LARYNGOSCOPYLARYNGOSCOPY

Dr.Ramesh ParajuliMS (Otorhinolaryngology)

Chitwan medical college teaching hospital,Bharatpur-10, Chitwan, NepalChitwan medical college teaching hospital,Bharatpur-10, Chitwan, Nepal

ROADMAPROADMAP

1.History 1.History

2.Indirect laryngoscopy2.Indirect laryngoscopy

3.Direct laryngoscopy3.Direct laryngoscopy 4.Flexible & Rigid fibre-optic laryngoscopy4.Flexible & Rigid fibre-optic laryngoscopy

5.New techniques in laryngeal endoscopy5.New techniques in laryngeal endoscopy Contact endoscopy Contact endoscopy MicrolaryngoscopyMicrolaryngoscopy

6.Stroboscopy6.Stroboscopy

HISTORYHISTORY

18061806: : Bozzini (inventor of archetypal laryngoscope)Bozzini (inventor of archetypal laryngoscope)

18291829:: Babington (Glottiscope) Babington (Glottiscope)

18531853:: Desmoreaux Desmoreaux

18541854:: Manuel Garcia (“Autolaryngoscopy”) Manuel Garcia (“Autolaryngoscopy”)

18571857:: Czermak (head band mirror) Czermak (head band mirror)

Morell, Mackenzie, TurckMorell, Mackenzie, Turck

Early 1900Early 1900:: Chevalier Jackson Chevalier Jackson

-use of magnification -use of magnification -sniffing position-sniffing position19411941: : RobertRobert MillerMiller

1943 1943 : Robert Macintosh: Robert Macintosh

19501950:: Operating microscope Operating microscope

19601960:: Hopkins (rod lens telescope) Hopkins (rod lens telescope)

Late 1960Late 1960:: Jako & Kleinsasser (fiberoptic laryngoscope Jako & Kleinsasser (fiberoptic laryngoscope used with operating microscope)used with operating microscope)

LaryngoscopyLaryngoscopy

Internal ExaminationInternal Examination

Mirror (Indirect Laryngoscopy)Mirror (Indirect Laryngoscopy)

Laryngoscope (Direct Laryngoscopy)Laryngoscope (Direct Laryngoscopy)

Indications for LaryngoscopyIndications for Laryngoscopy

Diagnostic:Diagnostic:1.Hoarseness 10.Shortness of breath1.Hoarseness 10.Shortness of breath

2.Voice changes 11.Dysarthria2.Voice changes 11.Dysarthria

3.Chronic cough 12.Stridor3.Chronic cough 12.Stridor

4.Choking episodes 13.Suspicion of laryngeal 4.Choking episodes 13.Suspicion of laryngeal

5.Odynophagia/Dysphagia foreign body5.Odynophagia/Dysphagia foreign body

6.Chronic throat pain 14.Suspicion of carcinoma6.Chronic throat pain 14.Suspicion of carcinoma

7.Globus sensation (Biopsy) 7.Globus sensation (Biopsy)

8.Hemoptysis 15.Dyspnea8.Hemoptysis 15.Dyspnea

9.Referred otalgia9.Referred otalgia

Therapeutic:Therapeutic:

11.Intubation .Intubation

2.Foreign body removal2.Foreign body removal

3.Biopsy of a growth in hypopharynx or vocal cords3.Biopsy of a growth in hypopharynx or vocal cords

4.Treatment for benign & malignant diseases: eg Laser 4.Treatment for benign & malignant diseases: eg Laser therapy, Microlaryngeal Surgerytherapy, Microlaryngeal Surgery

5.Placing gastric tube, Transesophageal echocardiac probe5.Placing gastric tube, Transesophageal echocardiac probe

Indirect LaryngoscopyIndirect Laryngoscopy

Simplest method of larynx & vocal cord examinationSimplest method of larynx & vocal cord examination

Most adults and older childrenMost adults and older children

Significant skill & patient co-operationSignificant skill & patient co-operation

Examination of Oropharynx, hypopharynx & Larynx Examination of Oropharynx, hypopharynx & Larynx

Larynx examination:Larynx examination:

