Bronchoscopy and Esophagoscopy / A Manual of Peroral Endoscopy and Laryngeal Surgery

This book is one of the pioneering works in laryngology. The original text
is from the library of Indiana University Department of
Otolaryngology-Head and Neck Surgery, Bruce Matt, MD. It was scanned,
converted to text, and proofed by Alex Tawadros.

BRONCHOSCOPY AND ESOPHAGOSCOPY

A Manual of Peroral Endoscopy and Laryngeal Surgery

by

CHEVALIER JACKSON, M.D., F.A.C.S.

Professor of Laryngology, Jefferson Medical College, Philadelphia;

Professor of Bronchoscopy and Esophagoscopy, Graduate School of

Medicine, University of Pennsylvania; Member of the American

Laryngological Association; Member of the Laryngological,

Rhinological, and Otological Society; Member of the American Academy

of Ophthalmology and Oto-Laryngology; Member of the American

Bronchoscopic Society; Member of the American Philosophical Society;

etc., etc.

With 114 Illustrations and Four Color Plates

Philadelphia And London

W. B. Saunders Company

1922

Copyrights 1922, by W. B. Saunders Company

Made in U.S.A.

TO MY MOTHER TO WHOSE INTEREST IN MEDICAL SCIENCE THE AUTHOR OWES
HIS INCENTIVE, AND TO MY FATHER WHOSE CONSTANT ADVICE TO “EDUCATE
THE EYE AND THE FINGERS” SPURRED THE AUTHOR TO CONTINUAL EFFORT,
THIS BOOK IS AFFECTIONATELY DEDICATED.

PREFACE

This book is based on an abstract of the author’s larger work,
Peroral Endoscopy and Laryngeal Surgery. The abstract was prepared
under the author’s direction by a reader, in order to get a reader’s
point of view on the presentation of the subject in the earlier book.
With this abstract as a starting point, the author has endeavored, so
far as lay within his limited abilities, to accomplish the difficult
task of presenting by written word the various purely manual
endoscopic procedures. The large number of corrections and revisions
found necessary has confirmed the wisdom of the plan of getting the
reader’s point of view; and these revisions, together with numerous
additions, have brought the treatment of the subject up to date so far
as is possible within the limits of a working manual.
Acknowledgment is due the personnel of the W. B. Saunders Company for
kindly help.

CHEVALIER JACKSON.
OCTOBER, 1922.
II

CONTENTS PAGE

CHAPTER I INSTRUMENTARIUM 17
CHAPTER II ANATOMY OF LARYNX, TRACHEA, BRONCHI AND
ESOPHAGUS, ENDOSCOPICALLY CONSIDERED 52
CHAPTER III PREPARATION OF THE PATIENT FOR PERORAL
ENDOSCOPY 63
CHAPTER IV ANESTHESIA FOR PERORAL ENDOSCOPY 65
CHAPTER V BRONCHOSCOPIC OXYGEN INSUFFLATION 71
CHAPTER VI POSITION OF THE PATIENT FOR PERORAl ENDOSCOPY 73
CHAPTER VII DIRECT LARYNGOSCOPY 82
CHAPTER VIII DIRECT LARYNGOSCOPY (Continued) 91
CHAPTER IX INTRODUCTION OF THE BRONCHOSCOPE 97
CHAPTER X INTRODUCTION OF THE ESOPHAGOSCOPE 106
CHAPTER XI ACQUIRING SKILL 117
CHAPTER XII FOREIGN BODIES IN THE AIR AND FOOD PASSAGES 126
CHAPTER XIII FOREIGN BODIES IN THE LARYNX AND
TRACHEOBRONCHIAL TREE 149
CHAPTER XIV REMOVAL OF FOREIGN BODIES FROM THE LARYNX 156
CHAPTER XV MECHANICAL PROBLEMS OF BRONCHOSCOPIC
FOREIGN BODY EXTRACTION 158
CHAPTER XVI FOREIGN BODIES IN THE BRONCHI FOR
PROLONGED PERIODS 177
CHAPTER XVII UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES 181
CHAPTER XVIII FOREIGN BODIES IN THE ESOPHAGUS 183
CHAPTER XIX ESOPHAGOSCOPY FOR FOREIGN BODY 187
CHAPTER XX PLEUROSCOPY 199
CHAPTER XXI BENIGN GROWTHS IN THE LARYNX 201
CHAPTER XXII BENIGN GROWTHS IN THE LARYNX (Continued) 203
CHAPTER XXIII BENIGN GROWTHS PRIMARY IN THE
TRACHEOBRONCHIAL TREE 207
CHAPTER XXIV BENIGN NEOPLASMS OF THE ESOPHAGUS 209
CHAPTER XXV ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX 210
CHAPTER XXVI BRONCHOSCOPY IN MALIGNANT GROWTHS OF
THE TRACHEA 214
CHAPTER XXVII MALIGNANT DISEASE OF THE ESOPHAGUS 216
CHAPTER XXVIII DIRECT LARYNGOSCOPY IN DISEASES OF
THE LARYNX 221
CHAPTER XXIX BRONCHOSCOPY IN DISEASES OF THE TRACHEA
AND BRONCHI 224
CHAPTER XXX DISEASES OF THE ESOPHAGUS 235
CHAPTER XXXI DISEASES OF THE ESOPHAGUS (Continued) 245
CHAPTER XXXII DISEASES OF THE ESOPHAGUS (Continued) 251
CHAPTER XXXIII DISEASES OF THE ESOPHAGUS (Continued) 260
CHAPTER XXXIV DISEASES OF THE ESOPHAGUS (Continued) 268
CHAPTER XXXV GASTROSCOPY 273
CHAPTER XXXVI ACUTE STENOSIS OF THE LARYNX 277
CHAPTER XXXVII TRACHEOTOMY 279
CHAPTER XXXVIII CHRONIC STENOSIS OF THE LARYNX AND TRACHEA 300
CHAPTER XXXIX DECANNULATION AFTER CURE OF LARYNGEAL
STENOSIS 309
BIBLIOGRAPHY 311
INDEX 315

