Suspension Laryngoscopyassisted Percutaneous Dilatational

Total Page:16

File Type:pdf, Size:1020Kb

Suspension Laryngoscopyassisted Percutaneous Dilatational The Laryngoscope VC 2010 The American Laryngological, Rhinological and Otological Society, Inc. Suspension Laryngoscopy-Assisted Percutaneous Dilatational Tracheostomy in High-Risk Patients Hilliary N. White, MD; Dawn B. Sharp, MD; Paul F. Castellanos, MD Objectives/Hypothesis: To describe the out- This is most useful when T-PDT is considered unten- comes of bedside percutaneous dilatational tracheos- able or when transport to the operating room for a tomy (PDT) extended to the care of high-risk patients standard open tracheostomy is considered too cum- in the intensive care unit (ICU) by the use of suspen- bersome or potentially dangerous. sion laryngoscopy (SL) to secure the airway. Key Words: Percutaneous dilatational Study Design: Retrospective chart review. tracheostomy, suspension laryngoscopy, high risk. Methods: The records of 117 consecutive Level of Evidence:2c patients who underwent suspension laryngoscopy- Laryngoscope, 120:2423–2429, 2010 assisted percutaneous dilatational tracheostomy (SL- PDT) between April 2006 and May 2009 at our insti- tution were reviewed. Data gathered included patient INTRODUCTION demographics, anatomical conditions, ventilator set- tings, intraoperative findings, presence of coagulop- Tracheostomy, as a means of airway access, is one athy or anti-coagulation, and outcomes. of the oldest surgical procedures documented, dating Results: One hundred seventeen patients back approximately 4,000 years. As technology continues underwent SL-PDT. Eighty (68%) were considered to advance, there has been an increasing interest in high risk by virtue of one or more of the following: minimally invasive techniques over the years. Since the morbid obesity, coagulopathy, prior neck surgery or introduction of percutaneous dilatational tracheostomy head and neck trauma, laryngotracheal stenosis or (PDT) over 24 years ago by Ciaglia et al., the adaptation tracheomalacia, a high-riding innominate artery, or into most clinical spheres has been rather slow.1 The high ventilator demands. Thirty-five patients (30%) most common method for tracheostomy in critically ill had two or more of these risk factors. A total of 11 patients still remains open tracheostomy performed in (13.7 %) complications occurred in the high-risk 2 group. Two major and nine minor complications the operating room (OR). PDT was initially introduced occurred during the study. There were no adverse as an alternative method of airway management for sequelae. those patients in intensive care units (ICU) that was Conclusions: SL-PDT is a safe and effective unrelated to factors such as availability of the consulting means of bedside airway management in critically ill surgeon, OR time, and transportation assistance, but patients. This new technique offers several advan- rather to minimize perioperative complications of the tages over traditional percutaneous dilatational tra- standard tracheostomy procedure.1 cheostomy (T-PDT) and can be safely employed by A number of studies have been published compar- otolaryngologists, especially in high-risk patients. ing several techniques of PDT with the open surgical tracheostomy, and most suggest lower complication rates From the Department of Surgery, Division of Otolaryngology–Head or no statistical differences between the two methods. and Neck Surgery, University of Alabama at Birmingham, Birmingham, Recent meta-analyses have shown that PDT is easier to Alabama, U.S.A. perform, requires shorter operative times, produces less Editor’s Note: This Manuscript was accepted for publication March intraoperative and postoperative bleeding than the open 16, 2010. This work was an oral presentation at the 2010 Triological Society surgical technique, and results in fewer overall postoper- 3–5 Combined Sections Meeting, Orlando, Florida, U.S.A., February 5, 2010. ative complications. It has also been reported that Paul F. Castellanos, MD, is a consultant for Cook Critical Care, PDT in the intensive care unit ICU costs significantly Inc. The authors have no other funding, financial relationships, or con- less than surgical tracheostomy performed in the OR flicts of interest to disclose. 