Bronchoscopy

Bronchoscopy is of two types:
1. Rigid .
2. Flexible fibre optic.
RIGID BRONCHOSCOPY
Indications
A. Diagnostic
[ . To find out the cause for wheezing, haemoptysis,
or unexp lained cough persisting for more than
4 weeks.
2. When X- ray chest sho ws:
(a) Atelectasis of a segment, lobe or entire lung
(b) Opacity localised to a segment or lobe of lung
(c) Obstructive emphysema-to exclude foreign body
(d) Hilar or mediastinal shadows
3. Vocal cord palsy.
4. Collection of bronchial secretions for culture and
sensitivi ty tests, acid fas t bacilli, fun gus, malignant
cells.
8. Therapeutic
1. Removal of foreign bod ies.
2. Removal of retained secretions or mucus plug in
cases of head injuries, chest trauma, thoracic or
abdomi nal surge ry, or comatosed patients.
Anaesthesia
General anaesthesia with no endotracheal tube or with
only a small bore catheter is often preferred. It can also
be done under topical surface anaesthes ia.
Position
Same as fordirect laryngoscopy.
Technique
There are two methods to in trod uce bronc hoscope:
1. Direct method. Here bronchoscope is introduced
directly through the glottis.
2. Through laryngoscope. Here glo ttis is first exposed
with the help of a spatular type laryngoscope and
then the bronchoscope is introduced through the
laryngoscope into the trachea. Laryngoscope is then
withdrawn. This me thod is useful in infan ts and
young children, and in ad ults who have short neck
and thick tongue.
Details of Technique
l. A piece of ga uze is placed on the upper teeth for the ir
protect ion aga inst injury.
2. Proper-sized bronchoscope is lu bricated with a swab
of autoclaved liquid paraffin or gelly. It is held by the shaft
in surgeon's right hand in a pen- like fashion. Fingers of
the left hand are used to retract the upper lip and guide
the bronchoscope.
3. Now looking through the scope, tip of epiglottis is
identified first and the scope passed behind it and the
epiglottis lifted forward to expose the glottiS. Now bronchoscope
is rotated 90° clockwise so that its bevelled tip
is in the axis of glottis to ease its entry into the trachea.
Once trachea is entered, scope is rotated back to the original
position.
4. Bronchoscope is grad ually advanced and the entire
tracheobronchial tree examined. Axis of bronchoscope
should be made to correspond with axes of the trachea
and bronchi. To ac hieve this, head and neck are flexed
to the left when examining the right bronchial tree and
vice versa.
Openi ngs of all the segmental bronchi in both the
lungs are examined seriatim.
5. Direct vision, right angled and retrograde telescopes
can be used for magnification and detailed examination.
6. Biopsy of the les ion of susp icious area can be taken.
7. Secretions can be collected for exfoliative cytology,
or bacteriologic examination.
Post-operative Care
1. Keep the patient in humid atmosphere.
2. Watch for respiratory distress. This could be due to
laryngeal spasm or subglottic oedema if the proced ure
had been unduly prolonged or the bronchoscope
introduced repeatedly. Inspiratory stridor and suprasternal
retraction will ind icate need for tracheostomy.
Complications
1. Injury to teeth and li ps.
2. Haemorrhage from the biopsy site.
3. Hypox ia and cardiac arrest.
4. Laryngeal oedema.
Precautions During Bronchoscopy
l. Select proper size of bronchoscope according to
patient's age (see Table A 1).
2. Do not force bronchoscope thro ugh closed glott is.
3. Repeated removal and introduction of bronchoscope
should be avoided.
4. Procedure shou ld not be prolonged beyond 20 minutes
in infants and children, otherwise it may cause
subglottic oedema in pos t-operati ve period.
FLEXIBLE FIBRE OPTIC BRONCHOSCOPY
These days, flexible fibre optic bronchoscopy has
replaced rigid bronchoscopy for diagnostic procedures
particularly in adults. It provides magnification and better
illumination, and because of the smaller size, permits
examination of subsegmental bronchi. It is also easy to
use ll1 patients with neck or jaw abnormalities where rigid
bronchoscopy may almost be impossible technically.
This procedure can be performed under topical anaesthesia
and is very useful for bedside examination of the critically
ill patients. The suction/biopsy channel provided
in the fibrescope helps to remove secretions, inspissated
plugs of mucus or even small foreign bodies. Flexible
bronchoscope can also be easily passed through endotracheal
tube or the tracheostomy opening. However, it has
limited utiltty in children because of the problems of
ventilation.

Oesophagoscopy

Oesophagoscopy is of two types:
1. Rigid oesophagoscopy.
2. Flexible fibre-optic oesophagoscopy.
RIGID OESOPHAGOSCOPY
Indications
A. Diagnostic
1. To inves tigate cause for dysphag ia, e. g. cancer
oesophagus, cardiac achalas ia, strictures, oesophagitis,
diverticula, etc.
2. To find cause for retrosternal burning, e.g. reflux
oesophag itis or hiatus hernia.
3. To find cause for haematemesis, e.g. oesophageal
varices.
4. Secondaries neck with unknown primary (as a pan
of panendoscopy).
B. Therapeutic
1. Remova l of a foreign body.
2. Dilatation in case of oesophageal strictures or card
iac achalas ia.
3. Endoscopic removal of benign lesio ns, e. g. fibrom a,
papilloma, cysts, etc.
4. Insertion of Soutar's or Mou sseau ~B a rb in tube in
palliati ve treatment of oesophageal carcinoma.
5. Injection of oesophageal varices.
Contraindications
l.
2.
Trismus-makes the procedure technically difficult.
Disease of cervical spine, e.g. cervical trauma, spondylosis,
tu be rculous sp ine, osteophytes, kyphos is. They
make rigid oesophagoscopy technically difficult. Flexible
fibre -optic oesophagoscopy is performed in these
cases.
3. Receding mandible.
4. Aneurysm of aorta for fear of rupture and fatal haemorrhage.
5. Advanced heart, liver or kidney disease may be a
relative contraindication.
Anaesthesia
Genenll anaesthesia with oro-tracheal intubation, with
tube in the left corner of the mouth. it can be performed
under local anaesthesia in seleC(ed ind ividuals.
Position
Same as for direct laryngoscopy. Patient lies supine, head
is elevated by 10-15 cm, neck flexed on chest, and head
extended at adanto-occipital jo int. The purpose of this
positio n is to attain the axes of mouth, pharynx and
oesophagus in a straight line to pass the rigid tube easily.
This position can be achieved with the help of an ass istant
or a special head rest.
Technique
1. A piece of gauze is placed over the upper teeth to
protect teeth and lips.
2. Oesophagoscope is lubricated with a swab of autoclaved
liquid paraffin or jelly.
3. The oesophagoscope is held by its proximal end in
a pen-like fashion and introduced into the mouth
by the right side of the tongue and then towards the
midd le of its dorsum.
Now there a re 4 basic steps:
1. Identification of drytenoids. Once oesophagoscope
has been introduced to the back of tongue, it is
advanced gently by the left thumb and index finge r.
Epiglo ttis is first seen , then the endotracheal tube
and a little furth er down arytenoids can be identified.
2. Passing the cricophar)'ngeal sphincter. Keeping the tip
of oesophagoscope stric tly in the midline, behind
the larynx, it is lifted with movements of left thumb
to open the h ypopharynx. With slow but sustained
pressure, the sph incter will open and then the tip of
oesophagoscope can be guided easily into the
oesophag us. Never apply force to open the sphincter.
Sometimes, a fine bougie can be lIsed to find the
lumen. An add itional dose of muscle relaxant may
be required if sphincter does not open. Once oeso~
phagus has been entered, it is easier to advance the
scope, provided, oesophagea l lumen is kept constantly
in view.
3. Crossing the aortic arch and left bronchus. In an adult.
this natural narrowing lies about 25 cm from the
incisors. Aortic pulsa tion can be seen . When cro~sing
this area, head of the patient is slightly lowe red
so that oesophageal lumen is in line with that of the
scope.
4. Passing the cardia. Head and shoulders remain be 10\\'
the level of the table, head being slightly higher
than the shoulders and moved slightly to the right
At this stage, the oesophagoscope points to the lefr
ante rior-superior iliac spine. Cardia is identified b)
its redder and more velvety or rugose mucosa.
Never forget to inspect the oesophageal wall again
when the oesophagoscope is withdrawn.
Post-operative Care
1. Sips of plain water followed by usual diet may be
given in an uneventful oesophagoscopy.
2. Pat ient is watched for pain in the interscapular region,
surgical emphysema of neck, and ahrupt rise of temperatu
re. They indicate oesophageal perfora tion.
Complications
1. Injury to lips and teeth.
2. InJulY to ar)' tenoids.
3. Injur )' to pharyngeal mucosa. They are al l the result of
careless technique and can be avoided.
4. Perforation of oesophagus. Most often it occurs at the
site of Killian's dehiscence (near cricopharyngeal
sphincter) when undue force has been used to l'ass
the oesophagoscope. Surgical emphysema develops
within an hOLlr or so and the patient complains of
pain in the interscapular region. This may be complicated
by abscess in retropharyngeal space or
mediastinum ..
5. Compression of trachea. Oesophagoscope may press on
posterior tracheal wall, especially in child ren, causing
obstruction to respiration and cyanosis. Treatment is
immediate withdrawal of oesophagoscope.
FLEXIBLE FIBRE OPTIC OESOPHAGOSCOPY
Irs main ad va ntage over the rigid oesophagoscopy is
that it is an outdoor procedure , does not require general
anaesthes ia and can be used in patients wi th abnormalities
of spine or jaw where rigid endoscopy is technica
lly difficult. The oesophagus, stomach and duodenum
can all be examined in one sitting. Good illumination
and magni ication provided by the fibrescope helps in
the accurate diagnosis of the mucosa l disease affecting
these sites an.J permits taking of prec ision biopsies,
remova l of small fore ign bodies or benign tumours,
dila tation of webs or strictures and even injection of
bleeding varices with scleroSing agents. In ca 'es of malignant
disease, oesophrtgeal stent can be placed as a palliative
measure.
The procedure is pelfonned under local anaesthesia
with or without intravenous sed ation. The patient lies in
left lateral position and fib r>scope is pas eJ th rough a plastic
mouth prop inro the pharynx, post-cricoid area and
oesophagus, insufflating air as the endoscope is advanced,
to open tl1e lumen of oesophagus. These days flexible fibre
optic oesophagoscopy has practically replaced rigid
oesophagoscopyexc pt in some cases of foreign bodies.

