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\begin{document}

\title{Using an intubating bougie as a guide for flexible biopsy forceps in
laryngoscopy}



\author[1]{Nicky Seymour}%
\author[1]{Isobel Dodds}%
\author[1]{Andrew Moore}%
\affil[1]{Brighton and Sussex University Hospitals NHS Trust}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
Key points Laryngoscopy is performed to diagnose and treat diseases of
the hypopharynx and larynx Adequate exposure is essential for the
procedure and can be limited by a short neck, limited neck extension and
other patient factors When standard laryngoscopy biopsy forceps cannot
access an area of the pharynx, then flexible pulmonary or gastric biopsy
forceps can be used The flexible biopsy forceps can be loaded down a cut
intubating bougie to access difficult areas This correspondence explains
how to perform this technique and outlines the efficacy%
\end{abstract}%



\sloppy


\textbf{Main Document} : Using an intubating bougie as a guide for
flexible biopsy forceps in laryngoscopy

Correspondence: Our experience

\textbf{Key points}

Laryngoscopy is performed to diagnose and treat diseases of the
hypopharynx and larynx

Adequate exposure is essential for the procedure and can be limited by a
short neck, limited neck extension and other patient factors

When standard laryngoscopy biopsy forceps cannot access an area of the
pharynx, then flexible pulmonary or gastric biopsy forceps can be used

The flexible biopsy forceps can be loaded down a cut intubating bougie
to access difficult areas

This correspondence explains how to perform this technique and outlines
the efficacy

\textbf{Introduction}

Laryngoscopy~is the gold standard for the assessment of the larynx while
preserving airway, speech and swallowing ability. Direct and
micro-laryngoscopy are performed to diagnose, stage and treat lesions of
the hypopharynx and larynx for benign and malignant lesions and for
phono-microsurgery (1).

Good exposure, visualisation and access of the larynx are essential for
the procedure. In some patients it can be difficult to visualise and
access the whole larynx. In this situation, inadequate laryngeal
exposure could result in misdiagnosis, incomplete removal of lesions or
inadvertent injury to the vocal cords (2). Patient factors causing
difficult exposure include a short neck, macroglossia, retrognathia,
obesity or extension limitation of the cervical spine.

Objectives: This technical note outlines how an intubating bougie can be
used as a guide for flexible biopsy forceps in these difficult cases, to
obtain biopsy samples. The Eschmann tracheal tube introducer (also known
as the gum elastic bougie) is a 60cm long, 15 French gauge flexible
plastic device with a central lumen and a J angle at the distal tip (see
figure 1) (3). It can be shaped as required.

\textbf{Method}

This paper follows the SQUIRE 2.0 guidelines (Revised Standards for
Quality Improvement Reporting Excellence) (4).

Other papers outlining the use of a boogie as a guide were searched for
for using

MEDLINE and EMBASE using the search terms; ``laryngoscopy; biopsy;
exposure; bougie''. No other papers were found explaining this
technique.

The patients were positioned with the neck flexed and head extended. The
laryngoscope was inserted. The operator could then direct a 30 degree
Hopkins rod, or attach the laryngoscope handle to the suspension arm if
microlaryngoscopy was required.

If an area of the hypopharynx or larynx is difficult to access with the
standard biopsy forceps available on the laryngoscopy set, then a
flexible 2.0mm gauge, 100cm pulmonary biopsy forceps, with a 1.8mm jaw,
can be used. (figure 2). The distal tip of the bougie is cut to expose
the lumen. The assistant then loads the flexible biopsy forceps down the
bougie lumen, which can be manipulated into position to access the
difficult area (figure 3). The lesion is approached with an open jaw
biopsy forceps, pushed deep into the lesion and closed, feeling for
resistance. The biopsy forcep handle is controlled by the assistant,
whilst the operator holds the Hopkins rod and laryngoscope; or in
microlaryngoscopy, the bougie can be further guided by the operator.

