LARINGOSKOPIYA

From Big Medical Encyclopedia

LARINGOSKOPIYA (Greek larynx, laryng [os] a throat + skopeo — to observe, investigate) — a method of survey throats . Distinguish three types of L. — indirect, or mirror, direct and retrograde.

Indirect laringoskopiya

Fig. 1. The diagrammatic representation of a path of rays of light (are shown by a dotted line) at an indirect laringoskopiya.

The indirect laringoskopiya is developed by the singer and the singing teacher García (M. Garcia, 1854) for studying of physiology of a voice of singers. In medical practice indirect L. it is entered by Türk (L. Turck, 1866) and I. Chermaky (1863). It is made by means of a special guttural mirror (release various diameters — 8, 12, 15, 21, 25 and 27 mm). For lighting use the frontal lighter or the frontal mirror reflecting light of a lamp is (more often). It is more convenient to make a research in the darkened room. The light source (if use a frontal mirror) is from the right ear inspected. The doctor sits opposite to the patient. Having suggested the patient to open a mouth and to put out tongue, the doctor holds it I and III fingers of the left hand, and II fixes upper cutters or a lip of inspected. Having guided light reflected from a frontal mirror at area of a soft palate, the doctor the right hand enters through a mouth into an oral part of a throat previously warmed up (in order to avoid fogging) a guttural mirror. The handle of a mirror is held as a writing feather. The core of a mirror shall be at the left corner of the mouth inspected not to close a field of vision. The mirror is established thus that the rays of light reflected from it got into a throat (fig. 1). At the same time in a mirror the image of a throat is visible. According to instructions of the doctor inspected says a sound «And» or «Э», the throat rises and becomes more available to survey a little. Regarding cases it is necessary to push aside a little a dorsum of a mirror a soft palate and a uvula to' to a back wall of a throat. It is necessary to avoid a touch of a mirror To back and to sidewalls of a throat, and also a root of language in order to avoid emergence of an emetic reflex. To produce L. directly after meal pe it is recommended. If nevertheless there is an emetic reflex interfering carrying out L., apply a surface anesthesia — greasing of an oral and guttural part of a throat and upper part of a throat of 3 — 5% solution of cocaine, 1 — 2% solution of Dicainum or 2% solution of Pyromecainum. It is better to make, however, spraying by the same drugs.

Regarding cases (at the curtailed, rigid, thrown back epiglottis, short thick language) it is necessary to resort to procrastination of an epiglottis of a kpereda — to a root of language. It is made under surface anesthesia, by means of the special tool — the holder of an epiglottis or the guttural probe with cotton wool, navernuty on its end. At the same time language fixes either itself inspected, or the medical assistant.

It is necessary to consider that at indirect L. receive the «semi-return» image of a throat. The right and left half keep the places. The epiglottis (forming the forefront of a throat) is represented in a guttural mirror located behind. Back departments of a throat (e.g., arytenoid cartilages and interarytenoid space) are represented located in front.

Sometimes for detailed survey of a throat the doctor and the patient should hold also other positions. So, at insufficiently good visibility of back departments of a throat, during L. inspected shall stand, having inclined the head forward and down. The doctor at the same time sits on a chair or is kneeling. At insufficiently good visibility of front departments the doctor standing examines a throat of the patient sitting before it.

The Laringoskopichesky picture is normal also at some types of pathology. Fig. 1. The throat is normal: 1 — an epiglottis; 2 — vestibular folds; 3 — voice folds; 4 — a cherpalonadgortanny fold; 5 — an arytenoid cartilage; 6 — interarytenoid space; 7 — a back wall of a throat. Fig. 2. Acute laryngitis: sharp hyperemia and infiltration of an epiglottis, vestibular and voice folds, cherpalonadgortanny folds, interarytenoid space. Fig. 3. Acute epiglottiditis: hyperemia and infiltration of a mucous membrane of an epiglottis. Fig. 4. Acute inflammation of vestibular folds: sharp hyperemia and infiltration. Fig. 5. Acute inflammation of voice folds: sharp hyperemia and infiltration of a mucous membrane of voice folds. Fig. 6. Acute inflammation of interarytenoid space: sharp hyperemia and infiltration of a mucous membrane of arytenoid cartilages and interarytenoid space. Fig. 7. Hemorrhagic acute laryngitis: hemorrhage in the field of voice folds. Fig. 8. Acute subdepository (subcopular) laryngitis: sharp hyperemia and infiltration of a mucous membrane of subvoice area. Fig. 9. Phlegmonous laryngitis: abscess in the field of the left cherpalonadgortanny fold. Fig. 10. Chronic laryngitis: hyperemia and swelling of voice folds. Fig. 11. Pachydermia of voice folds: a massive thickening of an epithelium in the form of a fungoid eminence on voice folds. Fig. 12. Pachydermia of interarytenoid space: a thickening of an epithelium in interarytenoid space. Fig. 13. Singing small knots of a throat: symmetrically located dot eminences at free edge of voice folds.

