Reports

The tracheal lipoma usually appears as a smooth tumor that rises gently on the wall, with visible vessels on the surface.

In this case he has suffered a sarcomatous degeneration.

Liposarcoma.

Francisco Muñiz Hospital

Leiomyosarcoma: This image is not very precise, but there is a red wine formation that occupies all the light of the middle lobe bronchus.

The bubble crown indicates that the lesion does not infiltrate the entire perimeter of the wall, or that there is a pedicle, and that ventilation is still possible.

Leiomyosarcoma in a bronchial neoplasm with low frequency of presentation.

Warty appearance formation on the bronchial wall about to be captured by the biopsy forceps: Papilloma.

Not identifiable: contiguous to the spur, the tissue that has proliferated to occlude the light appears friable, vegetative and with a bulge in its irregular surface.
All due to an unrecognizable injury to the endoscopist.

Hamartoma confirmed.

Italian Hospital of the city of Buenos Aires

Although the usual morphology is usually «in cluster», this unique and sessile papilloma, identical in color to the mucosa, seems to be monitored from the trachea at the entrance to the main bronchi.

As a solitary hump this tumor emerges from the tracheal wall as if it were a uvula.
Chondrosarcoma confirmed (Francisco Muñiz Hospital).

With the help of a deflector, the clamp inserted inside has formed a 90 degrees angle and is ready to perform a transbronchial biopsy (BTB) in an upper lobe.

Confusing image in which the anatomical structures are difficult to recognize.

The tracheal domed ceiling ends in the anterior carinal triangle, barely visible.
On your right the source bronchus.

Large amount of blood and exudates fill the free space between the disordered tissues that occupy the light, occluding the left source bronchus.

A carcinoma of the esophagus has destroyed the posterior wall of the main bronchus, as it always does in this location given its vicinity, and a set of esophageal mucosa, and neoplastic tissue
now occupies the airway.

Flexible bronchoscopy performed to determine the possibility of operation of an esophageal carcinoma.

The longitudinal folds have completely disappeared due to the edema of the posterior wall.

A small bulge rises on the surface as a direct sign of infiltration by neoplastic tissue of the tracheal wall.

The bulging of the posterior wall «separates the longitudinal folds», and is a necessary effect of the posterior extrinsic compressions.

In the case, a carcinoma of the esophagus exerts a notorious repercussion that, due to its contiguity, it produces on the trachea all the way to the carina, which is also affected.

Exophytic lesion that sits on both carinal slopes. The surface is partially impacted and due to its large size it considerably reduces the light of both source bronchi.

Changes of coloration in the mucosa with very congested areas and general aspect that makes it similar to a bronchial carcinoma.

Non-Hodgkin lymphoma: The light of the intermediate bronchus is reduced by a multilobal formation, with a whitish, probably necrotic area.

The mucosa presents irregular  changes and diffuse inflammatory.

Endobronchial metastasis: A vegetating formation with a fairly smooth surface and with very inflamed areas, completely occludes the light from the left source bronchus at its entrance: clear cell carcinoma.

Clear cell carcinoma.

A voluminous mass of tissue occupies the light of the right source bronchus, with some protrusions on the surface.

Through a triangular light that allows pulmonary ventilation, you can see the entrance of the upper lobe.

A plane of separation with the mucosa of the bronchus around the perimeter of the lesion indicates that it has a base of distal implantation.

Bronchoscope stopped next to a smooth surface formation but irregular contour, with abnormally voluminous surface vessels.

It is an endotracheal metastasis of breast carcinoma.

At the bottom of the image, the edema, the enlarged and pale carina, the left main bronchus with its reduced entrance and clogged secretions complete the set of indicative elements of extended disease.

Italian Hospital of the city of Buenos Aires

A formation occludes the entrance of the lower right lobe and in its growth displaces the spur of the middle lobe.
A fairly common presentation of endobronchial metastases of renal carcinoma

Alejandro Posadas Hospital.

This bright, congested and pale tumor, obliterates the entrance of the bronchus culminate in the left upper lobe, allowing only the passage of air to the lingula.

Combination. In the upper part of the image we can see the lesion that is still submucosally located, in the form of a protrusion that seeks to burst into the light, with its plethoric parallel vessels. In the center of the photograph the lesion is vegetative and thrives inside the bronchial lumen. Carcinoma.

Image corresponding to the previous case, after a recanalization of the right source bronchus.
There are diffuse inflammatory changes and blood in the path of the bronchus, which can be followed up to the lower lobe.
The folds in the source bronchus, deep and tortuous, are diverted to enter the upper lobe, but it is occluded.

