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ENDOSCOPY                                         209

OPERATION. The patient lies supine on the table and the cervical spine is
flexed and the head then extended on the neck. This manoeuvre can be
accomplished by special devices on the table, by assistants or by the surgeon
himself. Whichever way is adopted, it has the effect of placing the oral cavity
and larynx in as straight a line as possible. The head and chest are then draped
and a tooth guard placed over the patient^s teeth.

The Jackson laryngoscope is passed first and guided into the larynx by
following the endotracheal tube. Care should be taken to examine the
following areas in every case—the valleculae, the lingual epiglottis, the
ary-epiglottic folds, the pyriform fossae and the postcricoid and inter-
arytenoid area. The laryngoscope is then passed in front of the endotracheal
tube and the laryngeal surface of the epiglottis is examined as are the false
cords, the ventricles, by pushing the false cords laterally, and the vocal cords.
At this point the Jackson laryngoscope {Fig. 104, 2) is removed and the
anterior commissure laryngoscope (Fig. 104, 3) is passed to examine the
anterior half of the glottis. It is then passed through the vocal cords and
the subglottis is examined.

Microlaryngoscopy. In recent years it has become common practice to carry
out all minor laryngeal surgery such as vocal cord stripping, removal of
masses, etc. using the technique of microlaryngoscopy. The Zeiss operating
microscope is used with a 400 mm objective so that the microscope will focus
on the vocal cords and leave enough room for hands and instruments. Special
laryngoscopes are used and they are suspended thus leaving the surgeon with
both hands free for using instruments. This is one of the main advantages of
the method, allowing, for example, the surgeon to use a sickle knife or
scissors in one hand, and a sucker hi the other. Apart from the magnification,
use of the microscope allows photographs to be taken. The method is not to
be recommended, however, for assessing the extent of large laryngeal tumours
because the size of the field is too limited to be of use and the lesions are
usually large enough not to require magnification.

Fibreoptic Laryngoscopy. This is usually done under local anaesthesia and the
flexible laryngoscope is passed through one side of the patient's nose and all
the previously mentioned areas are examined. It is particularly useful for
examining the laryngeal surface of the epiglottis and the anterior commissure,
both of which areas are difficult to see completely using other methods.
Instrumentation is impossible down the fibreoptic bundle and so its prime use
is for diagnostic examination.


ANATOMY, The trachea commences at the inferior border of the cricoid
cartilage opposite the inferior border of C6. From this point it descends
postero-inferiorly into the superior mediastinum to end at T5 by dividing into
the right and left main bronchi. There are 15-20 cartilaginous rings which are
incomplete posteriorly, the gap being filled by the trachealis muscle. The
lining is stratified columnar ciliated epithelium whose cilia produce an
upward movement of the mucus covering the surface. From within, the
mucosa looks moist and glistening with whitish ridges corresponding to the
cartilaginous rings. The male adult trachea is 12 cm long, and the female,