4,6–11 Send correspondence to Paul F. Castellanos, MD, University of Ala- and can be performed in less time. bama at Birmingham, BDB 563, 1530 3rd Avenue South, Birmingham, Despite the rapid evolution and improvements in AL 35294-0012. E-mail: [email protected] technique of PDT, there continues to be apprehension in DOI: 10.1002/lary.21019 the medical community about its applicability to the Laryngoscope 120: December 2010 White et al.: PDT in High Risk Patients 2423 high-risk patient.12 What constitutes absolute and rela- ing blood pressure, pulse, respiratory rate, oximetry, and tive contraindications has become a matter of debate. electrocardiography. Most published articles consider cervical injury, pediatric A Dedo laryngoscope, a Pilling-Weck Louie arm suspen- < sion apparatus (model 502245FF9; Pilling-Weck Surgical, Fort age 8 years, gross distortion of the neck anatomy, and emergency airway necessity as absolute contraindica- Washington, PA), a 5-mm 30 Storz rigid endoscope (Hopkins II, model 2604613A; Karl Storz Endoscopy Ltd., Tuttlingen, Ger- tions, whereas obesity with a short neck, coagulopathy, many), a Storz camera and light cord (IMAGE1, A3, model need for positive end-expiratory pressure (PEEP) of HF618406-H; Karl Storz Endoscopy Ltd.), and a modified 9.0 more than 20 cm of water, and evidence of infection in Mallinckrodt oral endotracheal tube (ETT) (model 86454; Mal- the soft tissues of the neck at the prospective surgical linckrodt Co., Juarez, Mexico) were used for the site are relative contraindications. However, several laryngotracheal examination and control of the airway. A single reports have recently emerged suggesting safety and fea- dilator Ciaglia Blue Rhino Percutaneous Tracheostomy Intro- sibility of performing PDT in patients with the ducer Kit (Cook Critical Care, Inc., Bloomington, IN) was used previously described contraindications.12–17 in all cases. Patient ventilation was maintained throughout the Suspension laryngoscopy-assisted percutaneous entire procedure, with only very brief intervals of apnea during dilatational tracheostomy (SL-PDT) is a blending of two ETT exchange and airway evaluation. The Dedo laryngoscope is placed just into the laryngeal techniques developed by the senior author (P.F.C.) to ac- inlet within the aperture of the false vocal folds. The airway is complish two important goals: airway evaluation and then trapped into place while the Louie arm apparatus is tracheostomy simultaneously, while maintaining the engaged and the patient is placed in suspension from the bed- highest level of patient safety. The first preliminary side table that is positioned over the patient’s chest. The ETT is report of this technique and patient clinical outcomes then removed and a rigid airway evaluation is performed dur- showed great promise in adopting this to all critically ill ing a short period of apnea. The airway evaluation is a careful patients with rare complications. Over the last several and quick visual inspection with the 30 Storz endoscope. We years, SL-PDT was offered to all critically ill patients establish whether or not there is a clear view of the larynx, the regardless of body habitus, coagulopathy, increased ven- presence and depth of arytenoid and cricoid ulcers, signs of pos- tilator requirements, or difficult airway anatomy, sible tracheoesophageal fistula formation or innominate artery fistula formation, and obstructing secretions. Secretions that internal or external. We have retrospectively investi- might obstruct the airway during the PDT procedure are com- gated the implementation of this procedure in all monly encountered and removed either via rigid suction or with patients, highlighting those with high-risk features. We the assistance of grasping forceps. A shortened 9.0 ETT placed present the outcomes of a consecutive series of patients over a 30 optical telescope is then used to reintubate the in whom SL-PDT was performed in the context of the patient and examine the relevant airway landmarks to guide consultant request for tracheostomy alone. accurate needle placement. This is shown in Figure 1. The re- mainder of the procedure is conducted exactly as already described in the literature. The SL-PDT technique is described MATERIALS AND METHODS in further detail in the previous paper by Sharp and Castella- Approval was obtained from the institutional review board nos titled, ‘‘Clinical Outcomes of Bedside Percutaneous for data collection. A list of 117 consecutive patients who under- Dilatational Tracheostomy With Suspension Laryngoscopy for went SL-PDT at the University of Alabama at Birmingham Airway Control.’’ A streaming video of the procedure can be Hospital from April 2006 to May 2009 was considered for the viewed at be at: www.pdtsurgeon.com/sl-pdt.mp4.2 study. All patients were included in our retrospective analysis. All patients received standard Shiley cuffed cannulas Recorded data consisted of patient age, sex, weight and except for two of each gender; number 6 cannulas in females height, admission diagnosis, indication for tracheostomy, and and number 8 in males. Two male patients in this series perioperative complications. Also, ventilator settings at the time received an 8.0 proximal Shiley Extended-Length Tracheostomy of procedure, history of prior neck surgeries, intraprocedural (XLT) tube. One was required secondary to morbid
