Otorhinolaryngology
Tracheobronchial Stent

Video Endoscopic Sequence 1 of 2.

Tracheobronchial Stent

This a 42 year-old, male, that 4 years previous suffering from a car accident in the United States, was treated for blunt chest trauma.

Airway stents, also known as tracheobronchial prostheses, are tube-shaped devices that are inserted into an airway. They are usually placed bronchoscopically and can be used to treat a variety of large airway diseases.

Airway stenting is an alternative approach for relieving airway stenosis when lesions are inappropriate for single-stage reconstruction.

Laryngeal and tracheal stents are solid or hollow absorbable or nonabsorbable tubes of various shapes, sizes, and materials. Stents are used as primary treatment for lumen collapse or to stabilize a reconstructive effort of the larynx or trachea to prevent collapse. Stents can be used for the larynx and the trachea individually, or they can be used interchangeably or concomitantly.

 

Tracheobronchial Stent


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.

 



Tracheobronchial Stent

Video Endoscopic Sequence 2 of 2.

Scar in the upper third of the Esophagus.

In the upper third of the esophagus there is a fibrotic ring apparently is a scar of trauma suffered in the accident.

 

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Video Endoscopic Sequence 1 of 8.

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

72 year-old, female with long-standing smoking.

Although a strong correlation is established between tobacco and alcohol consumption and SCC of the oral cavity and soft palate, the relationship to hard palate cancer is not as clear. Reverse smoking is a specific etiologic factor for SCC of the hard palate. In reverse smoking, the lit end of the cigarette is placed in the mouth so that an intense heat is generated during smoking. Other factors, including ill-fitting dentures, poor oral hygiene, mechanical irritation, and mouthwash, are implicated in oral cavity SCC; however, the evidence is less convincing.

SCC extension beyond the hard palate occurs in up to 70% of lesions. Posterior extension involves the soft palate, with possible velopharyngeal insufficiency and hypernasal speech. Palatal hypesthesia indicates trigeminal nerve involvement in the sphenopalatine foramen or pterygopalatine fossa extension.

 

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Video Endoscopic Sequence 2 of 8.

Squamous cell carcinoma of the soft palate

An absent corneal reflex is indicative of skull-base extension through the foramen rotundum, foramen ovale, or inferior orbital fissure.

Dental numbness may indicate perineural invasion. Middle ear effusion is suggestive of nasopharyngeal extension or invasion of the tensor veli palatini muscle.

Involvement of the mandibular division of the trigeminal nerve may manifest as hypesthesia along the mandible or wasting of the temporalis or masseter muscles. This is indicative of infratemporal fossa involvement. Trismus, malocclusion, and pain are symptoms of invasion of the pterygoid muscles. Extension to the gingiva requires assessment. Dental sockets provide a pathway of invasion to the alveolar process of the maxillary bone and into the maxillary sinus. Nasal floor involvement may occur by direct extension through the palate.



Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Video Endoscopic Sequence 3 of 8.

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Computerized Axial Tomography with 3D Imaging

Download de video clip by clicking on the image

 

 

 







Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Video Endoscopic Sequence 4 of 8.

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Neoformation focused on the soft palate of the maxilla on the anterior region protruding into the oral cavity caudally, cephalad, infiltrates the hard palate affecting the region of the incisors, ventrally extends 1 cm anterior to the dental arch . its lobed with contours defined, reinforces moderately after application of contrast, is about 48 x 48 mm. No extension into the pharynx shown. Or to the maxillary sinuses.

Computerized Axial Tomography with 3D Imaging

 

Download de video clip by clicking on the image



Cáncer Epidermoide del Paladar Blando

Video Endoscopic Sequence 5 of 8.

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Computerized Axial Tomography with 3D Imaging

 

 

Download de video clip by clicking on the image

 

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Video Endoscopic Sequence 6 of 8.

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

No lymphadenopathy was observed in the observed vascular spaces of the upper neck.

 

 

 

Download de video clip by clicking on the image

 

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Video Endoscopic Sequence 7 of 8.

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

The frontal sinuses are adequately pneumatized bilaterally.

Ethmoidal cells without alterations, sphenoid sinus inflammatory changes of the mucosa.

Nasal septum normal.

Own bones of the nose are normal.

