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Video Endoscopic Sequence 1 of 3.
Double Primary Cancers.
Adenocarcinoma of the cardias and simultaneous
carcinoma epidermoid of the larynx.
Four months previously, the patient presented with
hoarseness.
The etiology of oral epidermoide carcinoma is connected to
the abusive use of tobacco and alcohol, having been in
various studies demonstrated the effect synergetic of these
agents, the gastroesophageal reflux disease play role in
pathogenesis of the Squamous cell carcinoma of the larynx.
For further endoscopic information, download the video clip
by clicking on the endoscopic image. Wait to be
downloaded complete then Press Alt and Enter for full
screen ( Windows Media), Real Player: Ctrl and 3. All
endoscopic images shown in this Atlas contain video clips.
We recommend seeing the video clips in full screen mode.
Medline.
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Video Endoscopic Sequence 2 of 3.
Endoscopic view of Squamous cell carcinoma of the larynx.
Laryngeal cancer is the most common cancer of the upper
aerodigestive tract. The incidence of laryngeal tumors is
closely correlated with smoking, as head and neck tumors
occur 6 times more often among cigarette smokers than
among nonsmokers. The age-standardized risk of mortality
from laryngeal cancer appears to have a linear relationship
with increasing cigarette consumption. Death from
laryngeal cancer is 20 times more likely for the heaviest
smokers than for nonsmokers.
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Broncoscopy
INDICATIONS
A) DIAGNOSTIC USES
1. To evaluate lung lesions of unknown etiology that
appear on the chest x-ray (lung malignancy is always the
top priority and should be given very early appointment)
2. To assess airway patency.
3. To investigate unexplained hemoptysis (where TB work
up is negative), unexplained cough , localized wheeze or
stridor.
4. To search for the origin of suspicious or positive sputum
cytology.
5. To investigate the etiology of unexplained paralysis of a
vocal cord or hemidiaphragm, superior vena cava
syndrome, chylothorax or unexplained pleural effusion
(where pleural biopsy is negative).
6. To evaluate problems associated with endotracheal
tubes such as tracheal damage, airway obstruction or tube
placement.
7. To obtain material from microbiologic studies in
suspected pulmonary infections.
8. To evaluate the airways for suspected bronchial tear or
other injury after thoracic trauma.
9. To evaluate a suspected tracheosophageal fistula,
interstitial lung disease or bronchiectasis.
10. To determine the location and extent of respiratory.
tract injury after acute inhalation of noxious fumes or
aspiration of gastric contents.
11. To obtain material for study from the lungs of patients
with diffuse or focal lung diseases.
B) THERAPEUTIC USES
1. To remove retained secretions or mucus plugs not
mobilized by conventional noninvasive techniques
2. To remove foreign bodies.
3. To remove abnormal endobronchial tissue or foreign
material by use of forceps or laser techniques.
4. To perform difficult intubations.
Click here to enlarge the image in a new windows, click on
the image to download the video clip.
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Video Endoscopic Sequence 3 of 3.
Squamous cell carcinoma of the larynx.
We used a regular endoscopy forceps biopsy device to
get the biopsies of the larynx cancer.
Click here to see the complete video sequence on this case.
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Video Endoscopic Sequence 1 of 2.
Extensive carcinoma that invades larynx, epiglottis and
base of the tongue.
The history of supraglottic laryngectomies starts off in
1883 with Bill Roth, who performed the first
laryngectomy. This was a very morbid procedure at the
time, and many of his patients died on the operating room
table. Since then, Trotter was one of the first to excise an
epiglottic cancer via lateral pharyngotomy. It was Alonso
from South America in the 1950s who was the first to
describe the first supraglottic laryngectomy, but it wasn’t
until the 60s that Dr. Ogura standardized the technique and
showed its efficacy in treating this disease. In the 1970s,
Bocca was the first to report a large series of supraglottic
laryngectomies in his results.
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Video Endoscopic Sequence 2 of 2.
The image and the video clip display a carcinoma
that invades several extructures in the oropharingeal area.
