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Special Maneuvers

In this chapter we describe special maneuvers that have proved helpful in the past. We recommend that you retain them in your endoscopy armamentarium in order to deal with situations demanding special tricks.

 

Problem: Suspected Hypomobility

Solution:

  • Use flexible laryngoscopy for testing the respiratory mobility of the arytenoids and the vocal folds.
  • Video documentation with frame-per-frame off-line analysis is highly recommended.
  • Perform various maneuvers:
  • Repeated phonation of “eee”, quickly and slowly, in staccato mode
  • Repeated sniffing with sharp inspiratory nasal sniffs
  • Repeated “eee”-sniff (diadochokinesis) maneuvers
  • Throat-clearing and coughing
  • Laughing
  • Look for the active lateralization of muscular process during vigorous abductory maneuver, e.g. forceful sniffing (A, B)
  • Nota bene: The original definition of the “jostle sign” refers to a passive motion of the arytenoid by the other arytenoid. In our procedure of forceful sniffing, look for the active movement of the muscular process by activation of the posterior cricoarytenoid muscle. Sometimes it looks like a knee kicking under a blanket.

A) Look at posterior larynx, arrow points at region of muscular process. During phonation, the muscular process cannot be seen.

B) During forced inspiration, the arytenoid is actively maximally abducted and the muscular process may be visible (see arrow).

Note:

Respiratory mobility of the arytenoids and vocal folds should always be tested thoroughly and with several maneuvers.

Problem: Close-Up View of Vocal Folds Needed (Flexible Endoscopy)

Because of small morphologic changes of the vocal fold you want to get a very close-up view of the vocal folds.

Vocal folds, normal distance

Solution:

  • To get a very close-up view of the vocal folds or of the subglottis / trachea during flexible endoscopy perform the dipping maneuver with a long lasting inspiration through the nose 

Vocal folds, high magnification during dipping maneuver

Problem: Size of Reinke’s Edema Unclear

  • On occasion, localized Reinke’s edema or pedunculated lesions at the free edge of the vocal fold are found on the superior surface of the vocal fold and will not be detectable in shallow respiration.

Normal respiration

Solution:

  • Whether using rigid or flexible endoscopy, try asking the patient to perform a forced, rapid inspiration. This leads to suction of the medial part of the vocal folds into the glottis and thus the edema or pedunculated lesions at the free edge will become “aerodynamically medialized” and detectable.
  • Forced and rapid inspiration (see also inspiratory phonation) may also help to clear mucus from the free edge of the vocal fold while avoiding the throat-clearing with associated blurring of the lens.

Forced inspiration

Problem: Ventricular Folds Covering Vocal Folds or Pliability and Free Edge of Vocal Fold Unclear

(1) The vocal folds cannot be seen during phonation because they are concealed by the ventricular folds.

or

(2) You need a general impression about the mucosal pliability at the free vocal fold edge.

or

(3) You want to rule out additional masses on the superior surface of the vocal folds.

Solution:

During inspiratory phonation (both in rigid and flexible laryngoscopy), the following phenomena can be seen:

(1) Inspiratory phonation adducts the vocal folds and abducts ventricular folds. With the ventricular folds moving laterally, the entire superior vocal fold surface and parts of the ventricle can be seen.

(2) The free edge of the vocal folds is sucked into the glottis and shows where the mucosa of the free edge is normally pliable.

(3) Reinke’s edema or other mass lesions on the superior surface of the vocal folds can be detected.

Respiration

Inspiratory phonation

Note:

Forced and rapid inspiration and inspiratory phonation should always be part of the examination of benign mass lesions located on the vocal folds.

Problem: Ventricular Folds Covering Vocal Folds (See Above)

Ventricular folds are in a hyperadducted position and therefore cover the vocal folds.

