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Examination of child larynx by flexible fiberoptic laryngoscope
International Journal of Pediatric Otorhinolaryngologv, 5 (1983) 317- 323
317
Elsevier
Examination of child larynx by flexible fiberoptic laryngoscope * Tetsuzo Inouye Department of Otolao,ngology, National Defense Medical College, TokorozawaCity, Saitama (Japan)
(Received November 5th, 1982) (Accepted February 23rd, 1983)
Key words: fiberoptic laryngoscope -- subglottic stenosis -- laryngeal trauma -- laryngeal papilloma
Summary F o u r cases of laryngeal dysfunction are presented. The substantial advantages derived from the use of flexible fiberoptic instruments in children is described, together with a description of 3 scopes developed by the author.
Introduction To date, we have developed several types of fiberoptic laryngoscopes, viz.: Type 6C. This instrument is used primary for bronchoscopic examination. However, its excellent flexibility and viewing capability also allow it to be used for the examination of the adolescent larynx. It has the added advantage of a procedural channel through which biopsy may be performed (Fig. 1). Type L. The primary use of this scope is examination of the larynx. N o matter how misshapen the larynx is, the 90 ° and 130 ° flexibility of this instrument allow excellent viewing in either direction. Examination of the subgiottic area is accomplished with ease (Fig. 2). • Type P. Examination of the nasopharyngeal and laryngeal areas in infant's is the basic function of this scope. It is of smaller size and shorter length than the above, lending itself to use in small children and infants (Fig. 3).
* Presented paper, Third International Conference in Paediatric Otolaryngology, Bath, 16-18 September, 1982. 0165-5876/83/$03.00 © 1983 Elsevier Science Publishers B.V,
318
Fig. 1. Type C fiberoptic laryngoscope. Good flexibility and excellent view. Mainly used for bronchoscopy and laryngoscopy. Fig. 2. Type L fiberoptic laryngoscope. Mainly used for laryngeal examination. Flexibility is excellent. Fig. 3. Type P fiberoptic laryngoscope. Good only for examination purposes. No biopsy, no procedural channel,
Technique for the use of flexible fiberoptic scopes in children Following light surface anesthesia to the nose, pharynx and larynx, the child is seated on the examining chair, The appropriate scope is introduced into either nostril, and the tip advanced to the laryngeal inlet. Once the laryngeal inlet is identified, it may be demonstrated to persons other than the examiner by use of a videoscopic monitor, and recorded on video cassette tape. Movie and still cameras may be used for recording at any time, and replay of the video tape allows detailed examination and analysis of the pathology after the procedure.
Case Studies
A - - Diagnosis: bilateral posticus paralysis A two-year-old male with a history of multiple hospital admissions for aspiration pneumonia was bronchoscoped with a 6C scope because of dyspnea, stridor,
319
Fig. 4. Vocal cords fluctuate both in inspiration and expiration.
dysphagia, and a 20-month period of tube-feeding necessitated by the latter. Although he weighed 2570 g at birth, he was now undernourished and exhibited marked stridor, moderate inspiratory suprasternal retraction, and a b u n d a n t chest secretions. Both vocal cords fluctuated on inspiration and expiration. Both abduction and adduction are impaired (Figs. 4 and 5). A motion picture was taken with the tip of the scope fixed at 0.5 cm above the
Fig. 5. Both arytenoids do not move.
320
Fig. 6. Stenosis of very upper part of trachea above the ligation of fistula. Fig. 7. Marked stenosis at subglottic space probably caused by prolonged endotracheal intubation.
vocal cord. M o m e n t - t o - m o m e n t analysis of laryngeal motility is substantially simplified by the stop-motion technique. B - - diagnosis: subglottic stenosis
A 6-year-old male with a history of an H-type tracheoesophageal fistula at the T I - T 2 level, attended by all the pulmonary complications, was bronchoscoped with a Type L scope, because of dysphagia, dyspnea and stridor. His fistula had been
Fig. 8. T-tube insertion after removal of the stenosis. Fig. 9. Markedly misshaped cervical spines, esophagus and larynx.
