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RESPIRATORY ENDOSCOPY - LARINGOSCOPY / BRONCHOSCOPY
Dr. Marlos de Souza Coelho
Dr. Wilson de Souza Stori Jr.

Clinic of the Thorax
Respiratory Endoscopy Service
Hosítal Universitário Cajuru
Pontifícia Universidade Católica do Paraná

Further information and scheduling an appointment with:

Telephone:
55 41 3360 30 40
55 41 3266 35 00



INTRODUCTION
Endoscopy is the internal examination of an organ through optical instruments that may or not be adapted to micro cameras and monitors, constituting then the videoendoscopy.

Per Oral Endoscopy is the medical specialty that involves endoscopic examination done through mouth (per os). This denomination can be used as an equivalent to Bronchialesophagology, which is the specialty registered in the Federal Board of Medicine, responsible for the esophagus and airways endoscopic examinations.

Therefore, respiratory endoscopy is the field of Medicine responsible for endoscopies done through nose, mouth or through tracheostomy for nasal pits, pharynges, larynges and bronchium examination.

Bronchoscopy had its beginning in late XIX century. In the subsequent century it presented important advance concerning its clinical practical application. The technologic improve of bronchoscopic equipments, the advent of flexible bronchoscopy, associated to great medication evolution as well as the development of safe anesthetic procedures, all these contributed to the growth of this diagnostic tool.

In the ruins of Pompey, there had been found traces that evidence the attempt of the airway’s inspection through these instruments. In 1897, Gustav Killian, known as “Father of Bronchoscopy” made bronchoscopy known using a rigid esophagoscope to remove a foreign body of the airways.

Since 1912, Bronchoesophagology evolved as a specialty with the development of a rigid bronchoscope to remove foreign bodies from the trachea and principal bronchium, this equipment was developed by Chevalier Jackson. Jackson established the principles of this specialty, becoming its major figure.

In 1964, Dr. Shigeto Ikeda established patterns for the first flexible bronchoscope. Due to his great interest in the diagnosis of premature lung cancer, Dr. Ikeda developed an instrument that could enter even subsegmentar bronchium, visualize lesions and obtain biopsies and/or material for cytological exam. And in 1966, Machida Endoscopic Company Ltd. and Olympys Optical Company Ltd. produced the first bronchialfibroscope prototype. In April of 1970, Dr. Shigeto Ikeda presented his instrument and his initial experience in the annual meeting of the American Bronchoesophagology Association. Since then, the flexible bronchoscope became an instrumento of major importance to the diagnosis of several pulmonary diseases.

The improvement of flexible and rigid bronchoscopy, and recently of videoendoscopy, allowed the expansion of their indication. Nowadays, bronchoscopy is considered an invasive diagnostic procedure of greater practical application in pneumology and thoracic surgery.
 
EXAMINATIONS / PERFORMED PROCEDURES
LARYNGOSCOPY / VIDEOLARINGOSCOPY
FIBRONASOPHARINGOLARYNGOSCOPY / VEDEONASOPHARINGOLARYNGOSCOPY
BRONCHOSCOPY
BRONCOPHIBROSCOPY
VIDEOBRONCOFIBROSCOPY
LARINGOTRACHEAL STENOSIS EXPANSION
STENTS, LARYNGEAL AND TRACHEAL MOLDES PLACEMENT
REMOVAL OF FOREIGN BODIES FROM LARYNGES, TRACHEA AND BRONCHIUM
ENDOSCOPIC EVALUATION OF SWAlLOWING ( FEES- Fiberoptic examination of swallowing safety)
 
LARYNGOSCOPY / VIDEOLARINGOSCOPY
Laryngoscopy is the procedure performed to diagnose laryngeal diseases. When the exam is visualized on monitor screen it is called videolaryngoscopy.

THE EXAM

The exam is executed with the patient seated under topic anesthesia of the pharynges and supraglottic larynges.

It is performed through the mouth, allowing the diagnosis of oral cavity, oropharynges, hipopharynges and larynges diseases and specially the vocal fold diseases. All larynges structures receive attention in order to search for organic or functional lesions.

Kids allow the performance of laryngoscopy most times with certain facility. Laryngoscopy can not be tolerated eventually due to nausea or to resistance of the patient. In this case, FIBRONASOPHAGOLARYNGOSCOPY can be done. It must be said that tolerance to laryngoscopy exceeds 95%.

