Rigid esophagoscopy, bronchoscopy, and direct laryngoscopy are generally performed under general anesthesia for both diagnostic and therapeutic reasons. These procedures allow examination and biopsy of the larynx, lungs, and esophagus. Rigid esophagoscopy uses a 25cm rigid scope to examine the esophagus for tumors, strictures, or foreign bodies. Rigid bronchoscopy requires passing a rigid tube between the vocal cords into the trachea and main bronchi to remove foreign bodies or biopsy lung lesions. Direct laryngoscopy examines the larynx using small or large laryngoscopes inserted through the mouth. These procedures have risks of injury, bleeding, perforation, or other complications if not performed carefully.

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

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

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

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

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

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

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

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

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

12. Rigid esophagoscopy

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

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

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

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

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

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

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

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

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

22. • Surgical management:

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

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

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

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

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

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

35. Rigid Bronchoscopy

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

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

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

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

40. Scope in right bronchus Scope in left bronchus

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

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

45. THANK YOU…..