The aortic narrowing of the esophagus may not be noticed at all if the patient is placed in the proper sequential "high-low" position. It is only when the tube-mouth is directed against the left anterior wall that the actively pulsating aorta is felt.
The bronchial narrowing of the esophagus is due to backward displacement caused by the passage of the left bronchus over the anterior wall of the esophagus at about 27 cm. from the upper teeth in the adult. The ridge is quite prominent in some patients, especially those with dilatation from stenoses lower down.
The hiatal narrowing is both anatomic and spasmodic. The peculiar arrangement of the tendinous and muscular structure of the diaphragm acts on this hiatal opening in a sphincter-like fashion. There are also special bundles of muscle fibers extending from the crura of the diaphragm and surrounding the esophagus, which contribute to tonic closure in the same way that a pinch-cock closes a rubber tube. The author has called the hiatal closure the "diaphragmatic pinchcock."
Direction of the Esophagus.—The esophagus enters the chest in a decidedly backward as well as downward direction, parallel to that of the trachea, following the curves of the cervical and upper dorsal spine. Below the left bronchus the esophagus turns forward, passing through the hiatus in the diaphragm anterior to and to the left of the aorta. The lower third of the esophagus in addition to its anterior curvature turns strongly to the left, so that an esophagoscope inserted from the right angle of the mouth, when introduced into the stomach, points in the direction of the anterior superior spine of the left ileum.
It is necessary to keep this general course constantly in mind in all cases of esophagoscopy, but particularly in those cases in which there is marked dilatation of the esophagus following spasm at the diaphragm level. In such cases the aid of this knowledge of direction will greatly simplify the finding of the hiatus esophageus in the floor of the dilatation.
The extrinsic or transmitted movements of the esophagus are respiratory and pulsatory, and to a slight extent, bechic. The respiratory movements consist in a dilatation or opening up of the thoracic esophageal lumen during inspiration, due to the negative intrathoracic pressure. The normal pulsatory movements are due to the pulsatile pressure of the aorta, found at the 4th thoracic vertebra (24 cm. from the upper teeth in the adult), and of the heart itself, most markedly felt at the level of the 7th and 8th thoracic vertebrae (about 30 cm. from the upper teeth in adults). As the distances of all the narrowings vary with age, it is useful to frame and hang up for reference a copy of the chart (Fig. 46).
The intrinsic movements of the esophagus are involuntary muscular contractions, as in deglutition and regurgitation; spasmodic, the latter usually having some pathologic cause; and tonic, as the normal hiatal closure, in the author's opinion may be considered. Swallowing may be involuntary or voluntary. The constrictors are anatomically not considered part of esophagus proper. When the constrictors voluntarily deliver the bolus past the cricopharyngeal fold, the involuntary or peristaltic contractions of the esophageal mural musculature carry the bolus on downward. There is no sphincter at the cardiac end of the esophagus. The site of spasmodic stenosis in the lower third, the so-called cardiospasm, was first demonstrated by the author to be located at the hiatus esophageus and the spasmodic contractions are of the specialized muscle fibers there encircling the esophagus, and might be termed "phrenospasm," or "hiatal esophagismus." Regurgitation of food from the stomach is normally prevented by the hiatal muscular diaphragmatic closure (called by the author the "diaphragmatic pinchcock") plus the kinking of the abdominal esophagus.
In the author's opinion there is no spasm in the disease called "cardiospasm." It is simply the failure of the diaphragmatic pinchcock to open normally in the deglutitory cycle. A better name is functional hiatal stenosis.
At retrograde esophagoscopy the cardia and abdominal esophagus do not seem to exist. The top of the stomach seems to be closed by the diaphragmatic pinchcock in the same way that the top of a bag is closed by a puckering string.
The suggestions of the author in the earlier volumes in regard to preparation of the patient, as for any operation, by a bath, laxative, etc., and especially by special cleansing of the mouth with 25 per cent alcohol, have received general endorsement. Care should be taken not to set up undue reaction by vigorous scrubbing of gums unaccustomed to it. Artificial dentures should be removed. Even if no anesthetic is to be used, the patient should be fasted for five hours if possible, even for direct laryngoscopy in order to forestall vomiting. Except in emergency cases every patient should be gone over by an internist for organic disease in any form. If an endolaryngeal operation is needed by a nephritic, preparatory treatment may prevent laryngeal edema or other complications. Hemophilia should be thought of. It is quite common for the first symptom of an aortic aneurysm to be an impaired power to swallow, or the lodgment of a bolus of meat or other foreign body. If aneurysm is present and esophagoscopy is necessary, as it always is in foreign body cases, "to be fore-warned is to be forearmed." Pulmonary tuberculosis is often unsuspected in very young children. There is great danger from tracheal pressure by an esophageal diverticulum or dilatation distended with food; or the food maybe regurgitated and aspirated into the larynx and trachea. Therefore, in all esophageal cases the esophagus should be emptied by regurgitation induced by titillating the fauces with the finger after swallowing a tumblerful of water, pressure on the neck, etc. Aspiration will succeed in some cases. In others it is absolutely necessary to remove food with the esophagoscope. If the aspirating tube becomes clogged by solid food, the method of swab aspiration mentioned under bronchoscopy will succeed. Of course there is usually no cough to aid, but the involuntary abdominal and thoracic compression helps. Should a patient arrive in a serious state of water-hunger, as part of the preparation the patient must be given water by hypodermoclysis and enteroclysis, and if necessary the endoscopy, except in dyspneic cases, must be delayed until the danger of water-starvation is past.
As pointed out by Ellen J. Patterson the size of the thymus gland should be studied before an esophagoscopy is done on a child.
Every patient should be examined by indirect, mirror laryngoscopy as a preliminary to peroral endoscopy for any purpose whatsoever. This becomes doubly necessary in cases that are to be anesthetized.
A dyspneic patient should never be given a general anesthetic. Cocaine should not be used on children under ten years of age because of its extreme toxicity. To these two postulates always in mind, a third one, applicable to both general and local anesthesia, is to be added—total abolition of the cough-reflex should be for short periods only. General anesthesia is never used in the Bronchoscopic Clinic for endoscopic procedures. The choice for each operator must, however, be a matter for individual decision, and will depend upon the personal equation, and degree of skill of the operator, and his ability to quiet the apprehensions of the patient. In other words, the operator must decide what is best for his particular patient under the conditions then existing.
Children in the Bronchoscopic Clinic receive neither local nor general anesthesia, nor sedative, for laryngoscopic operations or esophagoscopy. Bronchoscopy in the older children when no dyspnea is present has in recent years, at the suggestion of Prof. Hare, been preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a child of six years) or a full physiologic dose of sodium bromide. The apprehension is thus somewhat allayed and the excessive cough-reflex quieted. The morphine should be given not less than an hour and a half before bronchoscopy to allow time for the onset of the soporific and antispasmodic effects which are the desiderata, not the analgesic effects. Dosage is more dependent on temperament than on age or body weight. Atropine is advantageously added to morphine in bronchoscopy for foreign bodies, not only for the usual reasons but for its effect as an antispasmodic, and especially for its diminution of endobronchial secretions. True, it does not diminish pus, but by diminishing the outpouring of normal secretions that dilute the pus the total quantity of fluid encountered is less than it otherwise would be. In cases of large quantities of pus, as in pulmonary abscess and bronchiectasis, however, no diminution is noticeable. No food or water is allowed for 5 hours prior to any endoscopic procedure, whether sedatives or anesthetics are to be given or not. If the stomach is not empty vomiting from contact of the tube in the pharynx will interfere with work.
