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Rules For Direct Laryngoscopy

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

1. The laryngoscope must always be held in the left hand, never in

the right.

2. The operator's right index finger (never the left) should be used

to retract the patient's upper lip so that there is no danger of

pinching the lip between the instrument and the teeth.

3. The patient's head must always be exactly in the middle line, not

rotated to the right or left, nor bent over sidewise; and the entire

ead must be forward with extension at the occipitoatloid joint only.

4. The laryngoscope is inserted to the right side of the anterior

two-thirds of the tongue, the tip of the spatula being directed toward

the midline when the posterior third of the tongue is reached.

5. The epiglottis must always be identified before any attempt is

made to expose the larynx.

6. When first inserting the laryngoscope to find the epiglottis,

great care should be taken not to insert too deeply lest the

epiglottis be overridden and thus hidden.

7. After identification of the epiglottis, too deep insertion of the

laryngoscope must be carefully avoided lest the spatula be inserted

back of the arytenoids into the hypo-pharynx.

8. Exposure of the larynx is accomplished by pulling forward the

epiglottis and the tissues attached to the hyoid bone, and not by

prying these tissues forward with the upper teeth as a fulcrum.

9. Care must be taken to avoid mistaking the ary-epiglottic fold for

the epiglottis itself. (Most likely to occur as the result of rotation

of the patient's head.)

10. The tube should not be retained too long in place, but should be

removed and the patient permitted to swallow the accumulated saliva,

which, if the laryngoscope is too long in place, will trickle down the

trachea and cause cough. (Swallowing is almost impossible while the

laryngoscope is in position.) The secretions may be removed with the


11. The patient must be instructed to breathe deeply and quietly

without making a sound.