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ENDOSCOPY
AK MishraMS,DNB, MNAMS
Types of Endoscopy
• Nasal Endoscopy• Laryngoscopy – Rigid / Flexible• Bronchoscopy – Rigid / Flexible• Oesophagoscopy – Rigid / Flexible
HISTORY
• Kussmaul (1868): oesophagoscopy technique from sword swallower
• Chevalier Jackson: Early 20th century– Distally lighted rigid scopes– Art of removal of FBs
• HH Hopkins: telescopic rod lens system• Ikeda (1958): Flexible fibreoptic broncho- &
esophagoscope
Advantages: Flexible fibreoptic scopes
• Safer, more comfortable for patient• Easier, More informative for physician• Periphery of bronchial tree accessible • Longer, more detailed examination under LA• Convenient for photography & documentation
Preparation of Patient
• Medical problems• Bleeding disorders• Adverse reactions to drugs• Appropriate Radiographic studies• Psychological preparation
Anesthesia
• General– in children– Adults if not cooperative for rigid DL,
B-scopy– Rigid Esophagoscopy
• Local– Adult rigid DL, B-scopy– Flexible fibreoptic scopy
Direct Laryngoscopy
• Is the specular examination of larynx• Direct visualisation of larynx• Is supplementary to IDL, not a substitute• No reversal of image
Endoscopic anatomy of larynx
• Base of tongue• Glosso-epiglottic folds• Epiglottis• Aryepiglottic folds• Pyriform sinus• False vocal cords• True vocal cords• Subglottis
Indications for DL• DIAGNOSTIC:• IDL is not possible or not conclusive but symptoms point to
laryngeal pathology eg Persistent hoarseness(>3 wks), dyspnoea, stridor, dysphagia
• See hidden areas of larynx – Infra hyoid epiglottis, Ant commissure, Ventricles, subglottis
• See hidden areas of hypopharynx – Base tongue, valleculae, Lower part of pyriform fossa
• Neoplasms – biopsy , Extent of growth• Trauma to neck – evaluation & possible stenting• VC paralysis –evaluation vs Cricoarytenoid arthritis • Unknown primary with cervical mets
Indications for DL Scopy
• Therapeutic:– Benign neoplasms, nodules, polyps - excision – Removal of FBs
Contraindications:– Dis of cervical spine– Marked airway obstruction– Recent cardiac decompensation
Technique
• Boyce position ( Barking dog position)– Neck flexed on chest by elevating head 10-15 cm– Head extended on atlanto – occipital jt
• Standard Laryngoscope• Anterior Commissure laryngoscope• Suspension laryngoscope
Post op care
• Coma position• Respiration / laryngospasm• Laryngeal oedema• Bleeding
Complications:- Injury to teeth/ lips/ tongue- Bleeding- Laryngeal oedema
Bronchoscopy- anatomy
• Trachea : 12/10 cm long – 13 x 18mm– 18 C shaped rings
• Carina – a sharp ridge• Rt main Bronchus: 2.5 cm long, 25 degree• Lt main Bronchus : 5 cm long, 45 degree• Secondary bronchi-3 on Rt, 2 on Lt • Tertiary bronchus: Bronchopulmonary
segments
Bronchopulmonary segmentsRt Lung
• Apical• Post• Ant• Lat• Med• Apical• Med basal• Ant basal• Lat basal• Post basal
Lt Lung• Apical-post• Ant• Sup Lingular• Inf Lingular• Apical• Med basal• Ant basal• Lat basal• Post basal
Bronchoscopy- endoscopic anatomy
• Tracheal rings• Thyroid gland- narrowing• Innominate artery – pulsation • Arch of aorta• Carina –sharp vertical crest
– Moves on respiration & cardiac pulsation
• Main bronchus: Rt is larger, more of a continuation of trachea– Expand in inspiration
B-scopy: Indications
• In nearly all patients with respiratory diseases that are not self limited and of short duration !
• A primary method of investigation in patients with diseases of respiratory system
Bronchoscopy Indications
• Diagnostic– Airway obstruction (e.g. tracheomalacia,
bronchomalacia)– Persistent/recurrent pneumonia– Tracheo-oesophageal fistula– Brushings for cytology– Transbronchial biopsy for histology– Failure to wean from ventilator– Haemoptysis
Bronchoscopy Indications
• Therapeutic– Removal of foreign body– Suctioning mucus plugs (e.g. in cystic fibrosis)– Facilitate endobronchial intubation for one lung– anaesthesia– Laser therapy– Balloon dilatation of trachea/bronchus
Suggested ETT and rigid bronchoscope sizes for childrenAge Cricoid airway Tracheal tube size Bronchoscope size
diameter (mm) ID ED (mm) Size ID EDPremature 4.0 2.5–3.0 3.5–4.0 2.5 3.2 4.0Term newborn 4.5 3.0–3.5 4.0–4.9 3.0 4.2 5.06 months 5.0 3.5–4.0 4.9–5.4 3.0 4.2 5.01 yr 5.5 4.0–4.5 5.4–6.2 3.5 4.9 5.72 yr 6.0 4.5–5.0 6.2–6.9 3.5 4.9 5.73 yr 7.0 5.0–5.5 6.9–7.4 4.0 5.9 6.75 yr 8.0 5.5–6.0 7.4–7.9 5.0 7.0 7.810 yr 9.0 6.5 cuffed 5.014 yr 11.0 6.5 cuffed 5.0
A larger bronchoscope may be helpful if there is a large air leak and IPPV is beingused.
B-scopy - technique
• Rigid bronchoscope may be passed into main bronchi
• Flexible scopes may be passed upto 4th order bronchi or even distally
• Biopsy• Bronchial washings• Bronchial brushings
Endoscopy – Flexible Fibreoptic
• OPD Procedure• LocalAnesthesia• In cervical ankylosis,
trismus• Less complications
Oesophagoscopy: Indications
• Diagnostic• Dysphagia• Neck Masses, VC paralysis• Hemetemesis• Oesophagitis
• Therapeutic• FB• Dilatation of Srictures• Varices• Stents in Malignancies
Oesophagoscopy: Contraindications
• Perforation previously• Cervical Ankylosis, Trauma• Trismus• Aneurysm of Aorta
Oesophagoscopy: Complications
• Bleeding• In Biopsy, Dilatation
• Perforation• Cervical:
– Cervical Tenderness– Surgical Emphysema
• Thoracic: (More serious)– Pain Chest, radiating to Back– Surgical Emphysema
Recent Advances: Video Laryngoscope
THANK YOU