Bronchoscopy and Esophagoscopy / A Manual of Peroral Endoscopy and Laryngeal Surgery

by Chevalier Jackson

The right hand is then free for the manipulation of forceps, and the insertion of the bronchoscope or other instrument. During introduction, the fingers of the right hand retract the upper lip so as to prevent its being pinched between the laryngoscope and the teeth. The introduction of the direct laryngoscope and exposure of the larynx is best described in two stages. 1. Exposure and identification of the epiglottis. 2. Elevation of the epiglottis and all the tissues attached to the hyoid bone, so as to expose the larynx to direct view.

First Stage.—The spatular end of the laryngoscope is introduced in the right side of the patient's mouth, along the right side of the anterior two-thirds of the tongue. It was the German method to introduce the laryngoscope over the dorsum of the tongue but in order to elevate this sometimes powerful muscular organ considerable force may be required, which exercise of force may be entirely avoided by crowding the tongue over to the left. When the posterior third stage of the tongue is reached, the tip of the laryngoscope is directed toward the midline and the dorsum of the tongue is elevated by a lifting motion imparted to the laryngoscope. The epiglottis will then be seen to project into the endoscopic field, as seen in Fig. 54.

[FIG. 54.—End of the first of direct laryngoscopy, recumbent adult patient. The epiglottis is exposed by a lifting motion of the spatular tip on the tongue anterior to the epiglottis.]

Second Stage.—The spatular end of the laryngoscope should now be tipped back toward the posterior wall of the pharynx, passed posterior to the epiglottis, and advanced about 1 cm. The larynx is now exposed by a motion that is best described as a suspension of the head and all the structures attached to the hyoid bone on the tip of the spatular end of the laryngoscope (Fig. 55). Particular care must be taken at this stage not to pry on the upper teeth; but rather to impart a lifting motion with the tip of the speculum without depressing the proximal tubular orifice. It is to be emphasized that while some pressure is necessary in the lifting motion, great force should never be used; the art is a gentle one. The first view is apt to find the larynx in state of spasm, and affords an excellent demonstration of the fact that the larynx can he completely closed without the aid of the epiglottis. Usually little more is seen than the two rounded arytenoid masses, and, anterior to them, the ventricular bands in more or less close apposition hiding the cords (Fig. 56). With deep general anesthesia or thorough local anesthesia the spasm may not be present. By asking the patient to take a deep breath and maintain steady breathing, or perhaps by requesting a phonatory effort, the larynx will open widely and the cords be revealed. If the anterior commissure of the larynx is not readily seen, the lifting motion and elevation of the head should be increased, and if there is still difficulty in exposing the anterior commissure the assistant holding the head should with the index finger externally on the neck depress the thyroid cartilage. If by this technic the larynx fails to be revealed the endoscopist should ask himself which of the following rules he has violated.

[FIG. 55.—Schema illustrating the technic of direct laryngoscopy on the recumbent patient. The motion is imparted to the tip of the laryngoscope as if to lift the patient by his hyoid hone. The portion of the table indicated by the dotted line may be dropped or not, but the back of the head must never go lower than here shown, for direct laryngoscopy; and it is better to have it at least 10 cm. above the level of the table. The table may be used as a rest for the operator's left elbow to take the weight of the head. (Note that in bronchoscopy and esophagoscopy the head section of the table must be dropped, so as to leave the head and neck of the patient out in the air, supported by the second assistant.)]

[FIG. 56.—Endoscopic view at the end of the second stage of direct laryngoscopy. Recumbent patient. Larynx exposed waiting for larynx to relax its spasmodic contraction.]

