home Adviсe Methods for studying the retina. Diagnosis of eye diseases - methods of eye examination in ophthalmology. Diagnosis of congenital glaucoma

Methods for studying the retina. Diagnosis of eye diseases - methods of eye examination in ophthalmology. Diagnosis of congenital glaucoma

An eye examination should be part of any physical and pre-sale examination. The completeness of the examination will depend on the doctor’s experience and the availability of special equipment. Although the information presented in this chapter is intended to provide the practitioner with the knowledge required to perform a sufficient/complete evaluation of the eye, some of the techniques described here may not be accessible to a limited number of professionals with specialized training and/or equipment. In order to correctly diagnose eye pathologies, it is necessary to know the normal anatomy of the eye. Therefore, a general understanding of normal equine eye anatomy and normal anatomical variations is also outlined here. Because there is considerable variation in the normal structure of the horse's eye, years of practice may be required before the examiner can confidently distinguish between normal and pathological variations. Comparing a healthy and diseased eye in the same horse also contributes to a more correct understanding of pathology and normality.

OPHTHALMOLOGICAL EQUIPMENT AND RESEARCH TECHNIQUES

Focus light source

A flashlight pen is rarely sufficient for examination; Using a bright light source such as a Finoff transilluminator is usually recommended. The use of some magnification equipment, such as a head loupe combined with a bright light source, is also helpful. Effective eye examination requires a variety of angles and distances between the light source, a comfortable position for the examiner, and the horse's eye. When through illumination is used parallel to the visual axis of the examiner and reflection from the tapetum or fundus, opacities of the transparent tissues or fluids of the eye (tear film, cornea, anterior chamber and aqueous humor, lens, vitreous) become visible. Directing the light at a 90" angle to the examiner's line of sight will clarify subtle corneal opacities such as ulcers, scars, furrows, and lipid or mineral deposits.

Biomicroscope with slit lamp

A portable slit-lamp biomicroscope provides the examiner with magnified images of the external structures of the eye (including the adnexa, conjunctiva, cornea, and sclera), anterior chamber, iris, iridocorneal angle, lens, and anterior vitreous. Using a slit lamp biomicroscope, it is impossible to examine the central and posterior parts of the vitreous body and the fundus of the eye without the use of special lenses. Slit lamp examination provides the examiner with a level of detail that cannot be achieved using any other equipment. The advantages of using a slit lamp are the identification of subtle abnormalities, such as opalescence and slight cellular infiltration, determination of the depth to which corneal or lens opacification extends; and accurate assessment of corneal thickness or depth of ulcers on its surface.

Direct ophthalmoscopy

When a direct ophthalmoscope is used to examine a horse's fundus, it provides a virtual vertical image that is magnified approximately eight times. Before performing ophthalmoscopy, the pupil should be dilated. With direct ophthalmoscopy, only a small area of the fundus can be visualized at a time; therefore, the examiner must sequentially change the field of view to assess the entire fundus and then mentally form the fundus. To visualize the bottom, a circular scale with condenser lenses should be set to 0 diopters and the reflection of the tapetum should be visualized from a distance of 0.5-1 m. The examiner should then approach the cornea to a distance of 2-3 cm to focus on the retinal image. A slight adjustment of the ophthalmoscope diopter scale (between -2 and +2) may be required to obtain clear focus. Distant direct ophthalmoscopy is a technique used to identify opacities in the cornea, lens, and vitreous that are blocking the passage of light from the ophthalmoscope. After dilation of the pupil, the examiner stands at arm's length from the horse's eye, adjusts the circular scale of the condenser lens to 0 dioptres, places the instrument opposite his eyebrow and observes the reflection through the ophthalmoscope. Opacities in the clear tissues or fluids of the eye appear as dark spots on the tapetum display.

Indirect ophthalmoscopy

Indirect ophthalmoscopy provides a larger field of view compared to direct ophthalmoscopy and allows for a more rapid, complete examination of the fundus. Requires a light source and a handheld condenser lens. The light can come from a hand-held source (Finoff transilluminator) or a special headset that includes a light source. The headset also contains a prism that separates the images entering the right and left eyes of the examiner, thus forming a three-dimensional image. The light source is directly adjacent to the eye of the examiner, and, being at a distance of an arm from the horse’s eye, a beam of light is directed into the eye and the reflection of the tapetum is observed. A converging lens is then inserted into the path of the light at a distance of approximately 2-5 cm from the surface of the cornea. The lens should be moved closer or further from the surface of the cornea until a clear image fills the lens. The lens should be held perpendicular to the light beam and then tilted slightly until the light reflection from the front and back surfaces of the condenser lens are closely aligned with each other. Excessive lens tilt may cause image distortion. Indirect ophthalmoscopy provides a true, inverted fundus image that appears 180 degrees inverted (upside down).

Local staining

Fluorescein sodium
The dye sodium fluorescein has several uses in ophthalmic diagnostics. It is most often applied topically to identify corneal ulcerations, and the dye will adhere to exposed corneal stroma but not to intact corneal epithelium. The paint turns a fluorescent apple green color when illuminated with a cobalt blue light source (available in many direct ophthalmoscopes). Topical sodium fluorescein staining can also assess the patency of the nasolacrimal duct and the presence of leakage from corneal wounds.
Bengal pink
Rose bengal staining is less commonly used than sodium fluorescein staining, but can be used to identify nonviable epithelium and diagnose tear film disorders, including keratoconjunctivitis sicca and tear film mucin deficiency. Dye absorption may also occur in equine herpesvirus keratitis and early stage fungal keratitis.

FIXING A HORSE FOR OPHTHALMOLOGICAL EXAMINATION

In uncoupled horses, examination is facilitated by a combination of intravenous sedation, motor nerve block, and local anesthesia. Sometimes a twist is required. A short-acting drug such as xylazine (0.5–1.0 mg/kg IV) or detomidine (0.005–0.2 mg/kg IV) is usually sufficient for sedation. For ophthalmological diagnostics, nerve blocks that cause eyelid akinesia are most practical. Several techniques have been described, but the author prefers to inject 1-2 ml of 2% lidocaine using a 25-gauge needle over the eyelid nerve at its intersection with the dorsal surface of the zygomatic arch. In this area, the eyelid nerve can be palpated by gently running the tip of an upright index finger along the zygomatic arch. Akinesia develops after 1-5 minutes, depending on the volume of the injection and the correctness of its implementation. The duration varies, but can be up to 2-3 hours. Diagnostic procedures, including tonometry, nasolacrimal duct irrigation, and keratoconjunctival scrapings for cytologic examination, may require the application of a local ophthalmic anesthetic (eg, 0.5% proparacaine).

EYE EXAMINATION

If possible, the ophthalmic examination should be performed in a quiet environment where darkness can be achieved. Examination in a bright light environment may obscure abnormalities in the clear media or tissues of the eye. It is often critical to adhere to a specific sequence when performing ophthalmic examinations and performing diagnostic tests, since performing one diagnostic test may bias the results of subsequent tests. Below are examples.

