DIAGNOSTIC ENDOSCOPY OF THE LARYNX, BRONCHUS,

AND ESOPHAGUS

Julie G. Cebrian, MD, FPSO-HNS

Introduction1.Laryngoscopy a. Indirect b. Direct

2. Bronchoscopy a. Rigid b. Flexible

3. Esophagoscopy a. Rigid b. Flexible

LaryngoscopyHistory :History :

• Manuel Garcia – 1830sManuel Garcia – 1830s - first to successfully visualize the larynx using dental mirror and sunlight

• Late 1800s – Mckenzie, JacksonLate 1800s – Mckenzie, Jackson and Hollinger and Hollinger

- design and modification of the rigid endoscopes

LaryngoscopyHistory :History :

• 1930s1930s advent of fiber optic illumination

• 1960s1960s flexible endoscopes

• 1970s1970s stroboscopic techniques

INDIRECT MIRROR Laryngoscopy

Probably the most important outpatientProbably the most important outpatient diagnostic procedure for examining the larynxdiagnostic procedure for examining the larynx

Its biggest drawback is a tendency to cause Its biggest drawback is a tendency to cause gagging in some patientsgagging in some patients

It may also not adequately allow for It may also not adequately allow for visualization of the anterior commissurevisualization of the anterior commissure

INDIRECT MIRROR Laryngoscopy

IndicationsIndications::

1. Hoarseness

2. Problems associated with the protection of the respiratory tract during swallowing

3. Cervical lymphadenopathy of unknown origin

4. Earache with normal examination findings

INDIRECT MIRROR Laryngoscopy

EquipmentEquipment::

1. Laryngeal Mirror

2. Head mirror with light source

3. Gauze

INDIRECT MIRROR Laryngoscopy

TechniqueTechnique::

DIRECT Laryngoscopy

I.I. Direct Flexible LaryngoscopyDirect Flexible Laryngoscopy

II.II. VideolaryngoscopyVideolaryngoscopy

III.III. Direct Rigid LaryngoscopyDirect Rigid Laryngoscopy

DIRECT Laryngoscopy

Performed under local Performed under local anesthesiaanesthesia

Excellent for evaluating larynxExcellent for evaluating larynx of trauma patient with of trauma patient with suspected cervical fracturesuspected cervical fracture

Can be used to evaluate Can be used to evaluate trachea and bronchi amongtrachea and bronchi among laryngectomized patientslaryngectomized patients

I. Flexible Fiberoptic Laryngoscopy

DIRECT LaryngoscopyI. Flexible Fiberoptic Laryngoscopy

DIRECT Laryngoscopy

Equipment:

1. Laryngeal endoscope 70° and 90°

2. Video camera

3. Video adapter

4. Light source and cable

5. Video recorder and monitor

II. Videolaryngoscopy

DIRECT Laryngoscopy

TechniqueTechnique::

II. Videolaryngoscopy

DIRECT Laryngoscopy

Advantage over Flexible LaryngoscopyAdvantage over Flexible Laryngoscopy

1.Clearer, sharper, brighter, larger images

2.Documentation of precise anatomic or structural changes of the larynx

3.Clear video image and high resolution

II. Videolaryngoscopy

DIRECT Laryngoscopy

1.1. Staging and biopsy of laryngopharyngeal Staging and biopsy of laryngopharyngeal lesions.lesions.

3. For patients in whom flexible laryngoscopy is3. For patients in whom flexible laryngoscopy is not possiblenot possible

2. Rule out a second primary tumor or as a part2. Rule out a second primary tumor or as a part of the work-up of metastatic tumors of un-of the work-up of metastatic tumors of un- known originknown origin

IndicationsIndications::III. Direct Rigid Laryngoscopy

DIRECT Laryngoscopy

4. Patients presenting with displaced or open 4. Patients presenting with displaced or open laryngeal fracturelaryngeal fracture

5. Provides surgical approach 5. Provides surgical approach

IndicationsIndications::

III. Direct Rigid Laryngoscopy

DIRECT Laryngoscopy

InstrumentsInstruments::