First of all at L. it is visible (tsvetn. fig. 1) free part of an epiglottis, cherpalonadgortanny folds, then arytenoid cartilages and interarytenoid cutting. Folds of a threshold have an appearance of the rollers located in the sagittal plane. Voice folds are under them, being sharply highlighted against the background of surrounding educations in the white color and a brilliant surface. Ventricles of a throat to consider the thresholds located between folds and voice folds at L. it is not possible, but at the expressed atrophic processes it is possible to see entrances to these educations. At survey of voice folds pay attention to their color, character of a surface, mobility, symmetry of movements at phonation. During a breath (the glottis is opened) determine width of a glottis, examine a cavum infraglotticum. Quite often it is possible to examine also upper parts of a trachea (in some cases all trachea, up to bifurcation). At the same time the cartilaginous rings translucent through a mucous membrane are visible. At the adult width of a glottis in the widest back department apprx. 8 mm is normal.

Indirect L. it is made to each adult patient and the child of advanced age in a LOR-hospital, on outpatient appointment, at preventive LOR-survey. To children of younger age to produce indirect L. in most cases it is not possible.

The direct laringoskopiya

the Direct laringoskopiya (an autoskopiya, a direktoskopiya, an ortoskopiya) is entered into practice by Kirstein (A. Kirstein, 1895) and based on an opportunity to straighten a corner between an axis of an oral cavity and an axis of a throat at a zaprokidyvaniye of the head of inspected. For a straight line of L. use special devices — laryngoscopes.

Laryngoscopes — endoscopic devices for survey of a throat. Use of laryngoscopes began since 1895. Various authors called them autoskopa, orthoospreys, direktoskopa, autoscopic spatulas. In the USSR the most widespread were been Zimont's orthoospreys, Tikhomirov's pallet and universal direktoskop Uidritsa.

Fig. 2. The laryngoscope for children: 1 — a blade; 2 — the handle in which the battery is located; 3 — replaceable blades of various form and the size.
Fig. 3. The laryngoscope for adults: 1 — a blade; 2 — the light guide; 3 — the handle.

The replaceable straight lines and curved blades (pallets) used as in our country, and abroad laringoskopichesky sets, having and the handle are most convenient for survey of a throat and various manipulations (for removal of foreign bodys, introduction of bronchoscopic tubes and an endotracheal tube to a trachea). In the USSR such sets are issued the Leningrad production association «Krasnogvardeets» (fig. 2 — 4). They are intended for carrying out a laringoskopiya at children (fig. 2) and adult (fig. 3). Sets for adults and universal set differ from children's in types and the sizes of blades.

For performing surgeries operational laryngoscopes with the device for an emphasis on a body of the patient are used that allows to fix the laryngoscope and to release hands of the doctor.

The system of lighting in laryngoscopes is various. Earlier in Zimont's orthoospreys and Tikhomirov's pallets for lighting reflectors were used. The system of lighting by means of the tiny endoscopic bulb of an incandescence strengthened in a blade was more convenient. In Undrits's direktoskopa food of a bulb was carried out via the transformer from the ordinary power supply network. In modern laryngoscopes the system of lighting from network and accumulators and more convenient — from the dry batteries placed in the handle of the device is used.

In some cases illumination from a tiny endoscopic bulb of an incandescence is insufficient, in the course of work the electric contact can be broken and arise sparking that is inadmissible during the work with etherization, especially in pressures chamber. These shortcomings laryngoscopes with autonomous sources of lighting and fiber glass light guides are deprived. By means of such lighting on subject to observation illumination of any size can be created. There are various options of use of light guides in laryngoscopes. In one laryngoscopes the light guide located in a blade is combined with the filament lamp fed from the battery located in the handle. In others (hl. obr. nurseries) light from the lighting device is transferred on the light fiber glass cable strengthened in the handle of a blade by its proximal end and the prism located here goes to the distal end of the laryngoscope.