As it is a dynamic exam, the patient’s cooperation is essential. Tape recording is important to the assistant doctor and to the fonoaudiologist because it allows them to observe the treatment’s evolution.

When lesions that request biopsy are found, the patient’s sedation or even anesthesia is necessary. If the lesion assaults one vocal fold in a superficial and diffuse way, the decortication of this fold, under general anesthesia and microsurgery of the larynges, allows the diagnosis in a safer way because biopsies, even multiple ones, may not detect larynges cancer in an initial phase, sometimes.
 
LARYNGOSCOPY/ VIDEOLARYNGOSCOPY INDICATION
• Disphony (hoarseness)
• Constant cleansing of throat
• Chronic cough
• Sore throat
• Foreign body sensation
• Lack of air feeling
 
PRINCIPAL DIAGNOSED DISEASES
• Disfunctional disphonies (voice alteration without organic lesions)
• Vocal nodule
• Wegener’s Granulomatosis
• Congenital/ acquired subglottis stenosis
• Congenital laryngeal anomalies (laryngomalacia, membranes and laryngeal clefts)
• Vocal fold paralysis
• Vocal fold granuloma
• Vocal fold polypus
• Laryngeal cysts / vocal folds
• Lateral/ anterior sacular cyst
• Supraglottic cyst
• Cystic higroma
• Subglottic retention cyst
• Oro-tracheal post-intubation lesions
• Chronic/ accurate laryngitis
• Reinke’s edema
• Tuberculosis, Blastomicosis
• Papiloma
• Laryngocele
• Laryngomalatia
• Laryngeal stenosis
• Foreign bodies
• Sarcoidosis
• Rheumatoid arthritis
• Hemangioma
• Paquidermia
• Gastroesophageal reflux / (esophagolaryngeal reflux) * traces
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Laryngeal Invasive Cancer
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Larynges Cancer
Invasion of Pharynx
Epiglottis and Subglottis
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Subglottic stenosis
post intubation
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Subglottic stenosis
post intubation
 
Left vocal fold paralysis
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Inspiration
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phonation
 
Right vocal fold cyst and left vocal fold paquidermia
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Left vocal fold cyst
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EXAMPLE
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Vocal fold
sinequia
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Post intubation
granuloma
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Granulomatous lesion
of larynges
(tuberculosis)
 
POSTERIOR GLOTTIC STENOSIS (POST INTUBATION)
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ANTERIOR GLOTTIC STENOSIS
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Endoscopic laryngoplasty
and glottic mold
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Endoscopic laryngoplasty
and glottic mold
 
FIBRONASOPHARINGOLARYNGOSCOPY - VIDEONASOPHARINGOLARYNGOSCOPY
It is an exam that uses a flexible equipment qith a 3mm diameter. It allows the visualization of the nasal pits, rinopharynx, hipopharynx and supraglottic larynges, with the possibility to view too trachea’s superior portion. It is done with the seated patient under topic anesthesia.
 
NASOPHARINGOLARYNGOSCOPY INDICATION
• Nasal breathing difficulty
• Oral breathing
• Sleep apnea
• Snoring
• Chronic nasal obstruction
• Chronic cough
• Sore throat, nose and ear pain
• Foreign body
• Rinorhea Recurrent epistaxis (repeating nasal bleeding)
• Nasal breathing noises
• Cephalea
 
DIAGNOSED DISEASES
A) NASAL/ NASOPHARYNGEAL

• Viral rhinitis: bacterial / medicamentous / vasomotor / atrophic (ozena) / allergic
• Septum perforation
• Nasal polypus
• Rinolitus
• Hypertrophic adenoids
• Pharyngeal tonsil hypertrophy
• Tornwaldt’s cyst
• Nasal septum hipercheratosis
• Nasal septum ulceration
• Septum detour
• Septum spur
• Septum perforation
• Agger Nasi
• Haller’s cell
• Rendu-Osler-Mesher’s Disease
• Juvenile angiofibroma
• Sinusitis/ rinosinusitis
• Nasal pit, pharyngeal, laryngeal cancer
• Medium Otitis
• Nasal shells hypertrophy

B) Laryngeal Diseases (clique aqui)
 
EXAMPLE
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allergic rhinitis
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Vasomotor rhinitis
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Bubbling shell
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Septum perforation
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Septum detour
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Septum spur
 
BRONCOFIBRESCOPY / VIDEOBRONCOFIBRESCOPY
It would be more appropriate call it Laringotracheobronchofibroscopy, once that with this exam we observe the larynges, trachea and subsegmentar bronchium, depending on the diameter of the used equipment.