Solution:

  • When the ventricular folds are covering the vocal folds during phonation, change from “eee” to “uuu” (especially in rigid laryngoscopy).
  • Phonation of “eee” usually pulls the tongue base and epiglottis forward. Phonation of “uuu” additionally leads to abduction of the ventricular folds. The ventricular folds will move more laterally, the epiglottis sits slightly more upright, and the vocal folds can be seen. Even with rigid endoscopy “uuu” is possible. Make sure that your patient really tries hard to phonate “uuu”.
  • Inspiratory phonation also adducts the true vocal folds and abducts false vocal folds (see above).

Problem: SLN Function Unknown or Free-Edge Problem

(1) You need detailed information about the superior branch of the recurrent superior laryngeal nerve function.

or

(2) You are not sure whether the margin of the vocal fold is smooth and straight.

Solution:

  • Falsetto phonation (both rigid and flexible laryngoscopy) leads to lengthening of vocal folds and gives information about CT muscle and superior laryngeal nerve function.
  • If very small epithelial lesions of the free margin exist, they will show as contour irregularity (particularly, when using stroboscopy).

Low phonation with shortened vocal folds

Falsetto phonation, vocal folds stretched

Note:

Falsetto phonation should always be part of the examination of benign mass lesions of the vocal folds.

Problem: Need to Inspect the Trachea

Suspected changes in the trachea (flexible endoscopy)

Solution:

Chin-tuck maneuver, combined with dipping maneuver 

Head bent forward and flexible endoscope near to glottis

Inspect the upper trachea

Problem: Need to Inspect Piriform Sinus and Postcricoid Region

You should inspect the piriform sinus and postcricoid region

Solution:

Ask the patient to perform a Valsalva maneuver (trumpet maneuver) while the endoscope is in place and the nostrils and mouth are completely closed.

While a Valsalva maneuver the postcricoid region can be seen.

In rare occasions, the upper horns of the thyroid cartilage stick into pharyngeal lumen during Valsalva maneuver.

Problem: The Epiglottis Is Covering the Vocal Folds

You cannot see the vocal folds because the epiglottis is covering them.

Solution:

  • Adjust the patient’s head and neck position to obtain a better view of the glottis (applies to rigid laryngoscopy).
  • Ask the patient to actively cause the mandible to protrude.
  • Phonation of “uuu” instead of “eee” (see above).

Ask patient to actively advance the mandible

Special Positioning of Endoscope or Patient

Sometimes specific laryngeal structures – mostly the vocal folds – cannot be seen with the normal position of the patient and the normal position of the endoscope. Especially in rigid endoscopy, changes of the position of the patient or the examiner or special maneuvers with the tip of the endoscope may help to achieve a better visualization of the vocal folds.

 

Below you will find some examples of insufficient exposure of the glottis.

Problem: The Uvula Disturbs

The uvula may intrude and disturb adequate illumination during rigid endoscopy.
When the endoscope lens is placed very close to a surface, the image will show a local washed-out whitish patch due to the camera’s averaging light management software.

The uvula, which is protruding into the upper part of the image, is “washed out,” unfocussed and is disturbing the average light values for the whole image.

Again, the uvula is in the way. The camera’s software senses the local white patch and automatically reduces the overall illumination for the image, thereby producing a darker picture. (The so-called AGC effect.)

Solution:

When “fighting” with the uvula, try dropping the endoscope tip and advancing it a bit more inferiorly.

Better, but not ideal. Use the techniques described in this chapter to improve the endolaryngeal view.

Problem: No Sufficient Exposure of the Larynx in Rigid Endoscopy

Here we show examples of suboptimal positions for the endoscope tip.

Tip of endoscope is too superior – anterior commissure cannot be seen. The entire upper part of the image displays the posterior pharyngeal wall (not region of interest).

Epiglottis is tilted too far posteriorly. Use maneuvers to advance epiglottis, e.g., let the patient phonate “uuu” or push the mandible forward.

Although the anterior commissure can be seen, the region of interest (endolarynx) is not in the center of the image. The tip of the endoscope is too far to the left.

In comparison to the preceding figure, after rotating the rigid endoscope shaft the glottis and endolarynx are now visualized better. However, the left ventricular fold is only seen in part. A better solution: Shift the endoscope tip to the midline!