1.At rest1.At rest

2.Gentle breathing2.Gentle breathing

3.During phonation3.During phonation

4.Coughing4.Coughing

Laryngeal Mirror Laryngeal Mirror

Technique :Technique :

1.Explain the procedure1.Explain the procedure

2.Sitting position2.Sitting position

3.Open mouth : topical anesthesia3.Open mouth : topical anesthesia

4.Placement of laryngeal mirror: defogging agent4.Placement of laryngeal mirror: defogging agent

5.Reverse image5.Reverse image

Inspecting areas in an orderInspecting areas in an order

Structure to be examined:Structure to be examined:

1.Base of the tongue 11.Ventricles1.Base of the tongue 11.Ventricles2.Vallecula 12.Anterior commissure2.Vallecula 12.Anterior commissure3.Median glossoepiglottic fold 13.Posterior wall of 3.Median glossoepiglottic fold 13.Posterior wall of 4.Pharyngoepiglottic folds larynx4.Pharyngoepiglottic folds larynx5.Lateral pharyngeal wall 14.Upper 2 or 3 5.Lateral pharyngeal wall 14.Upper 2 or 3 6.Epiglottis(both surfaces) tracheal rings6.Epiglottis(both surfaces) tracheal rings7.Arytenoids 15.Pyriform Fossa7.Arytenoids 15.Pyriform Fossa8.Aryepiglottic folds8.Aryepiglottic folds9.False cords9.False cords10.True cords10.True cords

Details of symmetry, motion, surface architecture, Details of symmetry, motion, surface architecture, evidence of inflammation & abnormal masses or growthevidence of inflammation & abnormal masses or growth

Pooling of saliva in PFS: 1.poor laryngeal sensation Pooling of saliva in PFS: 1.poor laryngeal sensation 2.weak lateral pharyngeal wall 3.inefficient swallow2.weak lateral pharyngeal wall 3.inefficient swallow

eg. growth or foreign body in postcricoid region or upper eg. growth or foreign body in postcricoid region or upper esophagusesophagus

Mobility of the vocal cords:Mobility of the vocal cords:

“ “eeh” or “aah”eeh” or “aah”

Glottic chinkGlottic chink

Most Common MistakesMost Common Mistakes

1.Procedure explanation1.Procedure explanation

2.Patient’s position2.Patient’s position

3.Focus light on mirror3.Focus light on mirror

4.Lifting uvula4.Lifting uvula

5.Visualising larynx directly without looking at adjacent 5.Visualising larynx directly without looking at adjacent structuresstructures

6.Recording side of lesion6.Recording side of lesion

7.Prolong high pitch “eeh”7.Prolong high pitch “eeh”

AdvantagesAdvantages

Easily availableEasily available

CheapCheap

Free of complicationsFree of complications

Easy to learnEasy to learn

Limitations of I/L Examination:Limitations of I/L Examination:

Uncontrollable gag reflexUncontrollable gag reflexApprox.10% patients I/L is Approx.10% patients I/L is not possible not possible

Anatomic variations eg. large tongue, micrognathia and Anatomic variations eg. large tongue, micrognathia and trismustrismus

Entire PFS (esp.apex) & Postcricoid region cant be seenEntire PFS (esp.apex) & Postcricoid region cant be seen

Perceptual errorPerceptual error

Killian’s ModificationKillian’s Modification: standing position of examiner : standing position of examiner with vertical and parallel placement of mirror to with vertical and parallel placement of mirror to posterior part of pharynx- for anterior commissureposterior part of pharynx- for anterior commissure

Fiber-optic LaryngoscopyFiber-optic Laryngoscopy

1.Flexible laryngscopy1.Flexible laryngscopy

2.Rigid laryngscopy2.Rigid laryngscopy

Flexible Nasopharyngolaryngoscopy(NPL)Flexible Nasopharyngolaryngoscopy(NPL)--Indications:Indications:-Young children-Young children-Difficult cases for IL exam: eg. Pts with excessive gags-Difficult cases for IL exam: eg. Pts with excessive gags

