70 Laryngoscopy, Bronchoscopy, & Esophagoscopy Flashcards
What are laryngoscopy, bronchoscopy, and esophagoscopy?
What are laryngoscopy, bronchoscopy, and esophagoscopy?
Laryngoscopy is the examination of the larynx. This can be performed indirectly using a head light and mirror and directly using rigid or flexible laryngoscopes. Bronchoscopy is examination of the trachea, bronchi, and its branches performed using either rigid or flexible bronchoscopes. Esophagoscopy is the endoscopic examination of the esophagus and this too may be performed using either flexible or rigid esophagoscopes.
When is office laryngoscopy indicated in adults?
When is office laryngoscopy indicated in adults?
Examination of the larynx in adults is part of the complete physical examination of the head and neck and can be performed using indirect or flexible laryngoscopy. In examining the larynx in an adult, the supraglottis, oropharynx, and hypopharynx are often visualized as well. Examination of the larynx and surrounding anatomic areas are indicated for complaints of dysphonia, chronic cough, globus sensation, chronic throat discomfort or pain, stridor, neck mass, thyroid mass, and obstructive sleep apnea.
When is office laryngoscopy indicated in children?
When is office laryngoscopy indicated in children?
Examining the larynx in children is indicated for stridor, voice abnormalities, and obstructive sleep apnea status post adenotonsillectomy.
What are different types of laryngoscopy?
What are different types of laryngoscopy?
Direct laryngoscopy is visualization of the larynx achieved by direct line-of-sight. This requires the use of a laryngoscope to achieve the proper view. The patient usually will be anesthetized, although some patients may tolerate laryngoscopy performed with the use of local and/or regional blocks. Direct laryngoscopy is performed to allow insertion of an endotracheal tube, inspect the larynx in its entirely, and to properly expose a portion of the larynx that requires biopsy or excision of a mass.
Indirect laryngoscopy is visualization of the larynx that involves instruments to achieve an “indirect” view of the larynx. The laryngeal mirror was the first instrument to be used to indirectly direct light from an external source into the larynx providing illumination and visualization of the structures. Indirect laryngoscopy can be limited by a patient’s gag reflex. Other forms of indirect laryngoscopy involve the use of angled telescopes (70 or 90 degree) or flexible laryngoscopes to visualize the larynx. Rigid endoscopic evaluation with an angled telescope can achieve a high-definition view of the larynx.
Flexible laryngoscopy is often performed in clinic using a flexible fiber-optic endoscope. The nasal cavity can be treated with a topical decongestant/anesthetic mixture to improve visualization and comfort of the examination. Lubrication of the telescope may aid in comfort as well. Flexible laryngoscopy can also be used to evaluate swallowing in a procedure termed flexible endoscopic evaluation of swallowing (FEES). This procedure involves visualization of the larynx while feeding the patient various consistencies to determine if there is aspiration or penetration of the food bolus into the larynx.
Videolaryngoscopy involves attaching a camera to an angled rigid endoscope or a flexible endoscope to project the image onto a monitor. Digital recording devices can record the video and allow storage of the examination for later visualization or review.
Videolaryngostroboscopy is videolaryngoscopy with the addition of a stroboscope. The stroboscope uses a microphone or EMG activity to detect the fundamental frequency of the vibrating vocal cords. The stroboscope flashes the light source based on the fundamental frequency creating the appearance of vocal cord wave in slow motion. This allows assessment of the mucosal wave of the vocal cord, which can help differentiate various pathologies of the vocal cord.
What are laryngoscopes and how do they differ?
What are laryngoscopes and how do they differ?
Laryngoscopes are instruments used to achieve visualization of the larynx while the patient is in the supine position. There are multiple types of laryngoscopes and their designs differ to achieve certain goals. Examples of laryngoscopes optimized for specific functions include an anterior commissure scope (has anterior flare and shorter interdental dimension allowing better view of anterior commissure), bivalved laryngoscopes to approach supraglottic and hypopharyngeal tumors, and slotted laryngoscopes, which allow intubation more easily. Many different types of laryngoscopes are capable of being suspended so that the surgeon may perform surgical procedures using a two-handed technique.
How is flexible laryngoscopy performed?
How is flexible laryngoscopy performed?
Prior to performing this procedure, the patient is counseled on this procedure. Usually, the nose is topically prepared with a combination of a local anesthetic and topical decongestant. Lubrication can be applied to the scope to allow added comfort for the patient. The scope is inserted into the nasal cavity and advanced posteriorly, allowing visualization of the nasopharynx. The scope is directed inferiorly to allow assessment of the oropharynx and then advanced to a position that allows proper assessment of the supraglottis and glottis. Voluntary vocalization and inspiration can confirm normal vocal cord mobility.
What are the proper positions for direct laryngoscopy?
What are the proper positions for direct laryngoscopy?
The proper patient positioning for rigid direct laryngoscopy is the sniffing position with the head extended on the neck and the neck flexed. A shoulder roll is not needed for direct laryngoscopy. To get adequate anterior exposure, sometimes it is necessary to increase the neck flexion further by lifting the head off of the table.
