Direct Laryngoscopy with Bronchoscopy

Description:

Direct laryngoscopy and bronchoscopy allows for visualization of the laryngeal structures and the upper bronchial tree using a rigid telescope. A rigid scope provides a clearer, higher resolution image than can be obtained with flexible fiberoptic laryngoscopy, but requires that the patient be anesthetized in order to tolerate the procedure.

Indications for Surgery:

Suspicion for any laryngeal or bronchial anomaly that cannot be definitively diagnosed on awake flexible fiberoptic laryngoscopy. A direct laryngoscopy setup is also required to perform endoscopic procedures on the larynx, such as biopsies or resections of vocal fold lesions (e.g., nodules, cysts, polyps, granulomas, papillomas).

Contraindications to Surgery:

Medical comorbidities that would preclude surgical or anesthesia risk.

Pre-Operative Evaluation:

A flexible fiberoptic laryngoscopic examination is performed prior to proceeding to direct laryngoscopy, unless the patient is unable to tolerate an awake examination.

Anesthesia:

General inhalation with spontaneous ventilation

Surgical Technique:

1. The patient is placed supine on the operating table and general anesthesia is induced intravenously and with mask inhalation. The patient remains spontaneously ventilating.
2. The table is rotated 90 degrees. A dental guard is placed over the maxillary teeth.
3. A laryngoscope is inserted into the pharynx and positioned to view the larynx, so that the vocal folds can be easily visualized. The laryngoscope can be suspended.
4. Additional anesthesia is obtained by spraying the vocal folds and trachea with 2% plain lidocaine.
5. The larynx is suctioned, and an adequate view of the glottis is confirmed.
6. A rigid bronchoscope is inserted through the barrel of the laryngoscope, and the supraglottis and glottis are examined.
7. The telescope or bronchoscope/telescope combination is passed through the vocal folds to examine the subglottis, and then further down to the carina.
8. The right and left mainstem bronchi are examined.
9. The patient is released from suspension, the laryngoscope is removed, and mask ventilation is resumed. Care of the patient is returned to the anesthesiologist for recovery.

Post-Operative Care:

• Direct laryngoscopy and bronchoscopy may be performed on an elective, outpatient basis
• No discharge medications are necessary, and the patient may resume a regular diet after the procedure.

Complications:

Complications from direct laryngoscopy and bronchoscopy are uncommon. If biopsy or other intervention is performed, there may be a risk of bleeding, granuloma or scar formation, or injury to local structures.