Solution:

Improvement of positioning the rigid endoscope tip.
See intraoral position of tip of rigid endoscope (see description above).

Good visualization of the larynx. Always try to image the larynx like in this example.

Problem: The Epiglottis Disturbs

The epiglottis may cover the glottic area while performing flexible endoscopy.

Solution:

  • Advance flexible endoscope until it passes the level of the epiglottic rim.
  • Phonation of “uuu” will shift the epiglottis into a more upright, vertical and anterior position.
  • Ask patient to change the position of their head to sniffing position with cervical spine and jaw moved forwards (see below: Change of patient’s head position)

Flexible endoscopy, larynx seen from the level of the uvula

Epiglottis hiding vocal folds, patient’s head bent forward

Problem: Need to Visualize Medial Surface of Vocal Fold

The medial surface of the vocal fold cannot be visualized on flexible endoscopy.

Solution:

  • Which nasal cavity is being used for the transnasal endoscopy? Try changing sides – right or left
  • When deciding which nasal cavity side is most suitable for passing the flexible endoscope, consideration should be given not only to the size of the nasal cavities but also to the question of which vocal fold is of special interest. Select the right nasal cavity when you want a really good view of the left vocal fold and vice versa.

Passage through right nasal cavity: Left vocal fold can be seen better

Passage through left nasal cavity: Right vocal fold can be seen better

Rigid Endoscopy – General Aspects of Positioning

  • The position of the tip of the endoscope depends on patient’s and examiner’s posture.

  • The position of the endoscope can be changed by different postures of the patient.

  • Note the change of angle between endoscope and neck with different postures.

  • For maximal anterior and posterior laryngeal exposures the positions of patient and examiner have to be changed accordingly.

Elbows-on-Knees Position – 90° Rigid Endoscope

  • The 90° endoscope is typically held horizontally.

Patient sitting, upper part of the body is straight and vertical

Patient sitting, upper part of the body slightly leaning forward, elbows on thighs

Patient sitting, upper part of the body strongly leaning forward, elbows on knees, neck hyperextended

Elbows-on-Knees Position – 70° Rigid Endoscope

  • The 70° endoscope is typically held steeper than the 90° endoscope.

Patient sitting, upper part of the body straight and vertical

Patient sitting, upper part of the body slightly leaning forward, elbows on thighs

Patient sitting, upper part of the body strongly leaning forward, elbows on knees, neck hyperextended. The axis of the endoscope almost points to the thoracic spine!

Positioning of Patient and Examiner in Rigid Laryngoscopy

Problem: Need to Visualize the Anterior Commissure or the Laryngeal Surface of the Epiglottis

Anterior commissure not visible

Normal position: Patient sitting, examiner sitting

Image of larynx with normal position

Solution:

Position according to Türck:

  • Patient sitting, examiner standing
  • Good for better view of anterior commissure
  • Use this position for the examination of the laryngeal surface of the epiglottis, too.

Image of larynx with position according to Türck

Patient sitting, examiner standing (or sitting): In rigid endoscopy, the anterior commissure and the petiole can be visualized (position according to Türck).

Problem: Suspected Posterior Glottic Stenosis (PGS)

Posterior larynx not visible

Solution:

Position according to Killian:

– Patient standing, examiner sitting

– Good for better view of posterior larynx

– Use this position for ruling out posterior glottic stenosis (PGS) and scarring

Patient standing (or sitting), examiner sitting: In rigid endoscopy the posterior larynx and sometimes the entire trachea all way down to the carina can be visualized (position according to Killian).

1a) Larynx after trauma seen with rigid endoscopy in normal position (respiration)

1b) Same patient seen with rigid endoscopy according to Killian technique and endoscope held more to the left side. Now one can see that the trauma has ruptured the attachment of the vocal ligament to the vocal process (vocal fold avulsion).

1c) same as in b), during Falsetto phonation and with zoom. Displacement between vocal process and vocal ligament can be seen.

2a) Partial immobility of vocal folds. Here, maximum abduction is shown. Larynx seen with rigid endoscopy in normal position (respiration).