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Extensive Larynx Carcinoma.
Squamous Cell Carcinoma of the Larynx.
Patient was referred to our unit for placement of PEG.
tube.
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Narrow Band Imaging (NBI).
NBI is an optical imaging technology. It works by altering
the white light source to consist of specific wavelength
bands, which take advantage of the scattering and
absorption properties of human tissues.
Because the gastrointestinal tract is mainly composed of
blood vessels and mucosa, narrow band illumination, which
is strongly absorbed by hemoglobin and penetrates only
the surface of tissues, is ideal for enhancing the contrast
between the two.
As a result, under narrow band illumination, capillaries on
the mucosal surface are displayed in brown and veins in
the submucosa are displayed in cyan on the monitor.
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Larynx Carcinoma.
Laryngeal carcinoma is one of the most common head and
neck tumours with an annual incidence of approximately 1
per 100,000. It should be suspected in any patient with
hoarseness of the voice for three weeks or longer until
proven otherwise.
Men are affected more often than women but during the
last decade, the number of cases in women has increased
such that they now account for about 20% of cases. Most
patients are elderly and almost always, are smokers.
Sixty percent of tumours occur in the glottis and present
early with dysphonia. If detected early, the prognosis is
excellent with a 90% 5 year cure rate.
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Video Endoscopic Sequence 1 of 8.
Case of Severe Epistaxis.
A 76 year-old female that one month previously was
hospitalized due to severe epistaxis in a hospital of the
Social Insurance of El Salvador, had been treated with
repeated anteroposterior nasal packing, presented
significant secondary anemia. Patient does not accept
sanguineous transfusions due to religious rules.
Three years earlier, we had practiced an upper endoscopy
and a colonoscopy, both were negative.
Due to generalized weakness, edema and anemia
(with Hb. 6.2 mg/dl) she was hospitalized.
2 days later she initiates with multiple melenas, the clinical
picture was of severe bleeding of the upper digestive tract,
nevertheless gastric lavage with nasogastric tube was
negative to bled, the next day the hemoglobin falls to 3.2
mg/dl, an upper endoscopy did not find any pathological site
that bled.
Due to the antecedent of epistaxis we decided to inspect
the nose with the endoscope that we use for the
upper gastrointestinal track, finding the images and videos
displayed here.
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Video Endoscopic Sequence 2 of 8.
Injection of absolute alcohol was injected into the lesion.
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Video Endoscopic Sequence 3 of 8.
Epistaxis
In rare cases, this condition may lead to massive bleeding
and even death. Although epistaxis can have an anterior or
posterior source, it most often originates in the anterior
nasal cavity.
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Video Endoscopic Sequence 4 of 8.
The image and the video clips display the second injection
of absolute alcohol
Epistaxis is one of the most frequent emergencies in
Otorhinolaryngology and occurs in other disciplines.
Epistaxis is classified on the basis of the primary bleeding
site as anterior or posterior. Hemorrhage is most
commonly anterior, originating from the nasal septum. A
common source of anterior epistaxis is the Kiesselbach
plexus, an anastomotic network of vessels on the anterior
portion of the nasal septum. Anterior bleeding may also
originate anterior to the inferior turbinate. Posterior
hemorrhage originates from branches of the sphenopalatine
artery in the posterior nasal cavity or nasopharynx.
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Video Endoscopic Sequence 5 of 8.
Approximately 90% of nosebleeds can be visualized in the anterior portion of the nasal cavity.
Massive epistaxis may be confused with hemoptysis or
hematemesis. Blood dripping from the posterior
nasopharynx confirms a nasal source.
Bimodal incidence exists, with peaks in those aged 2-10
years and 50-80 years.
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Video Endoscopic Sequence 6 of 8.
Those images and video clips are final status of absolute alcohol ablation.
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Video Endoscopic Sequence 7 of 8.
Epistaxis can be treated by either surgical means (eg,
cautery, vascular ligation) or endovascular embolotherapy.