-Neurological problems or Anatomical abnormalities: -Neurological problems or Anatomical abnormalities: micrognathia, cervical spine rigidity, instability or micrognathia, cervical spine rigidity, instability or immobility of TMJimmobility of TMJ

-Proper assessment of any condition in hypopharynx and -Proper assessment of any condition in hypopharynx and larynxlarynx

-Teaching purpose-Teaching purpose

-Photography & Video documentation-Photography & Video documentation

Longer interval for the hypopharynx & larynx Longer interval for the hypopharynx & larynx examinationexamination

(Apex of PFS: on Valsalva Maneuver)(Apex of PFS: on Valsalva Maneuver)

Fiberoptic telescopes with outer diameter as narrow as Fiberoptic telescopes with outer diameter as narrow as 2.2mm 2.2mm atraumatic passage through nares in atraumatic passage through nares in neonateneonate

--Smaller telescopes --- more comfortable Smaller telescopes --- more comfortable

--Larger telescopes --- better quality imageLarger telescopes --- better quality image

Contraindications:Contraindications:

No absolute contraindicationsNo absolute contraindications

1.Epiglottitis : Laryngospasm 1.Epiglottitis : Laryngospasm subsequent airway subsequent airway compromisecompromise

2.Croup2.Croup

3.Coagulopathies 3.Coagulopathies

4.Craniofacial trauma: intracranial instrumentation & 4.Craniofacial trauma: intracranial instrumentation & exacerbation of nasopharyngeal injuriesexacerbation of nasopharyngeal injuries

Specific work upSpecific work up

Routine Head & Neck Examination:Routine Head & Neck Examination:

- Nasal Patency- Nasal Patency

- Indirect Laryngoscopy- Indirect Laryngoscopy

EquipmentEquipment

1.Short cable endoscope1.Short cable endoscope: eg. : eg. Machida scopeMachida scope

Advantages:Advantages:

-Low cost -Low cost

-Adequate optical characteristics-Adequate optical characteristics

-Light weight, short cable-Light weight, short cable easy for routine basis easy for routine basis

Disadvantages: Disadvantages:

-Lack of suctioning capability-Lack of suctioning capability

-Precludes examination of subglottis & trachea-Precludes examination of subglottis & trachea

2.Long cable endoscope:2.Long cable endoscope: eg. eg. Olympus BronchofiberscopeOlympus Bronchofiberscope

AdvantagesAdvantages

-Second port: instillation of topical anesthetics, continuous -Second port: instillation of topical anesthetics, continuous suctioning & biopsysuctioning & biopsy

-Evaluation of tracheobronchial tree-Evaluation of tracheobronchial tree

Disadvantages Disadvantages

-High cost-High cost

-Extra length -Extra length

Flexible Fiberoptic LaryngoscopeFlexible Fiberoptic Laryngoscope Light -separate source. Light -separate source. The lever on the handle - deflection of the tip in two The lever on the handle - deflection of the tip in two directions. Two ports- insufflation and suctioningdirections. Two ports- insufflation and suctioning

AdvantagesAdvantages

1.Well tolerated :OPD or bed side1.Well tolerated :OPD or bed side sitting erect, supine positionsitting erect, supine position2.Not limited by fixation of spine or mandible2.Not limited by fixation of spine or mandible

3.Low chance of injury eg. teeth, mucosa3.Low chance of injury eg. teeth, mucosa

4.Excellent evaluation of larynx & tracheobronchial tree4.Excellent evaluation of larynx & tracheobronchial tree

5.Teaching sidearm5.Teaching sidearm

6.Suction & biopsy capability(olympus type)6.Suction & biopsy capability(olympus type)

7.Photography 7.Photography

DisadvantagesDisadvantages

1.Doesn’t maintain airway1.Doesn’t maintain airway

2.No surgical procedures possible except biopsy2.No surgical procedures possible except biopsy

Topical anesthesia, Lubrication, De-misting agentTopical anesthesia, Lubrication, De-misting agent

Passage from Passage from

NoseNose Nasopharynx, Pharynx & Larynx Nasopharynx, Pharynx & Larynx

MouthMouth Folded gauze, plastic bite block, Folded gauze, plastic bite block, examiner’s finger (edentulous infant)examiner’s finger (edentulous infant)

