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General Principles Of Position

Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

As will be seen in Fig. 47 the
trachea and esophagus are not horizontal in the thorax, but their long
axes follow the curves of the cervical and dorsal spine. Therefore, if
we are to bring the buccal cavity and pharynx in a straight line with
the trachea and esophagus it will be found necessary to elevate the
whole head above the plane of the table, and at the same time make
extension at the occipito-atloid joint. By this maneuver the cervical
spine is brought in line with the upper portion of the dorsal spine as
shown in Fig. 55. It was formerly taught, and often in spite of my
better knowledge I am still unconsciously prone to allow the head and
cervical spine to assume a lower position than the plane of the table,
the so-called Rose position. With the head so placed, it is impossible
to enter the lower air or food passages with a rigid tube, as will be
shown by a study of the radiograph shown in Fig. 49. Extension of the
head on the occipito-atloid joint is for the purpose of freeing the
tube from the teeth, and the amount required will vary with the degree
to which the mouth can be opened. Whether the head be extended,
flexed, or kept mid-way, the fundamental principle in the introduction
of all endoscopic tubes is the anterior placing of the cervical spine
and the high elevation of the head. The esophagus, just behind the
heart, turns ventrally and to the left. In order to pass a rigid tube
through this ventral curve the dorsal spine is now extended by
lowering the head and shoulders below the plane of the table. This
will be further explained in the chapter on esophagoscopy. In all of
these procedures, the nose of the patient should be directed toward
the zenith, and the assistant should prevent rotation of the head as
well as prevent lowering of the head. The patient should be urged as
Don't hold yourself so rigid.
Let your head and neck go loose.
Let your head rest in my hand.
Don't try to hold it.
Let me hold it.
Don't raise your chest.

[FIG. 47.--Schematic illustration of normal position of the
intra-thoracic trachea and esophagus and also of the entire trachea
when the patient is in the correct position for peroral bronchoscopy.
When the head is thrown backward (as in the Rose position) the
anterior convexity of the cervical spine is transmitted to the trachea
and esophagus and their axes deviated. The anterior deviation of the
lower third of the esophagus shows the anatomical basis for the high
low position for esophagoscopy]

[FIG. 48.--Correct position of the cervical spine for esophagoscopy
bronchoscopy. (Illustration reproduced from author's article Jour.
Am. Med. Assoc., Sept. 25, 1909)]

[FIG. 49.--Curved position of the cervical spine, with anterior
convexity, in the Rose position, rendering esophagoscopy and
bronchoscopy difficult or impossible. The devious course of the
pharynx, larynx and trachea are plainly visible. The extension is
incorrectly imparted to the whole cervical spine instead of only to
the occipito-atloid joint. This is the usual and very faulty
conception of the extended position. (Illustration reproduced from
author's article, Jour. Am. Med. Assoc., Sept. 25, 1909.)]

[76] For direct laryngoscopy the patient's head is raised above the
plane of the table by the first assistant, who stands to the right of
the patient, holding the bite block on his right thumb inserted in the
left corner of the patient's mouth, while his extended right hand lies
along the left side of the patient's cheek and head, and prevents
rotation. His left hand, placed under the patient's occiput, elevates
the head and maintains the desired degree of extension at the
occipito-atloid joint (Fig. 50).

[FIG 50.--Direct laryngoscopy, recumbent patient. The second assistant
is sitting holding the head in the Boyce position, his left forearm on
his left thigh his left foot on a stool whose top is 65 cm. lower than
the table-top. His left hand is on the patient's sterile-covered
scalp, the thumb on the forehead, the fingers under the occiput,
making forced extension. The right forearm passes under the neck of
the patient, so that the index finger of the right hand holds the
bite-block in the left corner of the patient's mouth. The fingers of
the operator's right hand pulls the upper lip out of all danger of
getting pinched between the teeth and the laryngoscope. This is a
precaution of the utmost importance and the trained habit of doing it
must be developed by the peroral endoscopist.]

Next: Position For Bronchoscopy And Esophagoscopy

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