Internal carotid arteriograms are obtained to exclude
aneurysms. Then, the external carotid artery is
catheterized and control angiography is performed initially
to map the vascular anatomy and to check for the presence
of a collateral supply to the intracranial circulation.
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Video Endoscopic Sequence 8 of 8.
Status after alcohol ablation
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Video Endoscopic Sequence 1 of 3.
Squamous cell carcinoma of the tongue
This 76 year-old male, was referred to our endoscopic unit
for the placement of a percutaneous endoscopic
gastrostomy (PGE) due to a carcinoma of the tongue.
Squamous cell carcinoma of the oral tongue represents one
of the more common malignancies encountered by the
general otolaryngologist as well as by one specializing in
head and neck surgery. In the management of the early
lingual cancers, a wide variety of therapeutics options have
been advocated in the literature, and in addition to
planning the treatment of the primary neoplasm,
management of the neck must be considered as well.
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Video Endoscopic Sequence 2 of 3.
Lingual carcinomas may appear as an exophytic mass, an
infiltrative lesion , or as a painful nonhealing ulcer, usually
on the lateral aspect of the tongue. However patients may
occasionally be seen with a painless mass in the substance
of the tongue, or areas of leukoplakia or of erythroplasia
may be noted. Ear pain is also a frequent presenting
complaint, owing to the innervation by the auriculotemporal
and lingual nerves, both branches of the trigeminal.
Smoking, alcohol, chronic trauma, and poor dental hygiene,
the usual predisposing factors implicated in cancers arising
elsewhere in the oral cavity, are also associated with
cancers of the oral tongue, although some suggest that the
linkage is not nearly as strong. Males are more commonly
affected than females, usually in the fifth or sixth decade.
Cancers of the oral tongue as well as the floor of the mouth
have been noted to be quite common in India, attributed to
the local custom of chewing the Betel leaf. Several reports
may also be found of oral tongue carcinomas in teenagers
and young adults. Often, there are no apparent risk factors
in this population and some reports suggest that the
cancers behave more aggressively in this group.
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Video Endoscopic Sequence 3 of 3.
The dorsal aspect of the tongue may be thought of as
divided into thirds. The anterior two thirds is known as the
oral tongue, and it is this portion that is mobile. The oral
tongue is demarcated from the posterior one third, or base
of the tongue by the circumvallate papillae. Just posterior
to these papillae is the sulcus terminalis, the embryologic
dividing line between the structures of the first branchial
arch (the oral tongue) and those deriving from the second,
third and fourth branchial arches (the tongue base). The
oral tongue is closely related anatomically to the tonsillar
pillars posterolaterally, and the floor of the mouth
inferiorly . The tongue is a muscular organ, composed of
both extrinsic and intrinsic muscles. The extrinsic muscles
serve primarily to change the position of the tongue and
thus attach outside of the lingual body. The intrinsic
muscles do not attach outside of the tongue and serve to
change the shape of the lingual surface.
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Carcinoma of the Base of the Tongue.
Etiology: Risk factors for the development of base of
tongue carcinoma include chronic alcohol and tobacco use,
older age, geographic location, and family history of upper
aerodigestive tract cancers. Environmental exposure to
polycyclic aromatic hydrocarbons, asbestos, and welding
fumes may increase the risk of pharyngeal cancer.
Nutritional deficiencies and infectious agents (especially
papillomavirus and fungi) also may play a significant role.
The most common symptoms associated with malignant
neoplasms of the tongue base are dysphagia, odynophagia,
sensation of a mass in the throat, or the presence of a mass
in the neck. Patients also may complain of referred ear pain
or hemoptysis. Delay in diagnosis is not uncommon because
of the common and sometimes vague nature of symptoms
and the relative inaccessibility of the base of the tongue to
examination. Upon physical examination, a mass is usually
palpable in this area. Extensive submucosal disease or a
strong gag reflex may make palpation more difficult.
Patients may have bilateral palpable adenopathy because
of the midline location and the high propensity for regional
lymph node metastases. Indirect or flexible fiberoptic
laryngoscopy in the office is a useful adjunct to the physical
examination.
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Larynx with ictericia (yellowish color).