321 demonstrated by esophagram and he had been operated upon at the age of two weeks. Because the site of the ligation and removal of the fistula was identified slightly lower, his subglottic stenosis was probably caused by prolonged pressure from an overinflated endotracheal cuff (Fig. 6). The patient still has a certain extent of dysphasia; however, dyspnea and stridor have been markedly improved, and chest sounds are much clearer than before the operation. Fortunately, the patient has no laryngeal paralysis, and he has learned how to swallow, which he could not do at all before the operation. During his sleep, his respirations are quieter but he has some stridor when he cries. All in all, the patient maintans good respiration. C - - Diagnosis: stenosis o f upper trachea
This 9-year-old male had been thrown out of a car at the age of 5. This resulted in severe injury to this larynx and upper trachea, necessitating a tracheostomy tube which he had worn since. Laryngoscopic examination with a type 6C scope revealed a subglottic stenosis, probably the result of prolonged endotracheai intubation. Fortunately, the patient has neither laryngeal paralysis nor stenosis of the larynx in spite of granulation tissue (Fig. 7). Although the patient was able to breathe through the larynx to a certain extent without the tracheostomy tube, the latter was necessary for good permanent respiration. A tracheo-fissure and removal of stenosis was performed and a T-tube was left in place to insure adequate respiration (Fig. 8).
Fig. 10. Very narrowed tracheal stenosis. Fig. 11. Regrowthof papilloma of posterior part of left vocal cord with narrowed trachea behind.
322
Fig. 12. Marked stenosis of upper trachea. Space respiration is very limited.
Respiratory distress was markedly improved 6 months after the operatio n, and the traCheostomy tube was removed. This T-tube insertion technique had been widely applied in the surgical treatment of laryngotracheal stenosis. D - - Diagnosis: subglottic stenosis
A 22-year-old male was referred to the author for laryngoscopy in 1965 because of laryngeal papollomatosis first treated with 3000 rad of external radiation at the age of two. Repeated excisions of papillomatas had left him almost aphonic. To complicate matters further, his cervical spines are disfigured, he has radiationinduced kyphosis, and is substantially under the norm for height and weight (Figs. 9 and 10). In spite of the rigidity of his neck, direct rigid laryngoscopy, has been accomplished many times over the past years. Removal of the papilloma has been best accomplished under local anesthesia using Frenkel laryngeal forceps to overcome the difficulty of flexing and extending the patient's neck. Since we have developed the flexible laryngofiberscopes, we have relied on this scope to remove the papilloma satisfactorily (Fig. 11). Fig. 12 demonstrates the marked subglottic stenosis and the diminished respiratory space remaining in this patient. Discussion
Flexible fiberoptic laryngoscopes have been used during the past few years, because of their flexibility and minimum discomfort to the children. A child usually tolerates the procedure very satisfactorily. On the other hand, the scope has some disadvantages because of the limitation of the visual field. The removal of foreign bodies is one of the disadvantages. The advantages and disad-
323 TABLE I ADVANTAGES AND DISADVANTAGES OF RIGID LARYNGOSCOPE AND FIBEROPTIC LARYNGOSCOPE
Handling Complications Resolving power Photography Removal of foreign body Biopsy Discomfort Observations Ventillation Intervention possibility
Rigid laryngoscope
Fiberoptic laryngoscope
difficult often clear excellent possible in every case possible in every case much clear good possible in almost every case
easy rare more to be investigated good limited to certain cases possible to a certain extent little clear good limited mainly to Type C
v a n t a g e s o f the flexible f i b e r o p t i c l a r y n g o s c o p e versus the rigid l a r y n g o s c o p e are s h o w n in T a b l e I.
Conclusion F l e x i b l e f i b e r o p t i c l a r y n g o s c o p e s p r o v i d e an easily h a n d l e d , w e l l - t o l e r a t e d m o d a l ity for the e x a m i n a t i o n of the n a s o p h a r y n x a n d l a r y n g o t r a c h e a l areas o f c h i l d r e n . C o o p e r a t i o n f r o m c h i l d r e n is excellent. T h e s c o p e s p r o v i d e v e r y c l e a r v i e w i n g , a n d c a m e r a s c a n be m o u n t e d for p e r m a n e n t r e c o r d i n g o n film o r v i d e o t a p e .