Permeablesl choanae.

 

 

 

Download de video clip by clicking on the image

 

 

 





Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

Video Endoscopic Sequence 8 of 8.

Squamous cell carcinoma of the soft palate that infiltrates the hard palate.

 

 

Download de video clip by clicking on the image

 

 

Squamous cell carcinoma 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.

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.

Medline.

 

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.

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.

Squamous cell carcinoma of the larynx.  We used a regular endoscopy forceps biopsy device to get the biopsies of the larynx cancer.

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.

Squamous cell carcinoma of the larynx.  We used a regular endoscopy forceps biopsy device to get the biopsies of the larynx cancer.

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.


 

carcinoma that invades larynx, epiglottis

Video Endoscopic Sequence 2 of 2.

The image and the video clip display a carcinoma that invades several extructures in the oropharingeal area.

Extensive Larynx Carcinoma.   SQUAMOUS CELL CARCINOMA OF THE LARYNX. Patient was referred to our unit for placement of PEG. tube.

Extensive Larynx Carcinoma.

Squamous Cell Carcinoma of the Larynx.

Patient was referred to our unit for placement of PEG.
tube.



Narrow Band Imaging (NBI). NBI is an optical imaging technology. It works by altering  the white light source to consist of specific wavelenght bands, which take advantage of the scattering and absorption properties of human tissues.

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.







 

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.

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.












 

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, and 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.  2 days later she initiates with multiple melenas, the clinical picture was of severe bleeding of the upper digestive tract,

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 of 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.









Injection of absolute alcohol was injected into the lesion.

Video Endoscopic Sequence 2 of 8.

Injection of absolute alcohol was injected into the lesion.

Epistaxis remains one of the most common otolaryngology emergencies. Despite considerable interest in the subject, there is still no consensus on the most appropriate primary therapeutic modality.

 

 

 

 


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.

Video Endoscopic Sequence 3 of 8.

Endoscopy of the site of an 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.

Not so many issues in Otolaryngology have so deeply shifted their paradigms in the last decades as the treatment of epistaxis. Terms like "untreatable epistaxis" and "conservative treatment" should be revised. The main reason for this paradigm shift was the advent of nasal endoscopy. If epistaxis was previously labeled as an "untreatable" condition and managed with multiple nasal packing, ligature of the carotid and/or maxillary arteries, or even vessel embolization, now they have shown to be easily diagnosed and treated through nasosinusal endoscopic surgery. Treatments previously considered "conservative", such as nasal packing seem much more traumatic, uncomfortable and, in some cases, with higher risks than simple endoscopic procedures, such as local cauterization or ligature of the sphenopalatine artery.

 

 

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.

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.



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.

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.












Those images and video clips are final status of absolute alcohol ablation.

Video Endoscopic Sequence 6 of 8.

Those images and video clips are final status of absolute alcohol ablation.

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.

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.

Status after alcohol ablation

Video Endoscopic Sequence 8 of 8.

Status after alcohol ablation

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 therapuetic 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.

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.

 

Squamous cell carcinoma of the tongue

 

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.

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.









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.

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.





 

 

 

 



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.

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.


Larynx with Jaundice

Larynx with Jaundice (yellowish color).


A 76 year-old woman with obstructive jaundice

Reflux Granuloma and Jaundice Larynx

Jaundice of Larynx

Reflux Granuloma and Jaundice Larynx


Reflux Granuloma

Reflux Granuloma

This a 66 year-old male who in an upper endoscopy a hiatal hernia and a bilobate vocal cord lesion is observed.





Granuloma de Reflujo

Reflux Granuloma

This bilobulada lesion of vocal cords is opposite to that observed in the image above





Small papilomas of the larynx.

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.


Enlarged Tonsils

Video Endoscopic Sequence 1 of 2.

Enlarged Tonsils.

 

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.

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.


Torus Palatinus

Video Endoscopic Sequence 1 of 1.

Torus Palatinus

Tori may be considered as specific exostosis, formed by a highly dense and strictly limited amount of bone marrow, covered with a thin mucosa, easy to flap and poorly vascularised.

Their growth is very slow and do not produce any symptoms except in edentulous patients where constructing and wearing partial dentures seems hazardous to impossible.