Bite block :kept between teeth to prevent damage to a Bite block :kept between teeth to prevent damage to a fiberoptic endoscopefiberoptic endoscope

Local anesthesiaLocal anesthesia: pt comfort & co-operation, ameliorate : pt comfort & co-operation, ameliorate reflex response (tachycardia, HTN, laryngospasm)reflex response (tachycardia, HTN, laryngospasm)

Topical anesthesiaTopical anesthesia Palate & PPW Palate & PPW

Precaution: pt shouldn’t eat or drink until adequate Precaution: pt shouldn’t eat or drink until adequate laryngeal sensation returnslaryngeal sensation returns

Topical decongestantsTopical decongestants: to decrease nasal mucosal : to decrease nasal mucosal edema, congestion or secretionsedema, congestion or secretions

Precaution : hyperthyroidism, cardiovascular disease, Precaution : hyperthyroidism, cardiovascular disease, HTN,DM, BPH, narrow angle glaucomaHTN,DM, BPH, narrow angle glaucoma

SterilisationSterilisation

Glutaraldehyde soaking: damage endoscopeGlutaraldehyde soaking: damage endoscope

ineffectiveineffective

staff health concern staff health concern

Ethylene oxide: very effective but requires 24 hrs to workEthylene oxide: very effective but requires 24 hrs to work

Wiping with swab : mayn’t prevent against infectious Wiping with swab : mayn’t prevent against infectious diseases eg. Tuberculosisdiseases eg. Tuberculosis

Better options:Better options:

1.Have more than one endoscope available in ENT department1.Have more than one endoscope available in ENT department

2.Protective disposable sheaths2.Protective disposable sheathspreferred methodpreferred method

3.Daily high level of disinfection of the endoscopes3.Daily high level of disinfection of the endoscopes

Rigid Fiberoptic EndoscopyRigid Fiberoptic Endoscopy

OPDOPD

Adults & in children as young as 6 -8 yrsAdults & in children as young as 6 -8 yrs

Position & technique for inserting :similar to mirror examPosition & technique for inserting :similar to mirror exam

Rigid telescope :angled lens 0 * or 90 * Hopkins rodRigid telescope :angled lens 0 * or 90 * Hopkins rod eg. storz rigid fiberoptic systemeg. storz rigid fiberoptic system

Image, size & clarity better than flexible fiberoptic systemImage, size & clarity better than flexible fiberoptic system

IndicationsIndications1.Brilliant illumination 1.Brilliant illumination better view of larynxbetter view of larynx

2.Photography 2.Photography

Contraindications:Contraindications:1.Respiratory distress1.Respiratory distress

2.Active bleeding in airway2.Active bleeding in airway

Advantages Advantages

1.Superb photographic capability1.Superb photographic capability

2.Excellent lighting & better evaluation of larynx2.Excellent lighting & better evaluation of larynx

ComplicationsComplications

1.Damage to teeth and pharyngeal mucosa1.Damage to teeth and pharyngeal mucosa

2.Evolving airway problems2.Evolving airway problems laryngeal laryngeal spasmspasm

Direct LaryngoscopyDirect Laryngoscopy

Direct visualisation of larynx & hypopharynxDirect visualisation of larynx & hypopharynx

Range from simple rigid scopes with a light bulb to Range from simple rigid scopes with a light bulb to complex fiberoptic video devicescomplex fiberoptic video devices

Rigid laryngoscopes manufactured - single-piece or a Rigid laryngoscopes manufactured - single-piece or a separate detachable blade with light source & handleseparate detachable blade with light source & handle

For a detachable handle and blade- light source is For a detachable handle and blade- light source is energized when the blade and handle are locked in the energized when the blade and handle are locked in the operating positionoperating position

A hook-on connection between the handle and blade A hook-on connection between the handle and blade is most commonly usedis most commonly used

Many blade typesMany blade types::

Macintosh blade-Macintosh blade- curved blade, sits anterior to epiglottis curved blade, sits anterior to epiglottis