Adenoidectomy

Adenoidectomy may be indicated alone or in combination
with tonsillectomy. In the latter event, adeno ids are
removed first and the nasopharynx packed before sta rting
tonsillectomy.
Indications
1. Adeno id hypertrophy causing snor in g, mouth
breathing, sleep apnoea syndrome or speech abnormaliti
es, i.e. (rhino lalia clausa).
2. Recurrent rhinosinusitis.
3. Chronic secretory otitis media associated with adenoid
hype rplas ia.
4. Recurrent ear discharge in benign CSOM associated
with adeno iditis/adenoid hyperplasia.
5. Dental malocclusion. Adenoidectomy does not correct
dental abnormalities but will prevenr its recurrence
after orthodontic treatment.
Contraindications
1. Cleft palate or submucous palate. Removal of adenoids
causes velopharyngeal insufficiency in such cases.
2. Haemorrhagic diathesis.
3. Acute infection of upper respiratory tract.
Anaesthesia
A lways general, with ora l endocracheal intubation.
Position
Same as for tonsillectomy. Hyperextension of neck should
always be avoided.
Steps of Operation
1. Boyle-Davis mouth-gag is inserted. Before actual
removal of adenoids, nasopharynx should always be
examined by retracting the soft palate with curved
end of the tongue depressor and by digital pa lpation ,
to confirm the diagnos is, to assess the size of adenoids
mass and to push the lateral adeno id mas:es
towards the midline.
2. Proper size of "adenoid curette with guard" is introduced
into the nasopharynx till its free edge touches
the posterior border of nasal septum and is then
pressed backwards to engage the adenoids. At this
level, head shou ld be slightly flexed to avoid injury
to the odontoid process.
3. With gentle sweep ing move ment, adenoids are shaved
off (Fig. 91.1) . Late ral masses are simi larly removed
with smaller curettes; small tags of lymphoid tissue
left behind are removed with punch forceps.4. Haemostasis is achieved by packing the area for
sometime. Persistent bleeders are electrocoagulated
under vision. If bleeding is still not controlled, a
postnasal pack is left for 24 hours.
Endoscopic Adenoidectomy
These days adeno ids can be removed more precisely by
using a debrider under endoscopic concro!.
Post-operative Care
Sdme as in tonsil lectomy. There is no dysphagia and
patient is up and about early.
Complications
l. Haemorrhage, usually seen in immed ia te postoperative
period. Nose and mouth may ' be full of
blood or the only indication may be vomitus of darkcoloured
blood which the patient had been swallowing
gradually in post-operative period. Ri sing pulse
rate is another indicator. Treatment is same as for
per-operat ive haemorrhage. Postnasal pack under
general anaesthesia is often requi red.
2. Injury to eustachian tube opening.
3. Injury to pharyngeal musculature and vertebrae. This is
due to hyperex tension of neck and undue pressure of
curette. Care should be taken when operating patients
of Down's syndrome as 10-20% of them have atlantoaxial
instability.
4. Velophar)lngeal insufficienc)l.
5. Nasopharyngeal stenosis due to scarring.
6. Recurrence. This is due to regrowth of adenoid tissue
left behind.