Recommended publications
  • Vocal Cord Dysfunction JAMES DECKERT, MD, Saint Louis University School of Medicine, St
    Vocal Cord Dysfunction JAMES DECKERT, MD, Saint Louis University School of Medicine, St. Louis, Missouri LINDA DECKERT, MA, CCC-SLP, Special School District of St. Louis County, Town & Country, Missouri Vocal cord dysfunction involves inappropriate vocal cord motion that produces partial airway obstruction. Patients may present with respiratory distress that is often mistakenly diagnosed as asthma. Exercise, psychological conditions, airborne irritants, rhinosinusitis, gastroesophageal reflux disease, or use of certain medications may trigger vocal cord dysfunction. The differential diagnosis includes asthma, angioedema, vocal cord tumors, and vocal cord paralysis. Pulmo- nary function testing with a flow-volume loop and flexible laryngoscopy are valuable diagnostic tests for confirming vocal cord dysfunction. Treatment of acute episodes includes reassurance, breathing instruction, and use of a helium and oxygen mixture (heliox). Long-term manage- ment strategies include treatment for symptom triggers and speech therapy. (Am Fam Physician. 2010;81(2):156-159, 160. Copyright © 2010 American Academy of Family Physicians.) ▲ Patient information: ocal cord dysfunction is a syn- been previously diagnosed with asthma.8 A handout on vocal cord drome in which inappropriate Most patients with vocal cord dysfunction dysfunction, written by the authors of this article, is vocal cord motion produces par- have intermittent and relatively mild symp- provided on page 160. tial airway obstruction, leading toms, although some patients may have pro- toV subjective respiratory distress. When a per- longed and severe symptoms. son breathes normally, the vocal cords move Laryngospasm, a subtype of vocal cord away from the midline during inspiration and dysfunction, is a brief involuntary spasm of only slightly toward the midline during expi- the vocal cords that often produces aphonia ration.1 However, in patients with vocal cord and acute respiratory distress.
    [Show full text]
  • Diagnostic Direct Laryngoscopy, Bronchoscopy & Esophagoscopy
    Post-Operative Instruction Sheet Diagnostic Direct Laryngoscopy, Bronchoscopy & Esophagoscopy Direct Laryngoscopy: Examination of the voice box or larynx (pronounced “lair-inks”) under general anesthesia. An instrument called a laryngoscope is carefully placed into the mouth and used to visualize the larynx and surrounding structures. Bronchoscopy: Examination of the windpipe below the voice box in the neck and chest under general anesthesia. A long narrow telescope is passed through the larynx and used to carefully inspect the structures of the trachea and bronchi. Esophagoscopy: Examination of the swallowing pipe in the neck and chest under general anesthesia. An instrument called an esophagoscope is passed into the esophagus (just behind the larynx and trachea) and used to visualize the mucus membranes and surrounding structures of the esophagus. Frequently a small biopsy is taken to evaluate for signs of esophageal inflammation (esophagitis). What to Expect: Diagnostic airway endoscopy procedures generally take about 45 minutes to complete. Usually the procedure is well-tolerated and the child is back-to-normal the next day. Mild throat or tongue discomfort may persist for a few days after the procedure and is usually well-controlled with over-the-counter acetaminophen (Tylenol) or ibuprofen (Motrin). Warning Signs: Contact the office immediately at (603) 650-4399 if any of the following develop: • Worsening harsh, high-pitched noisy-breathing (stridor) • Labored breathing with chest retractions or flaring of the nostrils • Bluish discoloration of the lips or fingernails (cyanosis) • Persistent fever above 102°F that does not respond to Tylenol or Motrin • Excessive coughing or respiratory distress during feeding • Coughing or throwing up bright red blood • Excessive drowsiness or unresponsiveness Diet: Resume baseline diet (no special postoperative diet restrictions).
