How is laryngoscopy of the larynx done? Laryngeal examination

1. As already happened said There are circumstances in which indirect laryngoscopy cannot be performed (in very young children) or must be performed so quickly that it cannot give a clear picture of the condition of the larynx. This applies primarily to young children, especially to children suffering from laryngeal papillomatosis. Removal of papillomas using the method of direct laryngoscopy, especially repeated, presents a number of invaluable advantages over the method of indirect laryngoscopy. Using direct laryngoscopy, papillomas are easier to remove and they can be removed in larger numbers due to better visibility of the larynx.
With direct laryngoscopy, one can see, and therefore diagnose, the presence of papillomas in the trachea.

2. When help direct laryngoscopy can not only see a foreign body in the larynx or in the upper part of the trachea, but also remove it. A number of endoscopists (Zimont, Tikhomirov, Yaroslavsky, etc.) recommend removing so-called floating, i.e., moving, foreign bodies in the trachea using direct laryngoscopy, while bronchoscopy should only be performed if removal of the foreign body using direct laryngoscopy fails. Zimont believes that direct laryngoscopy can almost completely replace bronchoscopy.
3. Direct laryngoscopy eliminates the need for or reduces the number of tracheobronchoscopy, which is important at an early age.

4. Direct laryngoscopy significantly reduced the number of tracheotomies performed at an early age for foreign bodies in the larynx or trachea.
5. Direct laryngoscopy significantly facilitates the production of a biopsy to determine the nature of the neoplasm, especially with the so-called recumbent epiglottis, which does not rise with phonation, covering the anterior part of the larynx.

6. Direct laryngoscopy facilitates operations on the oral and laryngeal parts of the pharynx.
7. For disorders breathing During various surgical interventions, direct laryngoscopy allows you to insert a catheter into the trachea under visual control, through which oxygen can be introduced into the respiratory tract.

8. Zimont using a straight line laryngoscopy opens retropharyngeal abscesses when the child is lying down. With this method, the possibility of pus getting into the respiratory tract is completely eliminated.

9. Direct laryngoscopy can be used for dissection and excision of scars from the subglottic space. S. Jackson used a galvanocaustic knife.

10. Direct laryngoscopy used for surgical treatment of laryngeal tuberculosis.
11. Jackson used direct laryngoscopy to provide emergency care for asphyxia during general anesthesia. Jackson notes that blowing oxygen directly into the trachea quickly restores normal breathing.

12. Direct laryngoscopy can be used when removing foreign bodies from the upper esophagus, especially in young children, in whom esophagoscopy can cause a reflexive sudden stop in breathing (A. Feldman).

Contraindications for direct laryngoscopy are ulcerative processes of the epiglottis, oropharyngeal cavity, pronounced aortic aneurysm, decompensated heart disease, large edema, severe arteriosclerosis, hypertension.
For children contraindication is sharp stenotic breathing. However, such breathing is a contraindication for direct laryngoscopy in adults.

LARINGOSCOPY(Greek larynx, laryng larynx + skopeo - observe, examine) - a method of examining the larynx. There are three types of L. - indirect, or mirror, direct and retrograde.

Indirect laryngoscopy

Indirect laryngoscopy was developed by the singer and singing teacher Garcia (M. Garcia, 1854) to study the physiology of the singers' voice. In honey indirect L. practice was introduced by Türk (L. Turck, 1866) and I. Chermak (1863). It is produced using a special laryngeal mirror (available in various diameters - 8, 12, 15, 21, 25 and 27 mm). For lighting, a frontal illuminator or (more often) a frontal reflector that reflects the light of the lamp is used. It is more convenient to carry out the study in a darkened room. The light source (if a frontal reflector is used) is located on the side of the subject's right ear. The doctor sits opposite the patient. Having invited the patient to open his mouth and stick out his tongue, the doctor holds it with fingers I and III of his left hand, and II fixes the upper incisors or lip of the subject. Having directed the light reflected from the frontal reflector onto the area of ​​the soft palate, the doctor with his right hand inserts a pre-heated (to avoid fogging) laryngeal mirror through the mouth into the oral part of the pharynx. The handle of the mirror is held like a pen. The mirror rod should be located at the left corner of the subject's mouth so as not to block the field of view. The mirror is installed so that the rays of light reflected from it enter the larynx (Fig. 1). At the same time, an image of the larynx is visible in the mirror. As directed by the doctor, the examinee pronounces the sound “I” or “E”, the larynx rises slightly and becomes more accessible for examination. In some cases, it is necessary to slightly push the soft palate and uvula toward the back wall of the pharynx with the back surface of the mirror. You should avoid touching the mirror to the back and side walls of the pharynx, as well as the root of the tongue, in order to avoid the occurrence of a gag reflex. It is not recommended to perform L. immediately after eating. If, however, a gag reflex occurs that prevents L., superficial anesthesia is used - lubricating the oral and laryngeal parts of the pharynx and the upper part of the larynx with 3-5% cocaine solution, 1 - 2% dicaine solution or 2% pyromecaine solution It is better, however, to spray with the same drugs.

In some cases (with a curled, rigid, upturned epiglottis, short thick tongue), it is necessary to resort to pulling the epiglottis anteriorly - to the root of the tongue. This is done under superficial anesthesia, using a special instrument - an epiglottis holder or a laryngeal probe with cotton wool screwed onto its end. In this case, the tongue is recorded either by the person being examined or by the doctor’s assistant.

It should be taken into account that with indirect L. a “semi-reverse” image of the larynx is obtained. The right and left halves retain their places. The epiglottis (forming the anterior part of the larynx) appears posteriorly in the laryngeal mirror. The posterior parts of the larynx (eg, arytenoid cartilages and interarytenoid space) appear to be located anteriorly.

Sometimes, for a detailed examination of the larynx, the doctor and the patient have to take other positions. So, if the posterior parts of the larynx are not clearly visible, during L. the subject should stand with his head tilted forward and down. The doctor sits on a chair or kneels. If visibility of the anterior sections is not good enough, the doctor standing examines the larynx of the patient sitting in front of him.