Miller blade-Miller blade- straight blade, sits posterior to epiglottis straight blade, sits posterior to epiglottis

usually for infants-larger comparative size of epiglottis, usually for infants-larger comparative size of epiglottis, Macintosh less effectiveMacintosh less effective

Rigid LaryngoscopeRigid Laryngoscope

Handle:Handle:

– It provides the power for the lightIt provides the power for the light

– Most often, disposable batteries are the power Most often, disposable batteries are the power sourcesource

– Fiberoptic-illuminated laryngoscopes may use a Fiberoptic-illuminated laryngoscopes may use a

remote electrically operated light sourceremote electrically operated light source

Laryngoscope handles in various sizesLaryngoscope handles in various sizes

– Most blades form a right angle with the handle when Most blades form a right angle with the handle when ready for use, the angle may also be acute or obtuseready for use, the angle may also be acute or obtuse

– Patil-Syracuse handle can be positioned and locked Patil-Syracuse handle can be positioned and locked

in four different positionsin four different positions

Patil-Syracuse handle. With this handle, the blade can be adjusted and Patil-Syracuse handle. With this handle, the blade can be adjusted and locked in four different positions (45°, 90°,135° or 180°) locked in four different positions (45°, 90°,135° or 180°)

BladeBlade– Blades are available in more than one sizeBlades are available in more than one size– Numbered, with the number increasing with size Numbered, with the number increasing with size

SizeSize Intended UseIntended Use

000000 Small premature infantSmall premature infant

0000 Premature infantPremature infant

00 NeonateNeonate

11 Small ChildSmall Child

22 ChildChild

33 AdultAdult

44 Large AdultLarge Adult

55 Extra Large AdultExtra Large Adult

LLaryngoscope blades aryngoscope blades

– Parts of bladeParts of blade::BaseBase - part that attaches to the handle, has a slot - part that attaches to the handle, has a slot for engaging the hinge pin of the handlefor engaging the hinge pin of the handle

Heel Heel - end of the base- end of the base

TongueTongue (spatula) (spatula)– Main shaftMain shaft– Compress and manipulate the soft tissues Compress and manipulate the soft tissues

(especially the tongue) and lower jaw (especially the tongue) and lower jaw – Blades referred to as curved or straight, Blades referred to as curved or straight,

depending on shape the tonguedepending on shape the tongue– Generally- straight blades provide better Generally- straight blades provide better

laryngeal visualization, curved blades make laryngeal visualization, curved blades make intubation easier intubation easier

FlangeFlange

– Projects off the side of the tongue Projects off the side of the tongue – Serves to guide instrumentation & deflect Serves to guide instrumentation & deflect

tissues from the line of vision tissues from the line of vision – Determines the cross-sectional shape of the Determines the cross-sectional shape of the

blade blade

TipTip

– Contacts either the epiglottis or vallecula & Contacts either the epiglottis or vallecula & directly or indirectly elevates the epiglottisdirectly or indirectly elevates the epiglottis

– Usually blunt and thickened to decrease traumaUsually blunt and thickened to decrease trauma

Light source:Light source:

- - Lamp (bulb) or fiberoptic bundle that transmits Lamp (bulb) or fiberoptic bundle that transmits light from a source in handlelight from a source in handle

– Fiberoptic-illuminated blade has an encased Fiberoptic-illuminated blade has an encased fiberoptic bundle - transmits light from source fiberoptic bundle - transmits light from source in the handle or base of bladein the handle or base of blade

– Because there is no bulb or electrical contact in Because there is no bulb or electrical contact in the blade, cleaning and sterilization are easierthe blade, cleaning and sterilization are easier

– Fiberoptic-illuminated blades to have a green Fiberoptic-illuminated blades to have a green mark on the heel.mark on the heel.