The aetiology of tori is not clear at all, even if genetics is supposed to be the most widely accepted factor. Other causes such as functional responses to superficial injuries, temporomandibular disorders, eating habits and diet, vitamin deficiency, and drugs causing an increase in calcium homeostasis have been evoked. On the other hand, some studies have been published on tori prevalence but conclusions did not demonstrate possible links between ethnical factors and aetiology.

Clinically, discovering of tori is frequently diagnosed in occasional way because those pathologies are asymptomatic. The request for clinical examination depends mainly on the size: in fact, in this case, they may perturb phonation, create ulceration of the mucosa, prosthetic instability or pain.

 

Oropharinx of a professional singer.                                 A 45 year-old male. Curiously one of the arathinoids is a little hypertrophic.

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.

 

Tonsils. Small crypts are observed.

Video Endoscopic Sequence 2 of 2.

Tonsils.

Small crypts are observed.

 

 


 

 

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.

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.





Larynx with ictericia.  A 59 year-old female with ictericia due to hepatic cirrhosis.

Larynx with ictericia.

A 59 year-old female with ictericia due to hepatic cirrhosis.

Oropharingeal lipoma. The left arathinoids shows a small yellowish nodule.

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. 


Nasopharynx. Observed through trans-fistula-gastrostomy retrograde endoscopy. Technical Novelty. 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.

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.


Reflux Granuloma. Laryngopharyngeal reflux (LPR).

Laryngopharyngeal reflux (LPR).

Reflux Granuloma.

Photograph and the video clips of the endolarynx, demonstating a left true vocal cord granuloma.



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.

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. 


This picture shows the diminution of the size after a month of treatment with PPI.

Video Endoscopic Sequence 2 of 2.

This picture shows the diminution of the size after one
month of treatment with PPI.

laryngopharyngeal reflux (LPR)

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. 


Hemangiom of the larynx. 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.

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.

Adult hemangiomas are bluish red, clearly defined, appearing most often in the region of glottis and supraglottis. They are more frequent with males.




Hemangioma of the larynx.

Hemangioma of the larynx.

Hemangiomas are the most common vascular tumors mostly (60%) seen in the head-neck region. Head-neck hemangiomas are seen frequently in the oral cavity, rarely in the larynx. Adult laryngeal hemangiomas are rare and often seen in the supraglottic region, therefore causing dysphagia/dysphonia.

Hemangiomas have a typical clinical course and may lead to life-threatening obstruction if the central respiratory tract is involved.

The principal symptom is hoarseness, occasional hemoptysis, and in advanced cases dysphagia and difficult breathing. They do not show tendency of spontaneous regression. The sources give varied opinions on therapeutic procedure with laryngeal hemangioma. The factors influencing the choice of therapy are age, type, size and localisation of the tumor, and the patient's discomforts.

Oropharynge-Esophagic Candidiasis.

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.


Oropharynge-Esophagic Candidiasis. 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.

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.



Oropharynge-Esophagic Candidiasis. 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.

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.








Oropharynge-Esophagic Candidiasis. 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.

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.

 

 

Oropharynge-Esophagic Candidiasis.

Video Endoscopic Sequence 5 of 5.

This image and the video clip display esophageal
candidiasis.




















Uvula with Herpes.

Uvula with Herpes.








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 .

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.

 

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.

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.


This endoscopy was performed with a thin endoscope 5.9 mm of diameter, the endoscope was advanced through the fistula showing the carina.

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.

The Main Carina.

Video Endoscopic Sequence 3 of 5.

The Main Carina

This video clip shows the introduction of the endoscope through of the fistula to the main carina.

ideo Endoscopic Sequence 4 of 5.

This video clip shows the introduction of the endoscope through of the fistula to the main carina.

This endoscopy was through the mouth showing the post surgical status of the surgery of the larynx.

Video Endoscopic Sequence 5 of 5.

This endoscopy was through the mouth showing the post
surgical status of the surgery of the larynx.

Squamous cell carcinoma of the larynx.

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.

 

Squamous cell carcinoma of the larynx.


Endoscopy of Squamous cell carcinoma of the larynx

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.


Hemorrhagic Esophagitis

Video Endoscopic Sequence 3 of 4.

