Careful use of a flexible pediatric bronchoscope can clarify much about a lesion. The bronchoscope should not be passed into a tightly stenotic lesion in order to avoid causing edema and inflammation, which might precipitate acute obstruction. Indeed, in a significantly symptomatic child, in whom the presence of stenosis is already known from radiologic study (even if definition is not wholly complete), bronchoscopy is usu-

figure 6-19 Congenital stenosis in a 3'A-year-old boy. A, Sagittal magnetic resonance study showing narrowed supracarinal segment. B, C, and D clarify tracheal diameters in a normal segment, at the beginning of cartilaginous "O" rings and at maximum stenosis.

ally best deferred to the time of planned surgical repair. This also applies to less critical patients. Surgeons must always do the bronchoscopy themselves, irrespective of any prior examinations.

Definitive bronchoscopy, ideally performed just prior to a planned surgical procedure for correction of the lesion, is best accomplished with rigid Storz ventilating pediatric bronchoscopes. The 3.5 mm rigid bronchoscope (OD 5.7 mm) will not pass through a tiny stenosis. However, either a flexible pediatric bronchoscope (2.7 mm) or a long telescope (OD 2 mm) allows a more distal examination. These may be inserted through a larger rigid (ventilating) bronchoscope seated proximally, or through a pediatric operating laryngoscope. Bronchoscopes should not be forced into a stenosis, nor should any attempt be made to dilate the narrowing, if it is congenital. Ventilation is maintained by intermittent placement of an endotracheal tube into the laryngoscope. Fine suction devices are necessary. Circular "O" rings of cartilage, found in many cases of congenital stenosis, are clearly visible bronchoscopically, if looked for (Figure 6-20A and Figure 1 [Color Plate 11]). Disordered or fused cartilages are present in congenital stenosis, but far less often (Figure 6-20B and Figure 2 [Color Plate 11]). As in adults, the larynx must be examined, especially in the presence of a postintubation lesion. The glottis is visualized in passing with the rigid bronchoscope and telescope. However, the pediatric Holinger laryngoscope, used in conjunction with a telescope, provides a superior view of laryngeal structures. If any complexity is identified, consultative examination by a pedi-atric otolaryngologist is advisable. Cooperation in the initial endoscopic examination of these patients is beneficial for all.

Tracheoesophageal fistula is identified in the membranous wall of the trachea (Figure 6-21). Instillation of methylene blue-colored saline into the esophagus via a high placed nasogastric tube may conclusively identify a small H fistula. Confusion can result if a large volume of dyed saline refluxes above the cricopharyngeus and spills over the arytenoids into the airway. Esophagoscopic identification of a fistula may be more difficult unless the fistula is large or distended by a cuffed tube in the trachea.

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