    [Show full text]
  • Efficacy of Fiberoptic Laryngoscopy in the Diagnosis of Inhalation Injuries
    ORIGINAL ARTICLE Efficacy of Fiberoptic Laryngoscopy in the Diagnosis of Inhalation Injuries Thomas Muehlberger, MD; Dario Kunar, MD; Andrew Munster, MD; Marion Couch, MD, PhD Background: Asignificantproportionofburnpatientswith Results: Six (55%) of 11 patients had clinical findings and inhalation injuries incur difficulties with airway protection, symptoms that indicated, under traditional criteria, endo- dysphagia, and aspiration. In assessing the need for intu- tracheal intubation for airway protection. Visualization of bation in burn patients, the efficacy of fiberoptic laryngos- the upper airway with fiberoptic laryngoscopy obviated the copy was compared with clinical findings and the findings need for endotracheal intubation in all 11 patients. These of diagnostic tests, such as arterial blood gas analysis, mea- patients also failed to evidence an increased risk of aspira- surement of carboxyhemoglobin levels, pulmonary func- tion or other swallowing dysfunction. tion tests, and radiography of the lateral aspect of the neck. Conclusions: In comparison with other diagnostic cri- Objective: To determine if these patients were at risk teria, fiberoptic laryngoscopy allows differentiation of for aspiration or dysphagia, barium-enhanced fluoro- those patients with inhalation injuries who, while at scopic swallowing studies were performed. risk for upper airway obstruction, do not require intu- bation. These patients may be safely observed in a moni- Design: Prospective study. tored setting with serial fiberoptic examinations, thus avoiding the possible complications associated with in- Settings: Burn intensive care unit in an academic ter- tubation of an airway with a compromised mucosalized tiary referral center. surface. In these patients, swallowing abnormalities do not manifest. Main Outcome Measures: Need for endotracheal in- tubation and potential for aspiration.
    [Show full text]
  • Table of Contents 1
    GENERAL THORACIC SURGERY DATABASE v.2.3 TRAINING MANUAL August 2017 Table of Contents 1. Demographics ................................................................................................................................................................. 2 2. Follow Up ........................................................................................................................................................................ 9 3. Admission ..................................................................................................................................................................... 10 4. Pre-Operative Evaluation ............................................................................................................................................. 14 5. Diagnosis (Category of Disease) ................................................................................................................................... 48 6. Procedure ..................................................................................................................................................................... 70 7. Post-Operative Events ................................................................................................................................................ 111 8. Discharge .................................................................................................................................................................... 135 9. Quality Measures ......................................................................................................................................................