With adults no anesthesia, general or local, is given for esophagoscopy. For laryngeal operation and bronchoscopy the following technic is used:
One hour before operation the patient is given hypodermatically a full physiologic dose of morphin sulphate (from 1/4, to 3/8 gr.) guarded with atropin sulphate (gr. 1/150). Care must be taken that the injection be not given into a vein. On the operating table the epiglottis and pharynx are painted with 10 per cent solution of cocain. Two applications are usually sufficient completely to anesthetize the exterior and interior of the larynx by blocking of the superior laryngeal nerve without any endolaryngeal applications. The laryngoscope is now introduced and if found necessary a 20 per cent cocain solution is applied to the interior of the larynx and subglottic region, by means of gauze swabs fastened to the sponge carriers. Here also two applications are quite sufficient to produce complete anesthesia in the larynx. If bronchoscopy is to be done the gauze swab is carried down through the exposed glottis to the carina, thus anesthetizing the tracheal mucosa. If further anesthetization of the bronchial mucosa is required, cocain may be applied in the same manner through the bronchoscope. In all these local applications prolonged contact of the swab is much more efficient than simply painting the surface.
[67] In cases in which cocain is deemed contraindicated morphin alone is used. If given in sufficient dosage cocain can be altogether dispensed with in any case.
It is perhaps safer for the beginner in his early cases of esophagoscopy to have the patient relaxed by an ether anesthesia, provided the patient is not dyspneic to begin with, or made so by faulty position or by pressure of the esophagoscopic tube mouth on the tracheoesophageal "party wall." As proficiency develops, however, he will find anesthesia unnecessary. Local anesthesia is needless for esophagoscopy, and if used at all should be limited to the laryngopharynx and never applied to the esophagus, for the esophagus is without sensation, as anyone may observe in drinking hot liquids.
Direct laryngoscopy in children requires neither local nor general anesthesia, either for diagnosis or for removal of foreign bodies or growths from the larynx. General anesthesia is contraindicated because of the dyspnea apt to be present, and because the struggles of the patient might cause a dislodgment of the laryngeal intruder and aspiration to a lower level. The latter accident is also prone to follow attempts to cocainize the larynx.
Technic for General Anesthesia.—For esophagoscopy and gastroscopy, if general anesthesia is desired, ether may be started by the usual method and continued by dropping upon folded gauze laid over the mouth after the tube is introduced. Endo-tracheal administration of ether is, however, far safer than peroral administration, for it overcomes the danger of respiratory arrest from pressure of the esophagoscope, foreign body, or both, on the trachea. Chloroform should not be used for esophagoscopy or gastroscopy because of its depressant action on the respiratory center.
For bronchoscopy, ether or chloroform may be started in the usual way and continued by insufflating through the branch tube of the bronchoscope by means of the apparatus shown in Fig. 13.
In case of paralysis of the larynx, even if only monolateral, a general anesthetic if needed should be given by intratracheal insufflation. If the apparatus for this is not available the patient should be tracheotomized. Hence, every adult patient should be examined with a throat mirror before general anesthesia for any purpose, and the necessity becomes doubly imperative before goiter operations. A number of fatalities have occurred from neglect of this precaution.
Anesthetizing a tracheotomized patient is free from danger so long as the cannula is kept free from secretion. Ether is dropped on gauze laid over the tracheotomic cannula and the anesthesia watched in the usual manner. If the laryngeal stenosis is not complete, ether-saturated gauze is to be placed over the mouth as well as over the tracheotomy tube.
Endo-tracheal anesthesia is by far the safest way for the administration of ether for any purpose. By means of the silk-woven catheter introduced into the trachea, ether-laden air from an insufflation apparatus is piped down to the lungs continuously, and the strong return-flow prevents blood and secretions from entering the lower air-passages. The catheter should be of a size, relative to that of the glottic chink, to permit a free return-flow. A number 24 French is readily accommodated by the adult larynx and lies well out of the way along the posterior wall of the larynx. Because of the little room occupied by the insufflation catheter this method affords ideal anesthesia for external laryngeal operations. Operations on the nose, accessory sinuses and the pharynx, apt to be attended by considerable bleeding, are rendered free from the danger of aspiration pneumonia by endotracheal anesthesia. It is the safest anesthesia for goiter operations. Endo-tracheal anesthesia has rendered needless the intricate negative pressure chamber formerly required for thoracic surgery, for by proper regulation of the pressure under which the ether ladened air is delivered, a lung may be held in any desired degree of expansion when the pleural cavity is opened. It is indicated in operations of the head, neck, or thorax, in which there is danger of respiratory arrest by centric inhibition or peripheral pressure; in operations in which there is a possibility of excessive bleeding and aspiration of blood or secretions; and in operations where it is desired to keep the anesthetist away from the operating field. Various forms of apparatus for the delivery of the ether-laden vapor are supplied by instrument makers with explicit directions as to their mechanical management.
We are concerned here mainly with the technic of the insertion of the intratracheal tube. The larynx should be examined with the mirror, preferably before the day of operation, for evidence of disease, and incidentally to determine the size of the catheter to be introduced, though the latter can be determined after the larynx is laryngoscopically exposed. The following list of rules for the introduction of the catheter will be of service (see Fig. 59).
1. The patient should be fully under the anesthetic by the open method so as to get full relaxation of the muscles of the neck. 2. The patient's head must be in full extension with the vertex firmly pushed down toward the feet of the patient, so as to throw the neck upward and bring the occiput down as close as possible beneath the cervical vertebrae. 3. No gag should be used, because the patient should be sufficiently anesthetized not to need a gag, and because wide gagging defeats the exposure of the larynx by jamming down the mandible. 4. The epiglottis must be identified before it is passed. 5. The speculum must pass sufficiently far below the tip of the epiglottis so that the latter will not slip. 6. Too deep insertion must be avoided, as in this case the speculum goes posterior to the cricoid, and the cricoid is lifted, exposing the mouth of the esophagus, which is bewildering until sufficient education of the eye enables the operator to recognize the landmarks. 7. The patient's head is lifted off the table by the spatular tip of the laryngoscope. Actual lifting of the head will not be necessary if the patient is fully relaxed; but the idea of lifting conveys the proper conception of laryngeal exposure (Fig. 55).
Bronchoscopic oxygen insufflation is a life-saving measure equalled by no other method known to the science of medicine, in all cases of asphyxia, or apnea, present or impending. Its especial sphere of usefulness is in severe cases of electric shock, hanging, smoke asphyxia, strangulation, suffocation, thoracic or abdominal pressure, apnea, acute traumatic pneumothorax, respiratory arrest from absence of sufficient oxygen, or apnea from the presence of quantities of irrespirable or irritant gases. Combined with bronchoscopic aspiration of secretions it is the best method of treatment for poisoning by chlorine gas, asphyxiating, and other war gases.