[17] CHAPTER I—INSTRUMENTARIUM

Direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy
are procedures in which the lower air and food passages are
inspected and treated by the aid of electrically lighted tubes
which serve as specula to manipulate obstructing tissues out of the
way and to bring others into the line of direct vision.
Illumination is supplied by a small tungsten-filamented, electric,
“cold” lamp situated at the distal extremity of the instrument in a
special groove which protects it from any possible injury during the
introduction of instruments through the tube. The bronchi and the
esophagus will not allow dilatation beyond their normal caliber;
therefore, it is necessary to have tubes of the sizes to fit
these passages at various developmental ages. Rupture or even
over-distention of a bronchus or of the thoracic esophagus is almost
invariably fatal. The armamentarium of the endoscopist must be
complete, for it is rarely possible to substitute, or to improvise
makeshifts, while the bronchoscope is in situ. Furthermore, the
instruments must be of the proper model and well made; otherwise
difficulties and dangers will attend attempts to see them.

Laryngoscopes.—The regular type of laryngoscope shown in Fig. I
(A, B, C) is made in adult’s, child’s, and infant’s sizes. The
instruments have a removable slide on the top of the tubular
portion of the speculum to allow the removal of the laryngoscope
after the insertion of the bronchoscope through it. The infant size
is made in two forms, one with, the other without a removable slide;
with either form the larynx of an infant can be exposed in but a few
seconds and a definite diagnosis made, without anesthesia, general or
local; a thing possible by no other method. For operative work on the
larynx of adults, such as the removal of benign growths, particularly
when these are situated in the anterior portion of the larynx, a
special tubular laryngoscope having a heart-shaped lumen and a
beveled tip is used. With this instrument the anterior commissure is
readily exposed, and because of this it is named the anterior
commissure laryngoscope (Fig. 1, D). The tip of the anterior
commissure laryngoscope can be used to expose either ventricle of the
larynx by lifting the ventricular band, or it may be passed through
the adult glottis for work in the subglottic region. This instrument
may also be used as an esophageal speculum and as a pleuroscope. A
side-slide laryngoscope, used with or without the slide, is
occasionally useful.

Bronchoscopes.—The regular bronchoscope is a hollow brass tube
slanted at its distal end, and having a handle at its proximal or
ocular extremity. An auxiliary canal on its under surface contains
the light carrier, the electric bulb of which is situated in a recess
in the beveled distal end of the tube. Numerous perforations in the
distal part of the tube allow air to enter from other bronchi when the
tube-mouth is inserted into one whose aerating function may be
impaired. The accessory tube on the upper surface of the bronchoscope
ends within the lumen of the bronchoscope, and is used for the
insufflation of oxygen or anesthetics, (Fig. 2, A, B, C, D).

For certain work such as drainage of pulmonary abscesses, the lavage
treatment of bronchiectasis and for foreign-body or other cases with
abundant secretions, a drainage-bronchoscope is useful The drainage
canal may be on top, or on the under surface next to the light-carrier
canal. For ordinary work, however, secretion in the bronchus is best
removed by sponge-pumping (Q.V.) which at the same time cleans the
lamp. The drainage bronchoscope may be used in any case in which the very
slightly-greater area of cross section is no disadvantage; but in
children the added bulk is usually objectionable, and in cases of
recent foreign-body, secretions are not troublesome.

