Direct laryngoscopy, Indirect laryngoscopy etc.

1. LARYNGOSCOPYLARYNGOSCOPY
Dr.Ramesh Parajuli
MS (Otorhinolaryngology)
Chitwan medical college teaching hospital,Bharatpur-10, Chitwan, NepalChitwan medical college teaching hospital,Bharatpur-10, Chitwan, Nepal

2. ROADMAPROADMAP
1.History1.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 endoscopyContact endoscopy
MicrolaryngoscopyMicrolaryngoscopy
6.Stroboscopy6.Stroboscopy

3. HISTORYHISTORY
18061806:: Bozzini (inventor of archetypal laryngoscope)Bozzini (inventor of archetypal laryngoscope)
18291829:: Babington (Glottiscope)Babington (Glottiscope)
18531853:: DesmoreauxDesmoreaux
18541854:: Manuel Garcia (“Autolaryngoscopy”)Manuel Garcia (“Autolaryngoscopy”)
18571857:: Czermak (head band mirror)Czermak (head band mirror)
Morell, Mackenzie, TurckMorell, Mackenzie, Turck

4. Early 1900Early 1900:: Chevalier JacksonChevalier Jackson
-use of magnification-use of magnification
-sniffing position-sniffing position
19411941:: RobertRobert MillerMiller
19431943 : Robert Macintosh: Robert Macintosh
19501950:: Operating microscopeOperating microscope
19601960:: Hopkins (rod lens telescope)Hopkins (rod lens telescope)
Late 1960Late 1960:: Jako & Kleinsasser (fiberoptic laryngoscopeJako & Kleinsasser (fiberoptic laryngoscope
used with operating microscope)used with operating microscope)

5. LaryngoscopyLaryngoscopy
Internal ExaminationInternal Examination
Mirror (Indirect Laryngoscopy)Mirror (Indirect Laryngoscopy)
Laryngoscope (Direct Laryngoscopy)Laryngoscope (Direct Laryngoscopy)

6. 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 laryngeal4.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

7. 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 Laser4.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

8. 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 & LarynxExamination 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

9. Laryngeal MirrorLaryngeal Mirror

10. 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

12. Structure to be examined:Structure to be examined:
1.Base of the tongue 11.Ventricles1.Base of the tongue 11.Ventricles
2.Vallecula 12.Anterior commissure2.Vallecula 12.Anterior commissure
3.Median glossoepiglottic fold 13.Posterior wall of3.Median glossoepiglottic fold 13.Posterior wall of
4.Pharyngoepiglottic folds larynx4.Pharyngoepiglottic folds larynx
5.Lateral pharyngeal wall 14.Upper 2 or 35.Lateral pharyngeal wall 14.Upper 2 or 3
6.Epiglottis(both surfaces) tracheal rings6.Epiglottis(both surfaces) tracheal rings
7.Arytenoids 15.Pyriform Fossa7.Arytenoids 15.Pyriform Fossa
8.Aryepiglottic folds8.Aryepiglottic folds
9.False cords9.False cords
10.True cords10.True cords

13. 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 sensationPooling 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 uppereg. 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

14. 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 adjacent5.Visualising larynx directly without looking at adjacent
structuresstructures
6.Recording side of lesion6.Recording side of lesion

15. AdvantagesAdvantages
Easily availableEasily available
CheapCheap
Free of complicationsFree of complications
Easy to learnEasy to learn

16. Limitations of I/L Examination:Limitations of I/L Examination:
Uncontrollable gag reflexUncontrollable gag reflexApprox.10% patients I/L isApprox.10% patients I/L is
not possiblenot possible
Anatomic variations eg. large tongue, micrognathia andAnatomic 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

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

18. Fiber-optic LaryngoscopyFiber-optic Laryngoscopy
1.Flexible laryngscopy1.Flexible laryngscopy
2.Rigid laryngscopy2.Rigid laryngscopy

19. 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 ormicrognathia, 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

20. Longer interval for the hypopharynx & larynxLonger 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 asFiberoptic telescopes with outer diameter as narrow as
2.2mm2.2mm atraumatic passage through nares inatraumatic passage through nares in
neonateneonate
--Smaller telescopes --- more comfortableSmaller telescopes --- more comfortable
--Larger telescopes --- better quality imageLarger telescopes --- better quality image