Neuro-ophthalmological examination

Palpebral and corneal reflexes
The palpebral and corneal reflexes demonstrate the functional integrity of the V and VII pairs of cranial nerves. The palpebral reflex is checked by lightly touching the periocular area. The examiner should note the speed and completeness of eyelid closure. The corneal reflex is assessed by lightly touching the surface of the cornea with a cotton swab. A normal response involves retraction of the eyeball and closure of the eyelids.
Oculocephalic reflex
The oculocephalic reflex indicates the state of the vestibular tract, the medial longitudinal fasciculus and the cranial nerves innervating the external muscles of the eye, including the III, IV and VI pairs. As the horse's head moves from side to side and then up and down, you should pay attention to the resulting eye movements. The normal response is physiological nystagmus with a rapid phase in the direction of head displacement.
Pupil response to light (pupillary reflex)
The pupillary response to light (PLR) characterizes the afferent function of the retina, optic nerve and visual pathway, as well as the efferent function of the third pair of cranial nerves (parasympathetic components). RZS should be assessed in the dark and before sedation or instillation of topical mydriatics. Before assessing the RZ, the examiner should check the symmetry of the pupils. If the examiner stands 2 meters directly in front of the horse and uses a straight ophthalmoscope (set to 0 diopter), it is possible to simultaneously observe the reflection of the tapetum of both eyes. This procedure should be performed in ambient light and in darkness. Differences in pupil size (anisocria) should be noted. To assess RSD, it is necessary to point a bright focal light source at the eye and monitor the degree of constriction of the ipsilateral pupil (direct RSD). The examiner then quickly moves the light source to illuminate the contralateral eye and observes the degree of constriction already present (consistent ESR), as well as the increase in constriction that should occur under direct stimulation. In horses, the amplitude (magnitude) of the coordinated RGS is minimal. The use of a dim light source, as well as fear and excitement will reduce the speed and completeness of the RZS. Normal RSV does not indicate the state of vision, since vision is a cortical phenomenon and not a reflex.
Vision assessment
The ability of a horse to move between a series of obstacles in its path or in an unfamiliar environment can help characterize a functional visual deficit. It is advisable to carry out this test under different lighting conditions. The threat response provides a rough estimate of the vision of an individual eye. Assessing threat response can be done by slowly bringing your hand into the horse's field of vision or gesturing in front of his eye while keeping the opposite eye closed. It is important not to cause a tactile reaction by causing excessive air movement or touching the whiskers. The threat response may not be perfect until the horse is 2-3 weeks of age. The glare reflex is a normal response to irritation by bright light directed at the eye and consists of retracting the eyeball and closing the eyelids. Since the blinding light reflex is a subcortical phenomenon, it is a valuable criterion in the clinical differentiation of cortical disorders.
rank of blindness from blindness associated with diseases of the retina, optic nerve or optic pathway.

EXAMINATION OF THE EYE ACCIDENTAL APPARATUS

Assessing anatomical or physiological abnormalities of the eyelids should be performed using illumination and, if necessary, magnification. A raised groove located above the eyelids parallel to their edges divides the upper and lower eyelids into the orbital and tarsal parts. Numerous eyelashes are located on the lateral two-thirds of the upper eyelid. Normally, the eyelashes are directed almost perpendicular to the surface of the cornea. Along the base of the lower eyelid and on the medial portion of the base of the upper eyelid there are varying numbers of vibrissae. Close examination of the eyelid margins reveals many small meibomian (tarsal) gland openings, approximately 40-50 in the upper eyelid and 30-40 in the lower eyelid. If you turn the eyelids slightly outward, the meibomian glands can be seen through the conjunctiva of the eyelids as dull, ivory or white lines oriented perpendicular to the edge of the eyelid.
When examining the surface of the conjunctiva, attention should be paid to signs such as hyperemia, chemosis and/or follicular formation. The conjunctiva of the eyelids is tightly adjacent to the eyelid, while the conjunctiva of the eyeball is less adherent and moves freely above the surface of the sclera. The conjunctiva of the eyeball is normally transparent to light, except when it is pigmented. The conjunctiva adjacent to the limbus is often pigmented, as is the temporal part of the conjunctiva of the eyeball. The lacrimal tubercle is a variable-sized, smooth, protruding conjunctival formation that is located on the medial side of the palpebral fissure. The tubercle is usually darkly pigmented and may have fine raised hairs on its surface.
With the exception of its anterior edge, the nictitating membrane is normally retracted into the posteronasal part of the orbit. The anterior margin is usually pigmented, although a lack of pigment may be normal in horses with weak periocular pigmentation. Retraction of the eyeball leads to passive movement of the nictitating membrane over the surface of the cornea. Retropulsion of the eyeball into the orbit (by pressing on the eye through the upper eyelid) entails protrusion of the nictitating membrane, thus facilitating inspection of its palpebral surface. The bulbar surface of the third eyelid can be examined by gently grasping the anterior edge with forceps and everting it using gentle outward traction. Sedation, eyelid auricular nerve block, and local anesthesia are usually required.

STUDY OF THE LACRIMAL APPARATUS

Aqueous tear production is assessed using the Schirmer tear test (STS). Although PPS is rarely performed in horses, indications include dry, matte-appearing corneas and chronic keratoconjunctivitis of unknown cause. The test is performed by placing a commercially available SPS strip between the cornea and the lower eyelid in the area near the junction of the lateral and middle thirds of the lower eyelid. Normal values in horses are extremely variable, but are generally quite high. Since commercially available PPS strips often become completely wet within one minute, it is recommended that the measurement be taken within 30 seconds; normal values are >20 mm/30 seconds. SPS should be performed before sedation or topical solutions, including anesthetics.
The study of the tear outflow system includes a visual inspection of the superior and inferior lacrimal openings (located at a distance of 8-9 mm from the medial corner of the eye on the conjunctival side of the eyelid border) and the nasal opening of the nasolacrimal duct (located medially at the bottom of the vestibule of the nasal cavity next to the mucocutaneous connection). Physiological patency of the nasolacrimal duct is assessed by instilling sodium fluorescein onto the ocular surface and observing the flow of dye through the nasal opening. In a healthy horse, the passage can take up to 5 minutes. Anatomical patency can be examined using a nasolacrimal catheter attached to a syringe filled with a rinsing solution (saline). A local anesthetic solution is instilled and a catheter is carefully inserted into the superior or inferior lacrimal punctum and the corresponding canaliculus. Then the non-catheterized point is closed, pressing it with a finger, and the nasolacrimal duct is irrigated with the solution through the nasal opening. This procedure can be performed in an easier alternative way by retrograde catheterization of the nasolacrimal duct with a urinary catheter (5Fr). The catheter is advanced 3-4 cm and 20-40 ml of saline solution is carefully injected from a syringe, while preventing its reverse outflow from the nasal opening, pressing the latter with a finger. The injected fluid should appear flowing from the lacrimal openings. Sedation is often required before irrigation of the nasolacrimal duct.

CORNEA STUDY

The cornea is assessed using a bright focal light source with or without additional magnification. Slit lamp examination provides additional detail, including approximate corneal thickness and depth of corneal lesions. The normal adult horse cornea is horizontally oval with a horizontal dimension of 28–32 mm, a vertical dimension of 23–26 mm, and approximately 0.7–0.8 mm thickness. The nasal side of the cornea is vertically wider than the temporal one. A normal cornea should be optically transparent, devoid of vascularization and not pigmented. A thin gray or white line is visible medially and laterally at the corneoscleral junction, which represents the trabecular attachments of the pectineal ligament to the posterior surface of the cornea. Subtle corneal opacities may be missed without the use of different lighting techniques during corneal examination. First, diffuse focal illumination should be directed perpendicular to the cornea and almost parallel to the viewer's visual axis. Then, while the observer maintains the same position, the light source should be directed obliquely, then almost perpendicular to the surface of the cornea, to reveal subtle or undetectable lesions. Topical application of sodium fluorescein will help identify corneal ulceration,

STUDY OF THE ANTERIOR CHAMBER

The anterior chamber is examined using a focal light source (with or without additional magnification) and a slit-lamp biomicroscope. The depth of the anterior chamber (the distance between the posterior surface of the cornea and the lens-iris diaphragm) and the transparency of the aqueous humor should be determined. Deviations in the depth of the anterior chamber may indicate a change in the normal position or volume of the lens. Aqueous humor is normally optically transparent. A uniform cloudiness of this fluid indicates abnormally high protein content or the presence of cells. Focal opacification may indicate the presence of vitreous or fibrin in the anterior chamber. A slit lamp examination can detect minor opacities that may not be detected without the use of this instrument.
A readily available and inexpensive alternative to the slit-lamp biomicroscope that can be used to determine anterior chamber depth and aqueous humor clarity is a direct ophthalmoscope set to a minimum pinhole aperture. The instrument is held approximately 1 cm from the center of the cornea. The examiner does not see through the instrument, but instead has the opportunity to take an advantageous position perpendicular to the direction of the light beam. This allows the examiner to observe how a beam of light passes through the cornea, aqueous humor and the anterior part of the lens. Reflections should be observed at the interfaces between the air and the tear film (corneal reflection) and the aqueous humor and the anterior lens capsule (lenticular reflection). The light should not be visible passing through the aqueous humor. If the examiner observes a homogeneous beam of light passing through aqueous humor (for example, “light in fog”), then opacification is present. The ventral part of the anterior chamber should be inspected for settled (gravitational) cellular debris.

