Categories: DIRECT LARYNGOSCOPY
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery
The dorsally recumbent
patient is so placed that the head and shoulders extend beyond the
table, the edge of which supports the thorax at about the level of the
scapulae. During introduction, the head must be maintained in the same
relative position to the table as that described for direct
laryngoscopy, that is, elevated and extended. The first assistant, in
this case, sits on a stool to the right of the patient's head, his
left foot resting on a box about 14 inches in height, the left knee
supporting the assistant's left hand, which being placed under the
occiput of the patient maintains elevation and extension. The right
arm of the assistant passes under the neck of the patient, the bite
block being carried on the middle finger of the right hand and
inserted into the left side of the patient's mouth. The right hand
also prevents rotation of the head (Fig. 51). As the bronchoscope or
esophagoscope is further inserted, the head must be placed so that the
tube corresponds to the axis of the lumen of the passage to be
examined. If the left bronchus is being explored, the head must be
brought strongly to the right. If the right middle lobe bronchus is
being searched, the head would require some left lateral deflection
and a considerable degree of lowering, for this bronchus, as before
mentioned, extends anteriorly. During esophagoscopy when the level of
the heart is reached, the head and upper thorax must be strongly
depressed below the plane of the table in order to follow the axis of
the lumen of the ventrally turning esophagus; at the same time the
head must be brought somewhat to the right, since the esophagus in
this region deviates strongly to the left.
[FIG. 51.--Position of patient and assistant for introduction of the
bronchoscope and esophagoscope. The middle of the scapulae rest on the
edge of the table; the head and shoulders, free to move, are supported
by the assistant, whose right arm passes under the neck; the right
middle finger inserts the bite block into the left side of the mouth.
The left hand, resting on the left knee maintains the desired degree
of elevation, extension and lateral deflection required by the
operator. The patient's vertex should be 10 cm. higher than the level
of the top of the table. This is the Boyce position, which has never
been improved upon for bronchoscopy and esophagoscopy.]
[FIG. 52.--Schema of position for endoscopy.
A. Normal recumbency on the table with pillow supporting the head.
The larynx can be directly examined in this position, but a better
position is obtainable.
B. Head is raised to proper position with head flexed. Muscles of
front of neck are relaxed and exposure of larynx thus rendered easier;
but, for most endoscopic work, a certain amount of extension is
desired. The elevation is the important thing.
C. The neck being maintained in position B, the desired amount of
extension of the head is obtained by a movement limited to the
occipito-atloid articulation by the assistant's hand placed as shown
by the dart (B).
D. Faulty position. Unless prevented, almost all patients will heave
up the chest and arch the lumbar spine so as to defeat the object and
to render endoscopy difficult by bringing the chest up to the
high-held head, thus assuming the same relation of the head to the
chest as exists in the Rose position (a faulty one for endoscopy) as
will be understood by assuming that the dotted line, E, represents the
table. If the pelvis be not held down to the table the patient may
even assume the opisthotonous position by supporting his weight on his
heels on the table and his head on the assistant's hand.]
In obtaining the position of high head with occipito-atloid extension,
the easiest and most certain method, as pointed out to me by my
assistant, Gabriel Tucker, is first to raise the head, strongly
flexed, as shown in Fig. 52; then while maintaining it
there, make the occipito-atloid extension. This has proven better
than to elevate and extend in a combined simultaneous movement.
If the patient would relax to limpness exposure of the larynx would be
easily obtained, simply by lifting the head with the lip of the
laryngoscope passed below the tip of the epiglottis (as in Fig. 55)
and no holding of the head would be necessary. But only rarely is a
patient found who can do this. This degree of relaxation is of course,
present in profound general ether anesthesia, which is not to be
thought of for direct laryngoscopy, except when it is used for the
purpose of insertion of intratracheal insufflation anesthetic tubes.
For this, of course, the patient is already to be deeply anesthetized.
The muscular tension exerted by some patients in assuming and holding
a faulty position is almost as much of a hindrance to peroral
endoscopy as is the position itself. The tendency of the patient to
heave up his chest and assume a false position simulating the
opisthotonous position (Fig. 52) must be overcome by persuasion. This
position has all the disadvantages of the Rose position for endoscopy.