Macintosh BladeMacintosh Blade– One of the most commonly used bladesOne of the most commonly used blades

– Tongue is curvedTongue is curved

– In cross section, the tongue, web, and flange In cross section, the tongue, web, and flange form a reverse Zform a reverse Z

– Cervical spine movement is greater with the Cervical spine movement is greater with the Macintosh blade compared with the Miller bladeMacintosh blade compared with the Miller blade

Miller Blade:Miller Blade:

– Tongue is straight with a slight Tongue is straight with a slight upward curve near the tipupward curve near the tip

– In cross section, the flange, In cross section, the flange, web, and tongue form a C with web, and tongue form a C with the top fattenedthe top fattened

Mallampati ClassificationMallampati Classification

Class IClass I-soft palate, fauces, uvula, tonsillar-soft palate, fauces, uvula, tonsillar

pillars visiblepillars visible

Class IIClass II-soft palate, fauces, uvula visible-soft palate, fauces, uvula visible

Class IIIClass III-soft palate, base of uvula visible-soft palate, base of uvula visible

Class IVClass IV-soft palate not visible-soft palate not visible

33..Mallampatti classificationMallampatti classification

Class I-IVClass I-IV

Direct LaryngoscopyDirect Laryngoscopy

Cormack & Lehane Cormack & Lehane - - Grade I-IVGrade I-IV

Grade I-Grade I- Entire laryngeal aperture visible Entire laryngeal aperture visible

Grade II-Grade II- Post commissure visible Post commissure visible

Grade III-Grade III- Epiglottis visible Epiglottis visible

Grade IV-Grade IV- Soft palate visible Soft palate visible

Cormack-Lehane laryngeal view scoring systemCormack-Lehane laryngeal view scoring system

Indications:Indications:

Diagnostic:Diagnostic:

1.When I/L not possible eg. young children, excessive gags, 1.When I/L not possible eg. young children, excessive gags, overhanging epiglottisoverhanging epiglottis

2.Hidden areas:2.Hidden areas:

Hypopharynx: base of tongue, vallecula, apex of PFSHypopharynx: base of tongue, vallecula, apex of PFS

Larynx: infrahyoid epiglottis, anterior commissure, ventricles Larynx: infrahyoid epiglottis, anterior commissure, ventricles & subglottic region& subglottic region

3.Extent of growth & biopsy3.Extent of growth & biopsy

Therapeutic:Therapeutic:

1.Removal of benign lesions of larynx1.Removal of benign lesions of larynx

2.Removal of foreign body from hypopharynx & larynx2.Removal of foreign body from hypopharynx & larynx

ContraindicationsContraindications

1.Injuries to cervical spine1.Injuries to cervical spine

2.Marked dyspnea2.Marked dyspnea

3.Recent coronary occlusion or cardiac problem3.Recent coronary occlusion or cardiac problem

ProcedureProcedure :-:-

Position: sniffing positionPosition: sniffing position

Anaesthesia: GA /LAAnaesthesia: GA /LA

Procedure :Procedure :

-eye cover, dental protection ,drapping-eye cover, dental protection ,drapping

-widest scope (different scope to visualise different subsites -widest scope (different scope to visualise different subsites of endolarynx)of endolarynx)

Head reaching Head reaching proximal edge of tableproximal edge of table

The “sniffer” or Boyce-The “sniffer” or Boyce-Jackson position Jackson position provides the best provides the best visualization of the visualization of the larynxlarynx

Neck flexed on Neck flexed on shoulders & head shoulders & head extended on neckextended on neck

Post-op carePost-op care

1.Left lateral position1.Left lateral position

2.Monitror Respiration :laryngeal spasm, cyanosis2.Monitror Respiration :laryngeal spasm, cyanosis

3.Repeated laryngoscopy3.Repeated laryngoscopyedema edema distress distress

4.Bleeding 4.Bleeding

ComplicationsComplications

1.Injury to lip, teeth & tongue1.Injury to lip, teeth & tongue

2.Bleeding 2.Bleeding

3.Laryngeal edema3.Laryngeal edema

4.Cervical spinal cord injury4.Cervical spinal cord injury

5.Swallowing or aspirating foreign body5.Swallowing or aspirating foreign body

Differences between I/L and D/LDifferences between I/L and D/L

I/LI/L D/LD/L

Foreshortening of AP diameterForeshortening of AP diameter No foreshorteningNo foreshortening