IRIS STUDY

The iris is most often colored in shades of brown, but can also be golden, blue or white. There may be differences between two irises or multiple colors of the same iris (iris heterochromia). With constriction, the pupillary fissure in an adult horse is horizontally oval, and in newborns it is almost round. With dilatation, the pupillary fissure is normally round, both in adults and in newborns. On the dorsal edge of the pupil there are hailstones corpora nigra (grape seed hailstones, granula iridica) - a series of prominent, intensely pigmented uveal bodies of varying sizes. Hailstones are also present below, but they protrude less. Sometimes there are no hailstones in a healthy eye. Close examination of the iris using oblique lighting reveals a textured surface with many fine grooves and folds. Permanent pupillary membranes (remnants of embryonic vessels) always arise from the edge of the iris surface and are often found in normal eyes.
It is possible to visualize the nasal and temporal zones of the peripheral part of the iris, where the trabeculae of the iridocorneal angle follow from the surface of the iris to the cornea. To study the nasal and temporal iridocorneal angles, there is no need to use goniolenses.

RESEARCH OF THE CLENS

A complete examination of the lens requires pharmacological mydriasis. The author recommends topical application of a 1% tropicamide solution. The lens should be examined for clouding, changes in position and size. A normal lens should be optically transparent. In older horses, the entire lens is yellow and nuclear sclerosis may be present, but this should not obstruct the passage of light. Light-obstructing lens opacities should be assessed for size, density, and location. Such opacities can be easily identified by distant direct ophthalmoscopy (described above). Examination of the lens using a biomicroscope with a slit lamp will identify extremely small lens opacities and facilitate their localization. The peripheral edge (equator) of the lens should not be visible. Visualization of the lens equator may indicate lens instability (subluxation, dislocation), microphakia (congenitally small lens), or lens coloboma.

REAR SECTOR STUDY

Topical application of a 1% tropicamide solution results in mydriasis, which can last 4-8 hours in a normal horse. Repeated application (2-3 times) of tropicamide at intervals of 3-5 minutes causes faster and more complete dilatation of the pupil. Longer-acting mydriatics, such as atropine sulfate, act more slowly, last longer and should not be used for diagnostic purposes.
The vitreous body is examined using a focal light source, a slit lamp, or a direct ophthalmoscope. Normally, the vitreous body is an optically transparent gel-like substance. Dense intravitreal opacities or liquefaction are abnormal and should be noted. Up to 4 months of age, remnants of the vitreous artery can be detected in horses.
The fundus of the horse can be examined using a single transilluminator, although much more detail can be observed with direct or indirect ophthalmoscopy. The equine fundus is topographically divided into the tapetum lucidum zone (reflective membrane), which is located in the dorsal half of the fundus, and the nontapetum zone. The tapetum zone is approximately triangular in shape and may be yellow, green or blue in color. The absence of tapetum lucidum is a variant of the norm. The nontapetum zone is generally highly pigmented, although lack of pigmentation in this zone is common in light-colored horses and in eyes with blue irises. Lack of pigmentation or weak pigmentation allows visualization of retinal vessels. A star-shaped arrangement of large veins (vein swirl) can often be seen on light-colored bottoms. The optic disc in horses is invariably located in the non-tapetum zone. It is located slightly ventral and lateral to the posterior pole of the eyeball and has a horizontal oval shape in adult animals and more rounded in young animals. The optic disc is orange-pink in color and its inferior edge is often irregular. Approximately 40-60 small retinal blood vessels extend radially from the periphery of the optic disc; arterioles and venules cannot be distinguished clinically. The vascular pattern of the equine retina contains sparsely branched blood vessels extending only a short distance from the disc. The retinal vessels that start from the disc in the horizontal meridian extend approximately 2 disc diameters from the latter. End to front, the tapetum emissaries and vascular capillary blood supply appear as multiple small, evenly distributed black dots (“Winslow’s stars”). There is a wide range of clinical appearance of normal fundus, and differentiation between normal and pathological variants is often difficult.

Surprisingly, a huge arsenal of examinations and diagnostic procedures is aimed at such a small organ of vision: from simple alphabetic tables to obtaining a layer-by-layer image of the retina and optic nerve head using OCT and a detailed study of the course of blood vessels in the fundus during FA.

Most studies are carried out according to strict indications. However, when going to see an ophthalmologist, be prepared to spend from half an hour to an hour or more, depending on the number and complexity of the tests you need and the workload of your doctor.

Determination of visual acuity and refraction

Visual acuity is determined for each eye separately. In this case, one of them is covered with a shield or palm. At a distance of 5 meters you will be shown letters, numbers or signs of various sizes that you will be asked to name. Visual acuity is characterized by the smallest signs that the eye can distinguish.

Next, you will be given a frame in which the doctor will put different lenses, asking you to choose which one allows you to see more clearly. Or they will install in front of you a device called a phoropter, in which lenses are changed automatically. Refraction is characterized by the power of the lens, which provides the highest visual acuity for that eye, and is expressed in diopters. Positive lenses are required for farsightedness, negative lenses for myopia, and cylindrical lenses for astigmatism.

Automatic refractometry and aberrometry

Based on the analysis of the wavefront of the eye, the aberrometer determines even imperceptible optical imperfections of its media. These data are important when planning LASIK.

Visual field examination

It is carried out using a device - a perimeter, which is a hemispherical screen. You are asked to fixate the mark with your eye and, as soon as you notice with your peripheral vision the luminous dots appearing in different parts of the screen, press the signal button or say “yes”, “I see”. The visual field is characterized by the space in which the eye, with a constantly fixed gaze, detects visual stimuli. Characteristic visual field defects occur due to eye diseases, such as glaucoma, as well as when the optic nerve and brain are damaged by a tumor or as a result of a stroke.

Measuring intraocular pressure

Non-contact measurement is carried out using an automatic tonometer. You are asked to place your chin on the stand of the device and fixate your gaze on the luminous mark. The autotonometer releases a stream of air in the direction of your eye. Based on the cornea's resistance to air flow, the device determines the level of intraocular pressure. The technique is absolutely painless, the device does not come into contact with your eyes.

The contact method for measuring intraocular pressure has been accepted as standard in Russia. After instilling the “freezing” drops, the doctor touches your cornea with a weight with a colored area. The level of intraocular pressure is determined on paper by the diameter of the imprint of the unpainted area. This technique is also painless.

Since glaucoma is a disease associated with increased intraocular pressure, regular measurement of it is a necessary condition for maintaining the health of your eyes.

Cover test

There are many methods for diagnosing strabismus. The simplest of them is the “cover” test. The doctor asks you to fix your gaze on an object in the distance and, alternately covering one of your eyes with your palm, watches the other to see if there is an orientation movement. If it occurs inwardly, divergent strabismus is diagnosed, if outwardly, convergent strabismus is diagnosed.

Biomicroscopy of the eye

A slit lamp or biomicroscope allows you to examine the structures of the eye under high magnification. You are asked to place your chin on the stand of the device. The doctor illuminates your eye with the light of a slit lamp and, under high magnification, first examines the anterior part of the eye (eyelids, conjunctiva, cornea, iris, lens), and then, using a strong lens, examines the fundus of the eye (retina, optic nerve head and blood vessels). Biomicroscopy allows you to diagnose almost the entire range of eye diseases.

Retinal examination

Using an ophthalmoscope, the doctor directs a beam of light into your eye and examines the retina, optic nerve head and blood vessels through the pupil.

Often, for a more complete view, you are first instilled with drops that dilate the pupil. The effect develops after 15-30 minutes. While they last, sometimes for several hours, you may experience difficulty focusing on nearby objects. In addition, the eye's sensitivity to light increases; it is recommended to wear sunglasses on the way home after the examination.

During an external (general) examination of the patient, features are noted that are directly or indirectly related to changes in the organ of vision. Thus, the presence of scars on the face formed after injuries or operations, especially in the area of the eyelids, the outer and inner corners of the palpebral fissure, may indicate previous damage to the eyeball.

The presence of blistering rashes on the skin of the forehead and temporal region in combination with blepharospasm most often indicates a herpetic lesion of the eyeball. The same combination can be observed with rosacea keratitis, in which, in addition to severe pain, irritation of the eyeball and damage to the cornea, there is damage to the facial skin - rosacea.