Neoplastic tissue persists in the medial wall of the main bronchus and the tracheal carina is unrecognizable.

A voluminous vegetative formation settles in the tracheal carina and completely occludes the light of the right source bronchus and reduces that of the left.

The surface is irregular, with protrusions and increased vascularization in some areas. The tissue that obstructs the right main bronchus has been necrotic.

The posterior tracheal wall seems to be thrown forward and the edema has erased the folds.

Giant cell carcinoma.

A vegetative formation sits on the right side of the carina.

It presents multiple mamelons that give it an irregular and hyperemic aspect that contrasts with the general pallor of the healthy mucosa.

An ecchymotic dot is distributed in the area of the edge of the main carina and in its posterior triangle.

Squamous cell carcinoma.

Trachea: a giant cell carcinoma has completely infiltrated the wall.

Two ends of the cartilaginous rings are visible in the light as a result of the destruction of their mucosa, now covered by thick purulent secretions and suffering continuous dehydration due to being exposed to the turbulent airflow caused by local narrowness and inflammation.

Complete loss of the normal anatomy of the main carina.

View from the distal trachea in which the carina can not be seen, due to the existence of a necrotic surface tissue, with dehydrated purulent secretions that subocludes the entry of both bronchi source: adenocarcinoma.

Two circular whitish and bright areas in the center of the image.
The effect is produced by the radiofrequency discharge through the thermocoagulation probe on the left.

Although the foreground magnifies the image, it is only the small biopsy forceps with fenestrae in its leaflets, commonly used with the flexible bronchoscope, doing its work of tissue capture for the diagnosis of this endobronchial tumor.

Another vegetative formation that occludes the bronchial lumen but seems «sunken» in the mucosa because it drags the folds towards it.

Tracheal tumor with double origin: two large formations occupy the center of the tracheal lumen, although there is still a sufficient area for ventilation.
In the image, the formations appear superimposed, but they have an independent origin constituted by pedicles that emerge from the tracheal wall.

Both correspond to a single primary carcinoma.

Small «bronchial bulge» very erect. Remember better a rock.

It is located at the end of the left source bronchus, near the crossroads and results from the invasion of the bronchial wall by a carcinoma.
The mucosa is pulled, forming grooves. Further, the widened spur suggests underlying adenomegalies.

Bronchial light «stabbing»: an «intramural, intraluminal and infiltrating» carcinoma deforms the light from the left source bronchus.

The intense edema and thickening of the bronchial mucosa contribute to the distortion and the marked reduction of the caliber.

On the left wall it acquires a cordoned appearance that forms mamelons as it ascends and occupies the upper end.

Mucous secretions located in the right source bronchus, which is occluded by a formation that gives it the appearance of «bottom of sac.»

This term should be reserved for the description of the bronchial stumps by surgical amputation during pneumonectomies.

Although the flexible bronchoscope still runs through the intermediate bronchus, a whitish image due to the small tumor occluding a segment of the base can be guessed in the distance.

In the form of a double tumor, this vegetative formation of large volume and with one of its ends partially necrotic, arises from the right source bronchus, but is also implanted in the tracheobronchial junction.

The biopsy does not present any inconvenience but, naturally, it is necessary to avoid capturing the whitish covering of the tumor to avoid false negative results.

Multilobed front of an adenocarcinoma that obstructs the passage of air.

Although similar to the previous case, here are indirect signs of neoplastic process, contiguous to the lesion.

Irregular edema with some small mamelons on a thickened carinal edge and distortion of the bronchial entrance right source, towards where the longitudinal folds of the posterior wall bend excessively.

Deformation of the entrance of the lower left lobar bronchus.

Its circumferential contour is now wavy.

There are changes in vascularization and several submucosal protrusions.

This pyramidal formation that emerges from the left source bronchus can be confused with a bronchial tumor, although it is an aged and retained blood clot that acquires this coloration composed of gray and burgundy.

Note the normal environment of the surrounding mucosa.

A fairly common presentation of large bronchial tumors, in which the surface suffers a necrosis due to being away from its base of implantation, better vascularized, and acquires a whitish creamy appearance.

The left upper lobe is occluded by an anomalous tissue, with a homogeneous and somewhat rough surface.

The secondary carina looks curiously linear and straight.

In the distance you can see the lower lobular, poorly lit.

View from the left source bronchus, near its fork in the carrefour.