The laryngoscopic picture is normal and in some types of pathology. Rice. 1. Normal larynx: 1 - epiglottis; 2 - vestibular folds; 3 - vocal folds; 4 - aryepiglottic fold; 5 - arytenoid cartilage; 6 - interarytenoid space; 7 - posterior wall of the larynx. Rice. 2. Acute laryngitis: severe hyperemia and infiltration of the epiglottis, vestibular and vocal folds, aryepiglottic folds, interarytenoid space. Rice. 3. Acute epiglottitis: hyperemia and infiltration of the mucous membrane of the epiglottis. Rice. 4. Acute inflammation of the vestibular folds: severe hyperemia and infiltration. Rice. 5. Acute inflammation of the vocal folds: severe hyperemia and infiltration of the mucous membrane of the vocal folds. Rice. 6. Acute inflammation of the interarytenoid space: severe hyperemia and infiltration of the mucous membrane of the arytenoid cartilages and interarytenoid space. Rice. 7. Hemorrhagic acute laryngitis: hemorrhage in the vocal folds. Rice. 8. Acute subglottic (subglottic) laryngitis: severe hyperemia and infiltration of the mucous membrane of the subglottic area. Rice. 9. Phlegmonous laryngitis: abscess in the area of ​​the left aryepiglottic fold. Rice. 10. Chronic laryngitis: hyperemia and swelling of the vocal folds. Rice. 11. Pachyderma of the vocal folds: massive thickening of the epithelium in the form of a mushroom-shaped elevation on the vocal folds. Rice. 12. Pachydermia of the interarytenoid space: thickening of the epithelium in the interarytenoid space. Rice. 13. Singing laryngeal nodules: symmetrically located point elevations on the free edge of the vocal folds.

First of all, when L. is visible (print. Fig. 1) the free part of the epiglottis, aryepiglottic folds, then the arytenoid cartilages and the interarytenoid notch. The folds of the vestibule look like ridges located in the sagittal plane. The vocal folds are located underneath them, standing out sharply against the background of the surrounding formations with their white color and shiny surface. The ventricles of the larynx, located between the folds of the vestibule and the vocal folds, cannot be seen during L., but with pronounced atrophic processes, the entrances to these formations can be seen. When examining the vocal folds, pay attention to their color, the nature of the surface, mobility, and symmetry of movements during phonation. During inspiration (the glottis is open), the width of the glottis is determined and the subglottic cavity is examined. It is often possible to examine the upper parts of the trachea (in some cases the entire trachea, up to the bifurcation). In this case, cartilaginous rings are visible, shining through the mucous membrane. In an adult, the normal width of the glottis in the widest posterior part is approx. 8 mm.

Indirect L. is performed for every adult patient and older child in an ENT hospital, at an outpatient appointment, or during a preventive ENT examination. In most cases, it is not possible for young children to perform indirect L.

Direct laryngoscopy

Direct laryngoscopy (autoscopy, directoscopy, orthoscopy) was introduced into practice by Kirstein (A. Kirstein, 1895) and is based on the ability to straighten the angle between the axis of the oral cavity and the axis of the larynx when tilting the head of the subject. For direct L., special devices are used - laryngoscopes.

Laryngoscopes- endoscopic devices for examining the larynx. The use of laryngoscopes began in 1895. Various authors called them autoscopes, orthoscopes, directoscopes, spatulas for direct laryngoscopy. In the USSR, the most common were the Zimont orthoscope, the Tikhomirov spatula and the Widritz universal directoscope.

The most convenient for examining the larynx and various manipulations (for removing foreign bodies, inserting bronchoscopic tubes and an endotracheal tube into the trachea) are laryngoscopic sets used both in our country and abroad, which have replaceable straight and curved blades (spatulas) and a handle. In the USSR, such sets are produced by the Leningrad production association “Krasnogvardeets” (Fig. 2-4). They are intended for laryngoscopy in children (Fig. 2) and adults (Fig. 3). Sets for adults and a universal set differ from children's in the types and sizes of blades.

To carry out surgical interventions, operating laryngoscopes with a device for resting on the patient’s body are used, which allows you to fix the laryngoscope and free the doctor’s hands.

The lighting system in laryngoscopes is different. Previously, Zimont orthoscopes and Tikhomirov spatulas used reflectors for lighting. More convenient was the lighting system using a miniature endoscopic incandescent light bulb mounted in the blade. In the Undritsa directoscope, the light bulb was powered through a transformer from a regular electrical network. Modern laryngoscopes use a lighting system from the mains and batteries, and a more convenient one - from dry batteries placed in the handle of the device.

In some cases, the illumination from a miniature endoscopic incandescent light bulb is insufficient; during operation, electrical contact may be disrupted and sparking may occur, which is unacceptable when working with ether anesthesia, especially in pressure chambers. Laryngoscopes with autonomous lighting sources and fiberglass light guides do not have these disadvantages. With the help of such lighting, illumination of any magnitude can be created at the observation object. There are various options for using light guides in laryngoscopes. In some laryngoscopes, a light guide located in the blade is combined with an incandescent lamp powered by a battery located in the handle. In others (mainly for children), the light from the lighting device is transmitted through a fiberglass light cable mounted inside the blade handle to its proximal end and is directed by a prism located here to the distal end of the laryngoscope.

In most laryngoscopes with light guides inside the blade, the light guide is strengthened so that its distal end is located close to the distal end of the blade, and the proximal end is connected to the light cable. A laryngoscope of this type is produced in the USSR by the Leningrad production association “Krasnogvardeets” (Fig. 4). A similar laryngoscope is used to work in a pressure chamber (Fig. 5). The lighting device is placed outside the pressure chamber. The light from it is transmitted through light cables through the glass sealing plug to the laryngoscope inside the pressure chamber.

The working parts of laryngoscopes - blades - come in the form of a solid tube or a tube with a longitudinal cutout; in the latter case, it is more convenient to use instruments for manipulation inside the larynx. Laryngoscope handles also have different shapes. They are straight, round for battery-powered laryngoscopes, massive with a rest for the index finger, sometimes in the shape of the letter L, like the Jackson laryngoscope. The handles of operating laryngoscopes have a device for attaching a chest support (Fig. 6). The handles of diagnostic laryngoscopes are usually attached to the blade at an angle of 90°, and for operating ones - at an acute angle.

For a detailed examination of the laryngeal ventricles, an optical laryngoscope - pharyngoscope - is used.

The blades of most manufactured laryngoscopes are made of brass with a mirror nickel coating, so they can withstand sterilization at temperatures not exceeding 120°. Stainless steel blades are increasingly being used, allowing any sterilization. Light bulbs and light guides are not sterilized, but are disinfected using cold methods adopted in the USSR.

There are reports in foreign literature about disposable plastic blades, but they are not mass-produced.

Direct laryngoscopy technique

Direct L. is performed on an empty stomach if possible. For the most part, superficial anesthesia of the mucous membrane of the pharynx and larynx is used (3-5% cocaine solution, 1-2% dicaine solution, 2% pyromecaine solution) with appropriate premedication. In some cases, short-term anesthesia is used. During the examination, the patient usually lies on his back with his head thrown back, less often sits on a chair. In some cases, the patient is placed on his stomach. During the insertion of the laryngoscope, the proximal part of the blade (some devices have a special plate) rests with great force on the incisors of the upper jaw. To avoid injury to these teeth, various devices are used - stick strips of adhesive plaster onto the supporting part of the blade or place a gauze napkin folded in several layers. Sometimes a rubber tube cut lengthwise is placed on the upper incisors. The best method, however, is to make an individual cast of the fuse from hardening plastic, for example, protacryl. In some cases, the laryngoscope is more easily inserted not along the midline, but from the side, from the corner of the mouth.