Bronchoscopic oxygen insufflation should be taught to every interne in every hospital. The emergency or accident ward of every hospital should have the necessary equipment and an interne familiar with its use. The method is simple, once the knack is acquired. The patient being limp and recumbent on a table, the larynx is exposed with the laryngoscope, and the bronchoscope is inserted as hereinafter described. The oxygen is turned on at the tank and the flow regulated before the rubber tube from the wash-bottle of tank is attached to the side-outlet of the bronchoscope. It is necessary to be certain that the flow is gentle, so that, with a free return flow the introduced pressure does not exceed the capillary pressure; otherwise the blood will be forced out of the capillaries and the ischemia of the lungs will be fatal. Another danger is that overdistension causes inhibition of inspiration resulting in apnea continuing as long as the distension is maintained, if not longer. The return flow from the bronchoscope should be interrupted for 2 or 3 seconds several times a minute to inflate the lungs, but the flow must not be occluded longer than 3 seconds, because the intrapulmonary pressure would rise. A pearl of amyl nitrite may be broken in the wash bottle. Slow rhythmic artificial respiratory movements are a useful adjunct, and unless the operator is very skillful in gauging the alternate pressures and releases with the thumb according to the oxygen pressure, it is vitally necessary to fill and deflate the lungs rhythmically by one of the well known methods of artificial respiration. Anyone skilled in the introduction of the bronchoscope can do bronchoscopy in a few seconds, and it is especially easy in cases of respiratory arrest, because of the limp condition of the patient.
The foregoing applies to cases in which a pulmotor would be used, such as apnea from electric shocks, etc. For obstructive dyspnea and asphyxia, tracheotomy is the procedure of choice, and the skillful tracheotomist would be justified in preferring tracheotomy for the other class of cases, insufflating the oxygen and amyl nitrite through the tracheotomic wound. The pulmotor and similar mechanisms are, perhaps, the best things the use of which can be taught to laymen; but as compared to bronchoscopic oxygen insufflation they are woefully inefficient, because the intraoral pressure forces the tongue back over the laryngeal orifice, obstructing the airway in this "death zone." By the introduction of the bronchoscope this death zone is entirely eliminated, and a free airway established for piping the oxygen directly into the lungs.
It is the author's invariable practice to place the patient in the dorsally recumbent position. The sitting position is less favorable. While lying on a well-padded, flat table the patient is readily controlled, the head is freely movable, secretions can be easily removed, the view obtained by the endoscopist is truly direct (without reversal of sides), and, most important, the employment of one position only favors smoother and more efficient team work, and a better endoscopic technic.
General Principles of Position.—As will be seen in Fig. 47 the trachea and esophagus are not horizontal in the thorax, but their long axes follow the curves of the cervical and dorsal spine. Therefore, if we are to bring the buccal cavity and pharynx in a straight line with the trachea and esophagus it will be found necessary to elevate the whole head above the plane of the table, and at the same time make extension at the occipito-atloid joint. By this maneuver the cervical spine is brought in line with the upper portion of the dorsal spine as shown in Fig. 55. It was formerly taught, and often in spite of my better knowledge I am still unconsciously prone to allow the head and cervical spine to assume a lower position than the plane of the table, the so-called Rose position. With the head so placed, it is impossible to enter the lower air or food passages with a rigid tube, as will be shown by a study of the radiograph shown in Fig. 49. Extension of the head on the occipito-atloid joint is for the purpose of freeing the tube from the teeth, and the amount required will vary with the degree to which the mouth can be opened. Whether the head be extended, flexed, or kept mid-way, the fundamental principle in the introduction of all endoscopic tubes is the anterior placing of the cervical spine and the high elevation of the head. The esophagus, just behind the heart, turns ventrally and to the left. In order to pass a rigid tube through this ventral curve the dorsal spine is now extended by lowering the head and shoulders below the plane of the table. This will be further explained in the chapter on esophagoscopy. In all of these procedures, the nose of the patient should be directed toward the zenith, and the assistant should prevent rotation of the head as well as prevent lowering of the head. The patient should be urged as follows: "Don't hold yourself so rigid." "Let your head and neck go loose." "Let your head rest in my hand." "Don't try to hold it." "Let me hold it." "Relax." "Don't raise your chest."
[FIG. 47.—Schematic illustration of normal position of the intra-thoracic trachea and esophagus and also of the entire trachea when the patient is in the correct position for peroral bronchoscopy. When the head is thrown backward (as in the Rose position) the anterior convexity of the cervical spine is transmitted to the trachea and esophagus and their axes deviated. The anterior deviation of the lower third of the esophagus shows the anatomical basis for the "high low" position for esophagoscopy]
[FIG. 48.—Correct position of the cervical spine for esophagoscopy
and
bronchoscopy. (Illustration reproduced from author's article Jour.
Am. Med. Assoc., Sept. 25, 1909)]
[FIG. 49.—Curved position of the cervical spine, with anterior convexity, in the Rose position, rendering esophagoscopy and bronchoscopy difficult or impossible. The devious course of the pharynx, larynx and trachea are plainly visible. The extension is incorrectly imparted to the whole cervical spine instead of only to the occipito-atloid joint. This is the usual and very faulty conception of the extended position. (Illustration reproduced from author's article, Jour. Am. Med. Assoc., Sept. 25, 1909.)]
[76] For direct laryngoscopy the patient's head is raised above the plane of the table by the first assistant, who stands to the right of the patient, holding the bite block on his right thumb inserted in the left corner of the patient's mouth, while his extended right hand lies along the left side of the patient's cheek and head, and prevents rotation. His left hand, placed under the patient's occiput, elevates the head and maintains the desired degree of extension at the occipito-atloid joint (Fig. 50).
[FIG 50.—Direct laryngoscopy, recumbent patient. The second assistant is sitting holding the head in the Boyce position, his left forearm on his left thigh his left foot on a stool whose top is 65 cm. lower than the table-top. His left hand is on the patient's sterile-covered scalp, the thumb on the forehead, the fingers under the occiput, making forced extension. The right forearm passes under the neck of the patient, so that the index finger of the right hand holds the bite-block in the left corner of the patient's mouth. The fingers of the operator's right hand pulls the upper lip out of all danger of getting pinched between the teeth and the laryngoscope. This is a precaution of the utmost importance and the trained habit of doing it must be developed by the peroral endoscopist.]
Position for Bronchoscopy and Esophagoscopy.—The dorsally recumbent patient is so placed that the head and shoulders extend beyond the table, the edge of which supports the thorax at about the level of the scapulae. During introduction, the head must be maintained in the same relative position to the table as that described for direct laryngoscopy, that is, elevated and extended. The first assistant, in this case, sits on a stool to the right of the patient's head, his left foot resting on a box about 14 inches in height, the left knee supporting the assistant's left hand, which being placed under the occiput of the patient maintains elevation and extension. The right arm of the assistant passes under the neck of the patient, the bite block being carried on the middle finger of the right hand and inserted into the left side of the patient's mouth. The right hand also prevents rotation of the head (Fig. 51). As the bronchoscope or esophagoscope is further inserted, the head must be placed so that the tube corresponds to the axis of the lumen of the passage to be examined. If the left bronchus is being explored, the head must be brought strongly to the right. If the right middle lobe bronchus is being searched, the head would require some left lateral deflection and a considerable degree of lowering, for this bronchus, as before mentioned, extends anteriorly. During esophagoscopy when the level of the heart is reached, the head and upper thorax must be strongly depressed below the plane of the table in order to follow the axis of the lumen of the ventrally turning esophagus; at the same time the head must be brought somewhat to the right, since the esophagus in this region deviates strongly to the left.