Tonsillectomy

Indications
They are d ivided inro:
A. Absolute
1. ReculTent infections of throat. This is the most common
indication. Recurrent infections are further defi ned as:
(a) Seven or more episodes in one year, or
(b) Five episodes per year fo r 2 years, or
(c) Three ep isodes per year for 3 years, or
(d) Two weeks or more of lost sch ool or work in one
year.
2. PeritonsiliLlr absces~. In children, tonsillectomy is done
4-6 weeks after abscess has been treated. In adults,
second attack of peri tonsillar abscess forms the
ahsolute indication.
3. Tons ill itis causing febrile se izures.
4. H ypertro phy of tonsils causing
• airway obstruction (s leep apnoea)
• difficul ty in deglutition
• interfe re nce with speech.
5. Suspici.on of malignancy'. A unilaterally enlarged tonsil
may be a lymphoma in c hildren and an epidermoid
carcinoma in adults. An excisional biopsy is done.
B. Relative
1. Diphther ia carriers, who do not respond to antibiotics.
2. Streptococcal carriers , who may be the source of
infection to orhers.
3. Chronic tonsillitis with bad tas te or halitosis which
is unresportS ive to medical treatment.
4. Recurrent streptocccal tonsillitis in a patient with
valvular heart disease.
C. As a Part of Another Operation
1. Palatopharyngoplasty which is done for sleep apnoea
syndrome.
2. Glossopharyngeal neurectomy. Tonsil is removed first
and then IX nerve is severed in the bed of tonsil.
3. Removal of styloid process.
Contraindications
1. Haemoglobin level less than 10 g%
2. Presence of acute infection in upper respira tory
tract, even ac ute tonsillit is. Bleeding is more in the
presence of acute infection.
3. Children under 3 years of age. They are at poor
surgica I risks.
4. Overt or submucous cleft palate.
5. Bleeding disorders, e.g. leukaemia, purp ura, aplastic
anaemia, haemophilia.
6. At the time of epidemic of polio.
7. Uncontrolled systemic disease, e.g. diabetes, cardiac
disease, hypertension or asthma.
S. Tonsillectomy is avoided during the period of menses.
Anaesthesia
Usually done under ge neral anaesthesia with endotracheal
intubatio n. In adu lts, it may be done under loca l
anaest hesia.
Position
Rose's position, i. e. patient lies supine with head
extended by plac ing a pillow under the shoulders. A rubber
ring is placed under the head to stabilise it (Fig. 90.1).
Hyperextension shou ld always be avo ided.
Steps of Operation (Dissection and
Snare Method)
1. Boyle-Davis mouth gag is introduced and opened. It
is held 111 place by Draffin 's bipods or a string over a
pulley (Fig. 90.2).2. Tonsil is grasped with tonsil-holding forceps and
pulled medially.
3. Incision is made in the mucous membrane where it
reflects from the tonsil to anterior pillar. It may be
extended along the upper po le to mucous membrane
between the tonsil and posterior pillar.
4. A blunt curved sc issor may be used to dissect the
tonsil from the peritonsillar tissue and separate its
upper pole.
5. Now the tonsil is held at its upper pole and trac tion
applied downwards and media ll y. Dissection is continued
with tonsillar dissector or scissors until lower
pole is reached (Fig. 90.3).
6. Now wire loop of tonsillar snare is threaded \.wer the
tonsil on to its pedicle, tightened, and the pedicle
cut and the tonsil removed.
7. A gauze sponge is placed in the fossa and pressure
applied for a few minutes.
8. Bleeding points are tied with silk. Procedure is
repeated on the other side.
Post-operative Care
1. Immediate general care
(a) Keep the patient in coma position until fully recovered
from anaesthesia.
(b) Keep a watch on bleeding from the nose and mouth.
(c) Keep check on vital signs, e.g. purse, respiration and
blood pressure.
2. Diet. When patient is fully recovered he is permitted
to take liquids, e.g. cold milk or ice cream. Sucking of ice
cubes gives relief from pain. Diet is gradually built from soft
to solid food. They may take custard, jell y, soft boiled eggs
or slice of bread soaked in milk on the 2nd day. Plenty of flu ids
should be encouraged.
3. Oral hygiene. Patient is given Condy's or salt
water gargles 3-4 times a da y. A mouth wash with plain
water after every feed helps to keep the mouth clean.
4. Analgesics. Pain, locally in the throat and referred
to ear, can be relieved by analgesics like paracetamol. An
analgesic can be given half an hour before meals.
5. Antibiotics. A suitable antibiotic can be· giv en
rally or by injection for a week.Patient is usually sent home 24 hou rs after operation
unless there is some complication. Patient can resume his
normal duties within 2 weeks.
Other methods for tonsillectomy (Table 90.1)
1. Guillotine method Largely abandoned. It can be
done ani y when tonsils are mobile and tonsil bed has not
been scarred by repeated infections.
2. Electrocautery. Both unipo lar and bipolar e lectrocautery
has been used. It reduces blood loss but causes
thermal injurr to tissues.
3. Laser tonsillectomy. !t is indica ted in coagu lat ion disorde
rs. Both KTP-5 I 2 and CO2 lasers have been used but
the former is preferred. Technique is similar to one used in
dissection method.
4. Laser ronsillorom)' , Another method is laser tonsillotomy
which aims to reduce the size of tonsils. It is indicated
in patients who are unable to tolerate general
anaesthesia. Tonsils are reduced by laser ablation up to
ante rior pillars by stage repeated applications.
5. Intmcapsular tonsillectomy. With the use of powered
instruments (debrided tonsil is removed but its capsule is
preserved in the hope to reduce post-operative pain.
6. Harmonic scalpel. It uses ultrasound to cut and coagulate
tissues. It is a cold method with less tissue damage
and post-operative pain compared to electrocautery
t,echnqu e.
7. Plasma-mediated ablation technique. In this ablation
method, protons are energized to break molecular bonds
between tissues. It is a cold method and does not cause
thermal injury.
8. Coblation tonsil/ectom)'.
9. Cr)'osurgical technique. Tonsil is frozen by app lication
of cryoprobe and then allowed to thaw. Two applications,
each of 3-4 minutes, are applied. Tons illar tissue will
undergo necrosis and later fall off leav ing a granulating
surface. Bleeding is less due to thrombosis of vesse ls
caused by freezing.
Complications
A. Immediate
1. Primary haemorrhage. Occurs at the time of operation.
It can be contro lled by pressure, ligation or electrocoagulation
of the bleeding vessels.
2. Reactionary haemorrhage. Occurs within a period of 24
hours and can be controlled by simple measures such as
removal of the clot, application of pressure or vasoconstrictor.
Presence of a clot prevents the clipping action of
the superior constrictor muscle on the vessels which pass
through it (compare post-partum uterine bleeding). If
above measures fail, ligation or electrocoagulation of the
bleeding vessels can be done under general anaesthesia.
3. Injur)' to tonsillar pillars, uvula, soft palate, tongue or
superior constrictor muscle due to bad surgical technique.
4. Injury to teeth.
5. Aspiration of blood.
6. Facial oedema. Some patients get oedema of the face
particularly of the eyelids.
7. Surgical emphysema. Rarely occurs due to injury (()
superior constrictor muscle.
B. Delayed
1. Secondary haemorrhage . Usually seen between the 5rh
to 10th posr-ope rative day. It is the result of sepsis and
premature separation of the membrane. Usually, it is heralded
by bloodstained sputum but may be profuse.
Sim ple measu res like removal of clot, topical application
of dilute adrenaline or hydrogen peroxide with pressure
usually suffice. For profuse bleeding, genera l
anaesthesia is given and bleeding vessel is electrocoaglllated
or ligated. Sometimes, approximation of pillar.with
mattress sutures may be required. Sometimes, external
carotid ligation may also be required.
Transfu sion of blood or plasma, depending on blooJ
loss, is given. Systemic antibiotics are given for control or
infection.
2. Infection. Infection of tonsillar fossa may lead t(
parapharyngeal abscess or otitis med ia.
3. Lung complications. Asp irat ion of blood, mucus ,lr
tissue fragments may cause atelectasis or lung abscess.
4. Scarring in soft palate and pillars.
5. Tonsillar remnants. Tonsil tags or tissue, left due tl
inadequate surgery, may get repeated ly infected.
6. Hypertrophy of lingual tonsil. This is a late complication
and is compensatory to loss of palati ne tonsils.
Sometimes, lymphoid tissue is left in the plica triangu ,
laris near the lower pole of tonsil, which later gets hype rtrophied.
Plica triangularis should, therefore be removed
during tonsillectomy.

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.

Leukoplakia

WHO defined leukoplakia as a clinical
white patch that cannot be characterised clinically or
pathologically as any other disease. It is a clinical definition
and does not take pathology into consideration.
Other white les ions of oral mucosa, i.e. lichen planus,
discoid lupus erythematosus, white spongy nevus and
candid iasus are excluded.
Aetiologic factors include smoking, tobacco chewing,
alcohol abuse particularly, if combined with smoking,
chronic trauma can also occur due to ill-fitting dentures
or cheek bites. It may also be associated with submucous
fibrosis, hyperplastic candidias is or Plummer-Vinson
syndrome.
Sites involved. Buccal mucosa and oral commissures are
the most common sites. It may however involve floor of
mouth, tongue, gingivobuccal sulcus and the mucosal
surface of lip. Buccal mucosa is the most common site in
India.
Age and Sex. Mostly, it is seen in the fourth decade,
males are affected two to three times more often.

Clinical types (a) Homogenous variety presents with a
smooth or wrinkled white patch. It is less often associated
with malignancy; (b) Nodular (speckled) variety
presents as white patches or nodules on erythematous
base; (c) Erosive (erythroleukoplakia) variety where leukoplakia
is interspersed with erythroplakia and has erosions
and fissures. The latter two varieties have higher incidence
of malignant transformation.
Histology. About 25% of leukoplakias may show some
form of epithelial dysplasia from mild to severe. Higher the
grade of dysplasia more are the chances of its going into
malignant change.
Malignant potential. The chances of leukoplakia
becoming malignant are cited from 1 to 17,5%. On an
average about 5% become malignant, Malignant potential
varies according to the site and type of leukoplakia,
and the duration of follow up.
Management
1, Many of the lesions will disappear spontaneously if
causative agent is removed.
2. In lesions with higher potential for malignant
change, a biopsy is taken to rule out malignancy.
3. In suspicious small lesions, surgical excision or ablation
with laser or cryotherapy can be done.

Acute Pharyngitis

Aetiology
Acute pharyngitis is very common and occurs due to varied
aetiological factors like viral, bacterial, fungal or others
Viral causes are more common. Acute
streptococcal pharyngitis (due to Group A beta haemolytic
streptococci) has received more importance because of its
aetiology in rheumatic fever and post-streptococcal
glomerulonephritis.
Clinical Features
Pharyngitis may occur in different grades of sever ity.
Milder infections present with discomfort in the throat,
some malaise and low grade fever. Pharynx in these cases
is congested but there is no lymphadenopathy. Moderate
and severe infections present with pain in throat, dysphagia,
headache, malaise and high fever. Pharynx in these
cases shows erythema, exudate and enlargement of to nsi
ls and lympho id follicles on the posterior pharyngea l
walL Ver), severe cases show oedema of soft palate and
uvula with enlargement of cervical nodes.
It is not possible, on clinical examination, to differentiate
viral from bacterial infections but, viral infections are
generally mild and are accompanied by rhinorrhea and
hoarseness while the bacterial ones are severe. Gonococcal
pharyngitis is mild and may even be asymptomatic.
Diagnosis
Culture of throat swab is helpful in the diagnosis of
bacterial pharyngitis. It can detect 90% of Group A
Streptococci. Diphtheria is cultured on special media. Swab
from a suspected case of gonococcal pharyngitis should be
cultured immediately without delay. Failure to get any
bacterial growth suggests a viral ae tiology.