True & false cord appear to be in True & false cord appear to be in contact with each othercontact with each other

Separated by ventriclesSeparated by ventricles

Inverted mirror imageInverted mirror image Direct visualisationDirect visualisation

Movement of cords seen betterMovement of cords seen better Seen only in LASeen only in LA

Under surface is not seenUnder surface is not seen Some idea is gainedSome idea is gained

Ventricles not seenVentricles not seen Seen by pressing the false Seen by pressing the false cordscords

OPD procedureOPD procedure Done in O TDone in O T

Difficult LaryngoscopyDifficult Laryngoscopy

BURPBURP

--BBackward, ackward, UUpward & pward & RRightward ightward PPressure on thyroid cartilageressure on thyroid cartilage

Simple aid for difficult Simple aid for difficult laryngoscopylaryngoscopy

Bullard LaryngoscopeBullard Laryngoscope

A rigid fiber-optic laryngoscope A rigid fiber-optic laryngoscope specially shaped to follow the specially shaped to follow the contour of oropharynxcontour of oropharynx

Working channel- suction, oxygen Working channel- suction, oxygen insufflation, LA or administrationinsufflation, LA or administration

Available in three sizes : pediatric, Available in three sizes : pediatric, pediatric long, and adultpediatric long, and adult

Advantages of Bullard LaryngoscopeAdvantages of Bullard Laryngoscope

Useful during difficult intubationUseful during difficult intubation

In neutral position. eg.unstable cervical spine, TMJ In neutral position. eg.unstable cervical spine, TMJ immobility, micrognathiaimmobility, micrognathia

Patients with mouth opening of just 6 mmPatients with mouth opening of just 6 mm

Safely used in pediatric population eg.anteriorly placed Safely used in pediatric population eg.anteriorly placed larynxlarynx

MicrolaryngoscopyMicrolaryngoscopy

Prof. Prof. Rosemarie Albrecht Rosemarie Albrecht - Germany (1954)- Germany (1954)

first microscopic visualization ofthe Vocal Foldsfirst microscopic visualization ofthe Vocal Folds

Prof. Prof. Oskar Kleinsassar Oskar Kleinsassar - Germany (1962)- Germany (1962)

- modern state of the art method of microlaryngosurgery- modern state of the art method of microlaryngosurgery

Dr. Dr. Geza Jako – Geza Jako – USA (1962) USA (1962) designed a series of designed a series of microlaryngeal instrumentsmicrolaryngeal instruments

Standard procedure for Endolaryngeal SurgeryStandard procedure for Endolaryngeal SurgeryAdvantages:Advantages:1.Binocular vision1.Binocular vision2.Bimanual handling2.Bimanual handling3.High resolution magnification3.High resolution magnification

Disadvantages:Disadvantages:Considerable force to bring oropharyngeal structure in Considerable force to bring oropharyngeal structure in

midlinemidline tissue injury tissue injury

Largest-caliber laryngoscopeLargest-caliber laryngoscope

Not a single “best” oneNot a single “best” one

that fits all situationsthat fits all situations

Contact area -upper teeth Contact area -upper teeth

- flat- flat

Anatomical configuration easesAnatomical configuration eases

exposure ant commissure exposure ant commissure

Suspension device Suspension device

Suspension gallows techniqueSuspension gallows technique

Magnification Magnification - Laryngeal telescopesLaryngeal telescopes

(0°, 30°, 70°)(0°, 30°, 70°)

350mm /400 mm - microscope350mm /400 mm - microscope

Advantages of Microlaryngoscopy over Advantages of Microlaryngoscopy over Direct Laryngoscopy:Direct Laryngoscopy:

- Binocular vision - Binocular vision - MagnificationMagnification- Better illumination Better illumination - Bimanual handlingBimanual handling

- Ability to use CO2 laserAbility to use CO2 laser

Contact EndoscopyContact Endoscopy

New phase in the development of endoscopyNew phase in the development of endoscopy

Commonly used in researchCommonly used in research

In 1865- DesmoreauxIn 1865- Desmoreaux

Jaupitre Jaupitre

Hamou Hamou

In vivo & in situ assessment of mucosa and underlying microvascular In vivo & in situ assessment of mucosa and underlying microvascular networknetwork