[FIG. 51.—Position of patient and assistant for introduction of the bronchoscope and esophagoscope. The middle of the scapulae rest on the edge of the table; the head and shoulders, free to move, are supported by the assistant, whose right arm passes under the neck; the right middle finger inserts the bite block into the left side of the mouth. The left hand, resting on the left knee maintains the desired degree of elevation, extension and lateral deflection required by the operator. The patient's vertex should be 10 cm. higher than the level of the top of the table. This is the Boyce position, which has never been improved upon for bronchoscopy and esophagoscopy.]
[FIG. 52.—Schema of position for endoscopy. A. Normal recumbency on the table with pillow supporting the head. The larynx can be directly examined in this position, but a better position is obtainable. B. Head is raised to proper position with head flexed. Muscles of front of neck are relaxed and exposure of larynx thus rendered easier; but, for most endoscopic work, a certain amount of extension is desired. The elevation is the important thing. C. The neck being maintained in position B, the desired amount of extension of the head is obtained by a movement limited to the occipito-atloid articulation by the assistant's hand placed as shown by the dart (B). D. Faulty position. Unless prevented, almost all patients will heave up the chest and arch the lumbar spine so as to defeat the object and to render endoscopy difficult by bringing the chest up to the high-held head, thus assuming the same relation of the head to the chest as exists in the Rose position (a faulty one for endoscopy) as will be understood by assuming that the dotted line, E, represents the table. If the pelvis be not held down to the table the patient may even assume the opisthotonous position by supporting his weight on his heels on the table and his head on the assistant's hand.]
In obtaining the position of high head with occipito-atloid extension, the easiest and most certain method, as pointed out to me by my assistant, Gabriel Tucker, is first to raise the head, strongly flexed, as shown in Fig. 52; then while maintaining it there, make the occipito-atloid extension. This has proven better than to elevate and extend in a combined simultaneous movement.
If the patient would relax to limpness exposure of the larynx would be easily obtained, simply by lifting the head with the lip of the laryngoscope passed below the tip of the epiglottis (as in Fig. 55) and no holding of the head would be necessary. But only rarely is a patient found who can do this. This degree of relaxation is of course, present in profound general ether anesthesia, which is not to be thought of for direct laryngoscopy, except when it is used for the purpose of insertion of intratracheal insufflation anesthetic tubes. For this, of course, the patient is already to be deeply anesthetized. The muscular tension exerted by some patients in assuming and holding a faulty position is almost as much of a hindrance to peroral endoscopy as is the position itself. The tendency of the patient to heave up his chest and assume a false position simulating the opisthotonous position (Fig. 52) must be overcome by persuasion. This position has all the disadvantages of the Rose position for endoscopy.
[FIG. 53.—The author's position for the removal of foreign bodies from the larynx or from any of the upper air or food passages. If dislodged, the intruder will not be aided by gravity to reach a deeper lodgement.]
The one exception to these general positions is found in procedures for the removal of foreign bodies from the larynx. In such cases, while the same relative position of the head to the plane of the table is maintained, the whole table top is so inclined as to elevate the feet and lower the head, known as Jackson's position. This semi-inversion of the patient allows the foreign body to drop into the pharynx if it should be dislodged, or slip from the forceps (Fig. 53).
Importance of Mirror Examination of the Larynx.—The presence of the direct laryngoscope incites spasmodic laryngeal reflexes, and the traction exerted somewhat distorts the tissues, so that accurate observations of variations in laryngeal mobility are difficult to obtain. The function of the laryngeal muscles and structures, therefore, can best be studied with the laryngeal mirror, except in infants and small children who will not tolerate the procedure of indirect laryngoscopy. A true idea of the depth of the larynx is not obtained with the mirror, and a view of the ventricles is rarely had. With the introduction of the direct laryngoscope it is found that the larynx is funnel shaped, and that the adult cords are situated about 3 cm. below the aryepiglottic folds; the cords also assume their true shelf-like character and take on a pinkish or yellowish tinge, rather than the pearly white seen in the mirror. They are not to any extent differentiated by color from the neighboring structures. Their recognition depends almost wholly on form, position and movement.
Accurate observation is stimulated in all pathologic cases by making colored crayon sketches, however crude, of the mirror image of the larynx. The location of a growth may be thus graphically recorded, so that at the time of operation a glance will serve to refresh the memory as to its site. It is to be constantly kept in mind, however, that in the mirror image the sides are reversed because of the facing positions of the examiner and patient. Direct laryngoscopy is the only method by which the larynx of children can be seen. The procedure need require less than a minute of time, and an accurate diagnosis of the condition present, whether papilloma, foreign body, diphtheria, paralysis, etc., may be thus obtained. The posterior pharyngeal wall should be examined in all dyspneic children for the possible existence of retropharyngeal abscess.
[PLATE II—DIRECT AND INDIRECT LARYNGEAL VIEWS FROM AUTHOR'S OIL-COLOR DRAWINGS FROM LIFE: 1, Epiglottis of child as seen by direct laryngoscopy in the recumbent position. 2, Normal larynx spasmodically closed, as is usual on first exposure without anesthesia. 3, Same on inspiration. 4, Supraglottic papillomata as seen on direct laryngoscopy in a child of two years. 5, Cyst of the larynx in a child of four years, seen on direct laryngoscopy without anesthesia. 6, Indirect view of larynx eight weeks after thyrotomy for cancer of the right cord in a man of fifty years. 7, Same after two years. An adventitious band indistinguishable from the original one has replaced the lost cord. 8, Condition of the larynx three years after hemilaryngectomy for epithelioma in a patient fifty-one years of age. Thyrotomy revealed such extensive involvement, with an open ulceration which had reached the perichondrium, that the entire left wing of the thyroid cartilage was removed with the left arytenoid. A sufficiently wide removal was accomplished without removing any part of the esophageal wall below the level of the crico-arytenoid joint. There is no attempt on the part of nature to form an adventitious cord on the left side. The normal arytenoid drew the normal cord over, approximately to the edge of the cicatricial tissue of the operated side. The voice, at first a very hoarse whisper, eventually was fairly loud, though slightly husky and inflexible. 9, The pharynx seen one year after laryngectomy for endothelioma in a man aged sixty-eight years. The purple papilla; anteriorly are at the base of the tongue, and from this the mucosa slopes downward and backward smoothly into the esophagus. There are some slight folds toward the left and some of these are quite cicatricial. The epiglottis was removed at operation. The trachea was sutured to the skin and did not communicate with the pharynx. (Direct view.)]
Contraindications to Direct Laryngoscopy.—There are no absolute contraindications to direct laryngoscopy in any case where direct laryngoscopy is really needed for diagnosis or treatment. In extremely dyspneic patients, if the operator is not confident in his ability for a prompt and sure introduction of a bronchoscope, it may be wise to do a tracheotomy first.