The process of inserting the laryngoscope blade is usually divided into three stages.

1. Inserting the laryngoscope blade through the mouth (more convenient when the patient’s tongue is protruded and fixed) along the root of the tongue while simultaneously tilting the patient’s head back. The upper part of the laryngoscope blade (or a special plate) rests more and more firmly on the incisors of the upper jaw. The blade is inserted into the lower part of the pharynx until the middle lingual-epiglottic ligament and the free part of the epiglottis come into view (Fig. 7, a).

2. The laryngoscope handle is slightly brought towards the chest so that the end of the blade goes around the edge of the epiglottis. Then the epiglottis is pressed to the root of the tongue with the end of the blade. For this purpose, the handle of the device is slightly removed from the chest and the blade is placed behind the free edge of the epiglottis. In this case, the arytenoid cartilages, the interarytenoid notch, and the posterior sections of the vestibular and vocal folds become clearly visible (Fig. 7.6).

3. Inserting the end of the laryngoscope blade almost to the vocal folds. In this case, all parts of the larynx become clearly visible (Fig. 7, c). If the visibility of the anterior commissure is insufficient, it is advisable to apply external pressure to the area of ​​the thyroid cartilage.

The laryngoscope, regardless of its design, is usually inserted with the right hand. After introducing and installing the laryngoscope in the desired position, if there is a need to carry out certain manipulations in the larynx (insertion of an endotracheal tube, removal of benign tumors, taking a piece of tissue for gistol, research, etc.), proceed depending on the design of the laryngoscope. Thus, the handle of the Tikhomirov spatula, the Undritz directoscope, the laryngoscope used for intubation, as well as the Brunings and Mezrin bronchoscopes are fixed with the left hand, leaving the right hand free to carry out certain manipulations.

When using an orthoscope or autoscope, a special lever connected to a handle is installed on the sternum area, thus fixing the instrument blade in the desired position.

Special types of direct L. include suspended and support L. Suspension L. consists in the fact that when the root of the tongue is pressed with a spatula, the weight of the hanging head of the patient lying on his back is used - the head is, as it were, “suspended” on the spatula. With supporting L., pressure on the root of the tongue is provided by the counterpressure of a lever resting on a special metal stand or on the patient’s chest (for example, when using a Jackson laryngoscope).

As a rule, direct L. creates opportunities for a much more detailed examination of the larynx and a large number of surgical interventions than indirect L.

Retrograde laryngoscopy is performed using a small nasopharyngeal speculum, which is inserted (pre-heated) through a tracheostomy, the edges of the cut have to be moved apart. At the same time, the instrument faces the mirror surface upward, towards the larynx. For lighting, use a frontal illuminator or reflector. In cases where retrograde L. is performed on the operating table immediately after opening the trachea, it is advisable to apply thick silk ligatures to the edges of the trachea incision (in the intercartilaginous spaces). The speculum is inserted by spreading the edges of the tracheal incision using the indicated ligatures. In some cases, a Trousseau dilator can be used. In cases where retrograde L. is performed on a patient with a formed tracheostomy, it is convenient to move its edges apart using a nasal dilator with medium (40 mm) or long (60 mm) jaws.

With retrograde L., the upper part of the trachea, the subglottic cavity and the lower surface of the vocal folds are visible.

Microlaryngoscopy

The so-called microlaryngoscopy - examination of the larynx using a special operating microscope (focal length 350-400 mm). Examination of the larynx through a microscope can be performed in combination with indirect L. The doctor and the subject occupy the same position as with traditional indirect L. In this case, the light is directed onto the mirror from the illuminator available in the microscope. The image of the larynx in the mirror is examined through a microscope (8- and 12.5-fold magnification is often used). Microlaryngoscopy is usually performed without anesthesia, less often with superficial anesthesia. This method is used for diagnosis and postoperative monitoring of patients.

Microlaryngoscopy in combination with direct L. is performed both for diagnosis and for carrying out endolaryngeal surgical interventions, which for one reason or another cannot be performed under the control of traditional L. methods. These include the removal of common papillomas and other benign neoplasms that have a wide range of base, extensive hyperplastic areas of the mucous membrane. Microlaryngoscopy makes it possible to more specifically take a piece of tissue for histol, research, which is of great importance for the early diagnosis of malignant neoplasms of the larynx. Direct microlaryngoscopy is usually performed under insufflation or intubation anesthesia. In the latter case, the thinnest endotracheal tube is used.

Bibliography: Antoniv V. F. and Triantafilidi I. T. The use of optics in the study and operations for diseases of the pharynx and larynx, Vestn, otorhinol., No. 6, p. 29, 1973; Gorobets E. S. and Tyukov V. L. Injection artificial ventilation of the lungs during general anesthesia during laryngoscopy and endotracheal surgical interventions, Zhurn, ushn., no. and throats, Bol., No. 4, p. 45, 1977; Multi-volume guide to otorhinolaryngology, ed. A. G. Likhacheva, vol. 1, p. 7, 472, M., 1960, bibliogr.; Surgical diseases of the pharynx, larynx, trachea, bronchi and esophagus, ed. V. G. Ermolaeva et al., p. 223, M., 1954, bibliogr.; With zermak I. N. Der Kehl-kopfspiegel in seine Verwerthung flir Physiologie und Medicin, Lpz., 1863; Klein-sasser O. Mikrolaryngoskopie und endo-laryngeale Mikrochirurgie, Stuttgart - N.Y., 1968, Bibliogr.; Lewy R. B. a. Brusca P. A. Difficult direct laryngoscopy, Laryngoscope (St Louis), v. 86, p. 567, 1976; Sauvage J. P. e. a. Notre experience de l'oxygene pulse et de l'anesth6sie generale dans les laryngoscopies directes en suspension, Ann. Ot, o-la-ryng. (Paris), t. 93, p. 577, 1976; Seif-f e r t A. Untersuchungsmethoden des Kehl-korfes, Handb. Hals, - Nasen - u. Ohren-heilk,. hrsg. v. A. Denker u. O. Kahler, Bd 1, S. 762, B. - Miinchen, 1925; T ii g s k L. Klinik der Krankheiten des Kehlkopfes und der Luftrohre, Wien, 1866.

