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SIMPLE DEVICE FOR LARYNGEAL ANAESTHESIA AT FIBREOPTIC BRONCHOSCOPY
989 SIMPLE DEVICE FOR LARYNGEAL ANAESTHESIA AT FIBREOPTIC BRONCHOSCOPY
SMOKING AND ORAL CONTRACEPTION IN CANCER OF THE CERVIX
SIR,-The usual way of anaesthetising the larynx and trachea during fibreoptic bronchoscopy is to instil lignocaine directly through the biopsy channel of the bronchoscope. When my colleagues Dr J. G. Hay and Dr J. R. Webb and I asked sixty patients
SIR,-The hypothesis linking risk of cervical cancer with male sexual behaviour (Sept. 11, p. 581) is persuasive, even convincing. Most of the epidemiological factors accepted as being associated with cervical malignancy fit within the concept of a venereally transmitted infective agent, presumably viral. Only two such associations-smoking and oral contraception-defied logical explanation on this basis, and Professor Skegg and his colleagues suggested the reason was likely to be an as yet unrecognised connection between these factors and sexual behaviour. This may be so; however, the effects of smoking and oral contraception on immune response could be an alternative explanation. Ferson et aLl reported, from a comparison with non-smoking matched controls, that male smokers, whether healthy or with stage I malignant melanoma, had reduced "natural killing" capacity of their blood leucocytes as well as lower blood levels of IgG and IgA. Ablin et al. used leucocyte adherence inhibition to demonstrate suppression of host immune response to malignant prostatic tissue Progesteroids have by exposure to diethylstilboestrol diphosphate. 3 also been labelled An increased risk of cervical cancer could therefore be expected in smokers and oral contraceptive takers if exposed to the infective causal agent whilst immunocompromised. Infection might be more easily contracted, less likely to subside spontaneously without sequelae, and immunosurveillance of any resultant abnormal cellular development could be defective.
was the most unpleasant part of a bronchoscopy 28% said passage of the bronchoscope through the larynx and 15% said anaesthesia of the larynx. I wish to describe a simple, inexpensive device for anaesthesia of the larynx and trachea. A 100 cm length of stiff autoclavable nylon tubing of 134 mm external diameter and 1 - 00 mm internal diameter (Portex Ltd, Hythe, Kent) is sealed at one end with a flame and a pair of forceps, ensuring that the tube will still pass through the biopsy channel of the bronchoscope. Small holes are made around the wall of the last 2 cm of the tube with a 23 G needle. These should be spaced out to avoid weakening the tube. A 19 G needle is placed in the open end of the tube. When fluid is injected through this needle a fine spray is produced at right angles to the long axis of the tube (figure). With the bronchoscope in the oropharynx the tube is passed through the suction channel of the bronchoscope and just through the open larynx. A guidewire may be used to stiffen the tube. Lignocaine is then injected through the tube from a syringe attached to the 19 G needle. A similar manoeuvre can be performed in the trachea and large bronchi. The patient usually coughs as the lignocaine sprays on to the larynx but subsequent passage of the bronchoscope seems to be much less unpleasant for the patient than it used to be with the established lignocaine instillation method. Smaller amounts of lignocaine are needed because the local anaesthetic can be more accurately applied where it is needed. The tube can be sterilised with the bronchoscope and reused. Fibreoptic bronchoscopy is unpleasant for the patient. Various premedications have been tried but the method of local anaesthesia is important. Anaesthesia of the superior layrngeal nerves by
what
holding lignocaine-soaked swabs in the pyriform fossae2is a complex and unpleasant procedure, and puncture of the cricothyroid membrane3to administer lignocaine directly to the airways can be hazardous. The device described costs a few pence and allows
more
controlled use of local anaesthetic.
Respiratory Function Laboratory, Guy’s Hospital, London SE1 9RT
P.J.REES
J, Higenbottam T, Holt D, Cochrane GM. Plasma concentraions of lignocaine during fibreoptic bronchoscopy. Thorax 1982; 37: 68-71. 2. Zavala DC. Bronchoscopy and cytology. In: Clark TJH, ed. Clinical investigation of respiratory disease. London: Chapman and Hall, 1981: 337-92. 3 Schillaci RF, Iacovoni VE, Conte RS. Transtracheal aspiration complicated by fatal endotracheal hemorrhage. N Engl J Med 1976; 295: 488-90. 1 Efthimiou
immunosuppressive.