    [Show full text]
  • Laryngectomy
    The Head+Neck Center John U. Coniglio, MD, LLC 1065 Senator Keating Blvd. Suite 240 Rochester, NY 14618 Office Hours: 8-4 Monday-Friday t 585.256.3550 f 585.256.3554 www.RochesterHNC.com Laryngectomy SINUS Voice change, difficulty swallowing, unexplained weight loss, ear or ENDOCRINE HEAD AND NECK CANCER throat pain and a lump in the throat, smoking and alcohol use are all VOICE DISORDERS SALIVARY GLANDS indications for further evaluation. Smoking and alcohol can contribute TONSILS AND ADENOIDS to these symptoms. A direct laryngoscopy – an exam of larynx (voice EARS PEDIATRICS box), with biopsy – will help determine if a laryngectomy is indicated. SNORING / SLEEP APNEA Laryngectomy may involve partial or total removal of one or more or both vocal cords. Alteration of voice will occur with either total or partial laryngectomy. Postoperative rehabilitation is usually successful in helping the patient recover a voice that can be understood. The degree of alteration in voice depends on the extent of the disease. Partial or total laryngectomy has been a highly successful method to remove cancer of the larynx. The extent of the tumor invasion, and therefore the extent of surgery, determines the way you will communicate following surgery. The choice of surgery over other forms of treatment such as radiation or chemotherapy is determined by the site of the tumor. It is quite likely that there has been spread of the tumor to the neck; a neck or lymph node dissection may also be recommended. Complete neck dissection (exploration of the neck tissues) is performed in order to remove known or suspected lymph nodes containing cancer that has spread from the primary tumor site.
    [Show full text]
  • Endoscopy Matrix
    Endoscopy Matrix CPT Description of Endoscopy Diagnostic Therapeutic Code (Surgical) 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) X 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via X inferior meatus or canine fossa puncture) 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via X puncture of sphenoidal face or cannulation of ostium) 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or X debridement (separate procedure) 31238 Nasal/sinus endoscopy, surgical; with control of hemorrhage X 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy X 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection X 31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery X 31253 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) X 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior 31256 Nasal/sinus endoscopy, surgical; with maxillary antrostomy X 31257 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior), including sphenoidotomy 31259 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior X and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus 31267 Nasal/sinus endoscopy, surgical; with removal of
    [Show full text]
  • Thoracic Surgery Institution: Nashville VA Medical Center & Duration: 6 Weeks Vanderbilt University Medical Center Supervising Physician: Eric L
    Thoracic Surgery Institution: Nashville VA Medical Center & Duration: 6 weeks Vanderbilt University Medical Center Supervising Physician: Eric L. Grogan, M.D. Contact Information: 615-300-2900 Year of Training: PGY-4 Educational Objectives: During this rotation, the resident will better understand the pathophysiology of thoracic diseases including lung, esophagus, and chest wall diseases. The resident will identify the general risks and complications of thoracic surgery operations, and learn the preoperative and postoperative care of patients undergoing thoracic surgery operations Evaluation of the resident's understanding of the patient and disease process will be reviewed (in part) at the time of operation and through resident-faculty interaction. Feedback will be verbal and timely; residents are encouraged to establish a dialogue with the faculty to facilitate feedback. Residents are expected to notify Dr. Grogan and meet with him when starting the service. Other Comments and Responsibilities Daily rounds will include the General Care Wards and the Intensive Care Unit at the VA. Medical Knowledge and Patient Care: I. CHEST WALL A. Anatomy, Physiology and Embryology Learner Objectives: • Understands the anatomy and physiology of the cutaneous, muscular, and bony components of the chest wall and their anatomic and physiologic relationships to adjacent structures; • Knows various operative approaches to the chest wall. Clinical Skills: • Recognizes the normal and abnormal anatomy of the chest wall. B. Acquired Abnormalities and Neoplasms Learner Objectives: • Evaluates and diagnoses primary and metastatic chest wall tumors, knows their histologic appearance, and understands the indications for incisional versus excisional biopsy; • Knows the radiologic characteristics of tumors. Clinical Skills: • Performs a variety of surgical incisions to expose components of the chest wall and interior thoracic organs.