Yu. B. Preobrazhensky; V. N. Sazontova (med. tech.).

The laryngoscope reflects the rays of the light source and at the same time gives a mirror image of the larynx. The laryngeal mirror differs from the nasopharyngeal mirror in its size - its diameter is 3 cm. The mirror is attached to the rod at an obtuse angle. To make it easier to fix the mirror, its rod is extended with a corresponding “larynx handle.” The position of the child and the light source is the same as during rhinoscopy.

When performing a mirror examination of the larynx, the active participation of the person being examined is necessary; he sticks out his tongue, which the doctor holds with a gauze pad between the thumb and fingers of his left hand.

The laryngeal mirror is heated so that it does not fog up from breathing; in addition, the examinee tolerates the touch of a warm mirror more easily than the touch of a cold one. The mirror is inserted into the oral cavity in such a way that its back surface comes into contact with the uvula of the soft palate. The mirror must be inserted carefully. Touching the arches, tonsils, root of the tongue, or the wall of the pharynx mostly causes a reflexive swallowing and vomiting movement.

The mirror rod should not be held in the midline, but so that it is in the left corner of the mouth and is not in the field of view. The laryngoscope handle is held in the right hand, like a pen with a feather.

When inserting the speculum, the first areas to be noticed are the fourth tonsil and the epiglottis. The subject is forced to vocalize “e” in a drawn-out manner; at this time, the epiglottis rises, and in the mirror one can see the entrance to the larynx and the true white vocal cords. During the inhalation following the moment of phonation, you can see the anterior commissure and, due to the wide divergence of the vocal cords, the anterior wall of the trachea. The mirror image is called semi-reverse, since the anterior section of the larynx in the mirror is located at the top, the posterior sections at the bottom, but the right side of the larynx is visible on the right, the left on the left. The vocal cords appear to run from top to bottom, but in fact they run horizontally from front to back. Thus, the laryngoscopic picture can be presented in the following form: “from above” the epiglottis and the anterior commissure of the vocal cords, “from below” the arytenoid cartilages moving together with the true ligaments. During inspiration, the interarytenoid space is visible between the arytenoid cartilages. When inhaling, the glottis appears as a triangle. Above the true ligaments, false ligaments are visible in the form of two red stripes. Between the true and false ligaments, depressions are visible - the entrance to the Morganian ventricles, on the sides of the larynx - aryepiglottic folds, outward from them - pear-shaped fossae. The fourth tonsil is visible at the root of the tongue.

If in older childhood the obstacle to laryngoscopy is the child’s fearfulness, hypertrophy of the tonsils, massive tongue and short frenulum of the tongue, then in early childhood this is added by the impossibility of the child’s active participation in the act of research, such as, for example, protruding the tongue, phonation at the request of the researcher, as well as an abundance of saliva, a reflex spasm of the larynx.

For laryngoscopy at an early age, a special technique is needed: the position of the child, his fixation, the light source and the position of the doctor are the same as for rhinoscopy. Using a spatula, pull the root of the tongue anteriorly and downward; at the same time, the epiglottis rises and the entrance to the larynx opens. A small mirror is inserted and placed in the usual position. Initially, there is a spasm of the glottis. There is no need to remove the mirror, since after a few seconds a deep breath begins; you need to take this moment to see the larynx. Inspiration is usually followed by coughing shocks with copious secretion of sputum, covering the speculum. You need to quickly remove the mirror from your mouth and insert another one, already warmed up and prepared by an assistant, into your mouth. By changing two or three mirrors, it is usually possible to examine the larynx of a child even up to 1 year old.

If it is necessary to examine the posterior wall of the larynx and the posterior wall of the trachea, “posterior laryngoscopy” is used. The child is placed on a chair, while the doctor sits on a low chair or kneels and looks up into a horizontally inserted and installed mirror. The light source is placed as high as possible. In this position, the angle of direction of the light rays changes, therefore the angle of their reflection also changes.

Sometimes it is necessary to resort to the method of direct laryngoscopy (foreign body stuck between ligaments, removal of papillomas, etc.). To use this method, you must have a Zimont, Undrits or Tikhomirov spatula, a frontal lamp, which can be replaced by a conventional frontal reflector and a light source, as with mirror laryngoscopy, and a low chair.

Direct laryngoscopy in older children is performed under local anesthesia; In young children, the examination can be performed without anesthesia, but it is still better under general anesthesia in a supine position.

During direct laryngoscopy, the child must sit or lie down; the mouth should be open, the tongue should be protruded and grasped by the doctor through a gauze pad. The principle of the method is based on the fact that the angle formed by the oral and laryngeal cavities can be straightened by movements of the head - throwing it back slightly.

The first step of laryngoscopy is to advance the spatula along the midline to the root of the tongue to the epiglottis. At the second moment, the spatula is passed over the edge of the epiglottis, as if through a threshold, pressing it towards the tongue; at the same time, when pressing the tongue, it is necessary to tilt the child’s head back a little - then not only the vocal cords, movements of the arytenoid cartilages and the posterior wall of the larynx, but also the trachea are visible.

When examining a child in a supine position, straightening the oropharyngeal angle is achieved by hanging the head over the edge of the operating table.

Mucus that interferes with the study is sucked out using a pump.

After the described study, the child should remain under medical supervision while observing the food and vocal regime (liquid cold food, silence) for 1-2 days.

Laryngoscopy is used for in-depth diagnosis and treatment of parts of the throat. It is performed by an experienced otolaryngologist to help patients with problems in the vocal cords, trachea, and nasopharynx. During the examination, the doctor uses special instruments that are inserted into the throat. Due to the frightening nature of this procedure, patients are often afraid of it and put it off. Let's take a closer look at how this happens to get rid of unnecessary fears.

Description and types of procedure

When the doctor says that laryngoscopy is needed, he explains to the patient how it will be done. Moreover, for the successful completion of this manipulation, the patient must be relaxed and calm. But the doctor’s main goal is to get rid of the disease, so he doesn’t see anything terrible in this process. Unlike the patient, who does not find this prospect pleasant. A good ENT specialist will quickly reassure his client and explain that they are afraid of the consequences of a protracted illness, and not of a minute examination. But not every good otolaryngologist can be a good psychologist. So let's figure it out for ourselves.

Exactly how the procedure will be performed depends on the doctor’s goals. Laryngoscopy may be prescribed for examination or treatment. Diagnostics is quick and does not require special preparation. Treatment requires more time and manipulation, but this does not mean that therapeutic laryngoscopy will be painful and scary. To solve complex medical problems, anesthesia or anesthesia is always used, in this case too.

