LARYNGOSCOPY

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

2.Indirect laryngoscopy

3.Direct laryngoscopy

4.Flexible & Rigid fibre-optic laryngoscopy

5.New techniques in laryngeal endoscopy

Contact endoscopy
Microlaryngoscopy

6.Stroboscopy
 HISTORY

1806: Bozzini (inventor of archetypal laryngoscope)

1829: Babington (Glottiscope)

1853: Desmoreaux

1854: Manuel Garcia (“Autolaryngoscopy”)

1857: Czermak (head band mirror)

Morell, Mackenzie, Turck
Early 1900: Chevalier Jackson
-use of magnification
-sniffing position
1941: Robert Miller

1943 : Robert Macintosh

1950: Operating microscope

1960: Hopkins (rod lens telescope)

Late 1960: Jako & Kleinsasser (fiberoptic laryngoscope

used with operating microscope)
 Laryngoscopy

Internal Examination

Mirror (Indirect Laryngoscopy)

Laryngoscope (Direct Laryngoscopy)

Indications for Laryngoscopy
Diagnostic:
1.Hoarseness 10.Shortness of breath
2.Voice changes 11.Dysarthria
3.Chronic cough 12.Stridor
4.Choking episodes 13.Suspicion of laryngeal
5.Odynophagia/Dysphagia foreign body
6.Chronic throat pain 14.Suspicion of carcinoma
7.Globus sensation (Biopsy)
8.Hemoptysis 15.Dyspnea
9.Referred otalgia
Therapeutic:
1.Intubation

2.Foreign body removal

3.Biopsy of a growth in hypopharynx or vocal cords

4.Treatment for benign & malignant diseases: eg Laser

therapy, Microlaryngeal Surgery

5.Placing gastric tube, Transesophageal echocardiac probe

Indirect Laryngoscopy
Simplest method of larynx & vocal cord examination
Most adults and older children
Significant skill & patient co-operation
Examination of Oropharynx, hypopharynx & Larynx
Larynx examination:
1.At rest
2.Gentle breathing
3.During phonation
4.Coughing
Laryngeal Mirror
Technique :

1.Explain the procedure

2.Sitting position

3.Open mouth : topical anesthesia

4.Placement of laryngeal mirror: defogging agent

5.Reverse image
Inspecting areas in an order
 Structure to be examined:

1.Base of the tongue 11.Ventricles

2.Vallecula 12.Anterior commissure
3.Median glossoepiglottic fold 13.Posterior wall of
4.Pharyngoepiglottic folds larynx
5.Lateral pharyngeal wall 14.Upper 2 or 3
6.Epiglottis(both surfaces) tracheal rings
7.Arytenoids 15.Pyriform Fossa
8.Aryepiglottic folds
9.False cords
10.True cords
Details of symmetry, motion, surface architecture,
evidence of inflammation & abnormal masses or growth

Pooling of saliva in PFS: 1.poor laryngeal sensation

2.weak lateral pharyngeal wall 3.inefficient swallow
eg. growth or foreign body in postcricoid region or upper
esophagus

Mobility of the vocal cords:

“eeh” or “aah”
Glottic chink
 Most Common Mistakes

1.Procedure explanation

2.Patient’s position

3.Focus light on mirror

4.Lifting uvula

5.Visualising larynx directly without looking at adjacent

structures

6.Recording side of lesion

 Advantages
Easily available

Cheap

Free of complications

Easy to learn
 Limitations of I/L Examination:

Uncontrollable gag reflexApprox.10% patients I/L is

not possible

Anatomic variations eg. large tongue, micrognathia and

trismus

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

Perceptual error
Killian’s Modification: standing position of examiner
with vertical and parallel placement of mirror to
posterior part of pharynx- for anterior commissure
 Fiber-optic Laryngoscopy

1.Flexible laryngscopy

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

-Neurological problems or Anatomical abnormalities:

micrognathia, cervical spine rigidity, instability or
immobility of TMJ

-Proper assessment of any condition in hypopharynx and

larynx

-Teaching purpose

-Photography & Video documentation

 Longer interval for the hypopharynx & larynx
examination
(Apex of PFS: on Valsalva Maneuver)