In order to establish the correct diagnosis, during a general examination it is also important to determine characteristic external changes in other areas, combined with pathology of the organ of vision, such as facial asymmetry (with trigeminal neuralgia in combination with neuroparalytic keratitis), unusual body proportions (brachydactyly ), tower (oxycephaly) or boat-shaped (scaphocephaly) skull, bulging eyes (thyrotoxicosis). After completing this stage of the examination, they move on to clarifying the patient’s complaints and collecting an anamnesis.

Sting analysis and medical history

Analysis of the patient's complaints allows us to determine the nature of the disease: whether it arose acutely or developed gradually. Moreover, among the complaints characteristic of many general diseases of the body, it is important to highlight complaints characteristic only of eye diseases.

Some complaints are so characteristic of a particular eye disease that on their basis it is already possible to establish a presumptive diagnosis. For example, the feeling of a speck, sand or foreign body in the eye and the heaviness of the eyelids indicate pathology of the cornea or chronic conjunctivitis, and gluing of the eyelids in the morning in combination with copious discharge from the conjunctival cavity and redness of the eye without a noticeable decrease in visual acuity indicates the presence of acute conjunctivitis , redness and itching in the area of the edges of the eyelids - the presence of blepharitis. At the same time, based on some complaints, it is easy to determine the localization of the process. Thus, photophobia, blepharospasm and excessive lacrimation are characteristic of damage and diseases of the cornea, and sudden and painless blindness is characteristic of damage and diseases of the light-receiving apparatus. However, in such cases, the complaint itself does not yet allow us to determine the nature of the disease; it is only an initial guideline.

Some complaints, for example, blurred vision, are made by patients with cataracts, glaucoma, diseases of the retina and optic nerve, hypertension, diabetes, brain tumors, etc. Moreover, only targeted questioning (ascertaining the medical history and complaints) allows the doctor to establish the correct diagnosis. Thus, a gradual decrease or loss of vision is characteristic of slowly developing pathological processes (cataracts, open-angle glaucoma, chorioretinitis, optic atrophy, refractive errors), and a sudden loss of visual functions is associated with circulatory disorders in the retina (spasm, embolism, thrombosis, hemorrhage), acute inflammatory processes (optic neuritis, central choroiditis and chorioretinitis), severe injuries, retinal detachment, etc. A sharp decrease in visual acuity with severe pain in the eyeball is characteristic of an acute attack of glaucoma or acute iridocyclitis.

It is advisable to collect anamnesis in stages. Initially, it is necessary to pay attention to the onset of the disease, ask the patient about the suspected cause and dynamics of the disease, the treatment performed and its effectiveness. It is necessary to find out the nature of the disease: sudden onset, acute or slowly developing, chronic, arising under the influence of unfavorable external factors. For example, an acute attack of glaucoma can occur against the background of emotional overload, prolonged stay in a dark room, overwork or hypothermia. Chronic diseases of the vascular tract (iritis, iridocyclitis, chorioretinitis) may be associated with hypothermia and weakened immunity. Inflammatory infiltrates and purulent ulcers of the cornea occur against the background of previous traumatic injuries, hypothermia, and after suffering from common infectious diseases.

If a congenital or hereditary pathology is suspected, then a family history is ascertained, this applies to zonular cataracts, hydrophthalmos, syphilitic keratitis or, for example, familial optic atrophy, familial amaurotic idiocy.

It is necessary to ask the patient about his working and living conditions, since some diseases of the organ of vision may be associated with exposure to occupational hazards: brucellosis in agricultural workers, progressive myopia in patients with constant visual load under unfavorable working conditions, electroophthalmia in electric welders, etc. d.

External eye examination

First of all, pay attention to whether the eyes are the same size? See if the eyelids are symmetrical and if they retract normally when looking up. Ptosis is drooping of the upper eyelid and lack of normal retraction when looking up. See if the conjunctiva is inflamed? Examine the cornea with a magnifying glass - are there any scratches on it? If you suspect scratches, inject 1% fluorescein into the eye to identify defects in the corneal epithelium.

An external examination is carried out in good daylight or artificial lighting and begins with an assessment of the shape of the head, face, and the condition of the auxiliary organs of the eye. First of all, the condition of the palpebral fissure is assessed: it can be narrowed due to photophobia, closed by swollen eyelids, significantly expanded, shortened in the horizontal direction (blepharophimosis), not completely closed (lagophthalmos), have an irregular shape (eversion or entropion of the eyelid, dacryoadenitis), closed at areas of fusion of the edges of the eyelids (ankyloblepharon). Then the condition of the eyelids is assessed, and partial or complete drooping of the upper eyelid (ptosis), a defect (coloboma) of the free edge of the eyelid, growth of eyelashes towards the eyeball (trichiasis), the presence of a vertical skin fold at the corner of the eyelid (epicanthus), can be detected. inversion or inversion of the ciliary edge.

When examining the conjunctiva, severe hyperemia without hemorrhage (bacterial conjunctivitis), hyperemia with hemorrhage and copious discharge (viral conjunctivitis) can be determined. In patients with pathology of the lacrimal organs, lacrimation can be noted.

In case of inflammation of the lacrimal sac or tubules, mucous, mucopurulent or purulent discharge is detected, the appearance of purulent discharge from the lacrimal openings when pressing on the area of the lacrimal sac (dacryocystitis). Inflammatory swelling of the outer part of the upper eyelid and an S-shaped curvature of the palpebral fissure indicate dacryoadenitis.

Next, the condition of the eyeball as a whole is assessed: its absence (anophthalmos), retraction (enophthalmos), protrusion from the orbit (exophthalmos), deviation to the side from the point of fixation (strabismus), enlargement (buphthalmos) or decrease (microphthalmos), redness (inflammatory diseases or ophthalmic hypertension), yellowish (hepatitis) or bluish (Van der Hove syndrome or blue sclera syndrome) color, as well as the condition of the orbit: deformation of the bone walls (consequences of injury), the presence of swelling and additional tissue (tumor, cyst, hematoma).

It should be taken into account that diseases of the organ of vision are characterized by the diversity and originality of clinical manifestations. To recognize them, a careful examination of both healthy and diseased eyes is necessary. The study is carried out in a certain sequence: first, the condition of the auxiliary organs of the eye is assessed, then its anterior and posterior sections are examined. In this case, they always begin with an examination and instrumental examination of the healthy eye.

The study of the orbit and surrounding tissues begins with an examination. First of all, the parts of the face surrounding the eye socket are examined. Particular attention is paid to the position and mobility of the eyeball, changes in which can serve as an indirect sign of a pathological process in the orbit (tumor, cyst, hematoma, traumatic deformity).

When determining the position of the eyeball in the orbit, the following factors are assessed: the degree of its protrusion or retraction (exophthalmometry), deviation from the midline (strobometry), the magnitude and ease of displacement into the orbital cavity under the influence of dosed pressure (orbitotonometry).

Exophthalmometry- assessment of the degree of protrusion (retraction) of the eyeball from the bony ring of the orbit. The study is carried out using a Hertel mirror exophthalmometer, which is a horizontal plate graduated in millimeters, on each side of which there are 2 mirrors intersecting at an angle of 45°. The device is placed tightly against the outer arcs of both orbits. In this case, the apex of the cornea is visible in the lower mirror, and in the upper mirror there is a number indicating the distance at which the image of the apex of the cornea is separated from the point of application. Be sure to take into account the initial basis - the distance between the outer edges of the orbit at which the measurement was made, which is necessary for performing exophthalmometry in dynamics. Normally, the distance of the eyeball from the orbit is 14-19 mm, and the asymmetry in the position of the fellow eyes should not exceed 1-2 mm.

The necessary measurements of the protrusion of the eyeball can be carried out using a regular millimeter ruler, which is placed strictly perpendicular to the outer edge of the orbit, while the patient’s head is turned in profile. The amount of protrusion is determined by the division, which is located at the level of the apex of the cornea.

