Rigid endoscopies in ent

1. RIGID ESOPHAGOSCOPY,
BRONCHOSCOPY & DIRECT
LARYNGOSCOPY
Dr. Sanjay Maharjan
Resident, ENT_HNS
Manipal teaching hospital
Pokhara.

2. • Adult bronchoscopy, rigid oesophagoscopy and
laryngoscopy for both diagnostic and therapeutic reasons
are generally done under general anaesthesia
• Pan endoscopy is commonly performed to rule out
synchronous primaries with SCC of upper aerodigestive
tract

3. Anaesthesia
• Airway may be maintained in a number of ways:
Nasal or oral endotracheal intubation with a small (6mm ID) tube
Intermittent jet ventilation
Intermittent extubation with endoscopy during apnoeic intervals
Open airway
Spontaneous breathing of anaesthetic gases administered
through suction port of the laryngoscope
Intravenous anaesthesia
Tracheostomy

4. Direct Laryngoscopy
• Indications:
• Diagnostic:
Biopsy of suspected malignancy in larynx & pyriform fossa
Examination of hidden areas of larynx (anterior commissure, laryngeal
ventricle, subglottis, infrahyoid epiglottis, pyriform fossa apex)
Unscucessful IL
• Therapeutic:
Remove FBs
Excision biopsy of benign laryngeal diseases
Dilatation of layngeal stricture

5. • Larger laryngoscopes: to
access endolaryngeal, upper
tracheal and hypopharyngeal
lesions;
• Smaller laryngoscopes: provide
access for difficult exposures
e.g. ant. commissure of larynx,
subglottis & upper trachea
• Light is delivered by a light
source
• Laryngoscope holder

7. • Technique:
• Patient in supine position
• Back of head well supported
on operating table
• Elevate head and flex neck to
allow better exposure and to
reduce pressure oropharyngeal
walls
• Select appropriate
laryngoscope
• Cover upper teeth with a dental
guard

8. • Insert laryngoscope keeping in midline
• Base of tongue, vallecula, epiglottis,
posterior pharyngeal wall and
arytenoids identified
• Keeping ET tube in view posteriorly,
advance tip of scope until vocal cords
come into view
• Fully inspect larynx by moving tip of
scope and moving it with non-dominant
hand placed externally on neck

9. • Inspect post part of larynx by directing tip of
scope behind endotracheal tube
• Subglottis by passing hopkin’s rod via
laryngoscope
• Pathology on laryngeal surface of epiglottis seen
by pressing down on larynx with non-dominant
hand while slowly retracting laryngoscope
• Inspect pyriform fossae and postcricoid regions
of hypopharynx
• Then valleculae and base of tongue
• Biopsy with long blakesley-like forceps

11. • Complications:
• Injury to lip, teeth & tongue
• Glottic trauma may involve vocal cord injury or dislocation of
arytenoid cartilages
• Aspiration of gastric contents, bronchospasm
• Bleeding from mucosal trauma or biopsies settles spontaneously;
only very rarely haemostasis with adrenaline soaked gauze or
cautery required
• Laryngeal edema
• Cervical spinal cord injury
• Tachycardia, arrhythmias, hypertension, and myocardial
ischemia or infarction d/t sympathetic stimulation

12. Rigid esophagoscopy

13. • 25cm rigid scope is usually adequate
• Indications
• Exclude 2nd primaries in SCC of upper aerodigestive tract
• Remove foreign bodies
• Biopsy, dilate or stent tumours
• Determine distal extent of hypopharyngeal and oesophageal
carcinoma
• Dilate strictures
• Exclude traumatic perforations with Penetrating injury of neck
• Inject oesophageal varices

14. • Technique:
• Proximal oesophagus follows
lordosis of C & thoracic spine; bring
both into straight line by elevating
head
• Prominent osteophytes may impair
advancement
• Thumb of non-dominant hand as a
fulcrum to protect teeth
• Keeping in midline advance scope
along PPW

15. • Alternatively, with neck
extended, pass scope via
right corner and floor of
mouth, and follow lateral wall
of right pyriform fossa to its
full depth
• Readjusting scope to midline
engages larynx and elevating
it anteriorly usually exposes
cricopharyngeus

16. • Scope comes to a dead-stop and pharyngeal
lumen disappears as one reaches
cricopharyngeal sphincter
• Ensure that bevel of scope is pointing upward
• Elevate tip of scope against post surface of
cricoid with non-dominant thumb
• Look for oesophageal lumen to appear while
applying steady, firm pressure against
contracted cricopharyngeus
• Slowly advance tip of scope always keeping
lumen in view

17. • Always consider possibility of pharyngeal
pouch (zenker’s diverticulum)
• Long metal sucker to clear esophageal
contents
• Tightly inflated ET tube cuff may compress
esophagus
• Once esophagoscope has been passed all
the way, carefully inspect for pathology &
mucosal trauma while slowly retracting
scope
• Biopsy lesions with long biopsy forceps