Treatment:

General measures. Bed rest, plenty of fluids, warm
sa line gargles or pharyngea l irrigations and analgesics
form the mainstay of tre atment.
Loca l discomfort in the throat in severe cases can be
relieved by lignocaine v iscous before meals to facilitate
swa llowing.
Specific treatment. Streptococcal pharyngitis (Group
A, be ta-haemo lyticus) is treated with penic illin G,
200,000 to 250,000 units orally four times a day for 10
days or benzathine penic ill in G, 600,000 units once i.m.
for patient <601b in weight and 1.2 million units once
i.m. for patient >60 lb. In penicillin-sensitive individuals,
erythromycin, 20 to 40 mg/kg body weight daily, in divided
oral doses for 10 days is equa lly effec ti ve .
Diphtheria is treated by diphthe ria antitoxin and
administration of pen icillin or erythromycin
Gonococcal pharyngitis responds to conven tional
doses of penicillin or tetracycline.

Pharyngoconjunctival fever. It is caused hy an adenovirus,
and is characterised by sore throat, fe ver and conjunc
ti vitis. There may be pain in abdomen, mimicking
appendicitis.
Acute lymphonodular pharyngitis. It is usually caused by
a coxsackie virus and characterised by fever, malaise and
sore th roat. White-yellow, solid nodules appear on the
posterior pha ryngeal wall in this type of pharyngitis.
Measles and chickenpox also cause pharyngitis. Measles is
characterised by the appearance of Koplik's spots (white
Spots surrounded by red areola) on the buccal mucosa
opposi te the molar tee th . The spots appear 3-4 days before
the appearance of rash .
Fungal Pharyngitis
Candida infection of the oropharynx can occur as an
extension of oral thrush. It is seen in pa tients who are
immunosuppressed, debilitated or taking high doses of
antimicrobials. Often patient complains of pain in the
throat with dysphagia. Nystatin is the drug of choice.
Miscellaneous Causes of Pharyngitis
Chlamydia trachomatis infection causes acute pharyngitis
and can be treated by erythromycin or sulphonamides.
Toxoplasmosis is caused by Toxoplasma gondii, an obligate
intracellular parasite. This infection is very rare.

Tonsil Anatomy

Palatine tonsils a re two in number. Each tonsil is an
ovoid mass of lymphoid tissue situated in the lateral wall
of oropharynx between the anterior and posterior pillars.
Actual size of the tonsil is bigger than the one that appears
from its surface as parts of tonsil extend upwards into
the soft palate , downwards into the base of tongue and
anteriorly into palatoglossal arch. A tonsil presents two
surfaces-a medial and a lateral, and two poles- an upper
and a lower.
Medial surface of the tonsil is covered by nonkeratinising
stratified squamous epithelium which dips
into the substance of tonsil in the form of crypts. Openings
of 12-15 crypts can be seen on the medial surface of the
tonsil. One of the crypts, situated near the upper part
of tonsil is very large and deep and is called crypta magna
or intratonsillar cleft. It represents the ventral
part of second pharyngeal pouch. From the main crypts
arise the secondary crypts, within the substance of tons il.
Crypts may be filled wi th cheesy material consisting of
epithelial cells, bacteria and food debris which can be
expressed by pressure over the anterior pillar.
Lateral surface of the tonsil presents a well -defin ed
fibrous capsule. Between the capsul e and the bed of tonsil
is the loose areolar tissue which makes it easy to d issect
the tonsil in the plane during tonSillectomy. It is also
the site for cullection of pus in peritonsillar abscess.
Some fibres of palatoglossus and pa latopharyngeus muscles
are a ttac hed to the capsule of the tonsil.
Upper pole of the tonsil extends into soft palate. Its
medial surface is covered by a semilunar fold, extending
be tween anterior and pos terior pillars and enclosing a
po tential space called supratonsillar fossa.
Lower pole of the tonsil is attached to the tongue. A
triangular fold of mucous membrane extends from anterior
pillar to the an te roinfe rior part of tonsil and encloses a
space called anterior tonsillar space. The tonsil is separated
from the tongue by a sulcus called tonsillolingual sulcus
which may be the seat of carcinoma.
Bed of the tonsil. It is formed by the superior constrictor
and styloglossus muscles. The glossopharyngeal nerve
and styloid process , if enlarged, may lie in relat ion to the
lower part of tonsillar fossa. Both these structures can be
surgically approached through the tonsil bed after tonsillectomy.
Outs ide the superior constrictor, tonsil is related
to the facial artery, submand ibular salivary gland, posterior
belly of digastric muscle, medial pterygoid muscle and the
angle of mandi ble.
Blood Supply
The tonsil is supplied by five arteries.
l. Tonsillar branch of fac ial artery. This is the main
artery.
2. Ascending pharyngeal artery from ex ternal caro tid.
3. Ascending palatine, a branch of fac ial artery.
4. Dorsal linguae branches of lingual artery.
5. Descending palatine branch of maxillary artery.
Venous Drainage
Veins from the tonsils drain into paratonsilbr ve in
which joins the common facial vein and pharyngeal
ve nous plexus.
Lymphatic Drainage
Lymphatics from the tonsil pierce the superior constrictor
and drain into upper deep cervical nodes particularly
rhe jugulodigastric (tonsillar) node si ruated below rhe
angle of mandible.
Nerve Supply
Lesse r palatine branches of sphenopalatine ganglion
(CN V) and glossopharyngeal nerve provide sensory
nerve supply.
Functions of Tonsils
Like other lymphoid masses of Waldeyer's ring, palatine
tonsi ls have a protective role and act as sentinels at the
portal of air and food passage. The crypts in tonsils increase
the surface area for contact with foreign substances.
Tonsils are larger in childhood and gradually diminish
near puberty. They are removed when they themselves
become the seat of disease.

Dysphagia

Dysphagia is difficulty in swa llowing. The term odynophagia
is used when swallowing causes pain. The
latter is more marked in ulcerative and inflammatory
lesions of food passages-oral cavi ty, oropharyn x and
oesophagus.
Aetiology
The ca use of dysphagia may be pre-oesophageal (i.e. due to
disturbance in the oral or pharyngeal phase of deglutition),
or oesophar;eal (when disturbance is in oesophageal
phase). This class ification is clinica lly useful as most of
the pre-oesophageal causes can be easily excluded by
phys ical examination while oesophageal ones require
in vestigation.
Pre-oesophageal Causes
(a) Oral phase. Normally, food must be masticated,
lubricated with saliva, converted into a bolus by movements
of tongue and then pushed into the pharynx by
elevation of the tongue against the hard palate. Any disturbance
in these events will cause dysphagia. Thus
cause may be:
(i) Disturbance in mastication: trismus, fractures of
mandible, tumours of the upper o r lower Jaw, disorders
of temporomandibular joints.
(ii) Disturbance in lubrication: xerostomia following radiotherapy,
M iku licz disease.
(iii) Disturbance in mobility, of tongue: paralysis of tongue,
painful ulcers, tumours of tongue, lingual abscess,
total glossectomy.
(i v) Defects of palate: cleft palate, oronasal fistula.
(v) Lesions of buccal cavity and floor of mouth: stomatitis,
ulcera tive les ions, Ludwig's angina.
(b) Pharyngeal phase. For a normal swallow, food
should enter the pharynx and then be directed towards
oesophageal opening. All unwanted communications
into the nasopharynx, larynx, oral cavity sh ould be
closed. Disturbances in this phase can arise from:
(i) Obstructive lesions of pharynx, e.g. tumours of
tonsil, soft palate, pharynx, base of tongue , supraglottic
larynx, or even obstruc tive hypertrophic
tonsils.
(i i) Inflammatory coruiitions , e.g. acute tonSillitis, peritonsillar
abscess, retro or para-pharyngea l abscess, acute
epiglottitis, oedema larynx.
(iii) Spasmodic conditions, e.g. tetanus, rabies.
(iv) Paralytic conditions. Paralysis of soft palate due to
diphtheria, bulbar palsy, cerebrovascular accidents.
They cause regurgitation into the nose.
Paralys is of larynx-lesions of vagus and bilateral
superior laryngea I nerves cause asp ira tion of food into
the larynx.
Oesophageal Causes
The lesions may lie in the lumen, on the wall or outside
the wall of oesophagus.
(a) Lumen. Obstruction to lumen can occur in atresia,
foreign body, strictures, benign or malignant tumours.
(b) Wall. It can be acute or chronic oesophagitis, or
motility disorde rs. The latter a re:
( i) Hypomotility disorders, e.g. achalasia, scleroderma,
amyo trophic lateral sclerosis.
(i i) Hypermotility disorders, e.g. cricopharyngeal
spasm, diffuse oesophageal spasm.
(c) Outside the wall. The lesions ~ause obstruction by
pressing on the oesophagus from outside:
(i) Hypopharyngeal diverticulum (see page 255).
(ii) H ia tus hernia.
(iii) Cervical osteophytes.
(iv) Thyroid les ions, e.g. en largement, tumours,
Hash imoto's thyroidi t is.
(v) Mediastinal lesions, e.g. tumours of mediastinum,
lymph node enlargement, ao rtic aneurysm, cardiac
enlargement.
(vi) Vascular rings (dysphagia lusoria).
Investigations
1. History. A detailed history is of paramount importa
nce. Ascertain, if dysphagia is of:
(i) Sudden onset (foreign body or impaction of food on
a preexisting stricture or malignancy, neurological
disorders),
(ii) Progressive (malignancy),
(iii) Intermittent (spasms or spasmodic episodes over an
organic les ion),
(iv) More to liquids (paralytic lesions),
(v) More to solids and progressing even to liquids
(malignancy or stricture),
(vi) Intolerance to acid food or fruit juices (ulcerative
lesions).
N ote any associated symptoms, e.g. regurgitation and
hea rt burn (hi atus hernia); regurgi tat ion of undigested
food while lying down, with cough at night (hypopharyngeal
diverticulum); asp iration into lungs (la ryngeal
paralysis); aspi ra tion into the nose (palatal pa ral ys is).
2. Clinical examination. Examination of oral cavity,
oropharynx, and larynx and hypopharynx can exclude
most of the pre-oesophageal causes of dysphagia.
Examination of the neck, chest and nervous system,
including cranial nerves should also be undertaken.
3. Blood examination. Haemogram is important in the
diagnosis and treatment of Plummer-Vinson syndrome
and to know the nutritional status of the patient.
4. Radiography
(a) X-ra)' chest: To exclude cardiovascular, pulmonary
and mediastinal diseases.
(b) Lateral view neck: To exclude cervical osteophytes
and any soft tissue les ions of post-cricoid or
retropharyngeal space.
(c) Barium swallow: It is useful in the diagnosis of malignancy,
cardiac achalas ia, strictures, diverticula; hiatus
hernia or oesophageal spasms. Combined with
fluoroscop ic control or cineradiography, it can help
in the diagnosis of motility disorders of oesophageal
wall or sphincters.
5. Manometric and pH studies. A pressure transducer
along with a pH electrode and an open-tipped catheter is
introduced into the oesophagus to measure the pressures
in the oesophagus and at its sphincters. Acid reflux into
the oesophagus is measured by pH electrode. It also
measures the effectiveness of oesophagus to clear the .ac id
load after acid solution is put in the oesophagus. These
studies help in motility disorders, gastro-oesophageal
reflux and to find whether oesophageal spasms are spontaneous
or acid-induced.
6. Oesophagoscopy. It gives direct examination of
oesophageal mucosa and permits biopsy specimens.
Flexible fibre-optic or rigid scopes can be used.
7. Other investigations. Bronchoscopy (for bronchial
carc inoma), cardiac catheterisation (for vascular anomalies),
thyroid scan (for malignant thyroid) may be required,
depending on the case.