21. Contraindications:Contraindications:
No absolute contraindicationsNo absolute contraindications
1.Epiglottitis : Laryngospasm1.Epiglottitis : Laryngospasm  subsequent airwaysubsequent airway
compromisecompromise
2.Croup2.Croup
3.Coagulopathies3.Coagulopathies
4.Craniofacial trauma: intracranial instrumentation &4.Craniofacial trauma: intracranial instrumentation &
exacerbation of nasopharyngeal injuriesexacerbation of nasopharyngeal injuries

22. Specific work upSpecific work up
Routine Head & Neck Examination:Routine Head & Neck Examination:
- Nasal Patency- Nasal Patency
- Indirect Laryngoscopy- Indirect Laryngoscopy

23. 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 basiseasy for routine basis
Disadvantages:Disadvantages:
-Lack of suctioning capability-Lack of suctioning capability
-Precludes examination of subglottis & trachea-Precludes examination of subglottis & trachea

24. 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
DisadvantagesDisadvantages
-High cost-High cost
-Extra length-Extra length

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

28. AdvantagesAdvantages
1.Well tolerated :OPD or bed side1.Well tolerated :OPD or bed side
sitting erect, supine positionsitting erect, supine position
2.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.Photography7.Photography

29. DisadvantagesDisadvantages
1.Doesn’t maintain airway1.Doesn’t maintain airway
2.No surgical procedures possible except biopsy2.No surgical procedures possible except biopsy

30. Topical anesthesia, Lubrication, De-misting agentTopical anesthesia, Lubrication, De-misting agent
Passage fromPassage from
NoseNose Nasopharynx, Pharynx & LarynxNasopharynx, Pharynx & Larynx
MouthMouth Folded gauze, plastic bite block,Folded gauze, plastic bite block,
examiner’s finger (edentulous infant)examiner’s finger (edentulous infant)

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

32. 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 & PPWPalate & PPW
Precaution: pt shouldn’t eat or drink until adequatePrecaution: 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

33. SterilisationSterilisation
Glutaraldehyde soaking: damage endoscopeGlutaraldehyde soaking: damage endoscope
ineffectiveineffective
staff health concernstaff 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 infectiousWiping 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 sheathspreferred methodpreferred method
3.Daily high level of disinfection of the endoscopes3.Daily high level of disinfection of the endoscopes

34. 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

36. IndicationsIndications
1.Brilliant illumination1.Brilliant illumination better view of larynxbetter view of larynx
2.Photography2.Photography
Contraindications:Contraindications:
1.Respiratory distress1.Respiratory distress
2.Active bleeding in airway2.Active bleeding in airway

37. AdvantagesAdvantages
1.Superb photographic capability1.Superb photographic capability
2.Excellent lighting & better evaluation of larynx2.Excellent lighting & better evaluation of larynx

38. ComplicationsComplications
1.Damage to teeth and pharyngeal mucosa1.Damage to teeth and pharyngeal mucosa
2.Evolving airway problems2.Evolving airway problems laryngeallaryngeal
spasmspasm

39. Direct LaryngoscopyDirect Laryngoscopy
Direct visualisation of larynx & hypopharynxDirect visualisation of larynx & hypopharynx
Range from simple rigid scopes with a light bulb toRange from simple rigid scopes with a light bulb to
complex fiberoptic video devicescomplex fiberoptic video devices
Rigid laryngoscopes manufactured - single-piece or aRigid laryngoscopes manufactured - single-piece or a
separate detachable blade with light source & handleseparate detachable blade with light source & handle

40. For a detachable handle and blade- light source isFor a detachable handle and blade- light source is
energized when the blade and handle are locked inenergized when the blade and handle are locked in
the operating positionthe operating position
A hook-on connection between the handle and bladeA hook-on connection between the handle and blade
is most commonly usedis most commonly used

41. Many blade typesMany blade types::
Macintosh blade-Macintosh blade- curved blade, sits anterior to epiglottiscurved blade, sits anterior to epiglottis
Miller blade-Miller blade- straight blade, sits posterior to epiglottisstraight 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