Instructions to the Patient.—Before beginning endoscopy the patient should be told that he will feel a very disagreeable pressure on his neck and that he may feel as though he were about to choke. He must be gently but positively made to understand (1) that while the procedure is alarming, it is absolutely free from danger; (2) that you know just how it feels; (3) that you will not allow his breath to be shut off completely; (4) that he can help you and himself very much by paying close attention to breathing deeply and regularly; (5) and that he must not draw himself up rigidly as though "walking on ice," but must be easy and relaxed.
Direct Laryngoscopy. Adult Patient.—Before starting, every detail in regard to instrumental equipment and operating room assistants, (including an assistant to hold the arms and legs of the patient) must be complete. Preparation of the patient and the technic of local anesthesia have been discussed in their respective chapters. The dorsally recumbent patient is draped with (not pinned in) a sterile sheet. The head, covered by sterile towels, is elevated, and slight extension is made at the occipitoatloid joint by the left hand of the first assistant. The bite block placed on the assistant's right thumb is inserted into the left angle of the patient's open mouth (see Fig. 50).
The laryngoscope must always and invariably be held in the left hand, and in such a manner that the greatest amount of traction is made at the swell of the horizontal bar of the handle, rather than on the vertical bar.
The right hand is then free for the manipulation of forceps, and the insertion of the bronchoscope or other instrument. During introduction, the fingers of the right hand retract the upper lip so as to prevent its being pinched between the laryngoscope and the teeth. The introduction of the direct laryngoscope and exposure of the larynx is best described in two stages. 1. Exposure and identification of the epiglottis. 2. Elevation of the epiglottis and all the tissues attached to the hyoid bone, so as to expose the larynx to direct view.
First Stage.—The spatular end of the laryngoscope is introduced in the right side of the patient's mouth, along the right side of the anterior two-thirds of the tongue. It was the German method to introduce the laryngoscope over the dorsum of the tongue but in order to elevate this sometimes powerful muscular organ considerable force may be required, which exercise of force may be entirely avoided by crowding the tongue over to the left. When the posterior third stage of the tongue is reached, the tip of the laryngoscope is directed toward the midline and the dorsum of the tongue is elevated by a lifting motion imparted to the laryngoscope. The epiglottis will then be seen to project into the endoscopic field, as seen in Fig. 54.
[FIG. 54.—End of the first of direct laryngoscopy, recumbent adult patient. The epiglottis is exposed by a lifting motion of the spatular tip on the tongue anterior to the epiglottis.]
Second Stage.—The spatular end of the laryngoscope should now be tipped back toward the posterior wall of the pharynx, passed posterior to the epiglottis, and advanced about 1 cm. The larynx is now exposed by a motion that is best described as a suspension of the head and all the structures attached to the hyoid bone on the tip of the spatular end of the laryngoscope (Fig. 55). Particular care must be taken at this stage not to pry on the upper teeth; but rather to impart a lifting motion with the tip of the speculum without depressing the proximal tubular orifice. It is to be emphasized that while some pressure is necessary in the lifting motion, great force should never be used; the art is a gentle one. The first view is apt to find the larynx in state of spasm, and affords an excellent demonstration of the fact that the larynx can he completely closed without the aid of the epiglottis. Usually little more is seen than the two rounded arytenoid masses, and, anterior to them, the ventricular bands in more or less close apposition hiding the cords (Fig. 56). With deep general anesthesia or thorough local anesthesia the spasm may not be present. By asking the patient to take a deep breath and maintain steady breathing, or perhaps by requesting a phonatory effort, the larynx will open widely and the cords be revealed. If the anterior commissure of the larynx is not readily seen, the lifting motion and elevation of the head should be increased, and if there is still difficulty in exposing the anterior commissure the assistant holding the head should with the index finger externally on the neck depress the thyroid cartilage. If by this technic the larynx fails to be revealed the endoscopist should ask himself which of the following rules he has violated.
[FIG. 55.—Schema illustrating the technic of direct laryngoscopy on the recumbent patient. The motion is imparted to the tip of the laryngoscope as if to lift the patient by his hyoid hone. The portion of the table indicated by the dotted line may be dropped or not, but the back of the head must never go lower than here shown, for direct laryngoscopy; and it is better to have it at least 10 cm. above the level of the table. The table may be used as a rest for the operator's left elbow to take the weight of the head. (Note that in bronchoscopy and esophagoscopy the head section of the table must be dropped, so as to leave the head and neck of the patient out in the air, supported by the second assistant.)]
[FIG. 56.—Endoscopic view at the end of the second stage of direct laryngoscopy. Recumbent patient. Larynx exposed waiting for larynx to relax its spasmodic contraction.]
RULES FOR DIRECT LARYNGOSCOPY 1. The laryngoscope must always be held in the left hand, never in the right. 2. The operator's right index finger (never the left) should be used to retract the patient's upper lip so that there is no danger of pinching the lip between the instrument and the teeth. 3. The patient's head must always be exactly in the middle line, not rotated to the right or left, nor bent over sidewise; and the entire head must be forward with extension at the occipitoatloid joint only. 4. The laryngoscope is inserted to the right side of the anterior two-thirds of the tongue, the tip of the spatula being directed toward the midline when the posterior third of the tongue is reached. 5. The epiglottis must always be identified before any attempt is made to expose the larynx. 6. When first inserting the laryngoscope to find the epiglottis, great care should be taken not to insert too deeply lest the epiglottis be overridden and thus hidden. 7. After identification of the epiglottis, too deep insertion of the laryngoscope must be carefully avoided lest the spatula be inserted back of the arytenoids into the hypo-pharynx. 8. Exposure of the larynx is accomplished by pulling forward the epiglottis and the tissues attached to the hyoid bone, and not by prying these tissues forward with the upper teeth as a fulcrum. 9. Care must be taken to avoid mistaking the ary-epiglottic fold for the epiglottis itself. (Most likely to occur as the result of rotation of the patient's head.) 10. The tube should not be retained too long in place, but should be removed and the patient permitted to swallow the accumulated saliva, which, if the laryngoscope is too long in place, will trickle down the trachea and cause cough. (Swallowing is almost impossible while the laryngoscope is in position.) The secretions may be removed with the aspirator. 11. The patient must be instructed to breathe deeply and quietly without making a sound.
[88] Difficulties of Direct Laryngoscopy.—The larynx can be directly exposed in any patient whose mouth can be opened, although the ease varies greatly with the type of patient. Failure to expose the epiglottis is usually due to too great haste to enter the speculum all the way down. The spatula should glide slowly along the posterior third of the tongue until it reaches the glossoepiglottic fossa, while at the same time the tongue is lifted; when this is done the epiglottis will stand out in strong relief. The beginner is apt to insert the speculum too far and expose the hypopharynx rather than the larynx. The elusiveness of the epiglottis and its tendency to retreat downward are very much accentuated in patients who have worn a tracheotomic cannula; and if still wearing it, the patient can wait indefinitely before opening his glottis. Over extension of the patient's head is a frequent cause of difficulty. If the head is held high enough extension is not necessary, and the less the extension the less muscular tension there is in the anterior cervical muscles. Only one arytenoid eminence may be seen. The right and the left look different. Practice will facilitate identification, so that the endoscopist will at once know which way to look for the glottis.
