Direct Laryngoscopy

It is direct visualisa tion of larynx and hypopharynx.
Indications
A. Diagnostic
1. When indirect laryngoscopy is not possible as in
infants and young children, and the symptomato logy
points to larynx and/or hypopharynx, e.g. hoarseness,
dyspnoea, stridor and dysphagia.
2. When indirect laryngoscopy has not been successful,
e.g. due to excessive gag reflex or overhanging
epiglo ttis obscuring a part of the complete view of
the larynx.
J. To examine hidden areas of:
Hypo/)har)'nx: Base of tongue, va lleculae and lower
part of pyriform fossa.
Larynx: Infrahyoid epiglottis, anterior commissure,
ventricles and subglottic region .
4. To find the extent of growth and take a bio psy.
B. Therapeutic
1. Removal of benign lesions of larynx, e.g. papilloma,
fibroma, vocal nodule, polyp or cyst.
2. Remova l of foreign bodies from larynx and
hypopharynx.
J. Dilatation of laryngeal stric;tures.
Contra indications
1. Diseases or injuries of cervica l spine.
2. Moderate or marked dyspnoea unless the airway has
been provided by tracheostomy.
J. Recent coronary occlusion or cardiac decompensatio
n.
Anaesthesia
General anaesthesia is preferred though this procedure can
be performed under local anaesthesia. In infants and young
children, no anaesthesia may be required if procedure is for
diagnostic purpose.
Position
Patient lies supine. Head is elevated by 10-15 cm by
placing a pillow under the occiput or by ra ising h ead flap
of the operation table. Neck is flexed on thorax and the
head extended on adamO-OCCipital jo int (Barking-dog
position) .
Procedure
1. A piece of gauze is placed on the upper teeth to protect
them. aga inst trauma.
2. Laryngoscope is lubricated with a little autoclaved
liqu id paraffin.
J. Laryngoscope is held by the handle in the left hand .
Right hand is used, to retract the lips and guide the
laryngoscope and to handle suction and instru ments.
4. Laryngoscope is introduced by one side of the
to ngue which is pushed to the oppos ite side till posterior
third of to ngue is reached. It is then moved to
the midline and lifted forward to bring the epiglo ttis
in view.
5. Laryngoscope is now advanced behind the epiglottis
and lifted forward without levering it on the upper
tee th or jaw (Fig. 87.1). This gi ves good view of the
interior of the larynx.
6. If anterior commissure laryngoscope is being used,
its t ip can be advanced further between the ventricular
bands to examine the ventricles and anterior
commissure . It can be passed between the vocal
cords to examine the subglottic region .
7. Following struc tures are examined seria lly: Base of
tongue, right and left valleculae, epiglottis, (its tip,
lingual and laryngeal surfaces ), right and left pyriform
sinuses, aryepiglottic fo lds, arytenoids, postcricoid
region, both false cord s, anter ior and
posterior commissure, right and left ventricles, right
and left voca l cords and subglottic area. Mobility of
voca l cords sh ould also be observed.
A right-angled te lescope can be used to see the undersurface
of voca l cords and the walls of the subglottis .
After rhe procedure is completed, laryngoscope is withdrawn
and lips and teeth examined for any injury.Post-operative Care
1. Patient is kept in coma position to prevent aspiration
of blood or secretions.
2. Patient's respiration should be watched for any
laryngeal spasm and cyanosis.
3. Trauma to larynx, especially if repeated attempts
at laryngoscopy have been made. It may lead to
laryngeal oedema and respiratory distress.
4. Bleeding may occur from the operative site. Patient
may spit blood. Care should be taken to prevent
aspiration.
Complications
1. [njury to lips and tongue if they are nipped between
the teeth and the laryngoscope .
2. [njury to teeth. They may get dislodged and fall into
pharynx.
3. Bleeding.
4. Laryngeal oedema.