Fiberoptic telescopes with outer diameter as narrow as

2.2mm atraumatic passage through nares in
neonate

-Smaller telescopes --- more comfortable

-Larger telescopes --- better quality image

 Contraindications:
No absolute contraindications

1.Epiglottitis : Laryngospasm  subsequent airway

compromise

2.Croup

3.Coagulopathies

4.Craniofacial trauma: intracranial instrumentation &

exacerbation of nasopharyngeal injuries
 Specific work up

Routine Head & Neck Examination:

- Nasal Patency
- Indirect Laryngoscopy
 Equipment

1.Short cable endoscope: eg. Machida scope

Advantages:
-Low cost
-Adequate optical characteristics
-Light weight, short cable easy for routine basis

Disadvantages:
-Lack of suctioning capability
-Precludes examination of subglottis & trachea
2.Long cable endoscope: eg. Olympus Bronchofiberscope

Advantages
-Second port: instillation of topical anesthetics, continuous
suctioning & biopsy
-Evaluation of tracheobronchial tree

Disadvantages
-High cost
-Extra length
Flexible Fiberoptic Laryngoscope Light -separate source.
The lever on the handle - deflection of the tip in two
directions. Two ports- insufflation and suctioning
 Advantages

1.Well tolerated :OPD or bed side

sitting erect, supine position
2.Not limited by fixation of spine or mandible

3.Low chance of injury eg. teeth, mucosa

4.Excellent evaluation of larynx & tracheobronchial tree

5.Teaching sidearm

6.Suction & biopsy capability(olympus type)

7.Photography
 Disadvantages

1.Doesn’t maintain airway

2.No surgical procedures possible except biopsy

Topical anesthesia, Lubrication, De-misting agent

Passage from
Nose Nasopharynx, Pharynx & Larynx
Mouth Folded gauze, plastic bite block,
examiner’s finger (edentulous infant)
Bite block :kept between teeth to prevent damage to a
fiberoptic endoscope
Local anesthesia: pt comfort & co-operation, ameliorate
reflex response (tachycardia, HTN, laryngospasm)

Topical anesthesia Palate & PPW

Precaution: pt shouldn’t eat or drink until adequate

laryngeal sensation returns

Topical decongestants: to decrease nasal mucosal

edema, congestion or secretions

Precaution : hyperthyroidism, cardiovascular disease,

HTN,DM, BPH, narrow angle glaucoma
 Sterilisation
Glutaraldehyde soaking: damage endoscope
ineffective
staff health concern

Ethylene oxide: very effective but requires 24 hrs to work

Wiping with swab : mayn’t prevent against infectious
diseases eg. Tuberculosis
Better options:
1.Have more than one endoscope available in ENT department

2.Protective disposable sheathspreferred method

3.Daily high level of disinfection of the endoscopes

 Rigid Fiberoptic Endoscopy

OPD

Adults & in children as young as 6 -8 yrs

Position & technique for inserting :similar to mirror exam

Rigid telescope :angled lens 0 * or 90 * Hopkins rod

eg. storz rigid fiberoptic system

Image, size & clarity better than flexible fiberoptic system

Indications
1.Brilliant illumination better view of larynx
2.Photography

Contraindications:
1.Respiratory distress
2.Active bleeding in airway
 Advantages

1.Superb photographic capability

2.Excellent lighting & better evaluation of larynx

 Complications

1.Damage to teeth and pharyngeal mucosa

2.Evolving airway problems laryngeal

spasm
 Direct Laryngoscopy
Direct visualisation of larynx & hypopharynx

Range from simple rigid scopes with a light bulb to

complex fiberoptic video devices

Rigid laryngoscopes manufactured - single-piece or a

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

A hook-on connection between the handle and blade

is most commonly used
Many blade types:
Macintosh blade- curved blade, sits anterior to epiglottis