Of the difficulties that pertain to the operator himself the greatest is lack of practice. He must learn to recognize the landmarks even though a high degree of spasm be present. The epiglottis and the two rounded eminences corresponding to the arytenoids must be in the mind's eye, for it is only on deep, relaxed inspiration that anything like a typical picture of the larynx will be seen. He must know also the right from the left arytenoid when only one is seen in order to know whether to move the lip of the laryngoscope to the right or the left for exposure of the interior of the larynx.
Instruments for Direct Laryngoscopy.—In undertaking direct laryngoscopy one must always be prepared for bronchoscopy, esophagoscopy, and tracheotomy, as well. Preparations for bronchoscopy are necessary because the pathological condition may not be found in the larynx, and further search of the trachea or bronchi may be required. A foreign body in the larynx may be aspirated to a deeper location and could only be followed with the bronchoscope. Sudden respiratory arrest might occur, from pathology or foreign body, necessitating the inserting of the bronchoscope for breathing purposes, and the insufflation of oxygen and amyl nitrite. Trachectomy might be required for dyspnea or other reasons. It might be necessary to explore the esophagus for conditions associated with laryngeal lesions, as for instance a foreign body in the esophagus causing dyspnea by pressure. In short, when planning for direct laryngoscopy, bronchoscopy, or esophagoscopy, prepare for all three, and for tracheotomy. A properly done direct laryngoscopy would never precipitate a tracheotomy in an unanesthetized patient; but direct laryngoscopy has to deal so frequently with laryngeal stenosis, that routine preparation for tracheotomy a hundred unnecessary times is fully compensated for by the certainty of preparedness when the rare but urgent occasion arises.
Direct Laryngoscopy in Children.—The epiglottis in children is usually strongly curled, often omega shaped, and is very elusive and slippery. The larynx of a child is very freely movable in the neck during respiration and deglutition, and has a strong tendency to retreat downward during examination, and thus withdraw the epiglottis after the arytenoids have been exposed. In following down with the laryngoscope the speculum is prone to enter the hypopharynx. Lifting in this location will expose the mouth of the esophagus and shut off the larynx, and may cause respiratory arrest. Practice, however, will soon develop a technic and ability to recognize the landmarks in state of spasm, so that on exposing the approximated arytenoid eminences the endoscopist will maintain his position and wait for the larynx to open. The procedure should be done without any form of anesthesia for the following reasons: 1. Anesthesia is unnecessary. 2. It is extremely dangerous in a dyspneic patient. 3. It is inadmissable in a patient with diphtheria. 4. If anesthesia is to be used, direct laryngoscopy will never reach its full degree of usefulness, because anesthesia makes a major procedure out of a minor one. 5. Cocain in children is dangerous, and its application more annoying than the examination.
Inducing a Child to Open its Mouth (Author's Method).—The wounding of the child's mouth, gums, and lips, in the often inefficacious methods with gags, hemostats, raspatories, etcetera, are entirely unnecessary. The mouth of any child not unconscious can be opened quickly and without the slightest harm by passing a curved probe between the clenched jaws back of the molars and down back of the tongue toward the laryngopharynx. This will cause the child to gag, when its mouth invariably opens.
[91] CHAPTER VIII—DIRECT LARYNGOSCOPY (Continued)
Technic of Laryngeal Operations.—Preparation of the patient and anesthesia have been mentioned under their respective chapters. The prime essential of successful laryngeal operations is perfect mastery of continuous left-handed laryngeal exposure. The right hand must be equally trained in the manipulation of forceps, and the right eye to gauge depth. Blood and secretions are best removed by a suction tube (Fig. 9) inserted through the laryngoscope, or directly into the pharynx outside the laryngoscope.
For the removal of benign growths the author's papilloma forceps, Fig. 29, or the laryngeal grasping forceps shown in Fig. 17 will prove more satisfactory than any form of cutting forceps. These growths should be removed superficially flush with the normal structure. The crushing of the base incident to the plucking off of the growth causes its recession. By this conservative method damage to the cords and impairment of the voice are avoided. For growths in the anterior portion of the larynx, and in fact for the removal of most small benign growths, the anterior commissure laryngoscope is especially adapted. Its shape allows its introduction into the vestibule of the larynx, and if desired it may be introduced through the glottic chink for the treatment of subglottic conditions. It will not infrequently be observed that a pedunculated subglottic growth which is found with difficulty will be pulled upward into view by the gauze swab introduced to remove secretions. The growth is then often held tightly between the approximated cords for a few seconds—perhaps long enough to grasp it with forceps.
[92] Removal of Growth from the Laryngeal Ventricle.—After exposing the larynx in the usual manner, if the head is turned strongly to the right, the tip of the laryngoscope, directed from the right side of the mouth, may be used to lift the left ventricular hand and thus expose the ventricle, from which a growth may be removed in the usual manner (Fig. 57). The right ventricle is exposed by working from the left side of the mouth.
[FIG. 57.-Schema illustrating the lateral method of exposing a growth in the ventricle of Morgagni, by bending the patient's head to the opposite side, while the second assistant externally fixes the larynx with his hand. M, Patient's mouth; T, thyroid cartilage; R, right side; L, left. V, B, ventricular band. C, C, vocal cord. The circular drawing indicates the endoscopic view obtainable by this method. The tube, E, is dropped to the corner of the mouth, B, and the tube is inserted down to R. The lip of the spatula can then be used to lift the ventricular band so as to expose more of the ventricle. The drawing shows an unusually shallow ventricle.]
Taking a Laryngeal Specimen for Diagnosis.—The diagnosis of carcinoma, sarcoma, and some other conditions can be made certain only by microscopic study of tissue removed from the growth. The specimen should be ample but will necessarily be small. If the suspected growth be small it should be removed entire, together with some of the basal tissues. If it is a large growth, and there are objections to its entire removal, the edge of the growth, including apparently normal as well as neoplastic tissue, is necessary. If it is a diffuse infiltrative process, a specimen should be taken from at least two locations. Tissue for biopsy is to be taken with the punch forceps shown in Fig. 28 or that in Fig. 33. The forceps may be inserted through the tube or from the angle of the mouth; the "extubal" method (see Fig. 58).
[FIG. 58.—Schema illustrating removal of a tumor from the upper part of the larynx by the author's "extubal" method for large tumors. The large alligator basket punch forceps, F, is inserted from the right corner of the mouth and the jaws are placed over the tumor, T, under guidance of the eye looking through the laryngoscope, L. This method is not used for small tumors. It is excellent for amputation of the epiglottis with these same punch forceps or with the heavy snare.]
Removal of large benign tumors above the cords may be done with the snare or with the large laryngeal punch forceps. Both are used in the extubal method.
Amputation of the epiglottis for palliation of odynophagia or dysphagia in tuberculous or malignant disease, is of benefit when the ulceration is confined to this region; though as to tuberculosis the author feels rather conservatingly inclined. Early malignancy of the extreme tip can be cured by such means. The function of the epiglottis seems to be to split the food bolus and direct its portions laterally into the pyriform sinuses, rather than to take any important part in the closure of the larynx. Following the removal of the epiglottis there is rarely complaint of food entering the larynx. The projecting portion of the epiglottis may be amputated with a heavy snare, or by means of the large laryngeal punch forceps (Fig. 33).
