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Difficulties Of Direct Laryngoscopy

Source: 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.

Next: Instruments For Direct Laryngoscopy

Previous: Rules For Direct Laryngoscopy

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