Miller blade- straight blade, sits posterior to epiglottis

usually for infants-larger comparative size of epiglottis,
Macintosh less effective
Rigid Laryngoscope
Handle:

– It provides the power for the light

– Most often, disposable batteries are the power

source

– Fiberoptic-illuminated laryngoscopes may use a

remote electrically operated light source
Laryngoscope handles in various sizes
– Most blades form a right angle with the handle when
ready for use, the angle may also be acute or obtuse

– Patil-Syracuse handle can be positioned and locked

in four different positions
Patil-Syracuse handle. With this handle, the blade can be adjusted and
locked in four different positions (45°, 90°,135° or 180°)
Blade
– Blades are available in more than one size
– Numbered, with the number increasing with size

Size Intended Use

000 Small premature infant
00 Premature infant
0 Neonate
1 Small Child
2 Child
3 Adult
4 Large Adult
5 Extra Large Adult
Laryngoscope blades
– Parts of blade:
Base - part that attaches to the handle, has a slot
for engaging the hinge pin of the handle

Heel - end of the base

Tongue (spatula)
– Main shaft
– Compress and manipulate the soft tissues
(especially the tongue) and lower jaw
– Blades referred to as curved or straight,
depending on shape the tongue
– Generally- straight blades provide better
laryngeal visualization, curved blades make
intubation easier
Flange

– Projects off the side of the tongue

– Serves to guide instrumentation & deflect
tissues from the line of vision
– Determines the cross-sectional shape of the
blade

Tip

– Contacts either the epiglottis or vallecula &

directly or indirectly elevates the epiglottis
– Usually blunt and thickened to decrease trauma
Light source:
- Lamp (bulb) or fiberoptic bundle that transmits
light from a source in handle

– Fiberoptic-illuminated blade has an encased

fiberoptic bundle - transmits light from source
in the handle or base of blade

– Because there is no bulb or electrical contact in

the blade, cleaning and sterilization are easier

– Fiberoptic-illuminated blades to have a green

mark on the heel.
Macintosh Blade
– One of the most commonly used blades

– Tongue is curved

– In cross section, the tongue, web, and flange

form a reverse Z

– Cervical spine movement is greater with the

Macintosh blade compared with the Miller blade
Miller Blade:

– Tongue is straight with a slight

upward curve near the tip

– In cross section, the flange,

web, and tongue form a C with
the top fattened
 Mallampati Classification

Class I-soft palate, fauces, uvula, tonsillar

pillars visible

Class II-soft palate, fauces, uvula visible

Class III-soft palate, base of uvula visible

Class IV-soft palate not visible

3.Mallampatti classification
Class I-IV
Direct Laryngoscopy
Cormack & Lehane - Grade I-IV

Grade I- Entire laryngeal aperture visible

Grade II- Post commissure visible

Grade III- Epiglottis visible

Grade IV- Soft palate visible

Cormack-Lehane laryngeal view scoring system
Indications:

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

2.Hidden areas:
Hypopharynx: base of tongue, vallecula, apex of PFS
Larynx: infrahyoid epiglottis, anterior commissure, ventricles
& subglottic region

3.Extent of growth & biopsy

Therapeutic:

1.Removal of benign lesions of larynx

2.Removal of foreign body from hypopharynx & larynx

 Contraindications

1.Injuries to cervical spine

2.Marked dyspnea

3.Recent coronary occlusion or cardiac problem

Procedure :-

Position: sniffing position

Anaesthesia: GA /LA

Procedure :
-eye cover, dental protection ,drapping
-widest scope (different scope to visualise different subsites
of endolarynx)
Head reaching
proximal edge of table

