DIAGNOSTIC

ENDOSCOPY OF THE
LARYNX, BRONCHUS,
AND ESOPHAGUS
Julie G. Cebrian, MD, FPSO-HNS

Introduction
1. Laryngoscopy
a. Indirect
b. Direct
2. Bronchoscopy
a. Rigid
b. Flexible
3. Esophagoscopy
a. Rigid
b. Flexible

Laryngoscopy
History :
Manuel Garcia 1830s
- first to successfully visualize
the larynx using dental mirror
and sunlight
Late 1800s Mckenzie, Jackson
and Hollinger
- design and modification of the
rigid endoscopes

Laryngoscopy
History
:
1930s advent of fiber optic illumination
1960s

flexible endoscopes

1970s stroboscopic techniques

INDIRECT MIRROR
Laryngoscopy
Probably the most important outpatient
diagnostic procedure for examining the larynx
Its biggest drawback is a tendency to cause
gagging in some patients
It may also not adequately allow for
visualization of the anterior commissure

INDIRECT MIRROR
Laryngoscopy
Indications:
1. Hoarseness
2. Problems associated with the protection of
the respiratory tract during swallowing
3. Cervical lymphadenopathy of unknown origin
4. Earache with normal examination findings

INDIRECT MIRROR
Laryngoscopy
Equipment:
1. Laryngeal Mirror
2. Head mirror with light source
3. Gauze

INDIRECT MIRROR
Laryngoscopy
Technique:

DIRECT Laryngoscopy

I. Direct Flexible Laryngoscopy

II. Videolaryngoscopy
III. Direct Rigid Laryngoscopy

DIRECT Laryngoscopy
I. Flexible Fiberoptic Laryngoscopy
Performed under local
anesthesia
Excellent for evaluating larynx
of trauma patient with
suspected cervical fracture
Can be used to evaluate
trachea and bronchi among
laryngectomized patients

DIRECT Laryngoscopy
I. Flexible Fiberoptic Laryngoscopy

DIRECT Laryngoscopy
II. Videolaryngoscopy
Equipment:
1. Laryngeal endoscope 70 and 90
2. Video camera
3. Video adapter
4. Light source and cable
5. Video recorder and monitor

DIRECT Laryngoscopy
II. Videolaryngoscopy

Technique:

DIRECT Laryngoscopy
II. Videolaryngoscopy
Advantage over Flexible Laryngoscopy
1. Clearer, sharper, brighter, larger images
2. Documentation of precise anatomic or
structural changes of the larynx
3. Clear video image and high resolution

DIRECT Laryngoscopy
III. Direct Rigid Laryngoscopy
Indications:
1. Staging and biopsy of laryngopharyngeal
lesions.
2. Rule out a second primary tumor or as a part
of the work-up of metastatic tumors of unknown origin
3. For patients in whom flexible laryngoscopy is
not possible

DIRECT Laryngoscopy
III. Direct Rigid Laryngoscopy
Indications:
4. Patients presenting with displaced or open
laryngeal fracture
5. Provides surgical approach

DIRECT Laryngoscopy
III. Direct Rigid Laryngoscopy
Instruments:

DIRECT Laryngoscopy
III. Direct Rigid Laryngoscopy
Technique:

DIRECT Laryngoscopy
III. Direct Rigid Laryngoscopy
Technique:

DIRECT Laryngoscopy
III. Direct Rigid Laryngoscopy
Complications:
1. Laryngeal edema
2. Bleeding
3. Airway compromise
4. Tooth fracture / avulsion

Direct laryngoscopy
FOREIGN BODY

Dentures in the right pyriform

sinus

Direct laryngoscopy
FOREIGN BODY

Fishbone stuck in the left

pyriform sinus

3 cm fishbone

BRONCHOSCOPY
Bronchoscopic Anatomy:
Trachea begins immediately
inferior to cricoid cartilage
Hollow tube 5 inches or 13 cms long
Supported by U-shaped bars of hyaline
cartilages
Divides into 2 main bronchi at the
carina

BRONCHOSCOPY
Bronchoscopic Anatomy:

Principal Bronchi

1. Right
Wider
Shorter (1 inch )
More vertical

2. Left
Narrower
Longer (2 inches)
More horizontal

BRONCHOSCOPY
Bronchoscopic Anatomy:

Secondary Bronchi

Lobar bronchus

Tertiary Bronchi

Segmental Bronchi
Gives rise to the
bronchopulmonary
segments

BRONCHOSCOPY
Bronchoscopic Anatomy:

The distance from the cricoid to the carina

is 10 cms
The lung is divided into 3 lobes on the right
and 2 lobes on the left.
There are a total of 18 bronchopulmonary
segments.