The exam is done with the patient laid, under sedation or, when necessary, using ANESTHESIA manipulated by an ANESTHESIOLOGIST, what makes the exam quicker and more comfortable for the patient. The patient reports that “couldn’t see nor view” the exam.

Besides permitting the view of structures and their alteration, the exam allows material collection through BRONCHOALVEOLAR WASHED, BRONCHIAL WASHED, BRONCHIAL BIOPSIES, TRANSBRONCHOFIBROSCOPIC BIOPSIES AND TRANSBRONCHOFIBROSCOPIC BIOPSIES PUNCTURES according to the need or solicitation of the assistant doctor.

Detailed reports with schemes and photographs of the found alteration are given to the patient and to the assistant doctor.

The collected material in the BRONCHOALVEOLAR WASHED (LBA) is sent to examination:
1) Differential counting of cells and leucocytes
2) Tuberculosis research
3) Fungus research
4) Bacteria
5) Others, depending on the indication or orientation of the assistant doctor (P. carinij, virus, asbestosic bodies, etc.)

The LBA and the bronchial rubbed or brushed (esfregaço ou escovado brônquico) are sent to citopathologic study and the biopsies are sent to anatomopathologic study.

THE REQUESTING DOCTOR, IF WILLS SO, MAY INDICATE THE LABORATORY IN WICH THE MATERIAL WILL BE EXAMED.
 
RIGID BRONCHOSCOPY
The rigid bronchoscopy is done under general anesthesia and, most times, with therapeutic purpose, being called then, THERAPEUTIC BRONCHOSCOPY.
 
BRONCHOSCOPY – INDICATION
A) DIAGNOSTIC BRONCHOSCOPY

• CRONIC COUGH
• WHISTLING AND LOCATED STRIDOR
• PERSISTENT PNEUMOTHORAX
• DIAPHRAGMATIC PARALYSIS
• DISFONY
• VOCAL FOLD PARALYSIS
• CHEMICAL OR TERMIC BURNT OF THE TRACHEOBRONCHIAL TREE
• PULMONARY ABSCESS
• THORACIC/CERVICAL TRAUMA (clique aqui)
• UNUSUAL/ ATYPICAL CYTOLOGY IN SPUTUM
• HEMOPTISIS
• BRONCHOGRAPHY
• BRONCHOALVEOLAR LAVAGE (clique aqui)
• PULMONARY INFECTION
• BRONCHOPLEURAL FISTULA
• TRACHEO/BRONCOESOPHAGIC FISTULA
• TRACHEOARTERIAL FISTULA
• BRONCHOGENIC CARCINOMA
Diagnosis
Staging
Follow up
• MEDIASTINAL NEOPLASIA
• ESOPHAGUS CARCINOMA
• MALIGNUM HEAD AND NECK NEOPLASIA
• TRACHEOBRONCHIAL FOREIGN BODY
• TRACHEOBRONCHIAL STENOSIS
• POST TRACHEOBRONCHOPLASTY
• INTERSTICIAL PULMONARY DISEASE
• UNEXPLAINED PLEURAL EFFUSION
• POST LUNG TRANSPLANT
• SUPERIOR CAVA VEIN SYNDROME
TRACHEOBRONCHIAL INHALATION OF GASTRIC CONTENT
• SLEEP APNEA
• RESPIRATORY OBSTRUCTION
• ABNORMAL RADIOLOGICAL FINDINGS (clique aqui)
• OTHER (clique aqui)

B) THERAPEUTIC BRONCHOSCOPY

• TRACHEOBRONCHIAL TREE CLEANSING
Retained secretion
Mucus corks
Pseudomembranes
Bronchi Asthma
Blood clots
Necrosis of the Tracheobronchial Mucus
Cystic Fibrosis
Fibrinous / purulent tracheitis)
• STENTS PLACEMENT
• BRONCHOALVEOLAR LAVAGE
Alveolar proteinosis
Tracheobronchial aspiration of Gastric Content
• PULMONARY ABSCESS DRAINAGE
• ATELECTASIA
• INTRALESIONAL INJECTION
• TRACHEAL INTUBATION
• AIR WAYS STENOSIS
• BRONCHOPLEURAL FISTULA
• HEMOPTISIS
• BRACHITHERAPY
• LASER RESECTION
• FOTODYNAMIC THERAPY
• CRIOTHERAPY
• ELECTRO SURGERY
• EXPANDING OF LARYNGEAL AND TRACHEAL STENOSIS
• CYST INHALATION
Mediastinal cysts
Bronchogenic cysts
• ABSCESS DRAINAGE
• FOREIGN BODIES REMOVAL
 
