers are examined in virtually every patient. To
reduce the risk of contamination from mucosal surfaces,
many otolaryngology clinics use an immersion protocol,
known as high-level disinfection (HLD), which eliminates
most organisms, including bacteria, mycobacteria, fungi,
and most spores.2 However, there are variations in the HLD
methods since there are no centrally regulated guidelines in
the United States.
Numerous studies have critically evaluated FFL cleaning
methods. Generally, immersion is deemed reasonably
effective in reducing colonization with bacteria and fungi3
and achieves high-level disinfection as well.3,4 A concern
for contamination of noncritical portions of otolaryngologic
instruments has been raised previously, since up to 5% of
FFL handles studied were contaminated after disinfection.5
However, to our knowledge, no study has analyzed ancillary
FFL equipment such as light cables or the efficacy of
immersion in addressing the eyepiece and driver knob.
The results from this study demonstrate that despite
using a widely accepted method of HLD, noncritical por-
tions of the laryngoscope can harbor organisms. Results
suggest that stricter protocols for cleaning the laryngoscope
eyepiece, handle, and light cords may be needed.
Of note, standard guidelines from FFL manufacturers rec-
ommend submersion of the entire laryngoscope in approved
disinfectants, which would potentially decontaminate its sub-
sites. In addition, manufacturer guidelines call for submersion
of light cords in disinfectant solution as well.
Automated endoscope reprocessors can also be used to
enhance cleaning. The use of a protective sheath is also an
effective method for protecting laryngoscope but leaves
contamination of accessory sites a possibility.1
There are weaknesses to this study, the first being a
small sample size. The efficacy changes proposed above
should be examined as well. While in this study, no organ-
isms considered pathogenic were recovered, a larger study
OtolaryngologyHead and Neck Surgery 150(2)
No. (%) of Positive Cultures Bacterial Species
Corynebacterium
Bacillus species
Gram-negative rod (nonfermentor)
Bacillus species
Coagulase-negative Staphylococcus
Normal oral flora
7 (41)
would be needed to determine if this possibility exists and,
more important, if this contamination can actually lead to a
nosocomial infection.
Conclusion
This microbiological evaluation of common instruments such
as the light cables for a flexible fiberoptic laryngoscope, along
with its eyepiece and driver knob, demonstrates a potential for
the presence of contaminants. Thus, per manufacturers recom-
mendations, otolaryngology clinics are encouraged to modify
the cleaning process to minimize hidden sources of contamina-
tion by addressing these highlighted areas.
Author Contributions
Jay M. Bhatt, study design, data acquisition, data interpretation,
manuscript revision and finalization; Ellena M. Peterson, microbiolo-
gical analysis, data interpretation, manuscript revision and finalization;
Sunil P. Verma, study design, data acquisition, data interpretation,
manuscript revision and finalization, study supervision.
Disclosures
Competing interests: Sunil P. Verma is a consultant for
Acclarent.
Sponsorships: None.
Funding source: None.
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