The “sniffer” or Boyce-

Jackson position
provides the best
visualization of the
larynx

Neck flexed on
shoulders & head
extended on neck
 Post-op care

1.Left lateral position

2.Monitror Respiration :laryngeal spasm, cyanosis

3.Repeated laryngoscopyedema  distress

4.Bleeding
 Complications
1.Injury to lip, teeth & tongue

2.Bleeding

3.Laryngeal edema

4.Cervical spinal cord injury

5.Swallowing or aspirating foreign body

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

Foreshortening of AP diameter No foreshortening

True & false cord appear to be in Separated by ventricles

contact with each other
Inverted mirror image Direct visualisation

Movement of cords seen better Seen only in LA

Under surface is not seen Some idea is gained

Ventricles not seen Seen by pressing the false

cords
OPD procedure Done in O T
 Difficult Laryngoscopy
BURP
-Backward, Upward & Rightward
Pressure on thyroid cartilage

Simple aid for difficult

laryngoscopy
 Bullard Laryngoscope

A rigid fiber-optic laryngoscope

specially shaped to follow the
contour of oropharynx

Working channel- suction, oxygen

insufflation, LA or administration

Available in three sizes : pediatric,

pediatric long, and adult
 Advantages of Bullard Laryngoscope

Useful during difficult intubation

In neutral position. eg.unstable cervical spine, TMJ

immobility, micrognathia

Patients with mouth opening of just 6 mm

Safely used in pediatric population eg.anteriorly placed

larynx
 Microlaryngoscopy
Prof. Rosemarie Albrecht - Germany (1954)
first microscopic visualization ofthe Vocal Folds

Prof. Oskar Kleinsassar - Germany (1962)

- modern state of the art method of microlaryngosurgery

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

instruments
 Standard procedure for Endolaryngeal Surgery
Advantages:
1.Binocular vision
2.Bimanual handling
3.High resolution magnification

Disadvantages:
Considerable force to bring oropharyngeal structure in
midline tissue injury
Largest-caliber laryngoscope

Not a single “best” one

that fits all situations

Contact area -upper teeth

- flat

Anatomical configuration eases

exposure ant commissure
 Suspension device

Suspension gallows technique

Magnification
- Laryngeal telescopes
(0°, 30°, 70°)

350mm /400 mm - microscope

 Advantages of Microlaryngoscopy over Direct
Laryngoscopy:

- Binocular vision
- Magnification
- Better illumination
- Bimanual handling

- Ability to use CO2 laser

 Contact Endoscopy

New phase in the development of endoscopy

Commonly used in research

In 1865- Desmoreaux

Jaupitre

Hamou
In vivo & in situ assessment of mucosa and underlying microvascular
network

Topical anesthesia or GA

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

larynx

Simple ,non invasive technique

Earlier subclinical stages of disease, Dx of early cancer, tumor margins,

select area for biopsy, assessment of the response to therapy
(radiotherapy/chemotherapy), F/U of cancer pts
 Contact Endoscopy of Larynx

-GA
-Microlaryngoscopy
-Commonly used two endoscopes:
7215 AA,7215 BA Karl Storz
-Surface epithelium and subsurface microvascular
plexus
-Magnification x60 and x150
 Mucosal surface-cleaned by suction or saline swab

Staining-1% methylene blue

Normal & abnormal appearance

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

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

 Special method to visualize vocal fold vibration

-In 1878-Oertel first performed Stroboscopy

-In early to mid 1900-Plateau

-In 1960-Vanden Berg, Rolf Timke (book on
stroboscopic examination of larynx)
Vocal fold vibration is fast(100 cycles/sec)

Ability of retina to process individual

images(5 images/sec)

Synchronized flashing light through rigid

or flexible telescope at a slightly slower
speed illusion of slow vocal fold
vibration

Slow motion view derived from many

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

Parameters – symmetry, amplitude, speed and phase

differences of waves on two cords

Vibrating part of vocal fold sharply defined, & anything

protruding from medial surface observed

Extremely fast vibratory motion gentle waving motion

 Valuable in assessing : functional & anatomical defects
1.Stiffness
2.Scar
3.Submucosal injury
4.Small vocal cord lesions eg. nodule, polyp, cyst
5.Estimating depth of invasion of a tumor & early detection
of glottic cancer
6.Identifying asymmetric mass or tension
7.Determining resumption of voicing activities after
phonosurgery
 Thank You

Thank you