Cardiac Achalasia

It is characterised by the absence of peristalsis in the body
of oesophagus and high resting pressure in lower
oesophageal sphincter; the latter also does not relax during
swallowing.
The symptoms of cardiac achalasia include dysphagia,
which is more to liquids than solids (reverse of that seen
in malignancy or strictures) and regurgitation of swallowed
food particularly at night.
The diagnosis is made by: (a) radiography (barium
swallow shows dilated oesophagus with narrowed rat tail
Lower end), sumetimes also called bird-beak appearance;
(b) manometric studies (low pressure in the body of
oesophagus and high pressure at lower sphincter and failure
of the sphincter to relax); (c) endoscopy (to exclude
benign stricture or any development of carcinoma which
is a common complication of this disorder.
The treatment of choice is the modified Heller's operation
(myotomy of the narrowed lower portion of the
oesophagus). Forceful pneumatic dilatation of the lower
oesophagus can be done in those unfit for surgery.

Gastro-oesophageal Reflux

It is due to decreased function of lower oesophageal
sphincter thus permitting regurgitation of gastric contents
into oesophagus. Other causes of gastro-oesophageal
reflux are pregnancy, hiatus hernia, scleroderma, excessive
use of tobacco and alcohol, and drugs that relax the
smooth muscle (anticholinergic, beta-adrenergic drugs
and calcium-channel blockers).
The symptoms of oesophageal reflux include substernal
pain, heartburn, and regurgitation.
The treatment consists of:
(a) Elevation of the head of bed at night.
(b) Avoiding food at least 3 hours before bed time.
(c) Antacids.
(d) Drugs that increase tone of lower oesophageal
sphincter, e.g. metoclopramide.
(e) H2 receptor antagonists, e.g. cimetidine and ranitidine.
(f) Avoiding smoking, alcohol, caffeine, chocolates,
mints and carbonated drinks.
(g) Antircflux surgery, e.g. Nissen's fundoplication.
Complications 01 Gastro-oesophageal
Reflux
I. Oe ophagus
• Oesophagi tis, oesophageal mucosal erosion and
haemorrhage
• Benign oesophageal stricture
• Barrett's oesophagus (normal squamous epithelium
of oesophagus is replaced by columnar
epithelium as a result of continuous inflammation).
It is a precancerous condition
II. Lung
• A piration pneumonia
• Asthma
• Bronchiectasis
III. Larynx
• Posterior laryngitis causing vague pain in throat,
hoarse ness and repeated throat clearing
• Pachyde rmia laryngis
• Contact ulcers and granulomas
• Posterior glottic stenosis
• Paroxysmal laryngospasm
• Carcinoma larynx
IV. Miscellaneous
• Globus hystencus

HIATUS HERNIA

It is displacement of stomach into the chest thtough
oesophageal opening of the diaphragm. Most patients are
elderly, past 40 years. This disorder is of two types:
(a) Sliding. Stomach is pushed into the thorax, in line
with the oesophagus. Reflux oesophagitis is common
and may ·give rise to ulceration and stenosis.
Haematemesis may occur. It is caused by raised
intra-abdom inal pressure.
(b) Paraoesophageal. A part of the stomach along with
its peritoneal covering passes up into the thorax by
the side of oesophagus. The gastro-oesophageal
junc tion still remains below the diaphragm and the
angle between oesophagus and stomach is maintained.
There is no reflux oesophagitis in this type of
hernia. The main symptom is dyspnoea on exertion
due to position of stomach in the thorax, and sometimes
bleeding.
Diagnosis of both types of hiatus hernia can be made
by barium swallow.
Treatment
Mainly it is surgical; the hernia is reduced and diaphragmatic
opening repaired. Early cases and those unfit for
surgery may be treated conservatively to reduce reflux
oesophagitis by measures such as ( i) sleeping with head
and chest raised; (ii) avoidance of smoking; (iii) use of
drugs that reduce acidity (antacids and cimetidine); (iv)
reduction of obesity; and (v) attention to the causes
which raises intra-abdominal pressure.

Physiology of Swallowing Or Deglutition

The act of swallowing is divided into three phases:
(a) Oral or buccal
(b) Pharyngeal
(c) Oesophageal
(a) Oral or buccal phase. The food which is placed in
the mouth is chewed, lubricated with saliva, converted
into a bolus and then propelled into the pharynx
by elevation of the tongue against the palate.
(b) Pharyngeal phase. It is initiated when the bolus of
food comes into contact with pharyngeal mucosa. A
series of reflex actions take place carrying the food
past oro- and laryngopharynx into the oesophagus.
The communications into nasopharynx, oral cavity
and larynx are cut off.
(i) Closure of nasopharynx: Soft palate contracts
against the Passavant's ridge on the posterior
pharyngeal wall and completely cuts off the
nasopharynx from oropharynx.
(ii) Closure of oropharyngeal isthmus: The entry of
food back into oral cavity is prevented by contraction
of tongue against the palate and
sphincteric action of palatoglossal muscles.
(iii) Closure of larynx: Aspiration into the larynx is
prevented by temporary cessation of respiration,
closure of laryngeal inlet by contraction of
aryepiglottic folds, closure of false and true
cords, and rising of larynx under the base of
tongue. The role of epiglottis in providing protection
to larynx is not clear but it is seen to
ueflect backwards when food passes into the
pyriform fossae.
(iv) Contraction of pharyngeal muscles and relaxation
of cricopharyngeus: Relaxation of cricopharyngeus
muscles is so timed and synchronous that
food passes from pharynx into the oesophagus
during contraction of pharyngeal muscles.
(c) Oesophageal phase. After food enters the oesophagus
, the cricopharyngeal sphincter closes and the
perista ltic movements of oesophagus takes the bolus
down the stomach. Gastro-oesophageal sphincter at
the lower end of oesophagus relaxes well before peristaltic
wave reaches and permits fluids to pass. Bolus
oUood is passed by contraction of peristaltic waves
and then the sphincter closes.
Regurgitation of food back into oesophagus is prevented
by (i) tone of gastro-oesophageal sphincter, (iil
negative intrathoracic pressure, (iii) pinch-cock effect of
diaphragm, (iv) mucosal folds, (v) oesophagogastric angle,
and (vi) slight pos itive intra-abdominal pressure.

