Rigid endoscopies

Rigid endoscopies in ent

1. Rigid esophagoscopy, bronchoscopy & direct laryngoscopy Dr. Sanjay Maharjan Resident, ENT_HNS Manipal teaching hospital Pokhara .

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

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

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

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

6. 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

7. 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

8. 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

9. 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

10. Rigid esophagoscopy

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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

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

19. 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

20. Surgical management:

21. 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

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

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

24. 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

25. 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

26. 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

27. Rigid Bronchoscopy

28. 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

29. 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

30. 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

31. 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 ..

32. Scope in right bronchus Scope in left bronchus

33. 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.

34. 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

35. Thank you…..