through the laryngoscope. Minor laryngeal procedures, such as removal of vocal cord polyps or granulomas, or even division of a posterior commissural stricture between the arytenoids, may be accomplished at this time. If considerable manipulation is required, it is preferable not to proceed at once to a further tracheal procedure, since glottic edema may become a problem postoperatively. In this way, tracheostomy may be avoided.

If the laryngeal lesion is of great complexity, such as a complete subglottic stenosis that will require laryngofissure and stenting, the patient may be transferred to the care of the otolaryngologist until that problem is resolved. Endoscopic examination may reveal details that were not evident from radiologic images, particularly in a high subglottic laryngotracheal lesion. I prefer to be certain that a complex laryn-geal reconstruction has truly succeeded before proceeding to an extended tracheal or laryngotracheal reconstruction. Such patients often already have a distal tracheostomy in place, which is removed at the time of the subsequent reconstruction.2 Maddaus and colleagues preferred to perform repair of both lesions concurrently, establishing a prolonged tracheostomy with stent placement for later removal.3

Pilling Suctiotip

figure 5-2 Basic equipment for a rigid bronchoscopy. From top to bottom: A, Jackson bronchoscope (Pilling) with a ventilatory sidearm and eyepiece cap at the right. Bronchoscopes of internal diameter 7, 8, and 9 mm are routinely provided for adult examination. B, Metal centimeter ruler. C, StorzHopkins telescope with a "gasket" to seal the bronchoscope. Telescopes of0°, 30°, and 90° are made available in the kit. D, Adequate large-bore suction tip, especially useful for brisk or massive hemoptysis, thick secretions, biopsy, or coring-out procedures.

figure 5-2 Basic equipment for a rigid bronchoscopy. From top to bottom: A, Jackson bronchoscope (Pilling) with a ventilatory sidearm and eyepiece cap at the right. Bronchoscopes of internal diameter 7, 8, and 9 mm are routinely provided for adult examination. B, Metal centimeter ruler. C, StorzHopkins telescope with a "gasket" to seal the bronchoscope. Telescopes of0°, 30°, and 90° are made available in the kit. D, Adequate large-bore suction tip, especially useful for brisk or massive hemoptysis, thick secretions, biopsy, or coring-out procedures.

Rigid Bronchoscopy

This technique best entails general anesthesia, which may be given safely even in the face of severe airway obstruction (see Chapter 18,"Anesthesia for Tracheal Surgery"). Numerous techniques have been described for the anesthetic management of rigid bronchoscopy under general anesthesia, including jet ventilation. I have found the Jackson ventilating bronchoscope, with a side port for attachment of an anesthesia tube and window eyepiece or telescopic gasket, to be highly satisfactory. The surgeon must be on hand during induction of anesthesia, especially when there is any degree of airway obstruction. Equipment for relief of obstruction must be immediately available if obstruction is present, and the anesthetist must have confidence that the surgeon can establish an airway at any moment. This presupposes complete competence in rigid bronchoscopy, which unfortunately seems in danger of becoming a lost art.

Our bronchoscopic set-up for examination of an adult includes 7, 8, and 9 mm rigid Jackson ventilating bronchoscopes (Figure 5-2). The tips of these bronchoscopes are oblique with rounded edges, and are easier to introduce through a tight stenosis or past a tumor than are the spade-like tips of the Storz instruments, which may also elevate a flap of mucosa (Figure 5-3). A large bore suction tip must be available. The Storz Hopkins telescopes are introduced through adapters placed over the open end of the rigid bronchoscope to provide a seal and permit ventilation (see Figure 5-2). When the telescope is not in place, a window cap is placed over the proximal end of the bronchoscope. Also available in the endoscopic room or immediately adjacent should be a kit of sterile pediatric Jackson rigid bronchoscopes of the following sizes: 3.5, 4, 5, and 6 mm. These may be used serially to dilate tightly stenotic lesions, as described in Chapter 19, "Urgent Treatment of Tracheal Obstruction." The Storz pediatric bronchoscopes are superb for diagnosis in children, but for dilation, the tip of the Jackson pediatric bronchoscope is preferable. If it is known that a high degree of obstruction is present, these bronchoscopes should be on the instrument table initially, along with selected small bougies (see Figure 19-1 in Chapter 19, "Urgent Treatment of Tracheal Obstruction").