If the doctor needs to examine the oral cavity or oropharynx in detail, he will use a special long-handled mirror. This mirror is inserted into the throat and reflects the condition of the mucous membrane. In medicine, this diagnostic method is called indirect laryngoscopy; it is suitable for a shallow examination, but the doctor’s actions are greatly limited. It is used during medical examinations and routine appointments for children and adults. This technique has been known for a very long time and the scheme for its implementation has not changed for almost two centuries. In the circles of modern doctors it is considered a rarity, but in state medical institutions it is mainly used.

This method is not suitable for solving more serious problems. For example, it is very difficult to perform for small children or to remove tumors in the throat. In such cases, direct laryngoscopy is indicated. It is performed using a flexible or rigid fiber laryngoscope. This device looks like a thin flexible hose or rigid tube on a handle with an optical system and lighting. Such an instrument is inserted deep into the larynx or trachea for inspection. The direct method also allows you to take biomaterial for biopsy, remove polyps, and remove foreign bodies. When using a flexible fiber laryngoscope, local anesthesia is administered, while a rigid one is always performed under general anesthesia in the operating room.

In some cases, it is necessary to examine the nasopharynx; this cannot be done through the oral cavity, so the instrument is inserted through the nose. This procedure is called retrograde laryngoscopy. In this case, local anesthesia is also indicated, so the patient does not feel much discomfort. The device transmits the image to a screen with multiple magnification, so the doctor can examine in detail all the necessary areas. The direct laryngoscopy technique is considered the most informative and least traumatic. Therefore, you should not be afraid of her.

In what cases is laryngoscopy prescribed?

The indirect technique is prescribed for the purpose of preventive examination or specific complaints. At the same time, an ENT specialist can immediately determine from the symptoms what type of diagnosis is needed. As a rule, in clinics, for simple tasks, a laryngeal mirror is used, that is, indirect laryngoscopy. In modern clinics they use a fibrolaryngoscope or an endoscope, that is, a direct technique.

This procedure is prescribed for:

• blood discharge during coughing;
• pain when swallowing;
• plaques in the ears;
• breathing problems through the nose or mouth;
• sensations of a foreign body in the throat;
• respiratory tract injuries;
• loss or change in voice for unknown reasons.

The direct method allows you to take materials for analysis and research, remove foreign objects, tumors, papillomas and polyps. Laryngoscopy is considered the main method for calculating throat cancer at all stages. Another attending physician may refer you for such a procedure, for example, after a CT or MRI of the head and neck. Also, any patient can undergo a preventive examination to ensure their health.

Contraindications for the study

Such diagnosis and treatment may not be indicated for all patients. Indirect laryngoscopy is extremely rarely used in young children, since it is very difficult to control the process in this case. However, the direct method also has its contraindications. It is not prescribed against the background of such problems:

• damage to the cervical vertebrae;
• cardiovascular diseases (hypertension, aortic aneurysm, heart disease);
• severe bleeding from the throat;
• during pregnancy;
• stenotic breathing;
• acute inflammation of the mucous membrane, parts of the throat;
• epilepsy.

Since direct laryngoscopy is performed under anesthesia or general anesthesia, it is very important to find out whether the patient is allergic to medications before the session. Also considered a relative contraindication is increased sensitivity, which greatly complicates the examination. In this case, other types of diagnostics, such as computed tomography, may be prescribed.

Where can I undergo this procedure and how much does it cost?

Whether prescribed by a doctor or simply for the purpose of a routine examination, you should first find out where you can get a laryngoscopy. Indirect is carried out in all public medical institutions. To do this, you just need to find an ENT office. Direct can most often be found in private clinics. If serious intervention is required, for example, tumor removal, it is better not to save. Expensive equipment in private institutions allows you to conduct a session not only quickly and comfortably, but with its help they obtain more accurate information that may be “missed” when examined with mirrors. It is very easy to find such a clinic in your city; the Internet will help with this. When searching for a website, you can immediately make an appointment if you provide a telephone number or an online registration form. Today, in order to become better acquainted with the process, you can search for photos and videos on the Internet, although often they only repel patients, despite the fact that they essentially do not cause any harm.

To choose the best clinic and reassure yourself, you can read patient reviews on websites. Also, responses are often left on city forums, here you can read how laryngoscopy is done, whether it hurts or not, they recommend a good doctor. The price for laryngoscopy is individual in each case. Indirect can be done for free or for a minimal cost in public clinics; indirect rigid or flexible will cost a little more. On average, such a service in a private clinic will cost 20-40 dollars if you just need an examination. The price of treatment can only be set in the clinic itself after diagnosis.

Preparation for the procedure

If you prepare properly, the appointment will be faster and easier. As a rule, ordinary indirect laryngoscopy does not require special preparations; it is only recommended to abstain from food 4 hours before the session and drink less. This is necessary in order to reduce the level of the gag reflex. If a direct method is planned, more painstaking preparation is needed. The patient may be prescribed additional examinations such as computed tomography or barium examination of the larynx and esophagus.

In addition, in order to reduce risks, the patient should undergo a blood test a week before the planned procedure. Be sure to check the level of coagulation and conduct allergy tests for medications. The doctor also warns the patient about the ban on certain types of medications, such as Aspirin and multivitamins, which reduce clotting. If direct rigid laryngoscopy is prescribed, then general anesthesia will be required. Drinking and eating are prohibited 7-8 hours before the start of the session. On the day of the procedure, you need to tell the doctor if you took any medications, since the components in them can unpredictably affect anesthesia.

How would this happen

Depending on the doctor’s goals, direct or mirror laryngoscopy will be prescribed. As a rule, the direct patient knows in advance so that there is time to prepare. A mirror examination is carried out immediately upon arrival at the ENT office for a quick examination. They go differently.

Indirect technique

First, the doctor will listen to complaints, and if there are any, study the medical history. If the visitor has dentures, they will be removed before the examination. Then the ENT and the patient sit on chairs opposite each other. At the same time, there will be another health worker in the office to assist. The doctor has a reflector attached to his head - a round reflector. The mirror is prepared and heated a little so that it does not fog up during inspection. It will not be hot, it will be brought to body temperature.

After preparing the instruments, the patient opens his mouth wide and extends his tongue as far as possible. The ENT catches the tongue on gauze or a sterile napkin; it will need to be held for a better view. Sometimes the doctor may ask the person being examined to hold his tongue so that the doctor has both hands free. Then the specialist adjusts the light correctly so that the oropharynx of the subject is illuminated. Slowly, without touching the root of the tongue, the doctor inserts the speculum into the throat. The mirror is located at an angle of 120 degrees, which makes it possible to examine the oral cavity, oropharynx, and vocal cords. To facilitate the examination, the doctor asks to pronounce vowel sounds: and, uh, long a.

