This book is based on an abstract of the author's larger work, Peroral Endoscopy and Laryngeal Surgery. The abstract was prepared under the author's direction by a reader, in order to get a reader's point of view on the presentation of the subject in the earlier book. With this abstract as a starting point, the author has endeavored, so far as lay within his limited abilities, to accomplish the difficult task of presenting by written word the various purely manual endoscopic procedures. The large number of corrections and revisions found necessary has confirmed the wisdom of the plan of getting the reader's point of view; and these revisions, together with numerous additions, have brought the treatment of the subject up to date so far as is possible within the limits of a working manual. Acknowledgment is due the personnel of the W. B. Saunders Company for kindly help.
CHEVALIER JACKSON. OCTOBER, 1922. II
CONTENTS PAGE
CHAPTER I INSTRUMENTARIUM 17 CHAPTER II ANATOMY OF LARYNX, TRACHEA, BRONCHI AND ESOPHAGUS, ENDOSCOPICALLY CONSIDERED 52 CHAPTER III PREPARATION OF THE PATIENT FOR PERORAL ENDOSCOPY 63 CHAPTER IV ANESTHESIA FOR PERORAL ENDOSCOPY 65 CHAPTER V BRONCHOSCOPIC OXYGEN INSUFFLATION 71 CHAPTER VI POSITION OF THE PATIENT FOR PERORAl ENDOSCOPY 73 CHAPTER VII DIRECT LARYNGOSCOPY 82 CHAPTER VIII DIRECT LARYNGOSCOPY (Continued) 91 CHAPTER IX INTRODUCTION OF THE BRONCHOSCOPE 97 CHAPTER X INTRODUCTION OF THE ESOPHAGOSCOPE 106 CHAPTER XI ACQUIRING SKILL 117 CHAPTER XII FOREIGN BODIES IN THE AIR AND FOOD PASSAGES 126 CHAPTER XIII FOREIGN BODIES IN THE LARYNX AND TRACHEOBRONCHIAL TREE 149 CHAPTER XIV REMOVAL OF FOREIGN BODIES FROM THE LARYNX 156 CHAPTER XV MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION 158 CHAPTER XVI FOREIGN BODIES IN THE BRONCHI FOR PROLONGED PERIODS 177 CHAPTER XVII UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES 181 CHAPTER XVIII FOREIGN BODIES IN THE ESOPHAGUS 183 CHAPTER XIX ESOPHAGOSCOPY FOR FOREIGN BODY 187 CHAPTER XX PLEUROSCOPY 199 CHAPTER XXI BENIGN GROWTHS IN THE LARYNX 201 CHAPTER XXII BENIGN GROWTHS IN THE LARYNX (Continued) 203 CHAPTER XXIII BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL TREE 207 CHAPTER XXIV BENIGN NEOPLASMS OF THE ESOPHAGUS 209 CHAPTER XXV ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX 210 CHAPTER XXVI BRONCHOSCOPY IN MALIGNANT GROWTHS OF THE TRACHEA 214 CHAPTER XXVII MALIGNANT DISEASE OF THE ESOPHAGUS 216 CHAPTER XXVIII DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX 221 CHAPTER XXIX BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND BRONCHI 224 CHAPTER XXX DISEASES OF THE ESOPHAGUS 235 CHAPTER XXXI DISEASES OF THE ESOPHAGUS (Continued) 245 CHAPTER XXXII DISEASES OF THE ESOPHAGUS (Continued) 251 CHAPTER XXXIII DISEASES OF THE ESOPHAGUS (Continued) 260 CHAPTER XXXIV DISEASES OF THE ESOPHAGUS (Continued) 268 CHAPTER XXXV GASTROSCOPY 273 CHAPTER XXXVI ACUTE STENOSIS OF THE LARYNX 277 CHAPTER XXXVII TRACHEOTOMY 279 CHAPTER XXXVIII CHRONIC STENOSIS OF THE LARYNX AND TRACHEA 300 CHAPTER XXXIX DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS 309 BIBLIOGRAPHY 311 INDEX 315
[17] CHAPTER I—INSTRUMENTARIUM
Direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy are procedures in which the lower air and food passages are inspected and treated by the aid of electrically lighted tubes which serve as specula to manipulate obstructing tissues out of the way and to bring others into the line of direct vision. Illumination is supplied by a small tungsten-filamented, electric, "cold" lamp situated at the distal extremity of the instrument in a special groove which protects it from any possible injury during the introduction of instruments through the tube. The bronchi and the esophagus will not allow dilatation beyond their normal caliber; therefore, it is necessary to have tubes of the sizes to fit these passages at various developmental ages. Rupture or even over-distention of a bronchus or of the thoracic esophagus is almost invariably fatal. The armamentarium of the endoscopist must be complete, for it is rarely possible to substitute, or to improvise makeshifts, while the bronchoscope is in situ. Furthermore, the instruments must be of the proper model and well made; otherwise difficulties and dangers will attend attempts to see them.