Endoscopic Operations for Laryngeal Stenosis.—Web formations may be excised with sliding punch forceps, or if the web is due to contraction only, incision of the true band may allow its retraction. In some instances liberation of adhesions will favor the formation of adventitious vocal cords. A sharp anterior commissure is a large factor in good phonation.
Endoscopic evisceration of the larynx will cure a few cases of laryngeal cicatricial stenosis, and should be tried before resorting to laryngostomy. A sliding punch forceps is used to remove all the tissue in the larynx out to the perichondrium, but care should be taken in cicatricial cases to avoid removing any part of either arytenoid cartilage. In cases of posticus paralysis the excision may include portions of the vocal processes of the arytenoids. Ventriculocordectomy is preferable to evisceration. The ventricular floor is removed with punch forceps (Fig. 33) first on one side, then after two months, on the other.
Vocal Results.—A whispering voice can always be had as long as air can pass through the larynx, and this may be developed to a very loud penetrating stage whisper. If the arytenoid motility has been uninjured the repeated pulls on the scar tissue may draw out adventitious bands and develop a loud, useful, though perhaps rough and inflexible voice.
Galvano-cauterization is the best method of treatment for chronic subglottic edema or hyperplasia such as is seen in children following diphtheria, when the stenosis produced prevents extubation or decannulation. The utmost caution should be used to avoid deep cauterizations; they are almost certain to set up perichondritis which will increase the stenosis. Some of the most difficult cases that have come to the author have been previously cauterized too deeply.
Galvano-cautery puncture of tuberculous infiltrations of the larynx at times yields excellent results in cases with mild pulmonary lesions, and has quite replaced the use of the curette, lactic acid, and other caustics. The direct method of exposing the larynx renders the application of the cautery point easy and accurate. In severely stenosed tuberculous larynges a tracheotomy should first be done, for though the reaction is slight it might be sufficient to close a narrowed glottis. The technic is the usual one for laryngeal operations. Local anesthesia suffices. The larynx is exposed. The rheostat having been previously adjusted to heat the electrode to nearly white heat, the circuit is broken and the electrode introduced cold. When the point is in contact with the desired location the current is turned on and the point thrust in as deeply as desired. Usually it should penetrate until a firm resistance is felt; but care must be used not to damage the cricoarytenoid joint. The circuit is broken at the instant of withdrawal. Punctures should be made as nearly as possible perpendicular to the surface, so as to minimize the destruction of epithelium and thus lessen the reaction. A minute gray fibrous slough detaches itself in a few days. Cautery puncture should be repeated every two or three weeks, selecting a new location each time, until the desired result is obtained. Great caution, as mentioned above, must be used to avoid setting up perichondritis. Many cases of laryngeal tuberculosis will recover as quickly by silence and a general antituberculous regime.
Radium, in form of capsules or of needles inserted in the tissues may be applied with great accuracy; but the author is strongly impressed with pyriform sinus applications by the Freer method.
After-care of endolaryngeal operations includes careful cleansing of the teeth and mouth; and if the extrinsic area of the larynx is involved in the wound, sterile liquid food and water should be given for four days. The patient should be watched for complications by a special nurse who is familiar with the signs of laryngeal dyspnea (q.v.). Complications during endolaryngeal operations are rare. Dyspnea may require tracheotomy. Idiosyncrasy to cocain, or the sight or taste of blood may nauseate the patient and cause syncope. Serious hemorrhage could occur only in a hemophile. The careless handling of a bite block might damage a frail tool or dental fixture.
Complications after endolaryngeal operations are unusual. Carelessness in asepsis has been known to cause cervical cellulitis. Emphysema of the neck has occurred. Edema of the larynx occasionally occurs, and might necessitate tracheotomy. Serious bleeding after operation is very rare except in bleeders. Hemorrhage within the larynx can be stopped by the introduction of a roll of gauze from above, tracheotomy having been previously performed. Morphin subcutaneously administered, has a constricting action on the vessels which renders it of value in controlling hemorrhage.
No one should do bronchoscopy until he is able to expose the glottis by left-handed direct laryngoscopy in less than one minute. When he has mastered this, one minute more should be sufficient to introduce the bronchoscope into the trachea.
Local anesthesia is usually employed in the adult. The patient is placed in the Boyce position shown in Fig. 51, with head and shoulders projecting over the edge of the table and supported by an assistant. The glottis is exposed by left-handed laryngoscopy. The instrument-assistant now inserts the distal end of the bronchoscope into the lumen of the laryngoscope, the handle being directed to the right in a horizontal position. The operator now grasps the bronchoscope, his eye is transferred from the laryngoscope to the bronchoscope, and the bronchoscope is advanced and so directed that a good view of the glottis is obtained. The slanted end of the bronchoscope should then be directed to the left, so as clearly to expose the left cord. In this position it will be found that the tip of the slanted end is in the center of the glottic chink and will slip readily into the trachea. No great force should be used, because if the bronchoscope does not go through readily, either the tube is too large a size or it is not correctly placed (Fig. 60). Normally, however, there is some slight resistance, which in cases of subglottic laryngitis may be considerable. The trained laryngologist will readily determine by sense of touch the degree of pressure necessary to overcome it. When the bronchoscope has been inserted to about the second or third tracheal ring, the heavy laryngoscope is removed by rotating the handle to the left, removing the slide, and withdrawing the instrument. Care must be taken that the bronchoscope is not withdrawn or coughed out during the removal of the laryngoscope; this can be avoided by allowing the ocular end to rest against the gown-covered chest of the operator. If preferred the operator may train his instrumental assistant to take off the laryngoscope, while the operator devotes his attention to preventing the withdrawal of the bronchoscope by holding the handle with his right hand. At the moment of insertion of the bronchoscope through the glottis, an especially strong upward lift on the beak of the spatula will facilitate the passage. It is necessary to be certain that the axis of the bronchoscope corresponds to the axis of the trachea, in order to avoid injury to the subglottic tissue which might be followed by subglottic edema (Fig. 47). If the subglottic region is already edematous and causes resistance, slight rotation to the laryngoscope, and bronchoscope will cause the bronchoscope to enter more easily.
[FIG. 59.—Insufflation anesthesia with Elsberg apparatus. Anesthetist has exposed the larynx and is about to introduce the silk-woven catheter. Note the full extension of the head on the table.]
[FIG. 60.—Schema illustrating the introduction of the bronchoscope through the glottis, recumbent patient. The handle, H, is always horizontally to the right. When the glottis is first seen through the tube it should be centrally located as at K. At the next inspiration the end B, is moved horizontally to the left as shown by the dart, M, until the glottis shows at the right edge of the field, C. This means that the point of the lip, B, is at the median line, and it is then quickly (not violently) pushed through into the trachea. At this same moment or the instant before, the hyoid bone is given a quick additional lift with the tip of the laryngoscope.]
[FIG. 61.—Schema illustrating oral bronchoscopy. The portion of the table here shown under the head is, in actual work, dropped all the way down perpendicularly. It appears in these drawings as a dotted line to emphasize the fact that the head must be above the level of the table during introduction of the bronchoscope into the trachea. A, Exposure of larynx; B, bronchoscope introduced; C, slide removed; D, laryngoscope removed leaving bronchoscope alone in position.]
