Laryngoscopy

LARYNGOSCOPY

Q. 1

Acute laryngeal spasm during indirect laryngoscopy is seen in?

 A

Acute epiglottitis

 B

Acute laryngo tracheo bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Q. 1

Acute laryngeal spasm during indirect laryngoscopy is seen in?

 A

Acute epiglottitis

 B

Acute laryngo tracheo bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Ans. A

Explanation:

Q. 2

During laryngoscopy and endo-tracheal intubation which of the maneuver is not performed:

 A

Flexion of the neck

 B

Extension of Head at the atlanto-occipital joint.

 C

The laryngoscope is lifted upwards levering over the upper incisors.

 D

In a straight blade laryngoscope, the epiglottis is lifted by the tip.

Q. 2

During laryngoscopy and endo-tracheal intubation which of the maneuver is not performed:

 A

Flexion of the neck

 B

Extension of Head at the atlanto-occipital joint.

 C

The laryngoscope is lifted upwards levering over the upper incisors.

 D

In a straight blade laryngoscope, the epiglottis is lifted by the tip.

Ans. C

Explanation:

Ans:C i.e. The laryngoscope is lifted upward levering over the upper incisiors.

Procedure of Endotracheal Intubation:

  • The correct position is with the lower part of the cervical spine flexed (by placing a pillow or other suitable pad under the patient’s occiput), and the atlanto-occipital joint extended(by tilting the head back) – the so-called “sniffing position”. This position aligns the axes of the mouth, pharynx and trachea, and will give the best visualization of the cords during laryngoscopy.
  • In a Straight Blade Laryngoscope,lift the epiglottis with the tip of the blade.

Q. 3

Anaesthesia used in microlaryngoscopy is 

 A

Pollarad tube of 10 mm diameter with heavy sedation

 B

Pollarad tube of 15 mm diameter with topical xylocaine

 C

Pollarad tube with infiltration block

 D

Heavy sedation on and Endotracheal intubation

Q. 3

Anaesthesia used in microlaryngoscopy is 

 A

Pollarad tube of 10 mm diameter with heavy sedation

 B

Pollarad tube of 15 mm diameter with topical xylocaine

 C

Pollarad tube with infiltration block

 D

Heavy sedation on and Endotracheal intubation

Ans. C

Explanation:

C i.e. Pollarad tube with infiltration block

When fire breaks out during laser vocal cord surgery, oxygen should be turned off, ventilation stopped, tracheal tube removed and submerged in water and the patient should be ventilated with facemasK. Airway damage is assessed with bronchoscopy and bronchial lavage, steroids, can be used for treatment.

Anesthesia for Endoscopic Surgeries of Airway

  • Endoscopy includes laryngoscopy, microlaryngoscopy (i.e. aided by an operating microscope), bronchoscopy & oesophagoscopy. These procedures may be accompanied by laser surgery.
  • Microlaryngoscopic surgeries include biopsy / surgery of laryngeal malignancy, vocal cord polyps etc. It is associated with some specific problems as – common field for anesthetist & surgeon, already reduced glottic opening d/t growth, laryngospasm (mediated by superior laryngeal nerve) d/t laryngeal stimulation, very high chances of aspiration and myocardial ischemia (- 4% due to sympethetic stimulation).

Preoperative Considerations

–  Sedative premedication is contraindicated in any patient with any significant degree of upper airway obstructionQ, d/t fear of aspiration. Glycopyrrolate, 1 hour before surgery minim­ize secretions, thereby facilitate ventilation. Pethidine & promethazine are only given if there is no airway obstruction.

Laser Precautions

  • General laser precautions include wearing protective spectacles to prevent retinal damage and evacuation of toxic fumes (laser plume) from tissue vaporization which may have potential to transmit microbacterial diseases.
  • Greatest fear during laser airway surgery is a tracheal tube fire. This can be avoided by using a technique of ventilation that does not involve a flammable tube or catheter (eg intermittent apnea or jet ventilation through the laryngoscope side port). The potential fuel source should have laser resistant properties (laser tubes or wrapping a tracheal tube with metallic tape) or be removed (supraglottic jet ventilation technique). The only non inflammable, laser proof tube is the all metal. Norton tube, which has no cuff. Most laser tubes have laser resistant properties around the shaft, but the cuff is not protected and can ignite. So there are double cuffs to seal the airway- if upper cuff is struck by laser and saline escapes, the lower cuff will continue to seal the airway.
  • No cuffed tracheal tube, or any currently available tube protection is completely laser proof. Therefore, whenever laser airway surgery is being performed with a tracheal tube in place, the following precaution should be observed.

