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Second Stage

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The spatular end of the laryngoscope should now be

tipped back toward the posterior wall of the pharynx, passed posterior

to the epiglottis, and advanced about 1 cm. The larynx is now exposed

by a motion that is best described as a suspension of the head and all

the structures attached to the hyoid bone on the tip of the spatular

end of the laryngoscope (Fig. 55). Particular care must be taken at

this stage not to pry
n the upper teeth; but rather to impart a

lifting motion with the tip of the speculum without depressing the

proximal tubular orifice. It is to be emphasized that while some

pressure is necessary in the lifting motion, great force should never

be used; the art is a gentle one. The first view is apt to find the

larynx in state of spasm, and affords an excellent demonstration of

the fact that the larynx can he completely closed without the aid of

the epiglottis. Usually little more is seen than the two rounded

arytenoid masses, and, anterior to them, the ventricular bands in more

or less close apposition hiding the cords (Fig. 56). With deep

general anesthesia or thorough local anesthesia the spasm may not be

present. By asking the patient to take a deep breath and maintain

steady breathing, or perhaps by requesting a phonatory effort, the

larynx will open widely and the cords be revealed. If the anterior

commissure of the larynx is not readily seen, the lifting motion and

elevation of the head should be increased, and if there is still

difficulty in exposing the anterior commissure the assistant holding

the head should with the index finger externally on the neck depress

the thyroid cartilage. If by this technic the larynx fails to be

revealed the endoscopist should ask himself which of the following

rules he has violated.

[FIG. 55.--Schema illustrating the technic of direct laryngoscopy on

the recumbent patient. The motion is imparted to the tip of the

laryngoscope as if to lift the patient by his hyoid hone. The portion

of the table indicated by the dotted line may be dropped or not, but

the back of the head must never go lower than here shown, for direct

laryngoscopy; and it is better to have it at least 10 cm. above the

level of the table. The table may be used as a rest for the operator's

left elbow to take the weight of the head. (Note that in bronchoscopy

and esophagoscopy the head section of the table must be dropped, so as

to leave the head and neck of the patient out in the air, supported by

the second assistant.)]

[FIG. 56.--Endoscopic view at the end of the second stage of direct

laryngoscopy. Recumbent patient. Larynx exposed waiting for larynx to

relax its spasmodic contraction.]