    [Show full text]
  • Exercise-Induced Laryngeal Obstruction
    American Thoracic Society PATIENT EDUCATION | INFORMATION SERIES Exercise-induced Laryngeal Obstruction Exercise-induced laryngeal obstruction (EILO) is a breathing problem that affects people during exercise. EILO is defined by inappropriate narrowing of the upper airway at the level of the vocal cords (glottis) and/or supraglottis (above the vocal cords). This can make it hard to get air into your lungs during exercise and cause a noisy breathing that can be frightening. EILO has also been called vocal cord dysfunction (VCD) or paradoxical vocal fold motion (PVFM). Most people with EILO only have symptoms when they Common signs and symptoms of EILO exercise, those some people may have the problem at During (or immediately after) high-intensity exercise, other times as well. (See ATS Patient Information Series with EILO you may experience: fact sheet ‘Inducible Laryngeal Obstruction/Vocal Cord ■■ Profound shortness of breath or breathlessness Dysfunction’) ■■ Noisy breathing, particularly when breathing in Where are the vocal cords and what do they do? (stridor, gasping, raspy sounds, or “wheezing”) Your vocal cords are located in your upper airway or ■■ A feeling of choking or suffocation that can be scary larynx. Your supraglottic structures (including your ■■ CLIP AND COPY AND CLIP Feeling like there is a lump in the throat arytenoid cartilages and epiglottis) are located above the ■■ Throat or chest tightness vocal cords and are part of your larynx. The larynx is often called the voice box and is deep in your throat. When These symptoms often come on suddenly during you speak, the vocal cords vibrate as you breathe out, exercise, and are typically quite noticeable or concerning to people around you as well.
    [Show full text]
  • Airway Assessment Authors: Dr Pierre Bradley Dr Gordon Chapman Dr Ben Crooke Dr Keith Greenland
    Airway Assessment Authors: Dr Pierre Bradley Dr Gordon Chapman Dr Ben Crooke Dr Keith Greenland August 2016 Contents Part 1. Introduction 3 Part 2. The traditional approach to normal and difficult airway assessment 6 Part 3. The anatomical basis for airway assessment and management 36 Part 4. Airway device selection based on the two-curve theory and three-column assessment model 48 DISCLAIMER This document is provided as an educational resource by ANZCA and represents the views of the authors. Statements therein do not represent College policy unless supported by ANZCA professional documents. Professor David A Scott, President, ANZCA 2 Airway Assessment Part 1. Introduction This airway assessment resource has been produced for use by ANZCA Fellows and trainees to improve understanding and guide management of airway assessment and difficult airways. It is the first of an airway resource series and complements the Transition to CICO resource document (and ANZCA professional document PS61), which are available on the ANZCA website. There are four components to this resource: Part 1. Introduction. Part 2. The traditional approach to normal and difficult airway assessment. Part 3. The anatomical basis for airway assessment and management: i) The “two-curve” theory. ii) The “three-column” approach. Part 4. Airway device selection based on the two-curve theory and three-column assessment model. OVERVIEW The role of airway assessment is to identify potential problems with the maintenance of oxygenation and ventilation during airway management. It is the first step in formulating an appropriate airway plan, which should incorporate a staged approach to manage an unexpected difficult airway or the institution of emergency airway management.