[FIG. 53.--The author's position for the removal of foreign bodies
from the larynx or from any of the upper air or food passages. If
dislodged, the intruder will not be aided by gravity to reach a deeper
The one exception to these general positions is found in procedures
for the removal of foreign bodies from the larynx. In such cases,
while the same relative position of the head to the plane of the table
is maintained, the whole table top is so inclined as to elevate the
feet and lower the head, known as Jackson's position. This
semi-inversion of the patient allows the foreign body to drop into the
pharynx if it should be dislodged, or slip from the forceps (Fig. 53).
TITLE Importance of Mirror Examination of the Larynx
The presence of
the direct laryngoscope incites spasmodic laryngeal reflexes, and the
traction exerted somewhat distorts the tissues, so that accurate
observations of variations in laryngeal mobility are difficult to
obtain. The function of the laryngeal muscles and structures,
therefore, can best be studied with the laryngeal mirror, except in
infants and small children who will not tolerate the procedure of
indirect laryngoscopy. A true idea of the depth of the larynx is not
obtained with the mirror, and a view of the ventricles is rarely had.
With the introduction of the direct laryngoscope it is found that the
larynx is funnel shaped, and that the adult cords are situated about 3
cm. below the aryepiglottic folds; the cords also assume their true
shelf-like character and take on a pinkish or yellowish tinge, rather
than the pearly white seen in the mirror. They are not to any extent
differentiated by color from the neighboring structures. Their
recognition depends almost wholly on form, position and movement.
Accurate observation is stimulated in all pathologic cases by making
colored crayon sketches, however crude, of the mirror image of the
larynx. The location of a growth may be thus graphically recorded, so
that at the time of operation a glance will serve to refresh the
memory as to its site. It is to be constantly kept in mind, however,
that in the mirror image the sides are reversed because of the facing
positions of the examiner and patient. Direct laryngoscopy is the only
method by which the larynx of children can be seen. The procedure need
require less than a minute of time, and an accurate diagnosis of the
condition present, whether papilloma, foreign body, diphtheria,
paralysis, etc., may be thus obtained. The posterior pharyngeal wall
should be examined in all dyspneic children for the possible existence
of retropharyngeal abscess.
[PLATE II--DIRECT AND INDIRECT LARYNGEAL VIEWS FROM AUTHOR'S OIL-COLOR
DRAWINGS FROM LIFE:
1, Epiglottis of child as seen by direct laryngoscopy in the
2, Normal larynx spasmodically closed, as is usual on first exposure
3, Same on inspiration.
4, Supraglottic papillomata as seen on direct laryngoscopy in a
child of two years.
5, Cyst of the larynx in a child of four years, seen on direct
laryngoscopy without anesthesia.
6, Indirect view of larynx eight weeks after thyrotomy for cancer of
the right cord in a man of fifty years.
7, Same after two years. An adventitious band indistinguishable from
the original one has replaced the lost cord.
8, Condition of the larynx three years after hemilaryngectomy for
epithelioma in a patient fifty-one years of age. Thyrotomy revealed
such extensive involvement, with an open ulceration which had reached
the perichondrium, that the entire left wing of the thyroid cartilage
was removed with the left arytenoid. A sufficiently wide removal was
accomplished without removing any part of the esophageal wall below
the level of the crico-arytenoid joint. There is no attempt on the
part of nature to form an adventitious cord on the left side. The
normal arytenoid drew the normal cord over, approximately to the edge
of the cicatricial tissue of the operated side. The voice, at first a
very hoarse whisper, eventually was fairly loud, though slightly husky
9, The pharynx seen one year after laryngectomy for endothelioma in
a man aged sixty-eight years. The purple papilla; anteriorly are at
the base of the tongue, and from this the mucosa slopes downward and
backward smoothly into the esophagus. There are some slight folds
toward the left and some of these are quite cicatricial. The
epiglottis was removed at operation. The trachea was sutured to the
skin and did not communicate with the pharynx. (Direct view.)]