Direct vision (direct laryngoscopy) offers the advantage of three-dimensional appreciation of the larynx, bimanual instrumentation, application of tools such as the laser, and clear visualization of “hidden” regions such as the piriform sinus and the postcricoid region. Due to the usage of a rigid scope, general anesthesia is mandatory. Rigid laryngoscopy is mostly part of a so-called panendoscopy including a flexible or rigid bronchoscopy and a flexible or rigid esophagoscopy.

Preoperative management includes proper documentation of the pathology in question and the status quo of laryngeal anatomy and physiology, preferably by videostroboscopy (Table 13.1). Management by anesthesia requires atraumatic intubation with a small endotracheal tube, typically a 5.0 tube. Most cases can be managed with the endotracheal tube in place. If necessary, jet ventilation can be used. Directly at the end of surgery, application of 4% lidocaine is prudent to minimize the risk of laryngospasm after extubation.

Different rigid laryngoscopes are available (Kleinsasser laryngoscope, Boston, Dedo, Ossoff, Zeitels, etc.). Proper positioning of the patient is the first step to good visualization during the procedure. The patient is in supine position, and the neck is extended using a pad under the shoulders and a soft ring under the head to attain stable positioning (Fig. 13.2).

Exposure is key to visualization and proper performance of surgical procedures. Different means of instrumentation (rigid laryngoscopes) are available, all offering excellent exposure Peroral rigid laryngoscopy begins with application of a tooth guard (Fig. 13.3), preferably using soft plastic dental protection with a metal coverage to prevent accidental damage to the teeth. The upper incisors are at greatest risk of injury as they are long and exposed to the rigid instrument. It is extremely important never to use the teeth as a fulcrum. Care is also taken not to injure the lips by pulling them inside with the laryngoscope and lacerating them between the scope and the teeth. Gentle insertion of the laryngoscope with lighting is performed with the left hand in the right-handed surgeon (Fig. 13.4). The right hand is then free for the usage of suction or a grasping instrument to aid proper exposure. Tongue and soft palate including the tonsils are inspected. Next the valleculae, tongue base and the lingual and laryngeal surface of the epiglottis are visualized. The aryepiglottic folds are followed posteriorly to visualize the arytenoid cartilages. The piriform sinus is inspected bilaterally. The endotracheal tube is then pushed anteriorly, and the postcricoid area is inspected thoroughly. The laryngoscope is used to lift the tip of the epiglottis. This so-called “engagement” of the epiglottis is necessary to gain clear visualization and access to the larynx. Now the attention is turned toward the larynx and the microscope is used for the following part of the procedure (Fig. 13.5). Proper inspection is performed including the false and true vocal cords; the ventriculus (sinus of Morgagni) is palpated with a hook. The anterior and posterior commissures are inspected. If the anterior commissure cannot be visualized, gentle cricoid pressure can be applied to maneuver the larynx in the proper position. The laryngoscope is retracted slowly; the tooth guard is removed. Finally, tongue base, floor of the mouth, lateral pharyngeal walls, and the lower part of the nasopharynx are palpated enorally and bimanually, using one finger enorally and the opposite hand from the outside.

Dysphonia is the most common symptom that leads to involvement of ear, nose, and throat specialist with the question of laryngeal pathology. Dysphonia is a subjective term that is used to describe perceptual irregularities of the voice. This symptom may be the result of numerous conditions affecting the lungs, the larynx, or the supraglottic airway. A differential diagnosis is summarized in Table 13.2.