If the information received is not enough, after a short break the process is repeated. One insertion of the mirror takes no more than 10 seconds. As a rule, one or two inspections are sufficient. Based on the data seen, the ENT makes a conclusion about the health of his patient or prescribes treatment. Sometimes a specialist comes to the conclusion that a mirror examination is not enough. In this case, the direct method is prescribed.

Direct technique

This is a slightly more complex process, but it gives the doctor more information and manipulation. It may be prescribed to a small child, for example, to remove stuck objects. This session is performed under local anesthesia; for this purpose, a special spray is sprayed into the throat, which quickly relieves pain. Most often, the patient lies down on the couch and throws his head back. A flexible laryngoscope with a light source and optics is inserted into the throat. Sometimes it is necessary to insert a fibrolaryngoscope through the nose; in this case, an anesthetic is also used in the form of drops.

The doctor conducts an examination and makes a conclusion. The process takes no more than 7-8 minutes.

Direct rigid laryngoscopy takes place exclusively in an operating room. It is needed for surgical procedures, removal of tumors, collection of biomaterial, etc. The patient does not feel anything, as he is under anesthesia.

Rehabilitation and complications

Before laryngoscopy, you can find out in advance how it is tolerated. After a mirror check, no special rehabilitation is needed. Sometimes, when pressure is applied to the back of the throat, small attacks of nausea occur, which quickly pass. Rigid or flexible diagnosis may be accompanied by complications, although this is rare. When using a flexible hose, attacks of gag reflexes may also occur, but in most cases they are dulled by the action of anesthetics. After the procedure, local anesthesia creates a feeling of a swollen throat, and swallowing is a little difficult. These symptoms go away after the drugs wear off.

Rigid laryngoscopy is a little more complicated. Nothing is felt during the intervention itself, but side effects may occur afterward. For example, in rare cases, patient reviews indicate a sore throat, hoarse voice, and difficulty swallowing. Such effects should disappear after 1-2 days. If biomaterial was collected, blood is periodically released within 24 hours. It's not scary if it lasts no more than a day. Bleeding from the throat and a constant iron taste in the mouth for 2-3 days is a reason to urgently consult an ENT specialist.

After examination or treatment, especially the rigid method, patients are advised to refrain from drinking and eating until the effect of the anesthetic wears off. Smokers should definitely abstain from nicotine for another 8-12 hours. If there are complications, such as bleeding, you can smoke only with the doctor's permission. After restoration of all functions, it is advised to drink warm sips in small sips, and only then eat.

FAQ

How is laryngoscopy performed: does it hurt or not?

Pain relief completely resolves the issue of pain during this process. In extreme cases, the urge to vomit may simply be unpleasant, but even this is blocked under local anesthesia. After a biopsy and rigid intervention, you may experience a sore throat that goes away after a couple of days.

How long does this procedure take?

A routine examination using mirrors or a flexible laryngoscope will take no more than 10 minutes. In this case, the entire examination takes place in several stages of 5-10 seconds. The operation takes from 15 to 60 minutes.

Is additional examination necessary after laryngoscopy?

Needed if prescribed by a doctor. It is also necessary to visit an ENT specialist if there are long-term side effects: bleeding, severe pain, or a dull voice. A cause for concern is symptoms that do not go away for 3-4 days.

What can replace it?

If you just need a diagnosis, you can use an endoscopic examination. It goes almost the same way and its cost is slightly different. Computed tomography is considered a more comfortable examination option for the patient, but do not forget that in this case the patient receives a dose of radiation. In addition, for diagnosing the organs of the ear, nose and throat, laryngoscopy and endoscopy remain the most informative.

In 1854, the Spanish singer Garcia (son) Manuel Patricio Rodriguez (1805-1906) invented the laryngoscope for indirect laryngoscopy. For this invention in 1855 he was awarded the degree of Doctor of Medicine. It should be noted, however, that the method of indirect laryngoscopy was known from earlier publications, dating back to 1743 (the obstetrician Levert's glotoscope). Then Dozzini (Frankfurt, 1807), Sem (Geneva, 1827), Babingston (London, 1829) reported similar devices operating on the principle of a periscope and allowing one to inspect the internal space of the larynx in a mirror image. In 1836 and 1838, the Lyon surgeon Baums demonstrated a laryngeal mirror, which exactly corresponds to the modern one. Then in 1840 Liston used a mirror similar to a dentist's, which he used to examine the larynx for a disease that caused its swelling. The wide introduction of the Garcia laryngoscope into medical practice is due to the neurologist of the Vienna Hospital L. Turck (1856). In 1858, Schrotter, a professor of physiology from Pest (Hungary), was the first to use artificial lighting and a round concave mirror with a hole in the middle (Schrotter reflector) with a rigid vertical Cramer headband adapted to it for indirect laryngoscopy. Previously, sunlight reflected from a mirror was used to illuminate the larynx and pharynx.

Modern indirect laryngoscopy techniques are no different from those used 150 years ago.

They use flat laryngeal mirrors of various diameters, attached to a narrow rod inserted into a special handle with a screw lock. To avoid fogging of the mirror, it is usually heated on an alcohol lamp with the mirror surface facing the flame or in hot water. Before inserting the mirror into the oral cavity, check its temperature by touching the back metal surface to the skin of the back surface of your own hand. Indirect laryngoscopy is usually performed in a sitting position with the body of the person being examined slightly tilted forward and the head slightly tilted backward. If there are removable dentures, they are removed. The technique of indirect laryngoscopy requires certain skills and appropriate training. The essence of the technique is as follows. The doctor with his right hand takes the handle with the mirror fixed in it, like a writing pen, so that the mirror surface is directed at an angle downwards. The subject opens his mouth wide and sticks out his tongue as much as possible. The doctor, with the first and third fingers of the left hand, grabs the tongue wrapped in a gauze napkin and holds it protruded, at the same time, with the second finger of the same hand, lifts the upper lip for a better view of the pharynx area, directs a beam of light into the oral cavity and inserts a heated mirror into it . The back surface of the mirror presses against the soft palate, moving it backwards and upwards. To avoid the reflection of the uvula of the soft palate in the mirror, which is an obstacle to viewing the larynx, it must be completely covered with a mirror. When inserting the mirror into the oral cavity, you should not touch the root of the tongue and the back wall of the pharynx, so as not to cause a pharyngeal reflex. The rod and handle of the mirror rest on the left corner of the mouth, and its surface should be oriented so that it forms an angle of 45° with the axis of the oral cavity. The light flux directed at the mirror and reflected from it into the laryngeal cavity illuminates it and the corresponding anatomical formations. To examine all structures of the larynx, the angle of the mirror is changed by manipulating the handle so as to sequentially examine the interarytenoid space, scoop, folds of the vestibule, vocal folds, pyriform sinuses, etc. Sometimes it is possible to examine the subglottic space and the posterior surface of two or three tracheal rings. The larynx is examined during quiet and forced breathing of the subject, then during phonation of the sounds “i” and “e”. When pronouncing these sounds, the muscles of the soft palate contract, and protruding the tongue helps to raise the epiglottis and open the supraglottic space for viewing. At the same time, phonatory closure of the vocal folds occurs. Inspection of the larynx should not last more than 5-10 s; repeated inspection is carried out after a short pause.