A 76 year-old woman with obstructed ictericia.
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Small papilomas of the larynx.
Papillomas are benign epithelial tumors that are caused by
infection with the human papilloma virus (HPV). They are
the most common benign neoplasms affecting the larynx
and upper respiratory tract. Malignant degeneration to
squamous cell carcinoma can occur, but is very rare. The
overall prevalence ranges from 2 per 100,000 adults to 4.5
per 100,000 children. Thus, over 10,000 Americans suffer
from respiratory papillomas.
Laryngeal papillomas are similar to verrucae on the skin
(common wart) and condyloma acuminatum, or genital
warts. Infection with the virus is ubiquitous. Using highly
sensitive detection methods such as the polymerase chain
reaction, estimates of infection with HPV range from 60 to
80% of women of childbearing age.
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Video Endoscopic Sequence 1 of 2.
Enlarged Tonsils
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Video Endoscopic Sequence 2 of 2.
Chronic Tonsillitis - These people have a chronic low grade
infection of the tonsils. Often they have large crypts which
are difficult to sterilize with antibiotics. The lymph nodes in_
the neck are usually swollen from constant stimulation.
Sometimes the crypts retain food and debris leading to
chronic halitosis (bad breath) and this in and of itself may
be an indication for tonsillectomy. The typical history from
these patients is that their sore throat gets better on
antibiotics, but then comes back as soon as they stop.
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Video Endoscopic Sequence 1 of 2.
Oropharinx of a professional singer.
A 45 year-old male.
Curiously one of the arathinoids is a little hypertrophic.
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Video Endoscopic Sequence 2 of 2.
Tonsils.
Small crypts are observed.
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Bilobulated Uvula.
Normal anatomical variation.
The uvula plays an important role in the articulation of the
sound of the human voice to form the sounds of speech. It
functions in tandem with the back of the throat, the palate,
and air coming up from the lungs to create a number of
guttural and other sounds. Consonants pronounced with
the uvula are not found in English; however, languages
such as Arabic, French, German, Hebrew, Ubykh, and
Hmong use uvular consonants to varying degrees. Certain
African languages use the uvula to produce click
consonants as well. In English (as well as many other
languages), it closes to prevent air escaping through the
nose when making some sounds.
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Larynx with ictericia.
A 59 year-old female with ictericia due to hepatic cirrhosis.
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Oropharyngeal lipoma.
The left arathinoids shows a small yellowish nodule
- Lipomas in the major airways can cause respiratory distress related to bronchial obstruction. Patients may present with either endobronchial or parenchymal lesions.
- Previously undiagnosed lipomas of the oropharynx may also lead to airway difficulty at the time of intubation.
- Patients with esophageal lipomas can present with obstruction, dysphagia, regurgitation, vomiting, and reflux; esophageal lipomas can be associated with aspiration and consecutive respiratory infections.
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Video Endoscopic Sequence 10 of 32.
Nasopharynx.
Observed through trans-fistula-gastrostomy retrograde
endoscopy.
We passed it from the mouth right to the back of the nose.
After observing the nasopharynx, the endoscope was
passed through the mouth.
This image and video clip is not usually observed in normal
endoscopic conditions.
With this possibility give us, an unlimited therapeutical
approach alone or together with the otorhinolaryngologist.
Click here to see the complete video sequence.
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Laryngopharyngeal reflux (LPR).
Reflux Granuloma
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Video Endoscopic Sequence 1 of 2.
Laryngopharyngeal reflux (LPR).
GRANULOMA - The vocal fold on the right side of the
picture has a granuloma attached to the vocal process
which is causing a small reactive lesion on the opposite
vocal process.
Laryngopharyngeal reflux (LPR) is the most common
cause of formation of a granuloma. Another common cause
is irritation from an endotracheal tube (the tube placed in
the throat for breathing during a surgery under general
anesthesia), which can rub against the back of the larynx.
Treatment for granuloma depends upon the size of the
lesion and the length of time it has been present, but most
likely will require control of reflux, and may also include
relative voice rest, and/or surgery and voice therapy.
