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Sir.—I agree with the findings of Mauro and associates. For the past 26 years I have used similar criteria and protocols for assessing the supraglottis. I have not observed any incidence of vasovagal responses nor have I observed trauma to the mouth, as described by Mauro et al. This may be because of my long-term relationship with my patients and their parents and several substantial differences in technique.
The parent and the child are asked to sit on my treatment room table. The child sits up on his parent's lap and is asked to "pant like a puppy" and keep his chin down (neck flexed). If this cannot be accomplished an adult restrains the child by pressing the child's arms onto the sides of his head as he lays on the table with his head flexed on a cushion. I have found that an indirect laryngoscopy is much less traumatic
KATZ FA. Oropharyngeal Examination for Suspected Epiglottitis. Am J Dis Child. 1988;142(12):1264. doi:10.1001/archpedi.1988.02150120018011