VEGETATING LESION (CANCER) OF THE LEFT INFERIOR LOBUS
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TRACHEOBRONCHIAL STENOSIS
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Infraestomachal
Tracheal Stenosis
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Cricotracheal
Stenosis
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Right Bronchium
Stenosis
 
Strange bodies (projectile and tooth fragment) Medium Lobus Bronchium
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BRONCHOSCOPY INDICATION IN U.T.I
a) BRONCHOALVEOLAR LAVAGE – BAW (clique aqui)

b) BRONCHOINHALATION (clique aqui)

c) THORACIC/ CERVICAL TRAUMA (clique aqui)

d) OTHER (clique aqui)
 
CONTRA-INDICATION OF BRONCHOSCOPY:
CONTRA-INDICATION:
1) HYPOXEMIA
2) UNCOOPERATIVE PATIENT / REFUSES TO BE SUBMITTED TOTHE EXAM
3) RIGID BRONCHOSCOPY: Cervical column instability, cervical column’s severe anchylosis, restriction of the temporomandibular articulation

RELATIVE CONTRA-INDICATION:
1) MALIGNANT ARRYTHMIA
2) CARDIAC INSTABILITY
3) REFRACTORY HYPOXEMIA
4) BLEEDING SUSCEPTIBILITY

FACTORS ASSOCIATED TO INCREASING THE RISK OF COMPLICATION:
1) UNCOOPERATIVE PATIENT
2) ANGINA
3) INSTABLE ASTHMA
4) MODERATE TO SEVERE HYPOXEMIA
5) HYPERCAPNIA
6) UREMIA
7) PULMONARY HYPERTENSION
8) IMMUNESUPPRESSION
9) SUPERIOR CAVA VEIN OBSTRUCTION
10) WEAKNESS, ADVANCED AGE OR MALNUTRITION
 
SWALLOWING ENDOSCOPIC EVALUATION (SEE)
(FEES – Fiberoptic Examination of Swallowing Safety)

This exam is used for endoscopic deglutition evaluation:
a-) it allows to evaluate the food contention in the oral cavity,
b-) presence of nasal leak,
c-) velopharyngeal closer,
d-) deglutition time and,
e-) laryngeal penetration and/ or inhalation presence. It is an excellent auxiliary method, but it is underused by neurologists and fonoaudiologists in most of the times because of lack of the exam availableness.

EXAM

We initially proceed the fibronasopharyngolaryngoscopy with the patient seated and with the equipment in such a position that we are able to visualize the hipopharynx and larynges. We offer food (artificially flavored) with different consistency: solid, liquid and soft. The exam can be tape recorded for posterior analysis. Even patients with neurological and/or muscular diseases and with sequels are can be submitted to this exam since they can answer a minimum order.

D.E.E. INDICATION

• Oropharyngeal disfagia (swallowing difficulty)
• Oral or nasal regurgitation
• Bronchial inhalation (the person chokes)
• Repetition respiratory infection
• Incapability to control food in the mouth
• Presence of food residues in the mouth
 
MOST IMPORTANT DIAGNOSED DISEASES / INDICATION
• Laryngeal inhalation and/or penetration
• Esophagic membrane
• Vertebral osteophyte
• Hypopharyngeal diverticulum
• Cricopharyngeal bar
• Tumor
• Post-operatory period of mouth, pharynx, larynges and neck related diseases
• Post radiotherapy sequel
• Cerebral Vascular Accident
• Bulbar Poliomyelitis
• Amyotrophic lateral sclerosis
• Parkinson Disease
• Cerebral Paralysis
• Encephalic Tumor
• Oculopharyngeal muscular dystrophy
• Miotonic dystrophy
• Miastenia Gravis
• Late discinesia and distonia
• Xerostomy (dry mouth sensation)
 
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Clínica do Tórax - Av. Comendador Franco, 2429 - Curitiba - PR
Fone 41 3266-3500 - Fax 41 3266-4349 - Fale Conosco - clinicadotorax@marloscoelho.com.br