Surgery by itself, without other measures, will often result
in the regrowth of the lesion in a short period of time.
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Video Endoscopic Sequence 2 of 2.
This picture shows the diminution of the size after one
month of treatment with PPI.
1. Medline
2. Medline.
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Vocal Cord and GERD.
laryngopharyngeal reflux (LPR)
Demonstrating arytenoid erythema and edema.
This 35 year old male with long standing reflux disease.
The upper endoscopy displayed reflux esophagitis.
Findings suggestive of laryngopharyngeal reflux include
the following: erythema of the arytenoid, interarytenoid
area or laryngeal surface of the epiglottis; a cobblestone
appearance of the interarytenoid area; edema of the true
vocal cords; inflammatory lesions of the true vocal cords,
such as granuloma and contact ulcer; and pooling of
secretions in the hypopharynx.
Edema of the true vocal cords can range from mild to
severe; severe edema has the appearance of polypoid
masses. Vocal cord edema of this degree can result in
severe dysphonia, stridor or airway compromise. The
edema develops in the superficial layer of the lamina
propria of the true vocal cords, also called
Reinke's space. Thus, it is often referred to as Reinke's
edema. The presence of edema of the true vocal cords is
highly suggestive of laryngopharyngeal reflux, even in the
absence of laryngeal erythema. Medline.
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Hemangioma of the larynx.
Infraglotic
The diagnosis of hemangioma is established by clinical
findings and history in most cases although ultrasound,
computer tomography, and particularly magnetic resonance
imaging may be helpful in certain situations. MRI can
accurately determine the extent of the lesion and the
finding of serpentine high-volume flow voids surrounded by
nonvascular soft tissue is characteristic of hemangiomas
Biopsy is rarely indicated and may be dangerous.
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Video Endoscopic Sequence 1 of 5.
Oropharynge-Esophagic Candidiasis.
A 27 year-old female, HIV-positive with Colonic
tuberculosis mimicking Crohn's disease, patient
complained of dysphagia and odynophagia.
Candidiasis is a frequent complication for HIV-positive
individuals.
Candida can infect the lining of the mucous membranes in
the esophagus, intestines.
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Video Endoscopic Sequence 2 of 5.
Candidiasis. White plaques are present on the buccal
mucosa and the undersurface of the tongue and represent
thrush. When wiped off, the plaques leave red erosive
areas.
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Video Endoscopic Sequence 3 of 5.
The usual clinical presentation of Candida esophagitis is
dysphagia and/or odynophagia in a patient with 1 or more
predisposing factors for the condition. Symptoms are
variable in severity, ranging from mild difficulty in
swallowing to such intense odynophagia that the patient is
unable to eat or swallow saliva. Other patients may present
with chest pain or gastrointestinal tract bleeding, and
occasionally, they may be asymptomatic.
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Video Endoscopic Sequence 4 of 5.
Oropharyngeal candidiasis is commonly associated with
esophageal candidiasis; therefore, the presence of oral
thrush may be helpful in suggesting the diagnosis of
Candida esophagitis in the appropriate clinical setting.
Nevertheless, only 50-75% of patients with Candida
esophagitis have oropharyngeal disease, and some
patients with oropharyngeal candidiasis and dysphagia are
found to have other types of esophagitis; therefore, the
correct diagnosis cannot always be suggested on the basis
of clinical presentation.
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Video Endoscopic Sequence 5 of 5.
This image and the video clip display esophageal
candidiasis.
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Uvula with Herpes.
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Endotracheal Tube
Proper management of the endotracheal tube is a critical
and often overlooked aspect of care for patients receiving
mechanical ventilation. Clinicians must take measures to
prevent complications related to the tube, and must
recognize and treat these complications if they do occur.
An endotracheal tube should be placed and maintained so
that the end of the tube is two to six cm above the carina.
In an average adult with an orally placed endotracheal tube,
the distal tip of the tube is usually appropriately positioned
midway between the vocal cords and the carina when the
tube is between the 18- and 24-cm mark measured at the
incisors.