BRONCHOSCOPY
History :
Gustave Killian 1897

first translaryngeal examination of the trachea

reported the removal of a foreign body from
bronchus

Early 1900s Jackson

fully developed the art of bronchoscopy

BRONCHOSCOPY
History :
Ikeda and associates 1968

reported the development of flexible

bronchoscope

Flexible Bronchoscope

BRONCHOSCOPY
Equipment :

Rigid Bronchoscopes

BRONCHOSCOPY
Indications :
A. Diagnostic
1.

Hemoptysis

2.

Mass lesion on radiograph

3.

Transbronchial biopsy

4.

Infectious process

5.

Search for second primary malignancy

6.

Evaluate tracheal/bronchial stenosis

BRONCHOSCOPY
Indications :
B. Therapeutic
1. Removal of foreign bodies
2.

Suction of inspissated mucus

3.

Broncheoalveolar lavage

4.

Transbronchial drainage of abscess

5.

Removal of obstructing lesion

6.

Dilatation/resection of cicatricial scar

RIGID BRONCHOSCOPY
Advantages :
1.

Provides more secure control of the airway

and permits ventilatory support.

2.

Allows insertion of larger working instrument

and suction tubes.

RIGID BRONCHOSCOPY
Techniques Direct Insertion :

RIGID BRONCHOSCOPY
Techniques Direct Insertion :

RIGID BRONCHOSCOPY
Techniques Direct Insertion :

RIGID BRONCHOSCOPY
Techniques Direct Insertion :

RIGID BRONCHOSCOPY
Techniques Insertion Using a
Laryngoscope:

RIGID BRONCHOSCOPY
Techniques Insertion Using a
Laryngoscope:

FLEXIBLE BRONCHOSCOPY
Advantages :
1.

Ability to visualize the subsegmental bronchi

2.

Allows the bronchoscopist to obtain selective

biopsies including brush type

3.

May be done under local anesthesia

FLEXIBLE BRONCHOSCOPY
Complications :
1.

Hemorrhage from blind biopsies

2.

Hypoxia, anoxia, and respiratory arrest

3.

Laryngospasm

4.

Cardiac arrythmia

BRONCHOSCOPY

Normal Trachea

Inflamed Trachea

BRONCHOSCOPY

Mucus Plug in Trachea

BRONCHOSCOPY

Tumor eroding the right

main bronchus

Extensive tumor of the right

main bronchus

BRONCHOSCOPY

Peanut found in the right secondary

bronchus

ESOPHAGOSCOPY
History :
Bozzini 1809

attempted to examine the upper esophagus

using mirror

Kussmaul 1869
examined the esophagus using urethroscope

described the proper head position to pass the

endoscope

ESOPHAGOSCOPY
History :
Jackson 1900s
invented the first modern esophagoscope
1930s
the birth of fiberoptic illumination
1960s

introduction of flexible endoscopes

ESOPHAGOSCOPY
Anatomy:
The esophagus is a tubular
structure about 10 inches or
25 cms.
start at the cricopharyngeus
and ends at the cardia
Cervical part is curved to the
left and the thoracic part is
curved to the right.

ESOPHAGOSCOPY
Anatomy - Constrictions:
1.

Cricopharyngeus
16 cms from the incisors

2.

Left main Stem Bronchus

27 cms from the incisors
> Aortic constriction

3.

Gastroesophageal Junction
38 cms from the incisors
> Diaphragmatic constriction

ESOPHAGOSCOPY
Indications :
1.

Diagnostic tool for evaluation of suspected

tumors, trauma, strictures, benign
inflammatory condition.

2.

Surgical approach.

ESOPHAGOSCOPY
Rigid Esophagoscopy - Advantages :
1.

Evaluates the cervical esophagus

2.

Allows the use of larger cannula and surgical

instruments

3.

Allows manipulation and removal of foreign

bodies and stricture dilatation

ESOPHAGOSCOPY
Flexible - Advantages :
1.

Improves visualization of the gastroesophageal

junction

2.

Allows instrumentation in patients with severe

limitation of the range of motion of the neck

3.

Done under local anesthesia with sedation

ESOPHAGOSCOPY
Instruments :

Rigid Bronchoscopes

Rigid Esophagoscopes

ESOPHAGOSCOPY
Technique

ESOPHAGOSCOPY
Complications :
1.

Injury to upper aerodigestive tract

2.

Aspiration of esophagogastric fluid, oral

secretions, and blood

3.

Dental trauma

4.

Arrythmia or changes in blood pressure

ESOPHAGOSCOPY
FOREIGN BODY

COIN most common foreign body seen

ingested by children

ESOPHAGOSCOPY
FOREIGN BODY

Mouse trapped in the

esophagus

ESOPHAGOSCOPY
ESOPHAGEAL DISEASES

Esophageal varices

Esophageal cancer

END OF LECTURE