Orbitotonometry- determination of the degree of displacement of the eyeball in the orbit or compressibility of retrobulbar tissues. The method allows you to differentiate between tumor and non-tumor exophthalmos. The study is carried out using a special device - a piezometer, which consists of a crossbar with two stops (for the outer angle of the orbit and the back of the nose), and the dynamometer itself with a set of replaceable weights, installed on the eye covered with a contact corneal lens. Orbitotonometry is performed in the supine position after preliminary drip anesthesia of the eyeball with a solution of dicaine. Having installed and fixed the device, they begin to measure, successively increasing the pressure on the eyeball (50, 100, 150, 200 and 250 g). The amount of displacement of the eyeball (in millimeters) is determined by the formula: V = E0 - Em

where V is the displacement of the eyeball during the reduction force; E0 - initial position of the eyeball; Em is the position of the eyeball after applying a reduction force.

A normal eyeball reduces by approximately 1.2 mm with every 50 g increase in pressure. At a pressure of 250 g it shifts by 5-7 mm.

Strabometry- measurement of the angle of deviation of the squinting eye. The study is carried out using various methods, both approximate - according to Hirshberg and Lawrence, and quite accurate - according to Golovin.

The eyelids are examined through routine examination and palpation, paying attention to their shape, position and direction of eyelash growth, the condition of the ciliary margin, skin and cartilage, eyelid mobility and the width of the palpebral fissure. The width of the palpebral fissure is on average 12 mm. Its change may be associated with different sizes of the eyeball and its displacement forward or backward, with drooping of the upper eyelid.

Study of the connective membrane (conjunctiva)

The conjunctiva lining the lower eyelid is easily everted when it is pulled down. In this case, the patient should look up. The inner and outer edges are pulled back alternately, the conjunctiva of the eyelid and the lower transitional fold are examined.

Eversion of the upper eyelid requires some skill. It is turned out with your fingers, and a glass rod or eyelid lifter is used to examine the upper transitional fold. When the patient looks down, the upper eyelid is lifted with the thumb of the left hand. With the thumb and forefinger of the right hand, grab the ciliary edge of the upper eyelid and pull it down and anteriorly. In this case, under the skin of the eyelid, the upper edge of the cartilaginous plate is outlined, which is pressed with the thumb of the left hand or a glass rod. and at this moment, with the fingers of the right hand, lift the lower edge of the eyelid and intercept it with the thumb of the left hand, fix it by the eyelashes and press it to the edge of the orbit. The right hand remains free for manipulation.

In order to examine the upper transitional fold, where various foreign bodies are often localized, causing severe pain and irritation of the eyeball, you should lightly press upward on the eyeball through the lower eyelid. It is even better to inspect the upper transitional fold using an eyelid lifter: its edge is placed on the skin at the upper edge of the cartilage of the eyelid, which is slightly pulled downwards, and it is turned inside out, pulling it onto the end of the eyelid lifter. After eversion of the eyelid, the ciliary edge is held with the thumb of the left hand at the edge of the orbit.

The normal conjunctiva of the eyelids is pale pink, smooth, transparent, and moist. Through it, the meibomian glands and their ducts are visible, located in the thickness of the cartilaginous plate perpendicular to the edge of the eyelid. Normally, the secretion is not detected in them. It appears when you squeeze the edge of the eyelid between your finger and a glass rod.

Vessels are clearly visible in the transparent conjunctiva.

Examination of lacrimal organs

The examination of the lacrimal organs is carried out by inspection and palpation. When the upper eyelid is retracted and the patient quickly looks inwards, the palpebral part of the lacrimal gland is examined. In this way, it is possible to detect prolapse of the lacrimal gland, its tumor or inflammatory infiltration. Upon palpation, you can determine pain, swelling, and hardening of the orbital part of the gland in the area of the upper outer corner of the orbit.

The condition of the lacrimal ducts is determined by examination, which is carried out simultaneously with the study of the position of the eyelids. The filling of the lacrimal duct and lake, the position and size of the lacrimal openings at the inner corner of the eye, and the condition of the skin in the area of the lacrimal sac are assessed. The presence of purulent contents in the lacrimal sac is determined by pressing under the internal commissure of the eyelids from bottom to top with the index finger of the right hand. At the same time, the lower eyelid is pulled back with the left hand to see the spilled contents of the lacrimal sac. Normally, the lacrimal sac is empty. The contents of the lacrimal sac are squeezed out through the lacrimal canaliculi and lacrimal openings. In cases of disruption of production and drainage of tear fluid, special functional tests are performed.

Pupils

Extraocular movements

They are especially important to study in cases of diplopia. Ask the patient to follow the tip of the pencil with his eyes as he moves it in the horizontal and vertical planes. Avoid extreme and sudden eye movements, as this will make it impossible to achieve gaze fixation, which simulates nystagmus.

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Visual acuity

It reflects central vision and does not reveal abnormalities in the visual fields.

Ophthalmoscopy

Features of the study of the organ of vision in children

When examining the organ of vision in children, it is necessary to take into account the characteristics of the child’s nervous system, his reduced attention, and the inability to fix his gaze on a specific object for a long time.

Thus, an external (external) examination, especially in children under 3 years of age, is best carried out together with a nurse, who, if necessary, fixes and presses the child’s arms and legs.

Eversion of the eyelids is carried out by pressing, pulling and moving them towards each other.

Inspection of the anterior part of the eyeball is carried out using eyelid lifters after preliminary drip anesthesia with a solution of dicaine or novocaine. In this case, the same examination sequence is followed as when examining adult patients.

Examination of the posterior part of the eyeball in very young patients is conveniently carried out using an electric ophthalmoscope.

The process of studying visual acuity and field of vision must be given the character of a game, especially in children aged 3-4 years.

It is advisable to determine the boundaries of the visual field at this age using the approximate method, but instead of fingers, it is better to show the child toys of different colors.

Research using instruments becomes quite reliable from about 5 years of age, although in each specific case it is necessary to take into account the child’s characterological characteristics.

When conducting a study of the visual field in children, it is necessary to remember that its internal boundaries are wider than in adults.

Each disease requires detailed study, and pathologies of the larynx are no exception. Examination of the larynx is an important process for establishing the correct diagnosis and prescribing the necessary treatment. There are different methods for diagnosing this organ, the main one of which is laryngoscopy.

Direct and indirect laryngoscopy

The procedure is carried out using a special device - a laryngoscope, which shows in detail the condition of the larynx and vocal cords. Laryngoscopy can be of two types:

straight;
indirect.

Direct laryngoscopy is performed using a flexible fiber laryngoscope, which is inserted into the lumen of the larynx. Endoscopic equipment can be used less frequently; this instrument is rigid and, as a rule, is used only at the time of surgery. The examination is performed through the nose. A few days before the procedure, the patient is asked to take certain medications that suppress mucus secretion. Before the procedure itself, the throat is sprayed with an anesthetic, and the nose is dripped with vasoconstrictor drops to avoid injury.

Indirect laryngoscopy - this examination of the larynx is performed by placing a special mirror in the throat. The second reflective mirror is located on the otolaryngologist’s head, which allows the lumen of the larynx to be reflected and illuminated. This method is used extremely rarely in modern otolaryngology; preference is given to direct laryngoscopy. The examination itself is carried out within five minutes, the patient is in a sitting position, the pharyngeal cavity is sprayed with an anesthetic to remove the urge to gag, after which a mirror is placed in it. To examine the vocal cords, the patient is asked to pronounce the sound “a” in an extended manner.

There is another type of laryngoscopy - this is a rigid examination. This procedure is quite difficult to perform; it is done under general anesthesia and takes about half an hour. A fibrolaryngoscope is inserted into the pharyngeal cavity and the examination begins. Rigid laryngoscopy allows not only to examine the condition of the larynx and vocal cords, but also to take a sample of material for a biopsy or remove existing polyps. After the procedure, an ice bag is placed on the patient's neck to prevent swelling of the larynx. If a biopsy was performed, sputum mixed with blood may come out within a few days; this is normal.

Laryngoscopy or fiberoscopy allows you to identify the following pathological processes:

neoplasms in the larynx, and a biopsy can already reveal a benign or malignant process;
inflammation of the mucous membrane of the pharynx and larynx;
Fibroscopy will also help to see the presence of foreign bodies in the pharynx;
papillomas, nodes and other formations on the vocal cords.

Complications with fiberoscopy

Examining the larynx in this way can cause certain complications. Regardless of what type of laryngoscopy was used to examine the larynx, swelling of this organ may occur, and along with it, disturbances in respiratory function. The risk is especially high in people with polyps on the vocal cords, a tumor in the larynx, and severe inflammation of the epiglottis. If asphyxia develops, an urgent tracheotomy is required, a procedure during which a small incision is made in the neck and a special tube is inserted to allow breathing.