As before mentioned, the lower air passages will not tolerate
dilatation; therefore, it is necessary never to use tubes larger than
the size of the passages to be examined. Four sizes are sufficient
for any possible case, from a newborn infant to the largest adult.
For infants under one year, the proper tube is the 4 mm. by 30 cm.;
the child’s size, 5 mm. by 30 cm., is used for children aged from one
to five years. For children six years or over, the 7 mm. by 40 cm.
bronchoscope (the adolescent size) can be used unless the smaller
bronchi are to be explored. The adult bronchoscope measures 9 mm.
by 40 cm.

The author occasionally uses special sizes, 5 mm. x 45 cm., 6 mm. x 35
cm., 8 mm. x 40 cm.

Esophagoscopes.-The esophagoscope, like the bronchoscope, is a
hollow brass tube with beveled distal end containing a small
electric light. It differs from the bronchoscope in that it has no
perforations, and has a drainage canal on its upper surface, or next
to the light-carrier canal which opens within the distal end of the
tube. The exact size, position, and shape of the drainage outlets is
important on bronchoscopes, and to an even greater degree on
esophagoscopes. If the proximal edge of the drainage outlet is too
near the distal end of the endoscopic tube, the mucosa will be drawn
into the outlet, not only obstructing it, but, most important,
traumatizing the mucosa. If, for instance, the esophagoscope were to
be pushed upon with a fold thus anchored in the distal end, the
esophageal wall could easily be torn. To admit the largest sizes of
esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are
made with both light canal and drainage canal outside the lumen of the
tube, leaving the full area of luminal cross-section unencroached
upon. They can, of course, be used for all purposes, but the slightly
greater circumference is at times a disadvantage. The esophageal and
stomach secretions are much thinner than bronchial secretions, and, if
free from food, are readily aspirated through a comparatively small
canal. If the canal becomes obstructed during esophagoscopy, the
positive pressure tube of the aspirator is used to blow out the
obstruction. Two sizes of esophagoscopes are all that are required—7
mm. X 45 cm. for children, and 10 mm. X 53 cm. for adults (Fig. 3, A
and B); but various other sizes and lengths are used by the author for
special purposes.* Large esophagoscopes cause dangerous dyspnea in
children. If, it is desired to balloon the esophagus with air, the
window plug shown in Fig. 6, is inserted into the proximal end of the
esophagoscope, and air insufflated by means of the hand aspirator or
with a hand bulb. The window can be replaced by a rubber diaphragm
with a perforation for forceps if desired. It will be noted that none
of the endoscopic tubes are fitted with mandrins. They are to be
introduced under the direct guidance of the eye only. Mandrins are
obtainable, but their use is objectionable for a number of reasons,
chief of which is the danger of overriding a foreign body or a lesion,
or of perforating a lesion, or even the normal esophageal wall. The
slanted end on the esophagoscope obviates the necessity of a mandrin
for introduction. The longer the slant, with consequent acuting of the
angle, the more the introduction is facilitated; but too acute an
angle increases the risk of perforating the esophageal wall, and
necessitates the utmost caution. In some foreign-body cases an acute
angle giving a long slant is useful, in others a short slant is
better, and in a few cases the squarely cut-off distal end is best. To
have all of these different slants on hand would require too many
tubes. Therefore the author has settled upon a moderate angle for the
end of both esophagoscopes and bronchoscopes that is easy to insert,
and serves all purposes in the version and other manipulations
required by the various mechanical problems of foreign-body
extraction. He has, however, retained all the experimental models, for
occasional use in such cases as he falls heir to because of a problem
of extraordinary difficulty.

* A 9 mm. X 45 cm. esophagoscope will reach the stomach of almost all
adults and is somewhat easier to introduce than the 10 mm. X 53 cm.,
which may be omitted from the set if economy must be practiced.

[FIG. I.—Author’s laryngoscopes. These are the standard sizes and
fulfill all requirements. Many other forms have been devised by the
author, but have been omitted from the list as unnecessary. The infant
diagnostic laryngoscope (C) is not for introducing bronchoscopes,
and is not absolutely necessary, as the larynx of any infant can be
inspected with the child’s size laryngoscope (B).

A Adult’s size; B, child’s size; C, infant’s diagnostic size; D,
anterior commissure laryngoscope; E, with drainage canal; 17,
intubating laryngoscope, large lumen. All the laryngoscopes are
preferred without drainage canals.]

[FIG. 2.—The author’s bronchoscopes of the sizes regularly used.

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