References 1 Greenblatt, G.M., Fiberoptic illuminating laryngoscope with remote light source--further development, Anesthesia Analgesia, 60 (1981) 841-843. 2 Klein, H.C., Why can't physicians examine the larynx? Amer. Med. Ass. 247 (1982) 2111. 3 Silberman, H.D., The use of the flexible fiberoptic nasopharyngolaryngoscope in the pediatric upper airway, Otolaryng. Clin. North Amer., I1 (1978) 365-371. 4 Tobin, H., Office fiberoptic laryngeal photography, Otolaryng. Head Neck Surg., 88 (1980) 172-173
317
Elsevier
Examination of child larynx by flexible fiberoptic laryngoscope * Tetsuzo Inouye Department of Otolao,ngology, National Defense Medical College, TokorozawaCity, Saitama (Japan)
(Received November 5th, 1982) (Accepted February 23rd, 1983)
Key words: fiberoptic laryngoscope -- subglottic stenosis -- laryngeal trauma -- laryngeal papilloma
Summary F o u r cases of laryngeal dysfunction are presented. The substantial advantages derived from the use of flexible fiberoptic instruments in children is described, together with a description of 3 scopes developed by the author.
Introduction To date, we have developed several types of fiberoptic laryngoscopes, viz.: Type 6C. This instrument is used primary for bronchoscopic examination. However, its excellent flexibility and viewing capability also allow it to be used for the examination of the adolescent larynx. It has the added advantage of a procedural channel through which biopsy may be performed (Fig. 1). Type L. The primary use of this scope is examination of the larynx. N o matter how misshapen the larynx is, the 90 ° and 130 ° flexibility of this instrument allow excellent viewing in either direction. Examination of the subgiottic area is accomplished with ease (Fig. 2). • Type P. Examination of the nasopharyngeal and laryngeal areas in infant's is the basic function of this scope. It is of smaller size and shorter length than the above, lending itself to use in small children and infants (Fig. 3).
* Presented paper, Third International Conference in Paediatric Otolaryngology, Bath, 16-18 September, 1982. 0165-5876/83/$03.00 © 1983 Elsevier Science Publishers B.V,
318
Fig. 1. Type C fiberoptic laryngoscope. Good flexibility and excellent view. Mainly used for bronchoscopy and laryngoscopy. Fig. 2. Type L fiberoptic laryngoscope. Mainly used for laryngeal examination. Flexibility is excellent. Fig. 3. Type P fiberoptic laryngoscope. Good only for examination purposes. No biopsy, no procedural channel,
Technique for the use of flexible fiberoptic scopes in children Following light surface anesthesia to the nose, pharynx and larynx, the child is seated on the examining chair, The appropriate scope is introduced into either nostril, and the tip advanced to the laryngeal inlet. Once the laryngeal inlet is identified, it may be demonstrated to persons other than the examiner by use of a videoscopic monitor, and recorded on video cassette tape. Movie and still cameras may be used for recording at any time, and replay of the video tape allows detailed examination and analysis of the pathology after the procedure.
Case Studies
A - - Diagnosis: bilateral posticus paralysis A two-year-old male with a history of multiple hospital admissions for aspiration pneumonia was bronchoscoped with a 6C scope because of dyspnea, stridor,
319
Fig. 4. Vocal cords fluctuate both in inspiration and expiration.
dysphagia, and a 20-month period of tube-feeding necessitated by the latter. Although he weighed 2570 g at birth, he was now undernourished and exhibited marked stridor, moderate inspiratory suprasternal retraction, and a b u n d a n t chest secretions. Both vocal cords fluctuated on inspiration and expiration. Both abduction and adduction are impaired (Figs. 4 and 5). A motion picture was taken with the tip of the scope fixed at 0.5 cm above the
Fig. 5. Both arytenoids do not move.
320
Fig. 6. Stenosis of very upper part of trachea above the ligation of fistula. Fig. 7. Marked stenosis at subglottic space probably caused by prolonged endotracheal intubation.
vocal cord. M o m e n t - t o - m o m e n t analysis of laryngeal motility is substantially simplified by the stop-motion technique. B - - diagnosis: subglottic stenosis
A 6-year-old male with a history of an H-type tracheoesophageal fistula at the T I - T 2 level, attended by all the pulmonary complications, was bronchoscoped with a Type L scope, because of dysphagia, dyspnea and stridor. His fistula had been
Fig. 8. T-tube insertion after removal of the stenosis. Fig. 9. Markedly misshaped cervical spines, esophagus and larynx.