Pharyngoscopy

Such a procedure as pharyngoscopy is familiar to absolutely everyone since childhood. This is a doctor's examination of the mucous membrane of the throat. Pharyngoscopy does not require preliminary preparation, but is performed using a frontal reflector. Such methods of examining the pharynx are familiar not only to the otolaryngologist, but also to the pediatrician and therapist. The technique allows you to examine the upper, lower and middle parts of the pharynx. IN
Depending on which part needs to be examined, the following types of pharyngoscopy are distinguished:

posterior rhinoscopy (nasal part);
mesopharyngoscopy (directly throat or middle section);
hypopharyngoscopy (lower pharynx).

The advantage of pharyngoscopy is the absence of any contraindications or complications after the procedure. The maximum that can occur is minor irritation of the mucous membrane, which goes away on its own after a few hours. The disadvantage of pharyngoscopy is the inability to examine parts of the larynx and perform a biopsy if necessary, as is possible with endoscopic methods.

Computed tomography and MRI

CT scan of the larynx is one of the most informative research methods. Computer sections allow you to obtain a layer-by-layer picture of all anatomical structures in the neck: larynx, thyroid gland, esophagus. Computed tomography can reveal:

various injuries and injuries of the larynx;
pathological changes in the lymph nodes in the neck;
the presence of goiter in the tissues of the thyroid gland;
the presence of various neoplasms on the walls of the esophagus and larynx;
condition of blood vessels (topography of the larynx).

The procedure is considered safe for the patient, since unlike conventional X-rays, computed tomography has significantly less radiation and does not harm the person. Unlike X-rays, the radiation exposure during tomography is tens of times less.

A special feature of the procedure is the ability to view the condition of an organ without interfering with it. Computed tomography plays an important role in detecting oncology. In this case, a contrast agent is used to examine the esophagus, larynx and other anatomical structures located nearby. With its help, X-ray rays show pathological areas in the pictures. The quality of X-rays using computed tomography is improved.

MRI of the larynx is similar in principle to CT, but is considered an even more advanced method. MRI is the safest non-invasive diagnostic method. If CT is allowed to be done only after certain periods of time, although the X-ray rays are not very strong during this procedure, there is still such a limitation. In the case of MRI, there is no such problem; it can be repeated several times in a row without harm to health. The difference in the procedure is that CT uses x-rays, or rather its rays, while MRI uses a magnetic field, which is completely harmless to humans. In any of the options, tomography of the larynx is a reliable and effective method for identifying pathologies.

Stroboscopy

X-rays, ultrasound, tomography and laryngoscopy cannot fully assess the condition of the vocal cords; stroboscopy of the larynx is required to examine them. This method involves flashes of light that coincide with vibrations of the ligaments, creating a kind of stroboscopic effect.

Pathologies such as inflammation in the ligaments or the presence of neoplasms are identified according to the following criteria:

not simultaneous movement of the vocal cords. So one fold begins its movement earlier, and the second is delayed;
uneven movement, one fold extends more into the midline than the second. The second fold has limited movement.

Ultrasound

A study such as an ultrasound of the neck area can preliminarily identify a number of pathologies, such as:

hyperthyroidism;
neoplasms in the neck, but malignancy can only be confirmed by a biopsy;
cysts and nodes.

An ultrasound will also show purulent inflammatory processes. But according to the ultrasound, the diagnosis is not is established and additional diagnostic procedures are required. For example, if an ultrasound revealed a formation in the esophagus, an endoscopic examination method with a biopsy will be prescribed. If the lymph nodes in the neck are affected or there is a suspicion of a tumor in the larynx, a CT or MRI will be prescribed, since these methods provide a more comprehensive picture of what is happening than ultrasound.

Methods for examining the larynx are varied; the use of one or another depends on the expected pathology and the affected organ. Any symptoms that do not go away should alert you and be a reason to visit an otolaryngologist. Only a specialist, having carried out the necessary examination, will be able to accurately establish a diagnosis and prescribe the appropriate treatment.

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When meeting a patient who complains of a sore throat or difficulty breathing, the doctor first of all evaluates his general condition, the respiratory function of the larynx, predicts the possibility of acute stenosis and, if indicated, provides emergency care to the patient.

Anamnesis

Already from the first words, by the nature of the sound of the patient’s voice (nasality, hoarseness, aphonicity, voice rattling, shortness of breath, stridor, etc.), one can get an idea of a possible disease. When assessing a patient’s complaints, attention is paid to their nature, duration, frequency, dynamics, dependence on endo- and exogenous factors, and concomitant diseases.

Visual inspection. The area of the larynx, which occupies the central part of the anterior surface of the neck, the submandibular and suprasternal areas, the lateral surfaces of the neck, as well as the supraclavicular fossa, is subjected to external examination. During the examination, the condition of the skin, the condition of the venous pattern, the shape and position of the larynx, the presence of swelling of the subcutaneous tissue, swelling, fistulas and other signs indicating inflammatory, tumor and other lesions of the larynx are assessed.

Palpation

Palpation of the larynx and the anterior surface of the neck is carried out with the head in the usual position and when it is thrown back, while the relief of the palpated area is assessed (Fig. 1).

Rice. 1. Protrusions and depressions of the preglottic region: 1 - protrusion of the hyoid bone; 2 - hypoglossal-thyroid cavity; 3 - protrusion of the thyroid cartilage (Adam's apple, Adam's apple); 4 - intercricoid-thyroid fossa; 5 — protrusion of the cricoid cartilage arch; 6 - subglottal protrusion formed by the first rings of the trachea; 7 - suprasternal cavity; pyak - hyoid bone; schkh - thyroid cartilage; px - cricoid cartilage; gr - sternum

At superficial palpation evaluates the consistency, mobility and turgor of the skin covering the larynx and surrounding areas. At deep palpation examines the area of the hyoid bone, the space near the corners of the lower jaw, then descends along the anterior and posterior edges of the sternocleidomastoid muscle, determining the condition of the lymph nodes. The supraclavicular fossa and attachment areas of the sternocleidomastoid muscle, lateral and occipital surfaces of the neck are palpated, and only then proceed to palpation of the larynx. It is covered on both sides with the fingers of both hands, fingering its elements. The shape, consistency are assessed, and the possible presence of pain and other sensations is determined. Then the larynx is shifted to the right and left, assessing its mobility, as well as the possible presence of sound phenomena - crunching (for cartilage fractures), crepitus (for emphysema). When palpating the area of the cricoid cartilage and conical ligament, the isthmus of the thyroid gland covering them is often revealed. Feeling the jugular fossa, ask the patient to make a swallowing movement: if there is an ectopic lobe of the thyroid gland, its push may be felt.

Laryngoscopy

Laryngoscopy is the main type of examination of the larynx. The complexity of the method lies in the fact that the longitudinal axis of the larynx is located at a right angle to the axis of the oral cavity, which is why the larynx cannot be examined in the usual way. Inspection of the larynx can be done either using a laryngeal speculum ( indirect laryngoscopy), when using which the laryngoscopic picture is presented in the form of a mirror image, or using special directoscopes designed for direct laryngoscopy.

For indirect laryngoscopy, flat laryngeal mirrors are used, similar to those used for posterior mirror epipharyngoscopy. To avoid fogging of the mirror, it is heated on an alcohol lamp with the mirror surface facing the flame or in hot water. Before inserting the mirror into the oral cavity, check its temperature by touching the back metal surface to the skin of the dorsal surface of the examiner’s hand.

Indirect laryngoscopy is carried out in three positions of the subject: 1) in a sitting position with the body slightly tilted forward and the head slightly tilted backward; 2) in Killian’s position (Fig. 2, a) for a better view of the posterior parts of the larynx; in this position, the doctor examines the larynx from below, standing in front of the person being examined on one knee, and he tilts his head down; 3) in the Turk position (b) to examine the anterior wall of the larynx, in which the examinee throws back his head, and the doctor examines from above, standing in front of him.

