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

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