III. Direct Rigid Laryngoscopy

DIRECT Laryngoscopy

TechniqueTechnique::

III. Direct Rigid Laryngoscopy

DIRECT Laryngoscopy

TechniqueTechnique::

III. Direct Rigid Laryngoscopy

DIRECT Laryngoscopy

ComplicationsComplications::

1. Laryngeal edema1. Laryngeal edema

2. Bleeding2. Bleeding

3. Airway compromise3. Airway compromise

4. Tooth fracture / avulsion4. Tooth fracture / avulsion

III. Direct Rigid Laryngoscopy

Direct laryngoscopyFOREIGN BODYFOREIGN BODY

Dentures in the right pyriform sinus

Direct laryngoscopyFOREIGN BODYFOREIGN BODY

Fishbone stuck in the left pyriform sinus 3 cm fishbone

BRONCHOSCOPYBronchoscopic Anatomy:Bronchoscopic Anatomy: Trachea begins immediately

inferior to cricoid cartilageHollow tube 5 inches or 13 cms long

Supported by U-shaped bars of hyaline cartilages

Divides into 2 main bronchi at the carina

BRONCHOSCOPYBronchoscopic Anatomy:Bronchoscopic Anatomy:

Principal Bronchi 1. Right

Wider Shorter (1 inch ) More vertical

2. Left Narrower Longer (2 inches) More horizontal

BRONCHOSCOPYBronchoscopic Anatomy:Bronchoscopic Anatomy:

Secondary Bronchi Lobar bronchus

Tertiary Bronchi Segmental Bronchi Gives rise to the

bronchopulmonary segments

BRONCHOSCOPYBronchoscopic Anatomy:Bronchoscopic Anatomy:

The distance from the cricoid to the carina is 10 cms

The lung is divided into 3 lobes on the right and 2 lobes on the left.

There are a total of 18 bronchopulmonary segments.

BRONCHOSCOPYHistory :History :

• Gustave Killian – 1897Gustave Killian – 1897

first translaryngeal examination of the trachea

• Early 1900s – JacksonEarly 1900s – Jackson fully developed the art of bronchoscopy

reported the removal of a foreign body from bronchus

BRONCHOSCOPYHistory :History :

• Ikeda and associates – 1968Ikeda and associates – 1968

reported the development of flexible bronchoscope

Flexible Bronchoscope

BRONCHOSCOPYEquipment Equipment ::

Rigid Bronchoscopes

BRONCHOSCOPYIndicationsIndications : :

A. Diagnostic

1.1. HemoptysisHemoptysis2.2. Mass lesion on radiographMass lesion on radiograph3.3. Transbronchial biopsyTransbronchial biopsy4.4. Infectious processInfectious process5.5. Search for second primary malignancySearch for second primary malignancy6.6. Evaluate tracheal/bronchial stenosisEvaluate tracheal/bronchial stenosis

BRONCHOSCOPYIndicationsIndications : :

B. Therapeutic

1. Removal of foreign bodies

2. Suction of inspissated mucus

3. Broncheoalveolar lavage

4. Transbronchial drainage of abscess

5. Removal of obstructing lesion

6. Dilatation/resection of cicatricial scar

RIGID BRONCHOSCOPYAdvantagesAdvantages : :

1. Provides more secure control of the airway and permits ventilatory support.

2. Allows insertion of larger working instrument and suction tubes.

RIGID BRONCHOSCOPYTechniques – Direct InsertionTechniques – Direct Insertion : :

RIGID BRONCHOSCOPYTechniques – Direct InsertionTechniques – Direct Insertion : :

RIGID BRONCHOSCOPYTechniques – Direct InsertionTechniques – Direct Insertion : :

RIGID BRONCHOSCOPYTechniques – Direct InsertionTechniques – Direct Insertion : :

RIGID BRONCHOSCOPYTechniques – Insertion Using a Techniques – Insertion Using a LaryngoscopeLaryngoscope::

RIGID BRONCHOSCOPYTechniques – Insertion Using a Techniques – Insertion Using a LaryngoscopeLaryngoscope::