Laryngoscopes.—The regular type of laryngoscope shown in Fig. I (A, B, C) is made in adult's, child's, and infant's sizes. The instruments have a removable slide on the top of the tubular portion of the speculum to allow the removal of the laryngoscope after the insertion of the bronchoscope through it. The infant size is made in two forms, one with, the other without a removable slide; with either form the larynx of an infant can be exposed in but a few seconds and a definite diagnosis made, without anesthesia, general or local; a thing possible by no other method. For operative work on the larynx of adults, such as the removal of benign growths, particularly when these are situated in the anterior portion of the larynx, a special tubular laryngoscope having a heart-shaped lumen and a beveled tip is used. With this instrument the anterior commissure is readily exposed, and because of this it is named the anterior commissure laryngoscope (Fig. 1, D). The tip of the anterior commissure laryngoscope can be used to expose either ventricle of the larynx by lifting the ventricular band, or it may be passed through the adult glottis for work in the subglottic region. This instrument may also be used as an esophageal speculum and as a pleuroscope. A side-slide laryngoscope, used with or without the slide, is occasionally useful.
Bronchoscopes.—The regular bronchoscope is a hollow brass tube slanted at its distal end, and having a handle at its proximal or ocular extremity. An auxiliary canal on its under surface contains the light carrier, the electric bulb of which is situated in a recess in the beveled distal end of the tube. Numerous perforations in the distal part of the tube allow air to enter from other bronchi when the tube-mouth is inserted into one whose aerating function may be impaired. The accessory tube on the upper surface of the bronchoscope ends within the lumen of the bronchoscope, and is used for the insufflation of oxygen or anesthetics, (Fig. 2, A, B, C, D).
For certain work such as drainage of pulmonary abscesses, the lavage treatment of bronchiectasis and for foreign-body or other cases with abundant secretions, a drainage-bronchoscope is useful The drainage canal may be on top, or on the under surface next to the light-carrier canal. For ordinary work, however, secretion in the bronchus is best removed by sponge-pumping (Q.V.) which at the same time cleans the lamp. The drainage bronchoscope may be used in any case in which the very slightly-greater area of cross section is no disadvantage; but in children the added bulk is usually objectionable, and in cases of recent foreign-body, secretions are not troublesome.
As before mentioned, the lower air passages will not tolerate dilatation; therefore, it is necessary never to use tubes larger than the size of the passages to be examined. Four sizes are sufficient for any possible case, from a newborn infant to the largest adult. For infants under one year, the proper tube is the 4 mm. by 30 cm.; the child's size, 5 mm. by 30 cm., is used for children aged from one to five years. For children six years or over, the 7 mm. by 40 cm. bronchoscope (the adolescent size) can be used unless the smaller bronchi are to be explored. The adult bronchoscope measures 9 mm. by 40 cm.