Fig. 4. Laringoskopichesky set with a fiber light guide: 1 — the lighter; 2 — a fiber glass cable; 3 — the laryngoscope; 4 — replaceable blades.
Fig. 5. Laringoskopichesky set for a pressure chamber: 1 — the lighter; 2 — a fiber glass cable; 3 — a stopper for a pressure chamber with the glass which is hermetically condensed in it; 4 — the laryngoscope and replaceable blades.

In the majority of laryngoscopes with light guides in a blade the light guide becomes stronger in such a way that its distal end is located close to the distal end of a blade, and proximal connects to a light cable. The laryngoscope of this kind is issued in the USSR the Leningrad production association «Krasnogvardeets» (fig. 4). The similar laryngoscope (fig. 5) is used to work in a pressure chamber. The lighting device is located out of a pressure chamber. Light from it is transmitted on light cables through glass of a sealing stopper to the laryngoscope in a pressure chamber.

Fig. 6. Operational laryngoscope of Jackson: 1 — a blade; 2 — the handle; 3 — an emphasis for a breast on a sliding bar.

Working parts of laryngoscopes — blades happen in the form of a continuous tube or a tube to a longitudinal cut, in the latter case it is more convenient to use tools for manipulations in a throat. Handles of laryngoscopes have also various form. They are straight lines round at laryngoscopes to battery food, massive to an emphasis for an index finger, sometimes in the form of a letter G, as at Jackson's laryngoscope. On handles of operational laryngoscopes there is a device for fastening of a chest emphasis (fig. 6). Handles of diagnostic laryngoscopes fasten to a blade usually at an angle 90 °, and operating rooms — at an acute angle.

For detailed survey of guttural ventricles the optical laryngoscope — faringoskop is used.

Blades of the majority of the released laryngoscopes are produced from brass with a mirror nickel covering therefore they maintain sterilization at a temperature not over 120 °. More and more widely the blades from stainless steel allowing any sterilization begin to be applied. Bulbs and light guides will not be sterilized, and disinfected in the cold ways accepted in the USSR.

In foreign literature there are messages on plastic blades disposable, but they are not produced in lots.

Technique of a direct laringoskopiya

Straight line of L. whenever possible make on an empty stomach. Mostly apply surface anesthesia of a mucous membrane of a throat and throat (3 — 5% solution of cocaine, 1 — 2% solution of Dicainum, 2% solution of Pyromecainum) with the corresponding premedication. In certain cases use a short-term anesthesia. During the research of the patient usually lies on spin with the head which is thrown back back, sits on a chair less often. In some cases the patient is stacked on a stomach. During introduction of the laryngoscope a proximal part of a blade (in some devices there is a special plate) with a big force leans on cutters of an upper jaw. In order to avoid an injury of these teeth use various devices — paste on a basic part of a blade of a strip of an adhesive plaster or enclose the gauze napkin curtailed into several layers. Sometimes put on the rubber tube cut lengthways upper cutters. The best method, however, is production of an individual mold — a safety lock from the hardening plastic, napr, pro-tacryl. In some cases introduction of the laryngoscope is more easily carried out not on the centerline, and sideways, from a corner of a mouth.

Fig. 7. Stages of introduction of the laryngoscope and laringoskopichesky pictures corresponding to them (below): and — introduction of a blade of the laryngoscope through a mouth along a root of language with a simultaneous zaprokidyvaniye of the head inspected (1 — an average lingual and epiglottidean sheaf, 2 — an epiglottis); — the end of a blade of the laryngoscope the epiglottis is pressed to a root of language (3 — arytenoid cartilages, 4 — interarytenoid cutting, 5 — voice folds; 6 — folds of a threshold); in — honor introduction of the end of a blade of the laryngoscope to voice folds (5 — voice folds, 6 — folds of a threshold, 7 — bifurcation of a trachea, 8 — rings of a trachea, the arrow specifies the direction of the movement of the laryngoscope at manipulations).

Process of introduction of a blade of the laryngoscope is usually divided into three stages.