Department of Obstetrics and Gynaecology, St James’s University Hospital, Leeds LS9 7TF
H. N. MACDONALD
PEPPERMINT OIL TO REDUCE COLONIC SPASM DURING ENDOSCOPY
SIR,-Colonic spasm can often be a hindrance to the colonoscopist cause the patient discomfort, particularly when no sedation is used, as during outpatient flexible sigmoidoscopy. Antispasmodic drugs such as hyoscine-N-butylbromide (’Buscopan’) and glucagon4,5 are used to produce colonic relaxation but they have to be given intravenously, which may be inconvenient with the patient and
in the left lateral position. Attention has been drawn to the use of enteric-coated peppermintoil capsules in the treatment of the irritable bowel syndrome.6 Peppermint oil is a safe substance, acting locally to produce smoothmuscle relaxation and we wondered if this naturally occurring carminative might relieve colonic spasm during endoscopy. We have used peppermint oil B.P., injected along the biopsy channel of the colonoscope, in twenty patients. In every case colonic spasm was relieved within 30 s, allowing easier passage of the instrument or assisting in polypectomy. As the oil may irritate the skin (or eye) we now use a diluted suspension of peppermint oil, with equally good effect. A peppermint oil preparation should be subjected to a prospective trial as an adjunct to colonoscopy. Royal Naval Hospital, Haslar, Gosport, Hants PO12 2AA
ROGER J. LEICESTER RICHARD H. HUNT
A, Lind A, Milton GW, Hersey P. Low natural killer-cell activity and immunoglobulin levels associated with smoking in human subjects. Int J Cancer 1979; 23: 603-09. 2. Ablin RJ, Bhatti RA, Guinan PD, Khin W. Modulatory effects of oestrogen on immunological responsiveness Clin Exp Immunol 1979; 38: 83-91. 3. Munroe JS. Progesteroids as immunosuppressive agents. J Reticulo Endothelial Soc 1971; 9: 361. 1. Ferson M, Edwards
4. Hunt RH.
5.
Colonoscopy intubation techniques with fluoroscopy. In: Hunt RH, Waye JD, eds. London: Colonoscopy: Techniques, clinical practice and colour atlas. London: Chapman & Hall, 1981: 144. Foster GE, Vellacott KD, Balfour TW, Hardcastle JD. Outpatient flexible fibreoptic sigmoidoscopy, diagnostic yield and the value of glucagon. Br J Surg 1981, 68: 463-64.
Tube in Olympus IT bronchoscope, showing spray.
6. Rees WDW, Evans
oil.
BK, Rhodes J. Treating irritable bowel syndrome with peppermint Br Med J 1979; ii: 835.
SMOKING AND ORAL CONTRACEPTION IN CANCER OF THE CERVIX
SIR,-The usual way of anaesthetising the larynx and trachea during fibreoptic bronchoscopy is to instil lignocaine directly through the biopsy channel of the bronchoscope. When my colleagues Dr J. G. Hay and Dr J. R. Webb and I asked sixty patients
SIR,-The hypothesis linking risk of cervical cancer with male sexual behaviour (Sept. 11, p. 581) is persuasive, even convincing. Most of the epidemiological factors accepted as being associated with cervical malignancy fit within the concept of a venereally transmitted infective agent, presumably viral. Only two such associations-smoking and oral contraception-defied logical explanation on this basis, and Professor Skegg and his colleagues suggested the reason was likely to be an as yet unrecognised connection between these factors and sexual behaviour. This may be so; however, the effects of smoking and oral contraception on immune response could be an alternative explanation. Ferson et aLl reported, from a comparison with non-smoking matched controls, that male smokers, whether healthy or with stage I malignant melanoma, had reduced "natural killing" capacity of their blood leucocytes as well as lower blood levels of IgG and IgA. Ablin et al. used leucocyte adherence inhibition to demonstrate suppression of host immune response to malignant prostatic tissue Progesteroids have by exposure to diethylstilboestrol diphosphate. 3 also been labelled An increased risk of cervical cancer could therefore be expected in smokers and oral contraceptive takers if exposed to the infective causal agent whilst immunocompromised. Infection might be more easily contracted, less likely to subside spontaneously without sequelae, and immunosurveillance of any resultant abnormal cellular development could be defective.
