Difficulties Of Direct Laryngoscopy

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

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.