18. • Pathology seen at rigid oesophagoscopy recorded as its
distance from upper incisors

19. • Complications of esophagoscopy:
 Mucosal tears/lacerations
 Esophageal perforation
Surgical Emergency
Leakage of esophageal and gastric content into mediastinum rapidly
leads to mediastinitis, sepsis and multiorgan failure
Clinical pointers
Pain in chest, back and neck, odynophagia, dysphagia, tachycardia,
tachypnoea, pyrexia, crepitus and signs of sepsis
MACKLERs triad : vomiting, severe chest pain, subcutaneous
emphysema

20. • Pneumo-mediastinum:
Hamman’s mediastinal
crunch over precordium on
auscultation
• Confirm the diagnosis
Chest X-ray
Gastrograffin swallow

21. • Conservative management:
Promptly diagnosed highly selected perforations
Pre requisite:
Cervical esophagus
Stable patients with no evidence of systemic sepsis
Minimal extra esophageal contamination
Management:
Nil per mouth
Broad spectrum antibiotics
Hemodynamic stabilization and intensive monitoring
Endoscopic insertion of nasogastric tube
Continuous nasogastric tube suction for 1 week

22. • Surgical management:

23. • Cervical perforation:
More easily treated
Primary repair if perforation
clearly visualized and no
distal obstruction OR
Drainage is adequate to
control leak since anatomic
strs of neck confine
extraluminal contamination to
limited space

26. • Thoracic perforation:
• Mid perforation approached
through right thoracotomy @
6th or 7th IC space
• Distal perforation
approached through left
thoracotomy @ 7th or 8th IC
space

28. • Abdominal perforation:
• Laparotomy approach to
repair perforation of intra-
abdominal esophagus

30. • Other methods:
Drainage only:
Only for cervical perforations
perforation site cannot be completely visualized and
when there is no distal obstruction
Diversion:
Indication:
• Patient unstable
• Defect large d/t tissue destruction from
contamination
• Pre-existing esophageal disease

31. • Goals:
• Control and drain extraluminal
contamination
• Divert esophagus proximally
with cervical esophagostomy
• Resection of remaining
esophagus
• Obtain gastric diversion with a
gastrostomy tube and feeding
tube access with a jejunostomy
• Close the diaphragmatic hiatus

33. • Endoscopic stent
placement:
Diagnostic endoscopy
performed to localize
perforation and measure
length of the injury
Covered stent at least 4 cm
longer than injury is used
Debridement and drainage of
extraluminal contamination

35. Rigid Bronchoscopy

36. • Indication:
• Acute airway obstruction due to intraluminal pathology
• Pathology requiring debulking, dilation or stenting
• Removing foreign bodies
• Screening for 2nd primaries
• Massive haemoptysis
• Large endobronchial biopsies
• Ablative surgery i.e. mechanical, laser,electrocautery, cryotherapy
• Stenting airway for obstruction, tracheomalacia,
• tracheoesophageal fistulae
• Balloon tracheobronchoplasty

37. • Technique:
• Advance scope in midline and identify epiglottis
• Lift epiglottis anteriorly with tip of bronchoscope
• Identify posterior laryngeal inlet i.e. arytenoids and posterior vocal
cords
• Tips to simply finding laryngeal inlet include:
Insert a Hopkins rod into scope
Elevate epiglottis with anaesthetist’s laryngoscope
First insert and suspend an operating laryngoscope and pass
bronchoscope through it
Follow endotracheal tube into larynx Passing between vocal cords

38. • Passing between the vocal
cords
• Remove pillow and extend
patient's head
• Rotate bronchoscope clockwise
through 90° keeping longer
edge of bevel to right side
• Advance scope with tip of bevel
directed between vocal cords
and slide shorter edge of bevel
against left vocal cord

39. • Passing along the trachea and
entering main bronchi
• Rotate scope back through 90°
• Advanced it into lower trachea
• Identify the carina
• To enter either bronchial system,
rotate patient’s head towards
contralateral shoulder and advance
scope..

40. Scope in right bronchus Scope in left bronchus

41. • Complication:
• Mechanical:
• Trauma to the teeth, oropharynx, vocal cords or other glottic
structures, laryngospasm, pneumothorax, and hemorrhage,
and death
• Systemic:
• Vasovagal syncope, hypoxemia, hypercarbia, medication
effects of general anesthesia, arrhythmia, post-procedural
respiratory failure, and death.

42. • Management of hemorrhage from airway:
Frequently encountered problem, and usually
abates on its own
Instillation of cooled saline into bronchus and
then clamping bronchus with fiberoptic scope tip
5 ml of thrombin may be instilled (5,000 U
dissolve in saline) or, alternately, 2 ml of 1:1000
epinephrine mixed with normal saline in a 1:10
mixture in order to produce vasoconstriction
Tranexamic acid
Activated factor VII has been instilled into lungs
with successful resolution of bleeding
Large thrombi may be removed by cryotherapy

45. THANK YOU…..