    [Show full text]
  • Icd-9-Cm (2010)
    ICD-9-CM (2010) PROCEDURE CODE LONG DESCRIPTION SHORT DESCRIPTION 0001 Therapeutic ultrasound of vessels of head and neck Ther ult head & neck ves 0002 Therapeutic ultrasound of heart Ther ultrasound of heart 0003 Therapeutic ultrasound of peripheral vascular vessels Ther ult peripheral ves 0009 Other therapeutic ultrasound Other therapeutic ultsnd 0010 Implantation of chemotherapeutic agent Implant chemothera agent 0011 Infusion of drotrecogin alfa (activated) Infus drotrecogin alfa 0012 Administration of inhaled nitric oxide Adm inhal nitric oxide 0013 Injection or infusion of nesiritide Inject/infus nesiritide 0014 Injection or infusion of oxazolidinone class of antibiotics Injection oxazolidinone 0015 High-dose infusion interleukin-2 [IL-2] High-dose infusion IL-2 0016 Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance Pressurized treat graft 0017 Infusion of vasopressor agent Infusion of vasopressor 0018 Infusion of immunosuppressive antibody therapy Infus immunosup antibody 0019 Disruption of blood brain barrier via infusion [BBBD] BBBD via infusion 0021 Intravascular imaging of extracranial cerebral vessels IVUS extracran cereb ves 0022 Intravascular imaging of intrathoracic vessels IVUS intrathoracic ves 0023 Intravascular imaging of peripheral vessels IVUS peripheral vessels 0024 Intravascular imaging of coronary vessels IVUS coronary vessels 0025 Intravascular imaging of renal vessels IVUS renal vessels 0028 Intravascular imaging, other specified vessel(s) Intravascul imaging NEC 0029 Intravascular
    [Show full text]
  • Laryngoscopy and Videostroboscopy
    Laryngoscopy and Videostroboscopy What is laryngoscopy and how is it performed? Laryngoscopy is the process of examining the larynx, the voice box. Because of its position deep in the throat, the larynx is not as easily examined with a flashlight, as the mouth and nose are. Special instruments are needed to evaluate this difficult-to-see area. Laryngoscopy is performed by using a light connected to either a mirror or a special tool, called a laryngoscope, which can visualize the larynx. Mirror laryngoscopy is performed by gently placing an angled mirror into the back of the mouth. Light is shone into the mouth and reflects off the mirror and downward towards the larynx. Mirror laryngoscopy has been performed since the late 1800’s and requires a mirror, a light source and gentle steady hand. Sometimes, mirror laryngoscopy can be challenging for both the physician and the patient, but it provides the most accurate color representation of the larynx; this can be helpful in diagnosing and monitoring treatment of disease that affect the larynx. Flexible laryngoscopy is the most commonly performed procedure for visualizing the larynx. In this case, a flexible endoscope (called a flexible laryngoscope), is typically inserted into one of the nostrils, into the back of the nose, behind the palate (and the gag reflex) and placed into position just above the larynx. Sometimes, anesthetic and decongestant medications are used to facilitate patient comfort. This examination gives an excellent birds-eye-view of the structures and functions of the voice box, allowing for the patient to speak, swallow and breathe naturally.
    [Show full text]
  • Rigid Laryngoscopy, Oesophagoscopy and Bronchoscopy in Adults
    OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY RIGID LARYNGOSCOPY, OESOPHAGOSCOPY & BRONCHOSCOPY IN ADULTS Johan Fagan, Mark De Groot Adult bronchoscopy, rigid oesophagoscopy teeth (Figure 3). Ask a dentist to make a and laryngoscopy for both diagnostic and customised guard for patients with therapeutic reasons are generally done abnormal teeth (Figure 4) or fashion one in under general anaesthesia. Panendoscopy the operating room from thermoplastic (all 3 procedures) is commonly performed sheeting (Figures 5a, b). to rule out synchronous primaries with squamous cell cancer of the upper aerodi- gestive tract. This chapter covers the tech- niques, pitfalls and safety measures of these 3 procedures. Morbidity of rigid endoscopy Sharing the airway with an anaesthetist requires close communication and a good understanding between surgeon and anaes- thetist. Figure 1: Protecting the lips with the fingers of the non-dominant hand It is surprising how often rigid endoscopy causes minor extralaryngeal and extra- oesophageal trauma. It is extremely easy to tear or perforate the delicate tissues that line the upper aerodigestive tract; this can lead to deep cervical sepsis, mediastinitis and death. Consequently it is important that a surgeon exercises extreme caution and knows when to abandon e.g. a difficult oesophagoscopy procedure. Mucosal injury occurs in up to 75% of cases and commonly involves the lips or Figure 2: Endoscopes exert excessive 1 angles of the mouth . To protect especially lateral pressure on the teeth to either side the lower lip one should advance the scope of a gap between the front teeth over the fingers of the non-dominant hand (Figure 1).
    [Show full text]