Sometimes examining the larynx during indirect laryngoscopy causes significant difficulties. Obstacles include an infantile, sedentary epiglottis, obscuring the entrance to the larynx; a pronounced (indomitable) gag reflex, observed most often in smokers, alcoholics, and neuropaths; a thick “unruly” tongue and a short frenulum; comatose or soporous state of the subject and a number of other reasons. An obstacle to examining the larynx is contracture of the temporomandibular joint, which occurs with a paratonsillar abscess or its arthrosis, as well as with mumps, phlegmon of the oral cavity, a fracture of the lower jaw, or with trismus caused by certain diseases of the central nervous system. The most common obstacle to indirect laryngoscopy is a pronounced pharyngeal reflex. There are some techniques to suppress it. For example, as a distraction, the subject is asked to count down two-digit numbers in his head or, clasping his hands with bent fingers, pull them with all his might, or the subject is asked to hold his tongue himself. This technique is also necessary when the doctor must have both hands free to carry out some manipulations inside the larynx, for example, removing fibroids on the vocal fold.

In case of an indomitable gag reflex, they resort to topical anesthesia of the root of the tongue, soft palate and posterior wall of the pharynx. Preference should be given to lubrication rather than aerosol spraying of the anesthetic, since the latter creates anesthesia that spreads to the oral mucosa and larynx, which can cause spasm of the latter. In young children, indirect laryngoscopy is practically impossible, therefore, if a mandatory examination of the larynx is necessary (for example, with its papillomatosis), they resort to direct laryngoscopy under anesthesia.

Picture of the larynx during indirect laryngoscopy

The picture of the larynx during indirect laryngoscopy is very characteristic, and since it is the result of a mirror image of the true picture, and the mirror is located at an angle of 45 ° to the horizontal plane (periscope principle), what is displayed is located in the vertical plane. With this arrangement of the displayed endoscopic picture, the anterior parts of the larynx are visible in the upper part of the mirror, often covered at the commissure by the epiglottis; the posterior sections, including the scoop and interarytenoid space, are displayed in the lower part of the speculum.

Since with indirect laryngoscopy, examination of the larynx is possible with only one left eye, i.e. monocularly (which is easy to verify when it is closed), all elements of the larynx are visible in the same plane, although the vocal folds are located 3-4 cm below the edge of the epiglottis. The lateral walls of the larynx are visualized sharply shortened and as if in profile. From above, that is, actually from the front, part of the root of the tongue with the lingual tonsil is visible, then the pale pink epiglottis, the free edge of which rises when the sound “i” is phonated, freeing up the laryngeal cavity for viewing. Directly under the epiglottis, in the center of its edge, you can sometimes see a small tubercle - tuberculum cpiglotticum, formed by the pedicle of the epiglottis. Below and posterior to the epiglottis, diverging from the angle of the thyroid cartilage and commissure to the arytenoid cartilages, there are vocal folds of a whitish-pearly color, easily identified by characteristic tremulous movements, sensitively reacting even to a slight attempt at phonation. During quiet breathing, the lumen of the larynx looks like an isosceles triangle, the sides of which are represented by the vocal folds, the apex seems to rest against the epiglottis and is often covered by it. The epiglottis is an obstacle to examining the anterior wall of the larynx. To overcome this obstacle, the Turk position is used, in which the person being examined throws back his head, and the doctor performs indirect laryngoscopy while standing, as if from top to bottom. For a better view of the posterior parts of the larynx, the Killian position is used, in which the doctor examines the larynx from below (standing on one knee in front of the patient), and the patient tilts his head down.

Normally, the edges of the vocal folds are even and smooth; when inhaling, they diverge somewhat; during a deep inhalation, the vocal folds diverge to the maximum distance and the upper rings of the trachea, and sometimes even the keel of the trachea, become visible. In some cases, the vocal folds have a dull reddish hue with fine vasculature. In thin, asthenic individuals with a pronounced Adam's apple, all the internal elements of the larynx stand out more clearly, and the boundaries between fibrous and cartilaginous tissues are well differentiated.

In the superolateral regions of the laryngeal cavity above the vocal folds, folds of the vestibule are visible, pink and more massive. They are separated from the vocal folds by spaces that are better visible in thin faces. These spaces represent the entrances to the ventricles of the larynx. The interarytenoid space, which is like the base of the triangular slit of the larynx, is limited by the arytenoid cartilages, which are visible in the form of two club-shaped thickenings covered with pink mucous membrane. During phonation, you can see how they rotate towards each other with their front parts and bring the vocal folds attached to them closer together. The mucous membrane covering the posterior wall of the larynx becomes smooth when the arytenoid cartilages diverge during inspiration; during phonation, when the arytenoid cartilages come together, it gathers into small folds. In some individuals, the arytenoid cartilages touch so closely that they seem to overlap each other. From the arytenoid cartilages, the aryepiglottic folds are directed upward and forward, which reach the lateral edges of the epiglottis and together with it serve as the upper boundary of the entrance to the larynx. Sometimes, with a subatrophic mucous membrane, in the thickness of the aryepiglottic folds you can see small elevations above the arytenoid cartilages; these are horn-shaped cartilages; lateral to them are the wedge-shaped cartilages. To examine the posterior wall of the larynx, the Killian position is used, in which the person being examined tilts his head to the chest, and the doctor examines the larynx from bottom to top, either kneeling in front of the patient, or the patient takes a standing position.

With indirect laryngoscopy, some other anatomical formations are also visible. Thus, above the epiglottis, in fact in front of it, the fossae of the epiglottis are visible, formed by the lateral lingual-epiglottic fold and separated by the medial lingual-epiglottic fold. The lateral parts of the epiglottis are connected to the walls of the pharynx using pharyngeal-epiglottic folds, which cover the entrance to the pyriform sinuses of the laryngeal part of the pharynx. During the expansion of the glottis, a decrease in the volume of these sinuses occurs; during the narrowing of the glottis, their volume increases. This phenomenon occurs due to contraction of the interarytenoid and aryepiglottic muscles. It is given great diagnostic importance, since its absence, especially on one side, is the earliest sign of tumor infiltration of these muscles or incipient neurogenic damage to them.

