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Direct laryngoscopy allows visualization of the larynx. It is used during general anesthesia, for surgical procedures of the larynx, and during resuscitation. This tool is useful in multiple hospital settings, from the emergency department to the intensive care unit and the operating room. By visualizing the larynx, endotracheal intubation is facilitated. This activity reviews the indications, contraindications, and complications of direct laryngoscopy and highlights the role of the interprofessional team in the management of these patients. Objectives: Identify the anatomical structures visualized during direct laryngoscopy. Describe the technique of direct laryngoscopy. Review the indications of direct laryngoscopy. Explain interprofessional team strategies for improving care coordination of patients undergoing direct laryngoscopy and improving outcomes. Access free multiple choice questions on this topic.

A direct laryngoscopy allows visualization of the larynx. It is used during general anesthesia, surgical procedures around the larynx, and resuscitation. This tool is useful in multiple hospital settings, from the emergency department to the intensive care unit and the operating room. By visualizing the larynx, endotracheal intubation is facilitated. This is an important step for a range of patients who are unable to secure their own airway, including those with altered mental status and those who are undergoing a surgical procedure. When using direct laryngoscopy to secure a patient's airway, the physician must be well acquainted with the anatomy, indications, contraindications, preparation, equipment, proper technique, personnel, and complications of the procedure for successful endotracheal intubation.[1][2][3]

As in many procedures, complications may arise. The laryngoscope may cause blunt or penetrating trauma to the oropharynx, larynx, and trachea or may chip teeth or lacerate the lips. Direct laryngoscopy involves the possibility of vocal cord damage as well as arytenoid cartilage dislocation. Meticulous technique is required at all times to avoid these complications. The most common complication of this procedure is a sore throat, which is reported to occur in 14% to 57% of patients who undergo intubation for general anesthesia. Sore throat is a broad definition but includes pain, discomfort, hoarseness of voice, dysphagia, and dry throat; these can occur alone or in a combination. Sore throat is usually mild and temporary and mostly resolves within 48 hours.[15] Complications of direct laryngoscopy and subsequent ETT placement can be classified into two categories: traumatic and non-traumatic. Traumatic injuries can include a direct blunt or penetrating trauma to the trachea, larynx, or oropharynx from either the laryngoscope blade, the ETT style, or the ETT itself. The damage can also occur to the lips, tongue, pharynx, esophagus, and teeth.[16] Chipped and broken teeth as a result of improper technique are a major complication to be wary of. In addition, the ETT can cause glottic trauma and cause damage to and paralysis of the vocal cords and dislocation of the arytenoid cartilages.[17] In rare instances, extreme flexion or extension of the neck during direct laryngoscopy can cause cervical spinal cord injuries in patients that have risk factors, such as patients with unstable cervical spinal column fractures, severe rheumatoid arthritis, or atlantoaxial instability.[18] Temporomandibular joint dislocation can happen in rare instances if excessive force is used to displace the mandible for laryngoscopy.

Complications of direct laryngoscopy and subsequent ETT placement can be classified into two categories: traumatic and non-traumatic. Traumatic injuries can include a direct blunt or penetrating trauma to the trachea, larynx, or oropharynx from either the laryngoscope blade, the ETT style, or the ETT itself. The damage can also occur to the lips, tongue, pharynx, esophagus, and teeth.[16] Chipped and broken teeth as a result of improper technique are a major complication to be wary of. In addition, the ETT can cause glottic trauma and cause damage to and paralysis of the vocal cords and dislocation of the arytenoid cartilages.[17] In rare instances, extreme flexion or extension of the neck during direct laryngoscopy can cause cervical spinal cord injuries in patients that have risk factors, such as patients with unstable cervical spinal column fractures, severe rheumatoid arthritis, or atlantoaxial instability.[18] Temporomandibular joint dislocation can happen in rare instances if excessive force is used to displace the mandible for laryngoscopy. Nontraumatic complications of direct laryngoscopy and ETT placement include aspiration of gastric contents[19], hypoxic brain injury from a prolonged attempt at intubation without adequate oxygenation[20], and bronchospasm.[21] Sympathetic surge causing tachycardia, dysrhythmias, myocardial ischemia, and/or infarction and hypertension can occur as a result of stimulation of the highly innervated glottis by the laryngoscopy blade.[22] Similarly, especially in younger patients, the laryngoscopic blade can stimulate the vagus nerve, which can cause profound bradycardia.[23] Esophageal intubation is also a well-recognized complication of direct laryngoscopy and is usually quickly recognized and corrected.[24] Barotrauma, pneumothorax, pneumoperitoneum, and hypotension are also well-known atraumatic complications of direct laryngoscopy.[25] Tracheal intubation can have chronic and long-term complications as a result of the irritation to the tissue, causing scarring, which can lead to laryngomalacia, tracheomalacia, tracheomalacia, or laryngeal stenosis (both glottic and subglottic).[26]

A direct laryngoscopy allows visualization of the larynx and is often used during general anesthesia, surgical procedures around the larynx, and resuscitation. This tool is useful in multiple hospital settings, from the emergency department to the intensive care unit and the operating room. By visualizing the larynx, endotracheal intubation is facilitated. Even though a minor procedure, one must be well acquainted with the anatomy, indications, contraindications, equipment, and personnel for the successful use of direct laryngoscopy.