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Video Endoscopic Sequence 1 of 5.
Traqueostomy Fistula
This 82 year-old male underwent a surgery of the larynx
due to an advanced squamous cell carcinoma
(total laryngectomy with glossectomy and partial
pharyngectomy). A Traqueostomy was performed, The
patient was referred for evaluation in our endoscopic unit
by the oncologist due to a bleeding in the Traqueostomy
Fistula.
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Video Endoscopic Sequence 2 of 5.
This endoscopy was performed with a thin endoscope 5.9
mm of diameter, the endoscope was advanced through the
fistula showing the carina.
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Video Endoscopic Sequence 3 of 5.
The Main Carina
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Video Endoscopic Sequence 4 of 5.
This video clip shows the introduction of the endoscope through of the fistula to the main carina.
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Video Endoscopic Sequence 5 of 5.
This endoscopy was through the mouth showing the post
surgical status of the surgery of the larynx.
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Video Endoscopic Sequence 1 of 4.
Squamous cell carcinoma of the larynx.
This 73 year-old male patient with a history of heavy smoking.
Over 95% of patients are smokers; 15 pack-years of smoking increase the risk 30-fold.
Sixty percent of patients present with localized disease
alone; 25% present with local disease and regional nodal
metastatic disease; and 15% present with advanced
disease, distant metastases, or both. Distant metastases
occur most frequently in the lungs and liver.
Common sites of origin are the true vocal cords (glottis)
and the supraglottic larynx. The least common site is the
subglottic larynx, where only 1% of primary laryngeal
cancers originate. Verrucous carcinoma, a rare variant of
squamous cell carcinoma, usually arises in the glottic area
and has a better survival rate than standard squamous cell
carcinoma.
Symptoms and Signs
Symptoms and signs differ based on the involved portion of
the larynx. Hoarseness is common early in glottic cancers
but is a late symptom for supraglottic and subglottic
cancers. Supraglottic cancer is often asymptomatic until it
manifests as a mass lesion (eg, with airway obstruction,
dysphagia, otalgia, or a hot potato voice) or with weight
loss. Such patients should be referred for indirect
laryngoscopy without delay.
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Video Endoscopic Sequence 2 of 4.
Endoscopy of Squamous cell carcinoma of the larynx.
Ninety percent of laryngeal cancer is squamous cell
carcinoma. Smoking, alcohol abuse, lower socioeconomic
status, and being male and > 60 yr increase risk. Early
diagnosis is common with vocal cord tumors because vocal,
swallowing, or respiratory symptoms develop early.
However, supraglottic tumors (above the vocal cords) and
subglottic tumors (below the vocal cords) are often very
large and at an advanced stage when diagnosed because
they are asymptomatic until obstructive symptoms develop.
Diagnosis is based on laryngoscopy and biopsy. Treatment
of early-stage tumors is with surgery or radiation.
Advanced-stage tumors are most often treated with
chemotherapy and radiation therapy. Surgery is reserved
for salvage treatment or lesions with significant
extralaryngeal extension or cartilage destruction.
Reestablishment of speaking ability is needed if a total
laryngectomy is done.
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Video Endoscopic Sequence 3 of 4.
Hemorrhagic Esophagitis
Our patient also has Hemorrhagic Esophagitis and subtotal
gastrectomy performed 2 year previous due to a peptic
disease.
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Video Endoscopic Sequence 4 of 4.
Retroflexed View
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Bronchoscopy
Bronchoscopy can be used for diagnosis or treatment
Bronchoscopy is used to make a diagnosis most commonly
for these conditions:
- persistent or unexplained cough;
- blood in the sputum (coughed up mucus material from the lungs);
- abnormal chest x-ray such as a mass, nodule, or inflammation in the lung; or
- evaluation of a possible lung infection.
- Bronchoscopy is used for treatment:
- to remove foreign bodies in the airway;
- to place a stent (a tiny tube) to open a collapsed airway due to pressure by a mass or tumor; or
- to remove a mass or growth that is blocking the airway.
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