72 Paediatric Endoscopy

Paediatric airway endoscopy is commonly performed. The main indications are stridor, feeding problems and hoarseness. Airway assessment starts with a thorough history. Ask about the birth history, feeding, the nature of any noisy breathing (stridor, stertor and wheezing). Note the breathing pattern, whether the baby is working hard, any evidence of tracheal tug or sternal recession. Flexible endoscopy in clinic is often well tolerated by babies and toddlers if the child is gently but firmly held by the mother. The endoscope can be introduced per orally using the examiner’s finger between the gums to protect the instrument, or transnasally. A good view of the adenoids, the nasopharynx and the upper larynx can be obtained.

Rigid laryngotracheobronchoscopy (LTB) nowadays means looking at the airway with a Hopkins rod lens, displaying the image on a monitor, and capturing still or video images which can be recorded and studied afterwards, sometimes combined with microscope examination (MLTB) to leave the surgeon’s hands free for manipulation of instruments. This requires skilled paediatric anaesthesia. The fibre-optic scope can be used as an adjunct to assess vocal cord movement or to view the trachea via a laryngeal mask.

72.1 Laryngotracheobronchoscopy: Technique

The anaesthetist will make sure to have venous access. The cords are sprayed with local anaesthetic to reduce gagging and laryngospasm. Spontaneous breathing is nearly always preferred to paralysis. Endotracheal intubation can be avoided if the anaesthetist places the end of the endotracheal tube in the pharynx leaving the larynx free for inspection during spontaneous respiration.

Specialised children’s instruments are used nowadays, for example, the Lindholm laryngoscope which has a blade that sits in the vallecula and provides a view of the cords, the arytenoids and the epiglottis. This is especially good to demonstrate the dynamic changes of laryngomalacia.

Be careful introducing the laryngoscope—it is easy to pinch the lips or bruise the gums. A swab can be useful to protect the gums or the teeth in an older child. Use suction gently and don’t poke the mucosa as it will swell up very quickly especially around the arytenoids. If there is a lot of mucosal swelling, an adrenaline-soaked patty can help to shrink the tissue to give you a better view but is not usually needed.

Check the dynamics of the supraglottis—the characteristic indrawing of the arytenoids and the epiglottis is easily seen in laryngomalacia. Check for a laryngeal cleft, assess the calibre of the subglottis and look at the carina and the orifices of the main stem bronchi. Look at the tracheal lumen. An extrinsic mass—often a vascular ring—will cause tracheal compression, and in tracheomalacia the lumen will be ellipsoid, sometimes closing completely during respiration. Pass the bronchoscope down to the carina and look at the posterior wall of the trachea to exclude a tracheo-oesophageal fistula. Check the mobility of the cords—best done when the child is waking up.

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