Oesophagus Anatomy

It is a fibromuscular tube, about 25 cm long in an adult. It
extends from the lower end of pharynx (C6) to the cardiac
end of stomach (T11)

It shows three normal constrictions and it is important to know
their location at oesophagoscopy. They are:
1. At pharyngo-oesophageal junction (C6 )-15 cm
from the upper incisors.
2. At crossing of arch of aorta and left main bronchus
(T 4)-25 cm fronl upper incisors.
3. Where it pierces the diaphragm (T 10)-40 cm from
upper incisors.
Foreign bodies in the oesophagus can be held up at
these constrictions.
The wall of oesophagus consists of four layers. From
within outwards, they are:
(a) Mucosa, which is lined by stratified squamous
epithelium.
(b) Submucosa, which connects mucosa to muscular layer.
(c) Muscular layer, which has inner circular and outer
longitudinal fibres. Circular fibres at the lower end
are thickened to form a cardiac sphincter. The upper
third of oesophagus has striated, the lower third
smooth, and the middle third both striated and
smooth muscle fibres.
(d) Fibrous layer, which forms loose covering of
oesophagus.
Nerve Supply
Parasympathetic fibres come from vagus nerves (X) and
sympathetic fibres from the sympathetic trunk.
Lymphatic Drainage
The cervical, thoracic and abdominal parts drain respectively
into deep cervical, posterior mediastinal and gastric
nodes.

Management Of Foreign Body In Respiratory Tract

Nature of Foreign Bodies
(a) Non-irritating type. Plastic, glass or metallic foreign
bodies are re latively non-irritating and may remain
symptomless for a long time.
(b) Irritating type. Vegetables or foteign bodies like
peanuts, beans, seeds, etc. set up a diffuse violent
reaction leading to congestion and oedema of the
tracheobronchi al mucosa-"vegetal bronchitis".
They also swell up with time causing ai rway obstruction
and later suppurat ion in the lung.
Clinical Features
Symptomatology of foreign body is divided into 3 stages:
1. Initial period of choking, gagging and wheezing.
This las ts for a short time. Foreign body may be coughed
out or it may lodge in the larynx or further down in the
tracheobronchial tree .
2. Symptomless interval. T he respiratory mucosa
adap ts to the presence of foreign body and initial symptoms
disappear. Symptomless interval will vary with the
size and nature of the foreign body ..
3. Later symptoms. They are caused by obstruction
to the airway, inflammation or trauma induced by the foreign
body and would depend on the site of its lodgement.
(a) Laryngeal foreign body A large foreign body may
totally obstruct the airway lead ing to sudden death
unless resuscitative measures are taken urgently. A
partially obstructive foreign body will cause discomfort
or pain in the throat, hoarseness of voice,
croupy cough, aphonia, dyspnoea, wheezing and
haemoptysis.

(b) Tracheal foreign body. A sharp foreign body will only
produce cough and haemoptysis. A loose foreign body
like seed may move up and down the trachea between
the carina and the undersurface of vocal cords causing
"audible slap" and "palpatory thud". Asthmatoid
wheeze may also be present. It is best heard at patient's
open mouth
(c) Bronchial foreign body. Most foreign bodies enter the
right bronchus because it is wider and more in line
with the tracheal lumen. A foreign body may totally
obstruct a lobar or segmental bronchus causing atelectasis
or it may ptoduce a check valve obstructionallowing
only ingress of air but, not egress, lead ing to
obstructive emphysema. For pathogenesis and clinical
picture of bronchial foreign body (see Fig. 63.2).
Emphysematous bulla may ruptu re causing spontaneous
pneumothorax. A foreign body may also shift from
one side to the other caUSing change in the physical
signs. A retained foreign body in the lung may la ter give
rise to pneumonitis, bronchiectasis or lung abscess.
Diagnosis
It can be made by detailed history of the foreign body
"ingestion", physical examinat ion of the neck and
chest and radiographs. X-rays of the following areas are
advised:
1. Soft tissue posteroanterior and lateral view of the
neck in its extended pOSition. T his can show radioopaque
and sometimes even the rad io lucent foreign
bodies in the larynx and trachea
2. Posteroanterior and lateral view of the chest.

3. X-ray chest at the end of inspiration and expiration .
Atelectasis and obstructive emphysema can be seen.
They also give indirect evidence of radiolucent
foreign bodies.
4. Fluoroscopy / videofluoroscopy. Evaluation during
inspiration and expiration can be made.
5. Bronchograms. To delineate radiolucent foreign bodies
or to evalu ate bronchiectasis.

Laryngeal foreign body. A large bolus of food
obstructed above the cords may make the patient totally
aphonic, unable to cry for help. He may die of asphyxia
unless immediate first aid measures are taken. The measures
consist of pounding on the back, turning the patient
upside down and foll owing Heimlich manoeuvre. These
measures should not be done if patient is only partially
obstructed, for fear of causing total obstruction.
Heimlich's manoeuvre. Stand behind the person, and
place your arms around his lower chest and give four
abdominal thrusts. The res idual air in the lungs may dislodge
the foreign body providing some airway.
Cricothyrotomy or emergency tracheostomy should
be done if Heimlich's manoeuvre fails. Once acute respiratory
emergency is over, foreign body can be removed
by direct laryngoscopy or by laryngofissure, if found
impacted.
Tracheal and bronchial foreign bodies can be removed
by bronchoscopy with full preparation and under general
anaesthesia. Emergency removal of these foreign bodies is
not indicated unless there is airway obstruction or they are
of the vegetable nature (e.g. seeds) and likely to swell up.
Methods to remove tracheobronchial foreign body:
1. Conventional rigid bronchoscopy.
2. Rigid bronchoscopy with telescopic aid.
3. Bronchoscopy with C-arm fluoroscopy.
4. Use of Dormia basket or Fogarty's balloon for rounded
objects.
5. Tracheostomy first and then bronchoscopy through
the tracheostome.
6. Thoracotomy and bronchotomy for peripheral foreign
bodies.
7. Flexible fibre optic bronchoscopy in selected adult
patients.

Tracheostomy

Indications for tracheostomy
A. Respiratory obstruction
1 . Infections
- Acute laryngo-tracheo -bronchitis, acute epiglottitis,
diphtheria
- Ludwig's angina, peritonsillar, retropharyngeal or
parapharyngeal abscess, tongue abscess
2. Trauma
- External injury of larynx and trachea
- Trauma due to endoscopies, especially in infants
and children
- Fractures of mandible or maxillofacial injuries
3. Neoplasms
- Benign and malignant neoplasms of larynx,
pharynx, upper- trachea , tongue and thyroid
4. Foreign body larynx
5. Oedema larynx due to steam, irritant fumes or gases,
allergy (angioneurotic or drug sensitivity), radiation
6. Bilateral abductor paralysis
7, Congenital anomalies
- Laryngeal web, cysts, tracheo -oesophageal fistula
- Bi lateral choanal atresia
B. Retained secretions
1. Inability to cough
- Coma of any cause, e.g. head in juries, cerebrovascular
accidents, narcotic overdose
- Paralysis of respiratory muscles, e.g. spinal injuries,
polio, Guillain- Barre syndrome, myasthenia gravis
- Spasm of respiratory muscles, tetanus, eclampsia,
strychnine poisoning
2. Painful cough
- Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
- Bulbar polio, polyneuritis, bilateral laryngeal
paralysis
C. Respiratory insufficiency
- Chronic lung conditions, viz. emphysema, chronic
bronchitis, bronchiectasis, atelectasis

Types of Tracheostomy
1. Emergency tracheostomy. It is employed when airway
obstruction is complete or almost complete and there

is an urgent need to establish the airway. Intubation or
laryngotomy are either not possible or feasible in such cases.
2. Elective tracheostomy (syn. tranquil, orderly or
routine tracheostomy ). This is a planned, unhurried
procedure. Almost all operative surgical facilities are
available, endotracheal tube can be put and local or general
anaesthesia can be given. It is of two types:
(a) Therapeutic: to relieve respiratory obstruction,
remove tracheobronchial secretions or give assisted
ventilation.

(b) Prophylactic, to guard against anticipated respiratory
obstruction or aspiration of blood or pharyngeal
secretions such as in extensive surgery of tongue,
floor of mouth, mandibular resection or laryngofissure.
Elective tracheostomy is often temporary and is closed
when indication is over.
3. Permanent tracheostomy. This may be required
for cases of bilateral abductor paralysis or laryngeal stenosis.
In laryngectomy or laryngopharyngectomy, lower trachea!
stump is brought to surface and stitched to the skin.