44. Rigid LaryngoscopeRigid Laryngoscope

45. Handle:Handle:
– It provides the power for the lightIt provides the power for the light
– Most often, disposable batteries are the powerMost often, disposable batteries are the power
sourcesource
– Fiberoptic-illuminated laryngoscopes may use aFiberoptic-illuminated laryngoscopes may use a
remote electrically operated light sourceremote electrically operated light source

46. Laryngoscope handles in various sizesLaryngoscope handles in various sizes

47. – Most blades form a right angle with the handle whenMost 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 lockedPatil-Syracuse handle can be positioned and locked
in four different positionsin four different positions

48. Patil-Syracuse handle. With this handle, the blade can be adjusted andPatil-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°)

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

50. LLaryngoscope bladesaryngoscope blades

51. – 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
HeelHeel - end of the base- end of the base
TongueTongue (spatula)(spatula)
– Main shaftMain shaft
– Compress and manipulate the soft tissuesCompress 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 betterGenerally- straight blades provide better
laryngeal visualization, curved blades makelaryngeal visualization, curved blades make
intubation easierintubation easier

52. FlangeFlange
– Projects off the side of the tongueProjects off the side of the tongue
– Serves to guide instrumentation & deflectServes to guide instrumentation & deflect
tissues from the line of visiontissues from the line of vision
– Determines the cross-sectional shape of theDetermines the cross-sectional shape of the
bladeblade
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

53. Light source:Light source:
-- Lamp (bulb) or fiberoptic bundle that transmitsLamp (bulb) or fiberoptic bundle that transmits
light from a source in handlelight from a source in handle
– Fiberoptic-illuminated blade has an encasedFiberoptic-illuminated blade has an encased
fiberoptic bundle - transmits light from sourcefiberoptic 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 inBecause 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 greenFiberoptic-illuminated blades to have a green
mark on the heel.mark on the heel.

54. 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 flangeIn cross section, the tongue, web, and flange
form a reverse Zform a reverse Z
– Cervical spine movement is greater with theCervical spine movement is greater with the
Macintosh blade compared with the Miller bladeMacintosh blade compared with the Miller blade

57. Miller Blade:Miller Blade:
– Tongue is straight with a slightTongue 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 withweb, and tongue form a C with
the top fattenedthe top fattened

58. 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

59. 33..Mallampatti classificationMallampatti classification
Class I-IVClass I-IV

60. Direct LaryngoscopyDirect Laryngoscopy
Cormack & LehaneCormack & Lehane -- Grade I-IVGrade I-IV
Grade I-Grade I- Entire laryngeal aperture visibleEntire laryngeal aperture visible
Grade II-Grade II- Post commissure visiblePost commissure visible
Grade III-Grade III- Epiglottis visibleEpiglottis visible
Grade IV-Grade IV- Soft palate visibleSoft palate visible

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

62. 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, ventriclesLarynx: infrahyoid epiglottis, anterior commissure, ventricles
& subglottic region& subglottic region
3.Extent of growth & biopsy3.Extent of growth & biopsy

63. 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

64. 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

65. 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)

66. Head reachingHead reaching
proximal edge of tableproximal edge of table
The “sniffer” or Boyce-The “sniffer” or Boyce-
Jackson positionJackson position
provides the bestprovides the best
visualization of thevisualization of the
larynxlarynx
Neck flexed onNeck flexed on
shoulders & headshoulders & head
extended on neckextended on neck

71. 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 laryngoscopyedemaedema  distressdistress
4.Bleeding4.Bleeding

72. ComplicationsComplications
1.Injury to lip, teeth & tongue1.Injury to lip, teeth & tongue
2.Bleeding2.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

73. 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 inTrue & 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 falseSeen by pressing the false
cordscords
OPD procedureOPD procedure Done in O TDone in O T

74. Difficult LaryngoscopyDifficult Laryngoscopy
BURPBURP
--BBackward,ackward, UUpward &pward & RRightwardightward
PPressure on thyroid cartilageressure on thyroid cartilage
Simple aid for difficultSimple aid for difficult
laryngoscopylaryngoscopy