Topical anesthesia or GATopical anesthesia or GA

Oral cavity, oropharynx, nasal cavity, nasopharynx, hypopharynx & Oral cavity, oropharynx, nasal cavity, nasopharynx, hypopharynx & larynxlarynx

Simple ,non invasive technique Simple ,non invasive technique

Earlier subclinical stages of disease, Dx of early cancer, tumor margins, Earlier subclinical stages of disease, Dx of early cancer, tumor margins, select area for biopsy, assessment of the response to therapy select area for biopsy, assessment of the response to therapy (radiotherapy/chemotherapy), F/U of cancer pts(radiotherapy/chemotherapy), F/U of cancer pts

Contact Endoscopy of LarynxContact Endoscopy of Larynx

-GA -GA

-Microlaryngoscopy -Microlaryngoscopy

-Commonly used two endoscopes:-Commonly used two endoscopes:

7215 AA,7215 BA Karl Storz7215 AA,7215 BA Karl Storz

-Surface epithelium and subsurface microvascular -Surface epithelium and subsurface microvascular plexusplexus

-Magnification x60 and x150-Magnification x60 and x150

Mucosal surface-cleaned by suction or saline swabMucosal surface-cleaned by suction or saline swab

Staining-1% methylene blueStaining-1% methylene blue

Normal & abnormal appearanceNormal & abnormal appearance

Cellular & nuclear morphology( shape, size, staining etc)Cellular & nuclear morphology( shape, size, staining etc)

Microvasculature pattern & architecture-vessels of Microvasculature pattern & architecture-vessels of varying size, thrombosis, ectasia, rupturevarying size, thrombosis, ectasia, rupture

StroboscopyStroboscopy

Special method to visualize vocal fold vibrationSpecial method to visualize vocal fold vibration

-In -In 18781878-Oertel first performed Stroboscopy-Oertel first performed Stroboscopy

-In early to mid -In early to mid 19001900-Plateau-Plateau

-In -In 19601960-Vanden Berg, Rolf Timke (book on -Vanden Berg, Rolf Timke (book on stroboscopic examination of larynx)stroboscopic examination of larynx)

Vocal fold vibration is fast(100 cycles/sec)Vocal fold vibration is fast(100 cycles/sec)

Ability of retina to process individual Ability of retina to process individual images(5 images/sec)images(5 images/sec)

Synchronized flashing light through rigid Synchronized flashing light through rigid or flexible telescope at a slightly slower or flexible telescope at a slightly slower speedspeed illusion of slow vocal fold illusion of slow vocal fold vibrationvibration

Slow motion view derived from many Slow motion view derived from many successive vibration cyclessuccessive vibration cycles

Allows evaluation of vocal fold vibration properties during Allows evaluation of vocal fold vibration properties during different phases of vibration cycle (adduction, different phases of vibration cycle (adduction, aerodynamic separation & recoil)aerodynamic separation & recoil)

Parameters – symmetry, amplitude, speed and phase Parameters – symmetry, amplitude, speed and phase differences of waves on two cordsdifferences of waves on two cords

Vibrating part of vocal fold sharply defined, & anything Vibrating part of vocal fold sharply defined, & anything protruding from medial surface observedprotruding from medial surface observed

Extremely fast vibratory motion Extremely fast vibratory motion gentle waving motiongentle waving motion

Valuable in assessing : functional & anatomical defectsValuable in assessing : functional & anatomical defects

1.Stiffness 1.Stiffness

2.Scar2.Scar

3.Submucosal injury3.Submucosal injury

4.Small vocal cord lesions eg. nodule, polyp, cyst4.Small vocal cord lesions eg. nodule, polyp, cyst

5.Estimating depth of invasion of a tumor & early detection 5.Estimating depth of invasion of a tumor & early detection of glottic cancerof glottic cancer

6.Identifying asymmetric mass or tension6.Identifying asymmetric mass or tension

7.Determining resumption of voicing activities after 7.Determining resumption of voicing activities after phonosurgeryphonosurgery

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