What makes laryngoscopy difficult?
What makes laryngoscopy difficult?
Difficult laryngoscopy entails not being able to visualize the larynx well. Factors contributing to this are usually anatomic factors. Trismus (inability to open mouth widely), micrognathia, tumors, infections, and trauma of the oropharynx and supraglottis can make laryngoscopy difficult.
How is the laryngoscopic view of the larynx classified?
How is the laryngoscopic view of the larynx classified?
When using an intubating laryngoscope, the view of the glottic opening should be reported. The grade of the view is important to communicate to other medical providers for future care of the patient to minimize risk involved for patients with known difficult laryngeal exposures. Grade I view occurs when the entirety of the vocal cords can be seen. Grade II occurs with a partial view of the true vocal cords. Grade III view occurs when only the arytenoids are viewed. Grade IV occurs when no laryngeal structures are visualized.
What should be reported while doing direct laryngoscopy that is part of the head and neck examination?
What should be reported while doing direct laryngoscopy that is part of the head and neck examination?
As otolaryngologists we are trained to examine the larynx in its entirety. This is most important in our head and neck cancer patients. A thorough examination includes visualization of the base of tongue, vallecula, epiglottis (remarking on the lingual and laryngeal surfaces), supraglottis, glottis, and hypopharynx.
What are the potential complications of direct laryngoscopy?
What are the potential complications of direct laryngoscopy?
Injury to anything from the lips to the larynx can occur. Care must be used to not pinch the lips between the laryngoscope and the teeth. Teeth can be inadvertently chipped, loosened, fractured, or avulsed. A tooth guard is used to help minimize dental injury. Difficult exposure of the larynx increases the chance of tooth injury. Should dental injury be recognized intraoperatively, immediate dental consultation should be sought. Other risks include injury to the vocal cords. Additionally, laryngospasm can occur, which inhibits adequate ventilation and, if not treated properly, and can lead to a respiratory arrest.
What is the narrowest portion of the airway in adults and children?
What is the narrowest portion of the airway in adults and children?
In adults the narrowest portion of the airway occurs at the glottis, whereas in children the narrowest portion is the subglottis. The significance of this is that as the airway grows in children, different sizes of endotracheal tubes are appropriate and knowing how to estimate and measure this becomes critical.
How is the appropriate endotracheal tube estimated?
How is the appropriate endotracheal tube estimated?
In children, the appropriate size endotracheal tube can be estimated by age. In children 2 years old and above, the formula (4 + age)/4 can estimate the appropriate size. In children under 2 years of age, it must be remembered that a newborn should be intubated with a 3.5 ETT. As an infant approaches one year of age, a 4.0 ETT becomes appropriate. By 2 years of age, a 4.5 ETT is appropriate. In adults, most men can accept an 8.0 ETT and women can tolerate a 7.5 ETT.
How is subglottic airway size measured?
How is subglottic airway size measured?
Subglottic airway sizing is determined by performing a leak test. Performing a leak test requires insertion of a series of uncuffed ETTs and viewing and/or listening for a leak to occur around the endotracheal tubes. This is meant to determine the degree of narrowing of a firm stenosis of the subglottic airway. Usually, the first tube is 0.5 size smaller than what is expected for the patient’s age. There should be a free leak around the tube if the airway is an appropriate diameter. Progressively larger tubes are placed until there is no leak of air at 25 cm H2O or less. The largest tube that allows a leak is considered the size of the airway. Based on the patient’s age and corresponding ETT that fits, the degree of stenosis can be determined using the scale created by Dr. Myer and Cotton (Table 70-1).
When is bronchoscopy indicated?
When is bronchoscopy indicated?
Bronchoscopy is indicated whenever symptoms suggest that disease or evidence of disease may be present in the tracheobronchial tree. The symptoms present will determine the goals of the procedure. In infants and children, indications for bronchoscopy are usually related to stridor, suspected foreign body aspiration, and other diseases of the lower airway and lung parenchyma. In adults, bronchoscopy is most often performed when there is hemoptysis, concern for neoplasm, and any other prolonged respiratory disease. In both children and adults, rigid bronchoscopy is vital to achieving success in difficult airway situations when direct laryngoscopy fails. The rigid bronchoscope can be used as a tool to bypass sites of obstruction. If rigid bronchoscopy cannot obtain an airway, a surgical airway is needed in the form of emergent tracheotomy or cricothyrotomy.
What is the grading system used to stage esophageal corrosive injuries?
What is the grading system used to stage esophageal corrosive injuries?
Esophageal corrosive injuries are graded on a scale of 0 through IV (Table 70-2). The scale is based on extent of mucosal damage. In general, patients with grade 0 to IIa lesions are able to have oral intake, while IIb to IV require total esophageal rest. No complications are usually associated with Grade 0 to IIa injuries. Frequent complications are noted for Grade IIb to IV lesions including esophageal strictures and full-thickness necrosis.