Even if the patient has a preexisting tracheostomy, bronchoscopic examination is commenced through the mouth, passing the rigid bronchoscope into the larynx and through the glottis as far distally as figure 5-3 Comparative tips of Jackson (above) and Storz (below) rigid bronchoscopes. The Jackson model is more easily introduced into a tightly stenotic lesion with a rotatory motion than the Storz model, with its more shovel-like tip.

is easily permitted. This provides a picture of the anatomy of the entire airway and more precise measurements of lengths of lesions and normal structures. If the obstructing lesion is not densely fibrotic, or if it is a tumor, then the bronchoscope is passed beyond the lesion. If the lesion is densely stenotic, particularly if it involves the subglottic larynx, or if there is discontinuity between the proximal airway and the more distal trachea, as occurs sometimes with postintubation stenoses or after trauma, then maximum information is obtained by examining the airway up to the point of obstruction, followed by completion of the examination of the distal trachea through the tracheostomy present.

Once the bronchoscope is passed and the airway is cleared of secretions (which may pool distal to a partially obstructing lesion), and also cleared of blood that may be incited by the examination, the 0° telescope is used first for visualization. Desired information about the larynx includes 1) status of both the structure and function of the glottis, including vocal cords, arytenoids, and the anterior and posterior commissures; and 2) airway diameter, deformities, stenosis, inflammation, edema, or involvement by tumor of the subglottic larynx down to the inferior margin of the cricoid cartilage.

The cricoid cartilage may be directly visualized, if not altered by pathology. It presents as a broad ring immediately above the narrower tracheal rings (Figure 5-4). If pathology has blurred this differential, gentle external pressure on the palpable cricoid cartilage by the bronchoscopist's finger, while looking through the 0° telescope, usually defines the exact level. For greatest precision, a no. 25 hypodermic needle may be passed through the skin and wall of the trachea or larynx, just below the cricoid, and its entry point into the airway noted. In adult males of average size, an 8 or 9 mm bronchoscope (40 cm long) is used initially. In smaller males or in females, the 7 mm bronchoscope is used initially. For visualization and manipulation of upper tracheal lesions (such as injection of triamcinolone or Depo-Medrol into lesions with special long hypodermic needles), a 9 mm bronchoscope, which is only 25 cm long, is useful (Figure 5-5).

After the larynx has been fully examined, the bronchoscope is passed distally, observing the tracheal configuration in anteroposterior and lateral directions and for abnormalities in the cartilaginous architecture. The membranous wall is characteristically smooth. The mucosa is examined for inflammation, easy bleeding or increased vascularity, extrinsic or submucosal deformities, and mucosal lesions. Areas of mala-cia can sometimes be detected, assisted by gentle palpation in the neck or by observing collapse with respiration as the patient's anesthesia is lightened. Malacia is better identified with the flexible bronchoscope

figure 5-4 Endoscopic delineation of the border between the inferior margin of cricoid cartilage and the uppermost tracheal rings. The cricoid is very broad compared to the narrow tracheal rings below. Bronchoscopic measurements of the tracheal length accurately use this point proximally. However, if the cricoid is indistinct or obscured by pathologic change, the glottis is used as the proximal landmark, but the approximate length of the subglottic larynx (to bottom of cricoid) must be subtracted to obtain the tracheal length.

figure 5-5 Equipment for intralaryngeal or intratracheal injection. A no. 20 needle with no. 25 tip is long enough to reach through an adult rigid bronchoscope (8 mm, 40 cm shown). A tuberculin syringe is necessary to develop sufficient pressure to inject fluid via the long needle with this fine tip. Also shown is a short bronchoscope (9 mm, 25 cm) to facilitate access to laryngeal and subglottic areas.