Tracheostomy has also been divided into high, mid or
low. A high tracheostomy is done above the level of thyroid
isthmus ( isthmus lies against Il, III and IV tracheal
rings). It violates the 1st ring of trachea. Tracheostomy at
this site can cause perichondritis of the cricoid cartilage
and subglottic stenos is and is always avoided. Only indication
for high tracheostomy is carcinoma of larynx because
in such cases, total larynx anyway would ultimately be
removed and a fresh tracheostome made in a clean area
lower down. A mid tracheostomy is the preferred one and
is done through the 11 or III rings and would entail division
of the thyroid isthmus or its retraction upwards or
downwards to expose this part of trachea. A low tracheostomy
is done below the level of isthmus. Trachea is
deep at this level and close to several large vessels; also
there are difficulties with tracheostomy tube which
impinges on suprasternal notch.
Technique
Whenever possible, endotracheal intubation should be
done before tracheostomy. This is specially important in
infants and children.
Position. Patient lies supine with a pillow under the
shoulders so that neck is extended. This brings the trachea
forward.
Anaesthesia. No anaesthesia is required in unconscious
patients or when it is an emergency procedure. In
conscious patients, 1-2% lignocaine with epinephrine is
infiltrated in the line of incision and the area of dissect ion.
Sometimes, general anaesthesia with intubation is used.
Steps of Operation
1. A vertical incision is made in the midline of neck,
extending from cricoid cartilage to just above the
sternal notch. This is the most favoured incision
and can be used in eme rgency and elective procedures.
It gives rapid access with minimum of bleeding
and tissue dissection. A transverse incision , 5 cm
long, made 2 fingers ' breadth above the sternal notch
can be used in elective procedures. It has the advantage
of a cosmetically better scar (Fig. 62.1) .
2. After incision, tissues are dissected in the midline.
Dilated veins are either displaced or ligated .
3. Strap muscles are separated in the midline and
retracted laterally.

4. Thyroid isthmus is displaced upwards or divided
between the clamps, and suture- ligated.
5. A few drops of 4% lignocaine are injected into the
trachea to suppress the cough when trachea is
incised.
6. Trachea is fixed with a hook and opened with a vertical
incision in the region of 3rd and 4th or 3rd and
2nd rings. This is then converted into a circular
opening. The first tracheal ring is never divided as
perichondritis of crico id cartilage with stenosis can
result.
7. Tracheostomy tube of appropriate size is inserted
and secured by tapes .
8. Skin incision should not be sutured or packed
tightly as it may lead to development of subcutaneous
emphysema.

Complications
A. Immediate (at the time of operation):
1. Haemorrhage.
2. Apnoea. This follows opening of trachea in a
patient who had prolonged respiratory obstruction.
This is due to sudden washing out of CO2 which
was acting as a respiratory stimulus. Treatment is to
administer 5% CO2 in oxygen or ass isted ventilation.
3. Pneumothorax due to injury to apical pleura.
4. Injury to recurrent laryngeal nerves.
5. Aspiration of blood.
6. Injury to oesophagus. This can occur with tip of
knife while incising the trachea and may result in
tracheo-oesophageal fistu lao
B. Intermediate (during first few hours or days):
1. Bleeding, reactionary or secondary.
2. Displacement of tube.
3. Blocking of tube.
4. Subcutaneous emphysema.
5. Tracheitis and tracheobronchitis with crusting in
trachea.
6. Atelectas is and lung abscess.
7. Local wound infection and granulat ions.
C. Late (with prolonged use of tube for weeks and
months):
1. Haemorrhage, due to erosion of major vessel.
2. Laryngeal stenosis, due to perichondritis of cricoid
cartilage.
3. Tracheal stenosis, due to tracheal ulceration and
infection.
4. Tracheo-oesophageal fistula, due to prolonged use of
cuffed tube or erosion of trachea by the tip of tracheostomytube.
5. Problems of decannulation. Seen commonly in
infants and children.
6. Persistent tracheocutaneous fistula.
7. Problems of tracheostomy scar. Keloid or unsightly
scar.
8. Corrosion of tracheostomy tube and aspiration of its
fragments into the tracheobronchial tree.

Dysphonia Plica Ventricularis (Ventricular Dysphonia)

Here voice is produced by ventricular folds (false cords)
which have taken over the function of true cords. Voice
is rough, low-pitched and unpleasant. Ventricular voice
may be secondary to impaired function of the true cord
such as paralysiS, fixation, surgical excision, or tumours.
Ventricular bands in these situations try to compensate
or assume phonatory function of true cords.
Functional type of ventricular dysphonia occurs in
normal larynx . Here cause is psychogenic. In this type,
voice begins normally but soon becomes rough when
false cords usurp the function of true cords. Diagnosis is
made on indirect laryngoscopy; the false cords are seen to
approximate partially or completely and obscure the
view of true cords on phonation. Ventricular dysphonia
secondary to laryngeal disorders is difficult to treat but
the function al type can be helped through voice therapy
and psychological counselling.

Hoarseness: Causes, Investigations, Differential Diagnosis

Hoarseness is defined as roughness of voice resulting
from variations of periodicity and/or intensity of consecutive
sound waves.
For production of normal voice, vocal cords should:
1. Be able to approximate properly with each other.
2. Have a proper size and stiffness.
3. Have an ability to vibrate regularly in response to air
column.
Any condition that interferes with the above functions
causes hoarseness.
(a) Loss of approximation may be seen in vocal cord paralysis
or fixation or a tumour coming in between the
vocal cords.
(b) Size of the cord may increase in oedema of the cord
or a tumour; there is a decrease in partial surgical
excision or fibrosis.
(c) Stiffness may decrease in paralysis, increase in spastic
dysphonia or fibrosis.
Cords may not be able to vibrate properly in the presence
of congestion, submucosal haemorrhages, nodule or
a polyp.

Aetiology:

Hoarseness is a symptom and not a disease per se . The
causes of hoarseness are summarised below:

Causes of hoarseness
1 . Inflammations
a.Acute: Acute laryngitis usually following
cold, influenza, exanthematous
fever, laryngo-tracheo-bronchitis,
diphtheria
b.Chronic(i) Specific. Tuberculosis, syphilis,
scleroma, fungal infections
(ii) Non-specific. Chronic laryngitis,
atrophic laryngitis
2. Tumours
a.Benign: Papilloma (so litary and multiple),
haemangioma, chondroma
fibroma, leukoplakia

b.Malignant: Carcinoma
c.Tumour-like masses: Vocal nodule, voca l polyp,
angiofibroma, amyloid tumour,
contact ulcer, cysts, laryngocele
3. Trauma: Submucosal haemorrhage,
laryngeal trauma (blunt and
sharp), foreign bodies, intubation

4. Paralysis: Paralysis of recurrent, superior
laryngeal Or" both nerves
5. Fixation of cords: Arthritis or fixation of cricoarytenoid
joints
6. Congenital: Laryngeal web, cyst, laryngocele
7. Miscellaneous: Dysphonia plica ventri cul ar'is,
myxoedema, gout
8. Functional: Hysterical aphonia

Investigations
1. History. Mode of onset and duration of illness,
patient's occupation, habits and associated complaints
are important and would often help to elucidate
the cause. Any hoarseness persisting for more ti-um
three weeks deserves examination of larynx. Malignancy
should be excluded in patients above 40 years.
2. Indirect laryngoscopy. Many of the local laryngeal
causes can be diagnosed.
3. Examination of neck, chest, cardiovascular and neurological
system would help to find cause for laryngeal
paralysis.
4. Laboratory investigations and radiological examination
should be done as per dictates of the cause suspected
on clinical examination.
5. Direct laryngoscopy and microlaryngoscopy help
in detailed examination, biopsy of the lesions and
assessment of the mobility of cricoarytenoid joints.
6. Bronchoscopy and oesophagoscopy may be required
in cases of paralytic lesions of the cord to exclude
malignancy.

Cancer Larynx

Aetiology
Both tobacco and alcohol are well established risk factors
in laryngeal cancer. Cigarette smoke contains benzopyrene
and other hydrocarbons which are carcinogenic
in man. Combination of alcohol and smoking increases
the risk 15-folds compared to each factor alone (2-3
folds). Previous radiation to neck for benign lesions or
laryngeal papilloma may induce laryngeal carcinoma.
Japanese and Russian workers have reported cases of
familial laryngeal malignancy incriminating genetic factors.
Occupational exposure to asbestos, mustard gas and
other chemical or petroleum products has also been
related to the genesis of laryngeal cancer but without
conclusive evidence.