FLEXIBLE BRONCHOSCOPYAdvantagesAdvantages : :

1. Ability to visualize the subsegmental bronchi

2. Allows the bronchoscopist to obtain selective biopsies including brush type

3. May be done under local anesthesia

FLEXIBLE BRONCHOSCOPYComplicationsComplications : :

1. Hemorrhage from blind biopsies

2. Hypoxia, anoxia, and respiratory arrest

3. Laryngospasm

4. Cardiac arrythmia

BRONCHOSCOPY

Normal Trachea Inflamed Trachea

BRONCHOSCOPY

Mucus Plug in Trachea

BRONCHOSCOPY

Tumor eroding the right main bronchus

Extensive tumor of the right main bronchus

BRONCHOSCOPY

Peanut found in the right secondary bronchus

ESOPHAGOSCOPYHistory :History :

• Bozzini – 1809Bozzini – 1809 attempted to examine the upper esophagus using mirror

• Kussmaul – 1869 Kussmaul – 1869 examined the esophagus using urethroscope described the proper head position to pass the endoscope

ESOPHAGOSCOPYHistory :History :

• Jackson – 1900sJackson – 1900s invented the first modern esophagoscope

• 1930s 1930s the birth of fiberoptic illumination

• 1960s 1960s introduction of flexible endoscopes

ESOPHAGOSCOPYAnatomyAnatomy::

The esophagus is a tubular structure about 10 inches or

25 cms. start at the cricopharyngeus and ends at the cardia

Cervical part is curved to the left and the thoracic part is curved to the right.

ESOPHAGOSCOPYAnatomy - ConstrictionsAnatomy - Constrictions::

1. Cricopharyngeus 16 cms from the incisors

2. Left main Stem Bronchus 27 cms from the incisors > Aortic constriction

3. Gastroesophageal Junction 38 cms from the incisors > Diaphragmatic constriction

ESOPHAGOSCOPYIndicationsIndications : :

1.1. Diagnostic tool for evaluation of suspected Diagnostic tool for evaluation of suspected

tumors, trauma, strictures, benign tumors, trauma, strictures, benign

inflammatory condition.inflammatory condition.

2.2. Surgical approach.Surgical approach.

ESOPHAGOSCOPYRigid Esophagoscopy - AdvantagesRigid Esophagoscopy - Advantages : :

1.1. Evaluates the cervical esophagusEvaluates the cervical esophagus

2.2. Allows the use of larger cannula and surgical Allows the use of larger cannula and surgical

instrumentsinstruments

3.3. Allows manipulation and removal of foreign Allows manipulation and removal of foreign

bodies and stricture dilatationbodies and stricture dilatation

ESOPHAGOSCOPYFlexible - AdvantagesFlexible - Advantages : :

1.1. Improves visualization of the gastroesophageal Improves visualization of the gastroesophageal

junctionjunction

2.2. Allows instrumentation in patients with severe Allows instrumentation in patients with severe limitation of the range of motion of the necklimitation of the range of motion of the neck

3.3. Done under local anesthesia with sedationDone under local anesthesia with sedation

ESOPHAGOSCOPYInstrumentsInstruments : :

Rigid Bronchoscopes

Rigid Esophagoscopes

ESOPHAGOSCOPYTechniqueTechnique

ESOPHAGOSCOPYComplicationsComplications : :

1.1. Injury to upper aerodigestive tractInjury to upper aerodigestive tract

2.2. Aspiration of esophagogastric fluid, oral Aspiration of esophagogastric fluid, oral secretions, and bloodsecretions, and blood

3.3. Dental traumaDental trauma

4.4. Arrythmia or changes in blood pressureArrythmia or changes in blood pressure

ESOPHAGOSCOPYFOREIGN BODYFOREIGN BODY

COIN – most common foreign body seen ingested by children

ESOPHAGOSCOPYFOREIGN BODYFOREIGN BODY

Mouse trapped in the esophagus

ESOPHAGOSCOPYESOPHAGEAL DISEASESESOPHAGEAL DISEASES

Esophageal varices Esophageal cancer

END OF LECTURE