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CHAPTER 41

Laryngoscopy, Bronchoscopy,

and Oesophagoscopy

V. T. Joseph
Michael Laschat
Catharine Mngongo

Introduction
Endoscopic visualisation of the airway and digestive tract has made
huge progress in the past decade due to the technological advances
in light and image transmission. The early designs followed Nitze’s
method of providing illumination with an incandescent bulb. These
have now been completely replaced with fibre-optic light systems
and Hopkins rod lens telescopes. A further development has been the
introduction of flexible fibre-optic endoscopes with high-definition
videocameras providing real-time, high-quality images. At the same
time, manufacturers have miniaturised endoscopic instruments so that
a wide range of these are now available for use in infants and children. Figure 41.1: Curved blade (Macintosh) and straight blade (Miller) laryngoscopes
with locking handles.
Laryngoscopy
Examination of the larynx is carried out for both diagnostic and thera- anaesthetists to intubate patients (Figure 41.1).
peutic indications. Technique
Diagnostic Direct laryngoscopy
Diagnostic indications for laryngoscopy include:
Curved-blade laryngoscope
• stridor, either congenital or acquired; The patient is placed supine with the neck slightly flexed and extension
• subglottic stenosis; at the atlanto-occipital joint. The neck should not be extended fully, as
this displaces the larynx anteriorly and moves it away from the line of
• cysts or masses causing airway obstruction;
vision. The curved blade is passed along the right side of the tongue,
• vocal cord palsy; and displacing it to the left. The tip of the blade is inserted into the val-
lecula, and the laryngoscope is lifted upward and forward so that the
• foreign bodies.
epiglottis is carried up and away from the laryngeal inlet to expose the
Therapeutic vocal cords.
Therapeutic indications for laryngoscopy include: Straight-blade laryngoscope
• subglottic stenosis; The tip of the blade is passed under the epiglottis and is used to lift it
up to expose the cords. This method is particularly useful in babies and
• aspiration/injection of mucous cysts, cystic hygromas; young infants.
• papillomas; Note that direct laryngoscopy with the handheld laryngoscope is
useful in providing rapid visualisation of the larynx, but because the
• lingual thyroid; and
surgeon has to hold the laryngoscope by hand, it is difficult to carry out
• webs. therapeutic manoeuvers.
Suspension laryngoscope
Instruments/Equipment Direct laryngoscopy performed by using the suspension laryngoscope
Laryngoscopy can be performed by using rigid or flexible instruments, (Figure 41.2) is frequently carried out by ear, nose, and throat (ENT)
each of which has certain specific advantages. surgeons. The equipment consists of a short tubular laryngoscope that
Rigid laryngoscopy is locked to a supporting arm that rests on a base plate lying against the
A rigid laryngoscopy may be done by using the indirect or direct method. anterior chest wall. This arrangement leaves the surgeon’s hands free
Indirect laryngoscopy to use instruments and even to position an operating microscope for
Indirect laryngoscopy is performed by using specially designed laryn- precise surgery.
geal mirrors in combination with a headlight. This enables the larynx The surgical procedures that can be done with the suspension
and the nasopharynx to be visualised. This method is frequently used laryngoscope include aspiration/marsupialisation of cysts, excision of
in adults, but in children it is often difficult to carry out this procedure. nodules, laser vaporisation of papillomas, and injection of bleomycin
Direct laryngscopy in cystic hygromas with laryngeal involvement.
Direct laryngoscopy is performed with handheld curved- or straight- Flexible laryngoscopy
blade instruments or by using the suspension laryngoscope, which
The instruments used for flexible laryngoscopy include the ultrathin
leaves both hands free to manipulate instruments. The curved Macintosh
bronchoscope, the standard flexible bronchoscope, and the specially
blade and the straight Miller blade laryngoscopes are routinely used by
designed flexible nasopharyngoscope (Figure 14.3). The ultrathin