– Inspired 02 conc. should be as low as possible may be upto 21%

N20 support combustion & should be replaced with air (N2) or heliumQ

– Tracheal tube cuffs should be filled with saline dyed with methylene blue to dessipate heat & signal cuff rupture

– A cuffed tube will minimize 02 conc. in the parynx. The addition of 2% lidocaine jelly (1:2 mixture with saline) can seal small laser induced cuff leaks, potentially preventing combustion

– Laser intensity & duration should be limited as much as possible.

– Saline soaked pledgets (completely saturated) should be placed in the airway to limit risk of ignition.

– A source of water (60 ml) should be immediately available in case of fire.


Muscle Relaxation

Profound muscle relaxation is the aim to provide masseter muscle relaxation for introduction of suspension laryngoscope & an immobile surgical field.

–  Anesthesia is induced with IV induction agent followed by a non depolarizing muscle relaxant; the vocal cords are sprayed with 3 ml lidocaine 4% to assist smooth anesthesia & to minimize the possibility of postextubation laryngospasmQ

–  Alternatively the cords may be painted with 3% cocaine at the end of procedure, which has the added advantage of reducing bleeding from operative site. 


Oxygentation & Ventilation

–  Microlaryngoscopy tubes are long, have a small internal and external diameter, and are designed specifically for endoscopic procedures (but not suitable for laser surgery). Typically 4 to 5 mm internal diameter tubes with high volume, low pressure cuffs are used in nasal or oral versions. The most popular anesthetic technique use a Coplan’s microlaryngoscopy tube (5mm ID, 31cm long, 10m1 cuff volume and constructed from soft plastic). It is designed for micro laryngeal surgery or for patient whose airway has been narrowed to such an extent that a normal sized tracheal tube cannot be inserted. The small tube diameter provides better visibility and access to surgical field but may lit incomplete exhalation and occlusion.

–  Most commonly the patients are intubated with small diameter (4 – 6 mm) tracheal tubesQ; – Standandard tracheal tubes of this size, however, are designed for pediatric patients. They tend to be too short for adult trachea (in length)Q with a low volume cuff that will exert high pressure against it

– A 4 – 6 mm microlaryngea tracheal (MLT) tubes (Mallinckrodt critical Care) is the same length as the adult tube, has disproportionately large high volume low pressure cuff, and is stiffer and less prone to compression than a regular tracheal tube.

– The advantages of intubation include – protection against aspiration, and the ability to administer inhalational anesthetics and enable monitoring of ventilation by capnography and spirometry, by measuring end tidal CO2Q

– In some cases (eg those involving posterior commissure), intubation may interfere with surgeon’s visualization and then alternatives are:

1.Insufflation of high flows of oxygen through small catheter placed in the trachea

2. Intermittent apnea technique.

  1. Jet ventilation through laryngoscope
  2. High frequency positive pressure ventilation (HFPPV)



Q. 4

In a direct laryngoscopy,which of the following can be visualized?

 A

Cricothyroid

 B

Lingual surface of epiglottis

 C

Arytenoids

 D

All

Q. 4

In a direct laryngoscopy,which of the following can be visualized?

 A

Cricothyroid

 B

Lingual surface of epiglottis

 C

Arytenoids

 D

All

Ans. D

Explanation:

Larynx: Epiglottis, aryepiglottic folds, arytenoids, cuneiform and corniculate cartilage, ventricular ands, ventricles, true cords, anterior commissure, posterior commissure, subglottis and rings of trachea.

Hypopharynx: Both pyriform fossae, post-cricoid region, posterior wall of laryngopharynx.

Oropharynx: Base of tongue, lingual tonsils, valleculae, media and lateral glosso-epiglottic folds.


Q. 5

Which of the following is difficult to visualize or examine on indirect laryngoscopy?