under topical anesthesia so that the patient may cooperate in maneuvers that emphasize collapse, usually cervical inspiratory collapse or intrathoracic expiratory collapse. Complete bronchoscopic examination to segmental levels is particularly important in patients with squamous cell cancer of the trachea, since they may well have concurrent squamous cell lesions of the aerodigestive tract. A flexible bronchoscope is easily passed through the telescopic "adapter" via the rigid bronchoscope to complete a distal survey of segmental bronchi. These patients also deserve complete endoscopic examination of the pharynx and esophagus, in addition to laryngoscopy and bronchoscopy.

The endoscopist should be familiar with normal and abnormal variations in the trachea (see Figure 1-2 in Chapter 1, "Anatomy of the Trachea"). Sabre-sheath trachea has been mistakenly identified as stenosis (see Chapter 14, "Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions"). Tracheopathia osteoplastica is very rare and may not be recognized when observed (see Chapter 15, "Tracheobronchial Malacia and Compression"). Findings in children and in congenital lesions of the trachea are described in Chapter 6, "Congenital and Acquired Tracheal Lesions in Children." Even the most severe deviations of the trachea due to extrinsic pressure, as seen with huge substernal and intrathoracic goiters, usually allow easy passage of a rigid bronchoscope (see Chapter 15, "Tracheobronchial Malacia and Compression"). The trachea widens and straightens out as the rigid bronchoscope is passed. Normal contraction of the posterior membranous wall, and its protrusion forward in response to cough, either in the awake patient or under lightened anesthesia, should not be confused with malacia. Pulsatile compression should especially be noted. Pulsation and extrinsic deformation is commonly seen in the left lateral wall of the lower trachea due to the adjacent aorta.

Bronchoscopes should not be pushed through a fibrous stenotic lesion with excessive force. Dilation should be carried out systematically (see Chapter 19, "Urgent Treatment of Tracheal Obstruction") to avoid splitting or perforating the tracheal wall proximal to the tough fibrous stricture of a postintubation stenosis. In the case of tumors, one can always initially pass the rigid bronchoscope beside the tumor, on the side where tumor is not attached to the tracheal wall, no matter how complete the obstruction appears to be. Cartilage will yield and permit the bronchoscope to pass, partly displacing the tumor. The bronchoscope can be passed through the center of the circumferential tumor, carefully following even a tiny opening. A small bougie can serve as a guide. Cardiopulmonary bypass has been unnecessarily employed to resect tumors that appear to be causing nearly complete obstruction. A severely obstructing tumor can be cored out using the rigid bronchoscopes, with additional trimming done with biopsy forceps (see Chapter 19, "Urgent Treatment of Tracheal Obstruction"). The technique is so simple that we have found it unnecessary to use the laser for this purpose.4 Bleeding has not been a problem, despite cautions and alarms cited as rationale for laser removal of obstructing tumor. I routinely measure findings, including the location of normal structures and of the upper and lower limits of lesions. This is performed by difference, as illustrated in Figure 5-6. Systematic measurement is begun with the tip of the bronchoscope touching the carina, as seen through the 0° telescope, which is kept just proximal to the tip of the bronchoscope. Measurement is made of the distance from a selected point on the upper teeth or gingival ridge to a fixed point at the hub of the bronchoscope, using a centimeter rule. The bronchoscope is then withdrawn until its tip is at the lower border of the lesion. Measurement is again made at this point and is repeated with the bronchoscope's tip at the upper border of the lesion. Other points also noted are the location of a tracheal stoma, the level of the inferior margin of the cricoid cartilage, and the level of the vocal cords. Distances are obtained by subtraction from the figures recorded (Figure 5-7). Even with the most meticulous measurement, such figures are accurate only to about 0.5 cm because of the imprecise level of points of measurement and the flexibility of tissues. I find it helpful to construct a diagram of the airway and its lesions (see Figure 5-7F). It is posted in the operating room for reference and a copy is recorded in the patient's chart.

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