75. Bullard LaryngoscopeBullard Laryngoscope
A rigid fiber-optic laryngoscopeA rigid fiber-optic laryngoscope
specially shaped to follow thespecially shaped to follow the
contour of oropharynxcontour of oropharynx
Working channel- suction, oxygenWorking 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

76. Advantages of Bullard LaryngoscopeAdvantages of Bullard Laryngoscope
Useful during difficult intubationUseful during difficult intubation
In neutral position. eg.unstable cervical spine, TMJIn 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 placedSafely used in pediatric population eg.anteriorly placed
larynxlarynx

77. MicrolaryngoscopyMicrolaryngoscopy
Prof.Prof. Rosemarie AlbrechtRosemarie Albrecht - Germany (1954)- Germany (1954)
first microscopic visualization ofthe Vocal Foldsfirst microscopic visualization ofthe Vocal Folds
Prof.Prof. Oskar KleinsassarOskar 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 microlaryngealdesigned a series of microlaryngeal
instrumentsinstruments

78. Standard procedure for Endolaryngeal SurgeryStandard procedure for Endolaryngeal Surgery
Advantages:Advantages:
1.Binocular vision1.Binocular vision
2.Bimanual handling2.Bimanual handling
3.High resolution magnification3.High resolution magnification
Disadvantages:Disadvantages:
Considerable force to bring oropharyngeal structure inConsiderable force to bring oropharyngeal structure in
midlinemidline tissue injurytissue injury

79. Largest-caliber laryngoscopeLargest-caliber laryngoscope
Not a single “best” oneNot a single “best” one
that fits all situationsthat fits all situations
Contact area -upper teethContact area -upper teeth
- flat- flat
Anatomical configuration easesAnatomical configuration eases
exposure ant commissureexposure ant commissure

81. Suspension deviceSuspension device
Suspension gallows techniqueSuspension gallows technique
MagnificationMagnification
- Laryngeal telescopesLaryngeal telescopes
(0°, 30°, 70°)(0°, 30°, 70°)
350mm /400 mm - microscope350mm /400 mm - microscope

82. Advantages of Microlaryngoscopy over DirectAdvantages of Microlaryngoscopy over Direct
Laryngoscopy:Laryngoscopy:
- Binocular vision- Binocular vision
- MagnificationMagnification
- Better illuminationBetter illumination
- Bimanual handlingBimanual handling
- Ability to use CO2 laserAbility to use CO2 laser

83. 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
JaupitreJaupitre
HamouHamou

84. In vivo & in situ assessment of mucosa and underlying microvascularIn 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 techniqueSimple ,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 therapyselect area for biopsy, assessment of the response to therapy
(radiotherapy/chemotherapy), F/U of cancer pts(radiotherapy/chemotherapy), F/U of cancer pts

85. 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

86. 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 ofMicrovasculature pattern & architecture-vessels of
varying size, thrombosis, ectasia, rupturevarying size, thrombosis, ectasia, rupture

89. 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)

90. Vocal fold vibration is fast(100 cycles/sec)Vocal fold vibration is fast(100 cycles/sec)
Ability of retina to process individualAbility of retina to process individual
images(5 images/sec)images(5 images/sec)
Synchronized flashing light through rigidSynchronized flashing light through rigid
or flexible telescope at a slightly sloweror flexible telescope at a slightly slower
speedspeed illusion of slow vocal foldillusion of slow vocal fold
vibrationvibration
Slow motion view derived from manySlow motion view derived from many
successive vibration cyclessuccessive vibration cycles

91. Allows evaluation of vocal fold vibration properties duringAllows 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 phaseParameters – symmetry, amplitude, speed and phase
differences of waves on two cordsdifferences of waves on two cords
Vibrating part of vocal fold sharply defined, & anythingVibrating part of vocal fold sharply defined, & anything
protruding from medial surface observedprotruding from medial surface observed
Extremely fast vibratory motionExtremely fast vibratory motion gentle waving motiongentle waving motion

92. Valuable in assessing : functional & anatomical defectsValuable in assessing : functional & anatomical defects
1.Stiffness1.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 detection5.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 after7.Determining resumption of voicing activities after
phonosurgeryphonosurgery

93. Thank YouThank You
Thank you