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 acc.u.mulated 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 a.s.sociated 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 deglut.i.tion, 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 p.r.o.ne 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 pa.s.sing 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 c.h.i.n.k 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 ill.u.s.trating 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 a.s.sistant 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 ill.u.s.trating 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 advent.i.tious 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 pa.s.s 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 advent.i.tious 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 ant.i.tuberculous 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.

[97] CHAPTER IX--INTRODUCTION OF THE BRONCHOSCOPE

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.

TECHNIC OF BRONCHOSCOPY

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 a.s.sistant.

The glottis is exposed by left-handed laryngoscopy. The instrument-a.s.sistant 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 c.h.i.n.k 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 a.s.sistant 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 pa.s.sage. 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 ill.u.s.trating the introduction of the bronchoscope through the glottis, rec.u.mbent 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 ill.u.s.trating 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 pa.s.sages, for while the lower air pa.s.sages are usually free from bacteria, the esophagus is a septic ca.n.a.l. 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 a.s.sistant's left hand should be at the patient's mouth holding the bite-block. This is removed and the a.s.sistant is on the wrong side of the table in the ill.u.s.tration 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 a.s.sistant's left hand is dropped out of the way to show the operator's method. The a.s.sistant during bronchoscopy holds the bite-block like a thimble on the index finger of the left hand, and the a.s.sistant 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 anch.o.r.ed 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 pa.s.sages, 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 a.s.sistant 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 pa.s.sing 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 (rec.u.mbent 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 a.s.sistant deflects the head to the left.