RULES FOR DIRECT LARYNGOSCOPY 1. The laryngoscope must always be held in the left hand, never in the right. 2. The operator's right index finger (never the left) should be used to retract the patient's upper lip so that there is no danger of pinching the lip between the instrument and the teeth. 3. The patient's head must always be exactly in the middle line, not rotated to the right or left, nor bent over sidewise; and the entire head must be forward with extension at the occipitoatloid joint only. 4. The laryngoscope is inserted to the right side of the anterior two-thirds of the tongue, the tip of the spatula being directed toward the midline when the posterior third of the tongue is reached. 5. The epiglottis must always be identified before any attempt is made to expose the larynx. 6. When first inserting the laryngoscope to find the epiglottis, great care should be taken not to insert too deeply lest the epiglottis be overridden and thus hidden. 7. After identification of the epiglottis, too deep insertion of the laryngoscope must be carefully avoided lest the spatula be inserted back of the arytenoids into the hypo-pharynx. 8. Exposure of the larynx is accomplished by pulling forward the epiglottis and the tissues attached to the hyoid bone, and not by prying these tissues forward with the upper teeth as a fulcrum. 9. Care must be taken to avoid mistaking the ary-epiglottic fold for the epiglottis itself. (Most likely to occur as the result of rotation of the patient's head.) 10. The tube should not be retained too long in place, but should be removed and the patient permitted to swallow the accumulated saliva, which, if the laryngoscope is too long in place, will trickle down the trachea and cause cough. (Swallowing is almost impossible while the laryngoscope is in position.) The secretions may be removed with the aspirator. 11. The patient must be instructed to breathe deeply and quietly without making a sound.

[88] Difficulties of Direct Laryngoscopy.—The larynx can be directly exposed in any patient whose mouth can be opened, although the ease varies greatly with the type of patient. Failure to expose the epiglottis is usually due to too great haste to enter the speculum all the way down. The spatula should glide slowly along the posterior third of the tongue until it reaches the glossoepiglottic fossa, while at the same time the tongue is lifted; when this is done the epiglottis will stand out in strong relief. The beginner is apt to insert the speculum too far and expose the hypopharynx rather than the larynx. The elusiveness of the epiglottis and its tendency to retreat downward are very much accentuated in patients who have worn a tracheotomic cannula; and if still wearing it, the patient can wait indefinitely before opening his glottis. Over extension of the patient's head is a frequent cause of difficulty. If the head is held high enough extension is not necessary, and the less the extension the less muscular tension there is in the anterior cervical muscles. Only one arytenoid eminence may be seen. The right and the left look different. Practice will facilitate identification, so that the endoscopist will at once know which way to look for the glottis.

Of the difficulties that pertain to the operator himself the greatest is lack of practice. He must learn to recognize the landmarks even though a high degree of spasm be present. The epiglottis and the two rounded eminences corresponding to the arytenoids must be in the mind's eye, for it is only on deep, relaxed inspiration that anything like a typical picture of the larynx will be seen. He must know also the right from the left arytenoid when only one is seen in order to know whether to move the lip of the laryngoscope to the right or the left for exposure of the interior of the larynx.

Instruments for Direct Laryngoscopy.—In undertaking direct laryngoscopy one must always be prepared for bronchoscopy, esophagoscopy, and tracheotomy, as well. Preparations for bronchoscopy are necessary because the pathological condition may not be found in the larynx, and further search of the trachea or bronchi may be required. A foreign body in the larynx may be aspirated to a deeper location and could only be followed with the bronchoscope. Sudden respiratory arrest might occur, from pathology or foreign body, necessitating the inserting of the bronchoscope for breathing purposes, and the insufflation of oxygen and amyl nitrite. Trachectomy might be required for dyspnea or other reasons. It might be necessary to explore the esophagus for conditions associated with laryngeal lesions, as for instance a foreign body in the esophagus causing dyspnea by pressure. In short, when planning for direct laryngoscopy, bronchoscopy, or esophagoscopy, prepare for all three, and for tracheotomy. A properly done direct laryngoscopy would never precipitate a tracheotomy in an unanesthetized patient; but direct laryngoscopy has to deal so frequently with laryngeal stenosis, that routine preparation for tracheotomy a hundred unnecessary times is fully compensated for by the certainty of preparedness when the rare but urgent occasion arises.