2b) Same patient seen with rigid endoscopy according to Killian technique. One can now see a scar bridge in the posterior larynx explaining the partial immobility of the vocal folds (posterior glottal stenosis).

Note:

In flexible endoscopy these structures can be seen more easily – but only when the tip of the endoscope is close enough!

Problem: Needing a Close-Up View of Vocal Folds or Anterior Commissure

How to obtain good quality close-up images of the glottis and anterior commissure using rigid endoscopy

A) Larynx seen from the usual position of the 70° endoscope

A) Normal position of the tip of a rigid endoscope within the oropharynx. For teaching purposes, the shaft of the endoscope was held in a pronounced lateral position in this picture.

Solution:

  • Position the tip of the rigid endoscope just above the laryngeal inlet.
  • Placing the distal shaft of the endoscope on the tongue base and pressing it downwards enables you to get a closer view of the glottis.
  • This works particularly well when using the 70° endoscope, with which you can obtain a very close view of the glottis and (sometimes) a close view of the anterior commissure.
  • Try the elbows-on-knees position

B) The tip of the endoscope has been positioned lower than in A), just above the laryngeal inlet. Again, for better demonstration purposes, the shaft of the endoscope is placed laterally.

If the patient can tolerate the more extreme positioning required for the 70° rigid endoscope you can also see the space between the petiole and anterior commisure.

B) The view of the larynx is magnified when the tip of the endoscope is positioned close to the glottis. This is achieved by pressing the shaft onto the tongue base. Note the excellent exposure of the anterior commissure.

Problem: Need to Inspect Morgagni’s Ventricle

How best to inspect Morgagni’s ventricle (rigid endoscopy)

Solution:

  • Select a 70° rigid endoscope and have the patient sit in the elbows-on-knees position.
  • Anesthetize the pharynx and larynx thoroughly.
  • Dip the tip of the endoscope into the larynx by pressing the shaft onto the tongue base, advance it into the supraglottis and then rotate the tip towards the ROI.

If the patient can tolerate the more extreme positions required by the 70° rigid endoscope it may even be possible to obtain a glimpse into the ventricles of Morgagni.

Problem: Need to Inspect the Piriform Sinus

How best to inspect the piriform sinus (rigid endoscopy)

Solution:

You can change the axis of laryngeal visualization by employing different oropharyngeal positions for the endoscope in addition to simply rotating its tip.

A): Tip of the endoscope in right lateral position and rotated to the left

B): Tip of the endoscope in the midline, not rotated

C): Tip of the endoscope in left lateral position and rotated to the right

Larynx seen using technique (A)

Larynx seen using technique (B)

Larynx seen using technique (C)

Change of the patient’s head position

Click to enlarge image

Head extended (chin lift) and turned to the right → See left piriform sinus

Head extended (chin lift)

Head extended (chin lift) and turned to the left → See right piriform sinus

Head bent to the right → See left piriform sinus

Neutral position

Head bent to the left → See right piriform sinus

Problem: Need to Visualize Specific Pharyngeal Structures

How best to expose specific pharyngeal structures

Solution:

Alter the position of the patient’s head (especially in flexible endoscopy). Depending on the position of the patient’s head it may be possible to achieve quite reasonable views of otherwise hidden parts of the pharynx.

Head turned to the right → See left piriform sinus

Head turned to the left → See right piriform sinus

Head bent forward and turned to the right → See left vallecula and epiglottis

Head bent forward → See both valleculae and epiglottis

Head bent forward and turned to the left → See right vallecula and epiglottis

Here, examples are shown how otherwise hidden parts of the pharynx can be visualized during flexible endoscopy when changing the patient’s head position.

Head extended and turned to the right

Head extended

Head extended and turned to the left

Head bent to the right

Neutral position

Head bent to the left

Head turned to the right

Head turned to the left

Head bent forward and turned to the right

Head bent forward

Head bent forward and turned to the left

Cervical spine and jaw moved backwards. Pharynx is very narrow.

Habitual head position

Cervical spine and jaw moved forwards. Pharynx and larynx are open.
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