 A

True vocal cord

 B

Anterior commissure

 C

Epiglottis

 D

False vocal cord

Q. 5

Which of the following is difficult to visualize or examine on indirect laryngoscopy?

 A

True vocal cord

 B

Anterior commissure

 C

Epiglottis

 D

False vocal cord

Ans. B

Explanation:

 

Hidden areas of larynx viz. infrahyoid epiglottis, anterior commissure, ventricles and subglottic region and apex of pyriform fossa are difficult to visualize by indirect laryngoscopy.



Q. 6

Microlaryngoscopy was started by:

 A

Bruce Benjamin

 B

Kleinsasser

 C

Chevalier Jackson

 D

None

Q. 6

Microlaryngoscopy was started by:

 A

Bruce Benjamin

 B

Kleinsasser

 C

Chevalier Jackson

 D

None

Ans. B

Explanation:

The present day microsurgical techniques of the larynx are a credit to Kleinsasser.


Q. 7

The procedure that should precede microlaryngoscopy is:

 A

Pharyngoscopy

 B

Esophagoscopy

 C

Rhinoscopy

 D

Laryngoendoscopy

Q. 7

The procedure that should precede microlaryngoscopy is:

 A

Pharyngoscopy

 B

Esophagoscopy

 C

Rhinoscopy

 D

Laryngoendoscopy

Ans. D

Explanation:

 

Microlaryngoscopy concentrates mainly on the glottic area in cases where the diagnosis is already established and unlike direct laryngoscopy, is not primarily concerned with other areas of larynx which should have been assessed preoperatively.



Q. 8

A girl, 4 yrs of age presented in emergency with mild re­spiratory distress. On laryngoscopy, she was diagnosed to have multiple juvenile papillo-matosis of the larynx . Next line of management is:

 A

Tracheostomy

 B

Microlaryngoscopy

 C

Steroid

 D

Antibiotics

Q. 8

A girl, 4 yrs of age presented in emergency with mild re­spiratory distress. On laryngoscopy, she was diagnosed to have multiple juvenile papillo-matosis of the larynx . Next line of management is:

 A

Tracheostomy

 B

Microlaryngoscopy

 C

Steroid

 D

Antibiotics

Ans. B

Explanation:

 

The management is microlarygoscopic surgery using CO, laser to ablate the lesion.

Steroids and antibiotics have no role.

Tracheostomy is reserved for those patients who have severe respiratory distress.



Q. 9

A patient is examined by an ENT Specialist doctor by the following test as shown in the image.Which are the other tests,that can also be used for the assessment of the same region which is being tested by the doctor? 

 A

Nasopharyngoscopy

 B

Examination under anaesthesia after palatal retraction.

 C

Digital palpation

 D

Laryngoscopy

Q. 9

A patient is examined by an ENT Specialist doctor by the following test as shown in the image.Which are the other tests,that can also be used for the assessment of the same region which is being tested by the doctor? 

 A

Nasopharyngoscopy

 B

Examination under anaesthesia after palatal retraction.

 C

Digital palpation

 D

Laryngoscopy

Ans. A

Explanation:

Ans:D.)Laryngoscopy

The image represents Posterior rhinoscopy test

Different methods of examining the Nasopharynx 

i. Posterior Rhinoscopy

ii. Nasopharyngoscopy.

iii. Examination under anaesthesia after palatal retraction.

iv. Digital palpation.

v. Radiological examination.

Posterior Rhinoscopy:

It is method of examination of the Nasopharynx.

Structures seen on posterior rhinoscopy:
– Both choanae

– Posterior end of nasal septum

– Opening of Eustachian

– Posterior end of superior/tube middle and inferior turbinates

– Fossa of Rosenmuller

– Torus Tubarius

– Adenoids

– Roof and posterior wall and nasopharynx.



Q. 10

lntra ocular pressure rises in ‑

 A

 Intubation & laryngoscopy

 B

 LMA

 C

 Infusion of IV propofol

 D

 Bag and mask ventilation

Q. 10

lntra ocular pressure rises in ‑

 A

 Intubation & laryngoscopy

 B

 LMA

 C

 Infusion of IV propofol

 D

 Bag and mask ventilation

Ans. A

Explanation:

Ans. is ‘a i.e., I ntubation & laryngoscopy 



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