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General Principles Of Position

Sources: 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 t
is 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.]