1. Introduction of a blade of the laryngoscope through a mouth (it is more convenient at the put-out and recorded language of the patient) along a root of language with a simultaneous zaprokidyvaniye of the head inspected. An upper part of a blade of the laryngoscope (or a special plate) at the same time leans on cutters of an upper jaw more and stronger. The blade is entered into the bottom of a throat until the average lingual and epiglottidean linking and a free part of an epiglottis come into the view (fig. 7, a).

2. The handle of the laryngoscope is slightly led to a breast so that the end of a blade rounded edge of an epiglottis. Then the epiglottis the end of a blade is pressed to a root of language. For this purpose the handle of the device is a little taken away from a breast and the blade is got for free edge of an epiglottis. At the same time there are well foreseeable arytenoid cartilages, interarytenoid cutting, back departments of vestibular and voice folds (fig. 7,6).

3. Honor introduction of the end of a blade of the laryngoscope to voice folds. At the same time there are well foreseeable all departments of a throat (fig. 7, c). If visibility of a precomissure is insufficient, it is reasonable to press outside on area of a thyroid cartilage.

The laryngoscope, irrespective of its design, is usually entered the right hand. After introduction and settings of the laryngoscope in the necessary situation if there is a need for carrying out these or those manipulations for a throat (introduction of an endotracheal tube, removal of high-quality new growths, capture of a piece of fabric for gistol, researches, etc.), arrive depending on a design of the laryngoscope. So, the handle of the pallet of Tikhomirov, Undrits's direktoskop, the laryngoscope used to an intubation, and also Bryunings and Mezrin's bronchoscopes is fixed the left hand, leaving right free for carrying out these or those manipulations.

During the use the orthoosprey or an autoskopa install the special lever connected to the handle on area of a breast, fixing, thus, a blade of the tool in the necessary situation.

To special types direct L. belong suspended and basic L. Podvesnaya L. is that during the pressing by the pallet of a root of language use weight of the hanging-down head of the patient lying on spin — the head «is as if suspended» on the pallet. At basic L. pressure upon a root of language is provided with the counter-pressure of the lever, I opirat shchegosya on a special metal rack or on a breast of the patient (e.g., during the use of the laryngoscope of Jackson).

As a rule, straight line of L. creates possibilities for much more detailed survey of a throat and carrying out a large number of operative measures, than indirect L.

The retrograde laringoskopiya is made by means of a small nasopharyngeal mirror, a cut enter (previously heating) through a tracheostoma, edges the cut should be moved apart. The tool at the same time is turned by a specular surface up, towards a throat. For lighting the frontal lighter or a reflector use. When retrograde L. make on the operating table directly after opening of a trachea, it is reasonable to impose on edges of a section of a trachea (in interchondral intervals) ligatures from thick silk. The mirror is entered, having moved apart edges of a section of a trachea by means of the specified ligatures. Regarding cases it is possible to use Trusso's dilator. When retrograde L. make to the patient with the created tracheostoma, it is convenient to move apart its edges by means of a nasal dilator with averages (40 mm) or long (60 mm) sponges.

At retrograde L. the upper part of a trachea, a cavum infraglotticum and a lower surface of voice folds is visible.

Mikrolaringoskopiya

More and more is widely adopted a so-called mikrolaringoskopiya — survey of a throat by means of a special operative microscope (focal length of 350 — 400 mm). The throat through a microscope can be examined in combination with indirect L. Vrach and inspected hold the same position, as well as at traditional indirect L. At the same time light to a mirror is directed from the lighter who is available in a microscope. The image of a throat in a mirror is considered in a microscope (use 8-and 12,5-fold increase more often). Mikrolaringoskopiya is made usually without anesthesia, is more rare with a surface anesthesia. This method is applied to diagnosis and postoperative overseeing by patients.

Mikrolaringoskopiya in combination with a straight line of L. make both for diagnosis, and for carrying out endolaryngeal surgical interventions which owing to these or those reasons cannot be made under control of traditional methods L. Removal of the widespread papillomas and other high-quality new growths having the wide basis, extensive giperplazirovanny sites of a mucous membrane concerns to them. Mikrolaringoskopiya gives the chance more purposefully to take a piece of fabric for gistol, researches that is of great importance for early diagnosis of malignant new growths of a throat. The direct mikrolaringoskopiya is made, as a rule, under an insufflyatsionny or intubation anesthesia. In the latter case use the thinnest endotracheal tube.



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Yu. B. Preobrazhensky; Century of H. Sazontova (medical tekhn.).

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