Rice. 2. The direction of the rays and the axis of vision during indirect laryngoscopy in the position of Killian (a) and Turk (b)

The doctor with his right hand takes the handle with a mirror fixed in it, like a writing pen, so that the mirror surface is directed at an angle downward. The subject opens his mouth wide and sticks out his tongue as much as possible. The doctor, with the first and third fingers of the left hand, grabs the tongue wrapped in a gauze napkin and holds it protruded, at the same time, with the second finger of the same hand, lifts the upper lip for a better view of the area being examined, directs a beam of light into the oral cavity and inserts a mirror into it. The back surface of the mirror presses against the soft palate, moving it backwards and upwards. When introducing a mirror into the oral cavity, you should not touch the root of the tongue and the back wall of the pharynx, so as not to cause a pharyngeal reflex. The rod and handle of the mirror rest on the left corner of the mouth, and its surface should be oriented so that it forms an angle of 45° with the axis of the oral cavity. The light flux directed at the mirror and reflected from it illuminates the cavity of the larynx. The larynx is examined during quiet and forced breathing of the subject, then during phonation of the sounds “i” and “e”, which facilitates a more complete examination of the supraglottic space and larynx. During phonation, the vocal folds close.

The most common obstacle to indirect laryngoscopy is a pronounced pharyngeal reflex. There are some techniques to suppress it. For example, the subject is asked to mentally count down two-digit numbers or, clasping his hands, pull them with all his might. The subject is also asked to hold his tongue himself. This technique is also necessary when the doctor needs to perform some manipulations in the larynx, for example, removing fibroids on the vocal fold.

In case of an indomitable gag reflex, they resort to topical anesthesia of the pharynx and root of the tongue. In young children, indirect laryngoscopy is practically impossible, therefore, if a mandatory examination of the larynx is necessary (for example, with its papillomatosis), they resort to direct laryngoscopy under anesthesia.

Laryngoscopy picture larynx with indirect laryngoscopy, it appears in a mirror image (Fig. 3): the anterior parts of the larynx are visible from above, often covered at the commissure by the epiglottis; the posterior sections, including the arytenoid cartilages and the interarytenoid space, are displayed in the lower part of the speculum.

Rice. 3. Internal view of the larynx during indirect laryngoscopy: 1 - root of the tongue; 2 - epiglottis; 3 - tubercle of the epiglottis; 4 - free edge of the epiglottis; 5 - aryepiglottic fold; 6 - folds of the vestibule; 7 - vocal folds; 8 - ventricle of the larynx; 9 - arytenoid cartilage with corniculate cartilage; 10 - wedge-shaped cartilage; 11 - interarytenoid space

With indirect laryngoscopy, examination of the larynx is possible with only one left eye looking through the opening of the frontal reflector (which is easy to verify when this eye is closed). Therefore, all elements of the larynx are visible in the same plane, although the vocal folds are located 3-4 cm below the edge of the epiglottis. The lateral walls of the larynx are visualized sharply shortened. From above, that is, actually from the front, part of the root of the tongue with the lingual tonsil (1) is visible, then the pale pink epiglottis (2), the free edge of which rises when the sound “i” is phonated, freeing up the laryngeal cavity for viewing. Directly below the epiglottis, in the center of its edge, you can sometimes see a small tubercle of the epiglottis (3), formed by the stalk of the epiglottis. Below and posterior to the epiglottis, diverging from the angle of the thyroid cartilage and commissure to the arytenoid cartilages, there are vocal folds (7) of a whitish-pearlescent color, easily identified by characteristic tremulous movements, sensitively reacting even to a slight attempt at phonation.

Normally, the edges of the vocal folds are even and smooth; when inhaling, they diverge somewhat; during a deep breath, they diverge to the maximum distance and the upper rings of the trachea, and sometimes even the keel of the tracheal bifurcation, become visible. In the superolateral regions of the laryngeal cavity, pink and more massive folds of the vestibule are visible above the vocal folds (6). They are separated from the vocal folds by the entrance to the ventricles of the larynx. The interarytenoid space (11), which is like the base of the triangular slit of the larynx, is limited by the arytenoid cartilages, which are visible in the form of two club-shaped thickenings (9), covered with pink mucous membrane. During phonation, you can see how they rotate towards each other with their front parts and bring the vocal folds attached to them closer together. The mucous membrane covering the posterior wall of the larynx becomes smooth when the arytenoid cartilages diverge during inspiration; during phonation, when the arytenoid cartilages come together, it gathers into small folds. In some individuals, the arytenoid cartilages touch so closely that they seem to overlap each other. From the arytenoid cartilages, the aryepiglottic folds (5) are directed upward and forward, which reach the lateral edges of the epiglottis and together with it serve as the upper boundary of the entrance to the larynx. Sometimes, with a subatrophic mucous membrane, in the thickness of the aryepiglottic folds you can see small elevations above the arytenoid cartilages - these are corniculate (Santorini) cartilages; Lateral to them are the Wriesberg cartilages (10).

The color of the laryngeal mucosa must be assessed in accordance with the medical history and other clinical signs, since normally it is not constant and often depends on bad habits and exposure to occupational hazards. In hypotrophic individuals of asthenic physique, the color of the mucous membrane of the larynx is usually pale pink; for normosthenics - pink; in obese, overweight people (hypersthenics) or smokers, the color of the mucous membrane of the larynx can be from red to bluish without pronounced signs of disease of this organ. When exposed to occupational hazards (dust, vapors of caustic substances), the mucous membrane acquires a varnished tint - a sign of the atrophic process.

Direct laryngoscopy

Direct laryngoscopy allows you to examine the internal structure of the larynx in a direct image and perform various manipulations on its structures to a fairly wide extent (removal of polyps, fibroids, papillomas using conventional, cryo- or laser surgical methods), as well as carry out emergency or planned intubation. This method was introduced into practice by M. Kirshtein in 1895 and was subsequently improved several times. The method is based on the use of hard directoscope, the introduction of which into the hypopharynx through the oral cavity becomes possible due to the elasticity and pliability of the surrounding tissues.

Indications to direct laryngoscopy are numerous, and their number is continuously growing. This method is widely used in pediatric otorhinolaryngology. For young children, a one-piece laryngoscope with a non-removable handle and a fixed spatula is used. For adolescents and adults, laryngoscopes with a removable handle and a retractable spatula plate are used.

Contraindications severe stenotic breathing, cardiovascular insufficiency, epilepsy with a low threshold of convulsive readiness, lesions of the cervical vertebrae that do not allow the head to be thrown back, and aortic aneurysm. Temporary or relative contraindications include acute inflammatory diseases of the mucous membrane of the oral cavity, pharynx, larynx, bleeding from the pharynx and larynx.

In young children, direct laryngoscopy is performed without anesthesia; in young children - under anesthesia; older people - either under general anesthesia or under local anesthesia with appropriate premedication, as in adults. For local anesthesia, various topical anesthetics can be used in combination with sedatives and anticonvulsants. To reduce general sensitivity, muscle tension and salivation, the subject is given one tablet 1 hour before the procedure phenobarbital(0.1 g) and one tablet sibazon(0.005 g). 0.5-1.0 ml of 1% solution is injected subcutaneously over 30-40 minutes promedola and 0.5-1 ml of 0.1% solution atropine sulfate. 10-15 minutes before the procedure, topical anesthesia is performed (2 ml of a 2% solution dicaine). 30 minutes before the specified premedication, in order to avoid anaphylactic shock, intramuscular injection of 1-5 ml of a 1% solution is recommended diphenhydramine or 1-2 ml of 2.5% solution diprazine(pipolfen).

The position of the subject can be different and is determined mainly by the condition of the patient. The study can be carried out in a sitting position, lying on your back, less often in a position on your side or stomach.

The direct laryngoscopy procedure consists of three stages (Fig. 4).

Rice. 4. Stages of direct laryngoscopy: a - first stage; b - second stage; c - third stage; The circles show the endoscopic picture corresponding to each stage; arrows indicate the directions of pressure on the laryngeal tissue of the corresponding parts of the laryngoscope

First stage(a) can be carried out in three ways: 1) with the tongue protruding, which is held with a gauze napkin; 2) with the normal position of the tongue in the oral cavity; 3) when inserting a spatula from the corner of the mouth. With all options, the upper lip is pushed upward and the patient's head is tilted slightly back. The first stage is completed by pressing the root of the tongue down and passing the spatula to the edge of the epiglottis.