Endoscopy of Squamous cell carcinoma of the larynx

Hemorrhagic Esophagitis

Our patient also has Hemorrhagic Esophagitis and subtotal gastrectomy performed 2 years previous due to a peptic disease.


 

Hemorrhagic Esophagitis

Video Endoscopic Sequence 4 of 4.

Hemorrhagic Esophagitis

Retroflexed View


Broncoscopy

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 ungs);

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.

Broncoscopy

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 ex ent 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.


Oropharynx Lipoma

Oropharynx Lipoma

A lipoma is seen slightly above the upper esophageal sphincter

Oropharyngeal lipomas are rare tumours.

Lipomas of the retro-parapharyngeal space are rare, slow-growing tumours and do not cause symptoms until they reach a large size. Computed tomography (CT) and magnetic resonance (RM) imaging are the essential investigations for the preoperative diagnosis. Surgical excision is the treatment of choice; the surgical approach is variable, depending on the size, location, vascularization and malignant potential of the lipoma.

Lipomas are the most common benign tumours of mesenchymal origin. Only 13% of these tumours arise in the head and neck and parapharyngeal space involvment is uncommon. Usually, lipomas are encapsulated subcutaneous or submucosal lesions that occur in the posterior region of the neck. Rarely they develop in the anterior region of the neck, infratemporal fossa, in or around the oral cavity, parotid gland, tonsillar area, hypopharynx, larynx and nasopharynx. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are the investigations of choice and help in definitive diagnosis preoperatively, although final histological confirmation is essential. Surgical excision is the treatment of choice. The surgical approach is based on the location, size, vascularization and malignant potential of the tumour.

 

Bilateral lipoma of oropharynx

Bilateral lipoma of oropharynx

 

Post Radiation Pharyngitis and esophagitis

Video Endoscopic Sequence 1 of 8.

Post Radiation Pharyngitis and esophagitis

This is an 83 year-old female, who because of cancer of the tongue, received 25 radiations therapy with linear accelerator presents with difficulty swallowing and dysphagia.

Severe edema of the oropharynx is observed

Tongue cancer

Video Endoscopic Sequence 2 of 8.

The upper esophageal sphincter is observed

 

 

 

 

 



Tongue cancer

Video Endoscopic Sequence 3 of 8.

The tongue is edematous

 

stenosis of the gastroesophageal junction

Video Endoscopic Sequence 4 of 8.

There are significant stenosis of the gastroesophageal junction

 

 

 

 

 

 



 esophagus dilation hydrostatic balloon

Video Endoscopic Sequence 5 of 8.

It proceeds to the respective dilation with hydrostatic balloon


Hydrostatic balloon dilation is being increasingly used for gastrointestinal stenoses.

Balloon Dilators, Flexible endoscopy allows the physician to directly view the stricture. 

Deflated balloons are placed through the scope and across the stricture. When inflated they become sausage shaped, stretch and break the stricture.

BALLOON DILATORS Deflated balloons are placed through the endoscope and across the stricture. When inflated, they become sausage-shaped, stretch, and break the stricture.

Under direct endoscopic observation, the balloon is then inflated Once the stricture is dilated, with either single or multiple balloons, the balloon is withdrawn through the endoscope, after emptying the water.

 

 esophagus dilation hydrostatic balloon

Video Endoscopic Sequence 6 of 8.

Status Post Dilation.

Subsequent status is observed with hydrostatic balloon dilation

 

 

 

 



 esophagus dilation hydrostatic balloon

Video Endoscopic Sequence 7 of 8.

Status Post Dilation.

Subsequent status is observed with hydrostatic balloon dilation.

 

Post Radiation Pharyngitis

Video Endoscopic Sequence 8 of 8.

Post Radiation Pharyngitis

The epiglottis is seen with some edema

 

Papilloma oropharynx

Secuencia Video Endoscópica 1 de 3.

Papilloma anterior to the oropharynx

A 42-year-old male at a routine endoscopy finds this lesion near the oropharynx.

 

 

Papilloma oropharynx

Secuencia Video Endoscópica 2 de 3.

Another image and video of oropharyngeal papilloma


 

Some biopsies are obtained which reveal to be a papilloma.

Secuencia Video Endoscópica 3 de 3.

Some biopsies are obtained which reveal to be a papilloma.

 

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