321 demonstrated by esophagram and he had been operated upon at the age of two weeks. Because the site of the ligation and removal of the fistula was identified slightly lower, his subglottic stenosis was probably caused by prolonged pressure from an overinflated endotracheal cuff (Fig. 6). The patient still has a certain extent of dysphasia; however, dyspnea and stridor have been markedly improved, and chest sounds are much clearer than before the operation. Fortunately, the patient has no laryngeal paralysis, and he has learned how to swallow, which he could not do at all before the operation. During his sleep, his respirations are quieter but he has some stridor when he cries. All in all, the patient maintans good respiration. C - - Diagnosis: stenosis o f upper trachea
This 9-year-old male had been thrown out of a car at the age of 5. This resulted in severe injury to this larynx and upper trachea, necessitating a tracheostomy tube which he had worn since. Laryngoscopic examination with a type 6C scope revealed a subglottic stenosis, probably the result of prolonged endotracheai intubation. Fortunately, the patient has neither laryngeal paralysis nor stenosis of the larynx in spite of granulation tissue (Fig. 7). Although the patient was able to breathe through the larynx to a certain extent without the tracheostomy tube, the latter was necessary for good permanent respiration. A tracheo-fissure and removal of stenosis was performed and a T-tube was left in place to insure adequate respiration (Fig. 8).
Fig. 10. Very narrowed tracheal stenosis. Fig. 11. Regrowthof papilloma of posterior part of left vocal cord with narrowed trachea behind.
322
Fig. 12. Marked stenosis of upper trachea. Space respiration is very limited.
Respiratory distress was markedly improved 6 months after the operatio n, and the traCheostomy tube was removed. This T-tube insertion technique had been widely applied in the surgical treatment of laryngotracheal stenosis. D - - Diagnosis: subglottic stenosis
A 22-year-old male was referred to the author for laryngoscopy in 1965 because of laryngeal papollomatosis first treated with 3000 rad of external radiation at the age of two. Repeated excisions of papillomatas had left him almost aphonic. To complicate matters further, his cervical spines are disfigured, he has radiationinduced kyphosis, and is substantially under the norm for height and weight (Figs. 9 and 10). In spite of the rigidity of his neck, direct rigid laryngoscopy, has been accomplished many times over the past years. Removal of the papilloma has been best accomplished under local anesthesia using Frenkel laryngeal forceps to overcome the difficulty of flexing and extending the patient's neck. Since we have developed the flexible laryngofiberscopes, we have relied on this scope to remove the papilloma satisfactorily (Fig. 11). Fig. 12 demonstrates the marked subglottic stenosis and the diminished respiratory space remaining in this patient. Discussion
Flexible fiberoptic laryngoscopes have been used during the past few years, because of their flexibility and minimum discomfort to the children. A child usually tolerates the procedure very satisfactorily. On the other hand, the scope has some disadvantages because of the limitation of the visual field. The removal of foreign bodies is one of the disadvantages. The advantages and disad-
323 TABLE I ADVANTAGES AND DISADVANTAGES OF RIGID LARYNGOSCOPE AND FIBEROPTIC LARYNGOSCOPE
Handling Complications Resolving power Photography Removal of foreign body Biopsy Discomfort Observations Ventillation Intervention possibility
Rigid laryngoscope
Fiberoptic laryngoscope
difficult often clear excellent possible in every case possible in every case much clear good possible in almost every case
easy rare more to be investigated good limited to certain cases possible to a certain extent little clear good limited mainly to Type C
v a n t a g e s o f the flexible f i b e r o p t i c l a r y n g o s c o p e versus the rigid l a r y n g o s c o p e are s h o w n in T a b l e I.
Conclusion F l e x i b l e f i b e r o p t i c l a r y n g o s c o p e s p r o v i d e an easily h a n d l e d , w e l l - t o l e r a t e d m o d a l ity for the e x a m i n a t i o n of the n a s o p h a r y n x a n d l a r y n g o t r a c h e a l areas o f c h i l d r e n . C o o p e r a t i o n f r o m c h i l d r e n is excellent. T h e s c o p e s p r o v i d e v e r y c l e a r v i e w i n g , a n d c a m e r a s c a n be m o u n t e d for p e r m a n e n t r e c o r d i n g o n film o r v i d e o t a p e .
References 1 Greenblatt, G.M., Fiberoptic illuminating laryngoscope with remote light source--further development, Anesthesia Analgesia, 60 (1981) 841-843. 2 Klein, H.C., Why can't physicians examine the larynx? Amer. Med. Ass. 247 (1982) 2111. 3 Silberman, H.D., The use of the flexible fiberoptic nasopharyngolaryngoscope in the pediatric upper airway, Otolaryng. Clin. North Amer., I1 (1978) 365-371. 4 Tobin, H., Office fiberoptic laryngeal photography, Otolaryng. Head Neck Surg., 88 (1980) 172-173