On second stage(b) the end of the spatula is slightly raised, placed over the edge of the epiglottis and advanced 1 cm; after this, the end of the spatula is lowered down, covering the epiglottis. During this movement, the spatula puts pressure on the upper incisors (this pressure should not be excessive; if you have removable dentures, they are removed first). The correct insertion of the spatula is confirmed by the appearance of the vocal folds in the field of view.

Before third stage(c) the patient’s head is tilted back even more. The tongue, if held, is released. The examiner increases the pressure of the spatula on the root of the tongue and the epiglottis (see the direction of the arrows) and, adhering to the median plane, places the spatula vertically (if the subject is sitting) or according to the longitudinal axis of the larynx (if the subject is lying down). In both cases, the end of the spatula is directed to the middle part of the respiratory gap. In this case, the posterior wall of the larynx comes into view first, then the vestibular and vocal folds, and the ventricles of the larynx. For a better view of the anterior parts of the larynx, the root of the tongue should be slightly pressed downwards.

Special types of direct laryngoscopy include supporting And hanging laryngoscopy(Fig. 5).

Rice. 5. Devices for supporting (a) direct laryngoscopy; b - schematic representation of direct suspension laryngoscopy

Modern laryngoscopes for suspension and support laryngoscopy are complex complexes that include spatulas of various sizes and sets of various surgical instruments specially adapted for endolaryngeal micromanipulation. These complexes are equipped with devices for injection ventilation of the lungs, anesthesia and video equipment that allows surgical interventions to be performed using an operating microscope and a video monitor.

For visual examination of the larynx, the method is widely used microlaryngoscopy, allowing you to enlarge the internal structures of the larynx. More convenient for examining hard-to-reach areas are fiber-optic devices, which are used, in particular, for functional disorders of the larynx.

Indications Microlaryngoscopy includes: doubt in the diagnosis of precancerous formations and the need for a biopsy, as well as the need for surgical elimination of defects that impair vocal function. Contraindications the same as with conventional direct laryngoscopy.

The use of microlaryngoscopy requires endotracheal anesthesia using a small caliber intubation catheter. Jet ventilation of the lungs is indicated only in particularly cramped anatomical conditions.

X-ray examination of the larynx

Due to the fact that the larynx is a hollow organ, there is no need for contrast during X-ray examination, but in some cases this method is used by spraying a radiopaque substance.

At overview And tomographic radiography is used direct And lateral projections. With a direct projection, the overlap of the spine on the cartilages of the larynx almost completely obscures them, therefore, in this projection, X-ray tomography is used, which removes the shadow of the spine beyond the image plane, keeping only the radiopaque elements of the larynx in focus (Fig. 6).

Rice. 6. X-ray tomographic image of the larynx in a direct projection (a) and a diagram of identifying elements (b): 1 - epiglottis; 2 - folds of the vestibule; 3 - vocal folds; 4 - pyriform sinuses

Using a tomographic examination, clear radiographs of frontal sections of the larynx are obtained, and it becomes possible to identify space-occupying formations in it. With functional radiography (during deep inspiration and phonation), the symmetry of her motor function is assessed.

When analyzing the results of an X-ray examination of the larynx, one should take into account the patient’s age and the degree of calcification of its cartilage, islands of which can appear from 18-2 years of age. The thyroid cartilage is most susceptible to this process.

As already noted, in some cases they resort to contrast radiography using aerosol spraying of a radiopaque substance (Fig. 7).

Rice. 7. X-ray of the larynx using a radiopaque substance by spraying: a - X-ray in a lateral projection and a schematic representation of its identifying features (b): 1 - oropharynx; 2 - laryngopharynx; 3 - supraglottic space; 4 - sub-fold space; 5 - interfold space; 6 - trachea; 7 — contours of the larynx, visualized by aerosol spraying of a contrast agent; c - X-ray of the larynx with spraying in a direct projection

Methods for functional research of the larynx

Voice function test begins already during a conversation with the patient when assessing the timbre of the voice and sound paraphenomena that arise when respiratory and vocal functions are impaired. Aphonia or dysphonia, stridorous or noisy breathing, distorted voice timbre and other phenomena may indicate the nature of the pathological process.

At volumetric processes In the larynx, the voice is compressed, muffled, its individual timbre is lost, and the conversation is often interrupted by a slow, deep breath. At “fresh” constrictor paralysis glottis, the voice loses sonority, a large amount of air is spent through the gaping glottis to pronounce a word, so the patient does not have enough air in the lungs to pronounce a whole phrase, which is why his speech is interrupted by frequent breaths, the phrase is fragmented into individual words and during a conversation hyperventilation occurs with respiratory pauses.

With chronic dysfunction of the vocal folds, when compensation of the vocal function occurs due to the folds of the vestibule, the voice becomes rough, low, hoarse. If there is a polyp, fibroma or papilloma on the vocal fold, the voice becomes as if cracked, rattling with admixtures of additional sounds resulting from the vibration of the formation located on the vocal fold. Laryngeal stenosis is recognized by the stridor sound that occurs during inspiration.

Study of the vocal function of the larynx

Vibrometry- one of the most effective methods for studying the vocal function of the larynx. For this they use accelerometers, in particular the so-called maximum accelerometer, measuring the moment a vibrating body reaches a given sound frequency or maximum acceleration in the range of phonated frequencies, that is, vibration parameters. The condition and dynamics of these parameters are assessed both normally and in various pathological conditions.

Rheography of the larynx (glotography)

The method is based on recording changes in ohmic resistance to electric current that occur when the vocal folds approach and diverge, as well as when their volume changes during phonation. Changes in resistance to electric current occur synchronously with the phonatory vibration of the vocal folds and are recorded in the form of oscillations (rheogram) using a special electrical device - a rheograph. The shape of the rheolaringogram reflects the state of the motor function of the vocal folds. During quiet breathing (without phonation), the rheogram appears as a straight line, slightly undulating in time with the respiratory excursions of the vocal folds. During phonation, oscillations arise that are close in shape to a sinusoid, the amplitude of which correlates with the volume of the sound emitted, and the frequency is equal to the frequency of this sound. Normally, the glotgram parameters are characterized by high regularity (constancy). In case of disturbances in motor (phonatory) function, these disturbances are displayed on recordings in the form of characteristic changes characteristic of organic and functional disorders. Often glotography is carried out simultaneously with registration phonograms. This type of research is called phonoglotography.

Stroboscopy of the larynx

Laryngeal stroboscopy is one of the most important methods of functional research, allowing visualization of the movements of the vocal folds at different frequencies of the stroboscopic effect. This allows you to visualize the movements of the vocal folds during phonation at a slow pace or even “stop” them in a certain state of spreading or collapsing.

Stroboscopy of the larynx is performed using special devices called strobe lights(from Greek strobos- whirling, erratic movement and skopo- I'm watching). Modern stroboscopes are divided into mechanical or optical-mechanical, electronic and oscillographic. In medical practice, video stroboscopic installations with wide multifunctional capabilities have become widespread (Fig. 8).

Rice. 8. Block diagram of a video stroboscopic installation (model 4914; Brühl and Kjær): 1 - video camera with a rigid endoscope; 2 — software electronic stroboscopic control unit; 3 — video monitor; M - socket for connecting a microphone; P - socket for connecting the strobe control pedal; IT - indicator board

In pathological conditions of the vocal apparatus, various stroboscopic patterns can be observed. When assessing these pictures, it is necessary to take into account visually the level of position of the vocal folds, the synchronicity and symmetry (mirroring) of their vibrations, the nature of their closure and auscultation the timbre color of the voice. Modern video stroboscopes make it possible to simultaneously record in dynamics the stroboscopic picture of the larynx, the amplitude-frequency characteristics of the phonated sound, the phonogram of the voice, and then perform a correlation analysis between the recorded parameters and the video stroboscopic image. In Fig. 9, a photograph of a stroboscopic picture of the larynx is shown.

Rice. 9. Videolaryngostroboscopic images of the vocal folds during normal phonation (according to D. M. Tomassin, 2002): a - phase of closure of the vocal folds: b - phase of opening of the vocal folds

Otorhinolaryngology. IN AND. Babiyak, M.I. Govorun, Ya.A. Nakatis, A.N. Pashchinin