The color of the laryngeal mucosa must be assessed in accordance with the medical history and other clinical signs, since normally it is not constant and often depends on smoking, drinking alcohol, and exposure to occupational hazards. In hypotrophic (asthenic) persons of asthenic physique, the color of the mucous membrane of the larynx is usually pale pink; for normosthenics - pink; in obese, plethoric (hypersthenic) persons or smokers, the color of the mucous membrane of the larynx can be from red to bluish without any pronounced signs of disease of this organ.

Direct laryngoscopy

Direct laryngoscopy allows you to examine the internal structure in a direct image and perform various manipulations on its structures to a fairly wide extent (removal of polyps, fibroids, papillomas using conventional, cryo- or laser surgical methods), as well as carry out emergency or planned intubation. The method was introduced into practice by M. Kirshtein in 1895 and was subsequently improved several times. It is based on the use of a rigid directoscope, the introduction of which into the hypopharynx through the oral cavity becomes possible due to the elasticity and pliability of the surrounding tissues.

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Indications for direct laryngoscopy

The indications for direct laryngoscopy are numerous, and their number is constantly growing. This method is widely used in pediatric otorhinolaryngology, since indirect laryngoscopy in children is practically impossible. For young children, a one-piece laryngoscope with a non-removable handle and a fixed spatula is used. For adolescents and adults, laryngoscopes with a removable handle and a retractable spatula plate are used. Direct laryngoscopy is used when it is necessary to examine parts of the larynx that are difficult to view with indirect laryngoscopy - its ventricles, commissure, the anterior wall of the larynx between the commissure and the epiglottis, and the subglottic space. Direct laryngoscopy allows for various endolaryngeal diagnostic manipulations, as well as for inserting an endotracheal tube into the larynx and trachea during anesthesia or intubation in the event of an emergency need for mechanical ventilation.

Contraindications for carrying out

Direct laryngoscopy is contraindicated in cases of severe stenotic breathing, severe changes in the cardiovascular system (decompensated heart defects, severe hypertension and angina), epilepsy with a low threshold of convulsive readiness, with lesions of the cervical vertebrae that do not allow tilting of the head, with an aortic aneurysm. Temporary or relative contraindications include acute inflammatory diseases of the mucous membrane of the oral cavity, pharynx, larynx, bleeding from the pharynx and larynx.

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Direct laryngoscopy technique

Of great importance for effective direct laryngoscopy is the individual selection of the appropriate laryngoscope model (Jackson, Undritz, Brunings Mezrin, Zimont, etc.), which is determined) by many criteria - the purpose of the intervention: (diagnostic or surgical), the position of the patient in which it is supposed to be carried out laryngoscopy, his age, anatomical features of the maxillofacial and cervical areas and the nature of the disease. The study is carried out on an empty stomach, except in emergency cases. In young children, direct laryngoscopy is performed without anesthesia, in young children - under anesthesia, in older children - either under anesthesia or under local anesthesia with appropriate premedication, as in adults. For local anesthesia, various topical anesthetics can be used in combination with sedatives and anticonvulsants. To reduce general sensitivity, muscle tension and salivation, the subject is given one tablet of phenobarbital (0.1 g) and one tablet of sibazon (0.005 g) 1 hour before the procedure. Over 30-40 minutes, 0.5-1.0 ml of a 1% solution of promedol and 0.5-1 ml of a 0.1% solution of atropine sulfate are injected subcutaneously. 10-15 minutes before the procedure, topical anesthesia is performed (2 ml of a 2% dicaine solution or 1 ml of a 10% cocaine solution). 30 minutes before the specified premedication, in order to avoid anaphylactic shock, intramuscular injection of 1-5 ml of a 1% solution of dimedrom or 1-2 ml of a 2.5% solution of diprazine (pipolfen) is recommended.

The position of the subject can be different and is determined mainly by the condition of the patient. It can be performed in a sitting position, lying on your back, less often in a position on your side or stomach. The most comfortable position for the patient and the doctor is the lying position. It is less tiring for the patient, prevents saliva from flowing into the trachea and bronchi, and in the presence of a foreign body, prevents its penetration into the deeper parts of the lower respiratory tract. Direct laryngoscopy is performed in compliance with the rules of asepsis.

The procedure consists of three stages:

1. advancing the spatula to the epiglottis;
2. passing it through the edge of the epiglottis towards the entrance to the larynx;
3. moving it along the posterior surface of the epiglottis to the vocal folds.

The first stage can be carried out in three ways:

1. with the tongue protruding, which is held with a gauze pad either by a doctor’s assistant or by the examiner himself;
2. with the normal position of the tongue in the oral cavity;
3. when inserting a spatula from the corner of the mouth.

In all variants of direct laryngoscopy, the upper lip is pushed upward. The first stage is completed by pressing the root of the tongue downwards and moving the spatula to the edge of the epiglottis.

At the second stage, the end of the spatula is slightly raised, placed over the edge of the epiglottis and advanced 1 cm; after this, the end of the spatula is lowered down, covering the epiglottis. In this case, the spatula presses on the upper incisors (this pressure should not be excessive). The correct direction of advancement of the spatula is confirmed by the appearance in the friction field posterior to the arytenoid cartilages of whitish vocal folds extending from them at an angle.

When approaching the third stage, the patient's head is tilted back even more. The tongue, if held outside, is released. The examiner increases the pressure of the spatula on the root of the tongue and the epiglottis (see the third position - direction of the arrows) and, adhering to the midline, places the spatula vertically (with the subject sitting) along the corresponding longitudinal axis of the larynx in the prone position of the examinee). In both cases, the end of the spatula is directed along the middle part of the breathing gap. In this case, the posterior wall of the larynx comes into view first, then the vestibular and vocal folds, and the ventricles of the larynx. For a better view of the anterior parts of the larynx, the root of the tongue should be slightly pressed downwards.

Special types of direct laryngoscopy include the so-called hanging laryngoscopy, proposed by Killian, an example of which is the Seifert technique. Currently, the Seifert principle is used when pressure on the root of the tongue (the main condition for passing the spatula into the larynx) is provided by the counterpressure of a lever resting on a special metal stand or on the chest of the subject.

The main advantage of the Seifert method is the release of both hands of the doctor, which is especially important during long and complex endolaryngeal surgical interventions.

Modern foreign laryngoscopes for suspension and support laryngoscopy are complex complexes, which include spatulas of various sizes and sets of various surgical instruments specially adapted for endolaryngeal intervention. These complexes are equipped with technical means for infectious ventilation, injection anesthesia and special video equipment that allows surgical interventions to be performed using an operating microscope and a television screen.