Difficulties in the Introduction of the Bronchoscope.—The beginner may enter the esophagus instead of the trachea: this might be a dangerous accident in a dyspneic case, for the tube could, by pressure on the trachea, cause respiratory arrest. A bronchoscope thus misplaced should be resterilized before introducing it into the air passages, for while the lower air passages are usually free from bacteria, the esophagus is a septic canal. If the given technic is carefully carried out the bronchoscope will not be contaminated with mouth secretions. The trachea is recognized as an open tube, with whitish rings, and the expiratory blast can be felt and tubular breathing heard; while if by mistake the bronchoscope has entered the gullet it will be observed that the cervical esophagus has collapsed walls. A puff of air may be felt and a fluttering sound heard when the tube is in the esophagus, but these lack the intensity of the tracheal blast. Usually a free flow of secretion is met with in the esophagus. In diseased states the tracheal rings may not be visible because of swollen mucosa, or the trachea itself may be in partial collapse from external pressure. The true expiratory blast will, however, always be recognized when the tube is in the trachea. Wide gagging of the mouth renders exposure of the larynx difficult.
[FIG. 62.—Insertion of the bronchoscope. Note direction of the trachea as indicated by the bronchoscope. Note that the patient's head is held above the level of the table. The assistant's left hand should be at the patient's mouth holding the bite-block. This is removed and the assistant is on the wrong side of the table in the illustration in order not to hide the position of the operator's hands. Note the handle of the bronchoscope is to the right.]
[FIG. 63.—The heavy laryngoscope has been removed leaving the light bronchoscope in position. The operator is inserting forceps. Note how the left hand of the operator holds the tube lightly between the thumb and first two fingers of the left hand, while the last two fingers are hooked over the upper teeth of the patient "anchoring" the tube to prevent it moving in or out or otherwise changing the relation of the distal tube-mouth to a foreign body or a growth while forceps are being used. Thus, also, any desired location of the tube can be maintained in systematic exploration. The assistant's left hand is dropped out of the way to show the operator's method. The assistant during bronchoscopy holds the bite-block like a thimble on the index finger of the left hand, and the assistant should be on the right side of the patient. He is here put wrongly on the left side so as not to hide the instruments and the manner of holding them.]
Examination of the Trachea and Bronchi.—All bronchial orifices must be identified seriatim; because this is the only way by which the bronchoscopist can know what part of the tree he is examining. Appearances alone are not enough. It is the order in which they are exposed that enables the inexperienced operator to know the orifices. After the removal of the laryngoscope, the bronchoscope is to be held by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooking over the upper teeth, while the thumb and index finger hold the bronchoscope, clamping it to the teeth tightly or loosely as required (Fig. 63). Thus the tube may be anchored in any position, or at any depth, and the right hand which was directing the tube may be used for the manipulation of instruments. The grasp of the bronchoscope in the right hand should be similar to that of holding a pen, that is, the thumb, first, and second fingers, encircle the shaft of the tube. The bronchoscope should never be held by the handle (Fig. 64) for this grasp does not allow of tactile sense transmission, is rigid, awkward, and renders rotation of the tube a wrist motion instead of but a gentle finger action. Any secretion in the trachea is to be removed by sponge pumping before the bronchoscope is advanced. The inspection of the walls of the trachea is accomplished by weaving from side to side and, if necessary, up and down; the head being deflected as required during the search of the passages, so that the larynx be not made the fulcrum in the lever-like action.
[FIG. 64.—At A is shown an incorrect manner of holding the bronchoscope. The grasp is too rigid and the position of the hand is awkward. B, Correct manner, the collar being held lightly between the finger and the thumb The thumb must not occlude the tube mouth.]
The Fulcrum of the Bronchoscopic Lever is at the Upper Thoracic Aperture; Never at the Larynx.—Disregard of this rule will cause subglottic edema and will limit the lateral motion of the tip of the bronchoscope. It is the function of the assistant to make the head and neck follow the direction of the proximal end of the bronchoscope and thus avoid any pressure on the larynx (see Peroral Endoscopy, Fig. 135, p. 164).
In passing down the trachea the following two rules must be kept in mind: 1. Before attempting to enter either main bronchus the carina must be identified. 2. Before entering either main bronchus the orifices of both should be identified and inspected. The carina is identified as a sharp vertical spur (recumbent patient) at the distal end of the trachea, on either side of which are the openings of the main bronchi. As the carina is situated to the left of the midline of the trachea, the lip of the bronchoscope should be turned toward the left, and slight lateral pressure should be made on the left tracheal wall while the head of the patient is held slightly to the right. This will expose the left bronchial orifice and carina.
Entering the Bronchi.—The lip of the bronchoscope should be turned in the direction of the bronchus to be explored, and the axis of the bronchoscope should be made to correspond as nearly as possible to the axis of this bronchus. The position of the lip is designated by the direction taken by the handle. Upon entering the right bronchus, the handle of the bronchoscope is turned horizontally to the right, and at the same time the assistant deflects the head to the left.
The right upper-lobe bronchus is recognized by its vertical spur; the orifice is exposed by displacing the right lateral wall of the right main bronchus at the level of the carina. Usually this orifice will be thus brought into view. If not the bronchoscope may be advanced downward 1 or 2 cm., carefully to avoid overriding. This branch is sometimes found coming off the trachea itself, and even if it does not, the overriding of the orifice is certain if the right bronchus is entered before search is made for the upper-lobe-bronchial orifice. The head must be moved strongly to the left in order to view the orifice. A lumen image of the right upper-lobe bronchus is not obtainable because of the sharp angles at which it is given off. The left upper-lobe bronchus is entered by keeping the handle of the bronchoscope (and consequently the lip) to the left, and, by keeping the head of the patient strongly to the right as the bronchoscopist goes down the left main bronchus. This causes the lip of the bronchoscope to bear strongly on the left wall of the left main bronchus, consequently the left upper-lobe-bronchial orifice will not be overridden. The spur separating the upper-lobe-bronchial orifice from the stem bronchus is at an angle approximately from two to eight o'clock, as usually seen in the recumbent patient. A lumen image of a descending branch of the upper-lobe bronchus is often obtained, if the patient's head be borne strongly enough to the right.
[FIG. 65.—Schema illustrating the entering of the anteriorly branching middle lobe bronchus. T, Trachea; B, orifice of left main bronchus at bifurcation of trachea. The bronchoscope, S, is in the right main bronchus, pointing in the direction of the right inferior lobe bronchus, I. In order to cause the lip to enter the middle lobe bronchus, M, it is necessary to drop the head so that the bronchoscope in the trachea TT, will point properly to enable the lip of the tube mouth to enter the middle lobe bronchus, as it is seen to have done at ML.]
Branches of the stem bronchus in either lung are exposed, or their respective lumina presented, by manipulation of the lip of the bronchoscope, with movement of the head in the required direction. Posterior branches require the head quite high. A large one in the left stem just below the left upper-lobe bronchus is often invaded by foreign bodies. Anterior branches require lowering the head. The middle-lobe bronchus is the largest of all anterior branches. Its almost horizontal spur is brought into view by directing the lip of the bronchoscope upward, and dropping the head of the patient until the lip bears strongly on the anterior wall of the right bronchus (see Fig. 65).