\textbf{Results}

In cases where laryngeal exposure was difficult and the method outlined
above was utilised 100\% had adequate tissue samples to achieve
histological diagnosis.

\textbf{Discussion}

Although angled telescopes and curved instrumentation may help overcome
challenges of difficult laryngeal access, we found that the flexible
biopsy forceps loaded down the lumen of a bougie is a useful adjunct for
more challenging cases. They are also readily available in most
hospitals. When using the flexible biopsy forceps alone, it was found
that there was not enough rigidity and guidance and the jaws often
missed the lesion. The bougie technique offers the rigidity needed and
as the plastic has memory, it will stay in the position required to
access difficult areas to obtain adequate samples needed for
histological diagnosis.

\textbf{Conclusion}

In cases where it is difficult to obtain biopsies due to limited
exposure of the larynx, flexible biopsy forceps loaded into the lumen of
an intubating bougie lends itself as a useful adjunct, and is easily
accessible in most hospitals.

\textbf{Figure list}

Figure 1: Image of intubating bougie

Figure 2: Image of flexible biopsy forceps

Figure 3: Image of loaded bougie with flexible biopsy forceps showing
the tips

\textbf{Word count} : 671

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Piazza C, Mangili S, Bon FD, Paderno A, Grazioli P, Barbieri D,
  Perotti P et al. Preoperative clinical predictors of difficult
  laryngeal exposure for microlaryngoscopy: The laryngoscore. \emph{The
  Laryngoscope} . 2014; 124:2561-2567. Avaliable from:
  doi.org/10.1002/lary.24803.
\item
  Pinar E, Calli C, Oncel S, Selek B, Tatar B. Preoperative clinical
  prediction of difficult laryngeal exposure in suspension laryngoscopy.
  European Archives of Oto-rhino-laryngology. 2009;266(5):699-703.
\item
  Mohammad~I. El-Orbany, M~Ramez Salem, Ninos~J. Joseph; The Eschmann
  Tracheal Tube Introducer Is Not Gum, Elastic, or a
  Bougie.\emph{Anesthesiology} 2004; 101:1240 doi:
  https://doi.org/10.1097/00000542-200411000-00032 Mohammad~I.
  El-Orbany, M~Ramez Salem, Ninos~J. Joseph; The Eschmann Tracheal Tube
  Introducer Is Not Gum, Elastic, or a Bougie.
  \emph{Anesthesiology}2004; 101:1240 doi:
  https://doi.org/10.1097/00000542-200411000-00032 Mohammad~I.
  El-Orbany, M~Ramez Salem, Ninos~J. Joseph; The Eschmann Tracheal Tube
  Introducer Is Not Gum, Elastic, or a Bougie.
  \emph{Anesthesiology}2004; 101:1240 doi:
  https://doi.org/10.1097/00000542-200411000-00032 Mohammad~I.
  El-Orbany, M~Ramez Salem, Ninos~J. Joseph; The Eschmann Tracheal Tube
  Introducer Is Not Gum, Elastic, or a Bougie.
  \emph{Anesthesiology}2004; 101:1240 Mohammad I, El-Orbany MD, Ramez
  Salem M, Ninos J, JosephBS The Eschmann Tracheal Tube Introducer Is
  Not Gum, Elastic, or a Bougie. \emph{Anesthesiology} . 2004;101:1240.
  Avaliable from: doi.org/10.1097/00000542-200411000-00032.
\item
  Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D.
  SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence):
  revised publication guidelines from a detailed consensus
  process.\emph{British Medical Journal Quality and Safety} .
  2016;25(12):986-992.
\end{enumerate}\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1-Intubating-bougie-image/Figure-1-Intubating-bougie-image}

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\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-2-Flexible-biopsy-forceps/Figure-2-Flexible-biopsy-forceps}

\end{center}
\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-3-loaded-bougie-with-flexible-biopsy-forceps-image/Figure-3-loaded-bougie-with-flexible-biopsy-forceps-image}

\end{center}
\end{figure}

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