was the most unpleasant part of a bronchoscopy 28% said passage of the bronchoscope through the larynx and 15% said anaesthesia of the larynx. I wish to describe a simple, inexpensive device for anaesthesia of the larynx and trachea. A 100 cm length of stiff autoclavable nylon tubing of 134 mm external diameter and 1 - 00 mm internal diameter (Portex Ltd, Hythe, Kent) is sealed at one end with a flame and a pair of forceps, ensuring that the tube will still pass through the biopsy channel of the bronchoscope. Small holes are made around the wall of the last 2 cm of the tube with a 23 G needle. These should be spaced out to avoid weakening the tube. A 19 G needle is placed in the open end of the tube. When fluid is injected through this needle a fine spray is produced at right angles to the long axis of the tube (figure). With the bronchoscope in the oropharynx the tube is passed through the suction channel of the bronchoscope and just through the open larynx. A guidewire may be used to stiffen the tube. Lignocaine is then injected through the tube from a syringe attached to the 19 G needle. A similar manoeuvre can be performed in the trachea and large bronchi. The patient usually coughs as the lignocaine sprays on to the larynx but subsequent passage of the bronchoscope seems to be much less unpleasant for the patient than it used to be with the established lignocaine instillation method. Smaller amounts of lignocaine are needed because the local anaesthetic can be more accurately applied where it is needed. The tube can be sterilised with the bronchoscope and reused. Fibreoptic bronchoscopy is unpleasant for the patient. Various premedications have been tried but the method of local anaesthesia is important. Anaesthesia of the superior layrngeal nerves by
what
holding lignocaine-soaked swabs in the pyriform fossae2is a complex and unpleasant procedure, and puncture of the cricothyroid membrane3to administer lignocaine directly to the airways can be hazardous. The device described costs a few pence and allows
more
controlled use of local anaesthetic.
Respiratory Function Laboratory, Guy’s Hospital, London SE1 9RT
P.J.REES
J, Higenbottam T, Holt D, Cochrane GM. Plasma concentraions of lignocaine during fibreoptic bronchoscopy. Thorax 1982; 37: 68-71. 2. Zavala DC. Bronchoscopy and cytology. In: Clark TJH, ed. Clinical investigation of respiratory disease. London: Chapman and Hall, 1981: 337-92. 3 Schillaci RF, Iacovoni VE, Conte RS. Transtracheal aspiration complicated by fatal endotracheal hemorrhage. N Engl J Med 1976; 295: 488-90. 1 Efthimiou
immunosuppressive.
Department of Obstetrics and Gynaecology, St James’s University Hospital, Leeds LS9 7TF
H. N. MACDONALD
PEPPERMINT OIL TO REDUCE COLONIC SPASM DURING ENDOSCOPY
SIR,-Colonic spasm can often be a hindrance to the colonoscopist cause the patient discomfort, particularly when no sedation is used, as during outpatient flexible sigmoidoscopy. Antispasmodic drugs such as hyoscine-N-butylbromide (’Buscopan’) and glucagon4,5 are used to produce colonic relaxation but they have to be given intravenously, which may be inconvenient with the patient and
in the left lateral position. Attention has been drawn to the use of enteric-coated peppermintoil capsules in the treatment of the irritable bowel syndrome.6 Peppermint oil is a safe substance, acting locally to produce smoothmuscle relaxation and we wondered if this naturally occurring carminative might relieve colonic spasm during endoscopy. We have used peppermint oil B.P., injected along the biopsy channel of the colonoscope, in twenty patients. In every case colonic spasm was relieved within 30 s, allowing easier passage of the instrument or assisting in polypectomy. As the oil may irritate the skin (or eye) we now use a diluted suspension of peppermint oil, with equally good effect. A peppermint oil preparation should be subjected to a prospective trial as an adjunct to colonoscopy. Royal Naval Hospital, Haslar, Gosport, Hants PO12 2AA
ROGER J. LEICESTER RICHARD H. HUNT
A, Lind A, Milton GW, Hersey P. Low natural killer-cell activity and immunoglobulin levels associated with smoking in human subjects. Int J Cancer 1979; 23: 603-09. 2. Ablin RJ, Bhatti RA, Guinan PD, Khin W. Modulatory effects of oestrogen on immunological responsiveness Clin Exp Immunol 1979; 38: 83-91. 3. Munroe JS. Progesteroids as immunosuppressive agents. J Reticulo Endothelial Soc 1971; 9: 361. 1. Ferson M, Edwards
4. Hunt RH.
5.
Colonoscopy intubation techniques with fluoroscopy. In: Hunt RH, Waye JD, eds. London: Colonoscopy: Techniques, clinical practice and colour atlas. London: Chapman & Hall, 1981: 144. Foster GE, Vellacott KD, Balfour TW, Hardcastle JD. Outpatient flexible fibreoptic sigmoidoscopy, diagnostic yield and the value of glucagon. Br J Surg 1981, 68: 463-64.
Tube in Olympus IT bronchoscope, showing spray.
6. Rees WDW, Evans
oil.
BK, Rhodes J. Treating irritable bowel syndrome with peppermint Br Med J 1979; ii: 835.