Diagnosis of Laryngeal Cancer
1. History. Symptomatology of glo ttic, subglottic
and supraglo ttic lesions would vary and is described
under appropriate heads. It is a dictum that any patient in
cancer age group having persistent or gmduall)' increasing
hoarseness of voice for 3 weeks must have laryngeal examination
to exclude cancer.
2. Indirect laryngoscopy
(a) Appearance of lesion. Appearance of lesion will vary
with the site of o ri gin.
(i) Lesions of suprahyoid epiglottis are usually
exophytic while those of infrahyoid epiglo ttis
are ulcerative.
(ii) Lesion of voca  cord may appear as raised nodule,
ulcer o r thickening.
(iii) Les ion of anterior commissure may appear as
gran ulation tissue.
(tv) Lesion of subglottic region appears as a raised
submucosal nodule, mostly involving the anterior
half
(b) Vocal cord mobility. Impairment or fixation of vocal
cord indicates deeper infiltration into thyroarytenoid
muscle, cricoarytenoid Joint or invasion of
recurrent laryngeal nerve, and is an important sign.
(c) Extent of disease. Spread of disease to vallecula, base
of tongue, pyriform fossa should be noticed .
3. Examination of neck. It is done to find (i) extralaryngeal
spread of disease, and (ii) nodal metastasis.
Growths of anterior commissure and subglottic region
spread through cricothyro id membrane and may produce
a midline swelling. They may a lso invade the thyrOid
cartilage and cause perichondritis wh en cartilage will be
tender on palpation. ThyrOid gland and strap muscles
may also be invaded.
Search should be made for metastatic lymph nodes,
their size and number; and also if they a re mobile or
fixed, unilateral, bilateral or contralateral.
4. Radiography
(a) X-ray chest is essential for co-existent lung disease
(e.g. tuberculosis), pulmonary metastasis or mediastinal
nodes.
(b) Soft tissue lateral view neck Extent or lesions of epiglottiS,
aryepiglottic folds, arytenoids and involvemenc
of preepiglottic space may be seen. Destruction of
thyroid cartilage may be seen.
(c) Contrast laryngograms. Rad o-opaque dye, dionosil, is
instilled into the larynx. Laryngograms outline the
surface extent of tumours. This investigation has now
been replaced by CT scan.
5. CT scan. It is a very useful investigation to find
the extent of tumour, invasion of pre-epiglottic or
paraepiglottic space, destruction of cartilage and lymph
node involvement.
6. Direct laryngoscopy. It is done to see (a) the hidden
areas of larynx and (b) extent of disease.
Hidden areas of the larynx include infrahyoid epiglottis,
anterior commissure, subglottis and ventricle, which
may not be clearly seen by mirror examination making
direct laryngoscopy essential.
7. Microlaryngoscopy. For small lesions of vocal
cords, laryngoscopy is done under microscope to better
visualise the lesion and take more accurate biopsy specimens
without damaging the cord.
S. Supravital staining and biopsy. Toluidine blue
is applied to the laryngeal lesion and then washed with
saline and examined under the operating microscope.
Carcinoma-in-situ and superficial carcinomas take up
the dye while leukoplakia does not. Thus, it helps to
select the area for biopsy in a leukoplakic patch.
Treatment of Laryngeal Cancer
It depends upon the site of lesion, extent of lesion, presence
or absence of nodal and distant metastases. Treatment
consists of:
1. Radiotherapy,
2. Surgery, (a) conservation laryngeal surgery, (b) total
laryngectomy,
3. Combined therapy.
1. Radiotherapy. Curative radiotherapy is reserved
for early lesions which neither impair cord mobility nor
invade cartilage or cervical nodes. Cancer of the vocal
cord without impairment of its mobility gives a 90% cure
rate after irradiation and has the advantage of preservation
of voice. Superficial exophytic lesions, especially of the tip
of epiglottis, and aryepiglottic folds give 70-90% cure rate.
Radiotherapy does not give good results in lesions with
fixed cords, subglottic extension, cartilage invasion, and
nodal metastases. These lesions require surgery.
2. Surgery. (a) Conservation surgery. Earlier total
laryngectomy was done for most of the laryngeal cancers
and the patient was left with no voice and a permanent
tracheostome. Lately, there has been a trend for conservation
laryngeal surgery which can preserve voice and also
avoid a permanent tracheal opening. However, few cases
would be suitable for this type of surgery and they should
be carefully selected. Conservation surgery includes:
(i) Excision of vocal cord after splitting the larynx
(cordectomy via laryngofissure),
(ii) Excision of vocal cord and anterior commissure
region (partial frontolateral laryngectomy),
(iii) Excision of supraglottis, i.e. epiglottis, aryepiglottic
folds, false cords and ventricle-a sort of transverse
section of larynx above the vocal cords (partial
horizontal laryngectomy).
(b) Total laryngectomy. The entire larynx including
the hyoid bone, pre-epiglottic space, strap muscles, and one
or more rings of trachea are removed. Pharyngeal wall is
repaired and lower tracheal stump sutured to the skin for
breathing.
Laryngectomy may be combined with block dissection
for nodal metastasis.
Total laryngectomy is indicated in the follOWing
conditions:
• T3 lesions (i.e. with cord fixed)
• All T4 lesions
• Invasion of thyroid or cricoid cartilage
• Bilateral arytenoid cartilage involvement
• Lesions of posterior commissure
• Failure after rad iotherapy or conservation surgery
• Transglottic cancers, i.e. tumours involving supraglottis
and glottis across the ventricle, causing fixation
of the vocal cord.
It is contraindicated in patients with distant metastasis.
3 . Combined therapy. Surgical ablation may be
combined with pre- or post-operative radiation to
decrease the incidence of recurrence. Pre-operative radiation
may also render fixed nodes resectable.

Vocal Rehabilitation After Total
Laryngectomy
After laryngectomy, patient loses his speech completely.
Various methods by which communication can be established
are listed in Table 603.
1. Oesophageal speech. In this, patient is taught to
swallow air and ho ld it in the upper oesophagus and then
slowly ej ect it from the oesophagus into the pharynx.
Patient can speak 6-10 words before re-swallowing air.
Voice is rough but loud and understandable.
2. Artificial larynx. It is used in those who fall to learn
oesophageal speech.
(a) Electrolarynx. It is a transistor ised, battery operated
portable de,' ice. Its vibrating disc is held against the soft

tissues of the neck and a low pitched sound is produced in
the hypopharynx which is further modulated into speech
by the tongue, lips, teeth and palate
(b) Transoral pneumatic device. Another tyre of art ificial
larynx is a transoral device. Here vibrations produced
in a rubber diaphragm are ca rried by a pbstic tube
into the back of the oral cavity where sound is converted
into speech by modulators. This is a pneumatic type of
device and uses expired air from the tracheostome to
vibrate the diaphragm.
3. Tracheo-oesophageal speech. Here attempt is made
to carry air from trachea to oesophagus or hypopharynx
by the creation of skin-lined fistula or by placement of an
artificial prosthes is. The vibrating column of air entering
the pharynx is then modulated into speech. This technique
has the disadvantage of food entering the trachea.
These days prosthesis (Blom-Singer or Panje) are being
used to shunt air from trachea to the oesophagus. They
have inbuilt valves which work only in one direction
thus preventing problems of aspiration.

Vocal Nodules (Singer's or Screamer's Nodes)

They appear symmetrically on the free edge of vocal cord,
at the junction of anterior one-third, with the posterior
two-thirds, as this is the area of maximum vibration of the

cord and thus subject to maximum trauma.
Their size varies from that of pin-head to half a pea.

Aetiology: They are the result of vocal trauma when person speaks in unnatural
low tones for prolonged periods or at high intensities.
They mostly affect teachers, actors, vendors or pop singers.
They are also seen in school going children who are too
assertive and talkative.
Pathologically, trauma to the vocal cord in the form of
vocal abuse or misuse causes oedema and haemorrhage in
the submucosal space. This undergoes hyalinisation and
fibrosis. The overlying epithelium also undergoes hyperplasia
forming a nodule. In early stages, the nodules appear
soft, reddish and oedematous swellings but later become
greyish or white in colour.
Symptoms: Patients with vocal nodules complain of hoarseness.
Vocal fatigue and pain in the neck on prolonged phonation,
are other common symptoms.
Treatment: Early cases of vocal nodules can be treated conservatively
by educating the patient in proper use of voice .
With this treatment, many nodules in children disappear
completely. Surgery is required for large nodules or nodules
of long-standing in adults. They are excised with
precision under operating microscope avoiding any
trauma to the underlying vocal ligament.
Speech therapy and re-education in voice production
are essential to prevent their recurrence.