A prominent mass rises on its side and bottom walls.
The longitudinal folds, very accentuated, lose their parallelism and tend to meet as they enter the upper and lower lobe bronchi.
The widening of the secondary carina and the intense edema contribute to the reduction of the bronchial lumen.

Tumor with «glove finger» appearance.

This lesion emerges from the right source bronchus and its independence from the bronchial wall is quite evident.

It may have a base of implantation much farther from its visible proximal end.

The tracheal carina is pushed to the left.

With a rather classic appearance, this large formation with large submucosal vessels, arises from the posterior tracheal wall and also from the angle that it forms with the lateral walls, as usually happens in adenoid cystic tumors.

The entrance to the upper right lobe bronchus is occluded.

In this case, the adenoma presents a familiar aspect.
The surface is smooth and a dense submucosal vascular network gives it an intense coloration.

Unlike the previous case, this adenoma that obstructs the left source bronchus presents several protrusions in its surface.

Thus, it is easily confused with other types of tumors, especially due to the enlarged appearance of the tracheal carina.

The carial edge can be seen at 9 o’clock.

At close range, a large mass occupies the right source bronchus, surmounted by bubbles formed by the instilled saline solution.

The formation is smooth, as happens in most adenomas, and the entire mucosa of the surrounding tissue is completely normal.

Carcinoid tumor that appears with a fairly classic appearance.

Due to its smooth convexity and its free contact with the bronchial walls it is compared with a «glove finger».

This lesion, somewhat lobed on its surface, completely seals the entrance to the lower lobe bronchus.

Photograph of the excised carcinoma.

Here you can see a cryobiopsy probe contacting a formation that subocludes the right source bronchus.

The cryoprobe reaches a temperature of -79º C at its end and adheres firmly to the tissue, making it easy to remove.

Location combination: Endoluminal vegetative formation and intramural lesion are present in this subocclusive lesion of the right upper lobe.

Blend of coloration: exophytic lesion showing an irregular and pinkish polylobulated area while its most prominent end is creamy white, as a product of necrosis in a distal area of the tumor.

«Threatening» aspect.

With its reddish coloration that declares a sufficient vascularization, and its thick vessels that crown the visible hemisphere of this tumor that from the entrance of the right source bronchus, it challenges the bronchoscopist, tempting him to defer the biopsy to a safer time.

A rigid bronchoscopy will make it possible to thermocoagulate the vessels and reduce the risk of hemorrhage.

Myofibroblastic or pseudoinflammatory tumor looks similar to a carcinoid tumor.

Jose de San Martin Clinic Hospital
Buenos Aires

Here the communication with the esophagus is so wide that it occupies the entire diameter of the tracheal posterior wall.

The condition responds to a long list of causes that include therapeutic accidents and is favored by the chronic prostration and poor nutrition of these patients.

Cetrángolo Hospital

This tracheoesophageal fistula has been surrounded by an over-elevated environment that crowns the central depression with its punctiform orifice.

Cetrángolo Hospital

Tracheoesophageal fistula.

Its edges have been epithelialized and after its circular access a feeding tube is observed.

Francisco Muñiz Hospital

Fistula occlusion.

A cyanoacrylate deposit fills a large fistula in the right source bronchus.
Undesirable mediate complication of a pneumonectomy.

Italian Hospital

Tracheoesophageal fistula: Intense edema of the entire tracheal mucosa, with extensive areas of submucosal hemorrhage.

The edema becomes irregular in the posterior wall and a U-shaped fissure occupies the center of the image.

The dark coloration of its path is due to the methylene blue instilled in the esophagus for its detection.

Isidoro R., Sinus Tracheal Fissure.
RAMR 2015; 3: 211-212.

View of the carina and the birth of the main bronchi.

A large depression precedes the orifice of the left source bronchus and communicates with the esophagus: Tracheobronchoesophageal fistula due to closed thorax trauma.

The dark and patchy coloration that becomes confluent in all the trachea closest to this image, is due to the presence of abundant accumulated carbon particles and combined with mucus.

They were inhaled during a fire and may exist with or without airway burn.

The endoscopic examination is «poorly lit»; this effect is a consequence of the absorption of light by the dark material that covers the mucosa.
A similar phenomenon occurs in exploratory endoscopy of copious hemoptysis in which the blood absorbs much of the illumination provided by the endoscope.

Particles phagocytized by macrophages can be seen in the sputum examination.

Francisco Muñiz Hospital

Burn of the upper airway: large anthracotic macules spread in groups over the mucosa of the tracheal wall, very swollen, after the accidental inhalation of smoke and hot gases.

Improper position of a Tutor.

Its inner end has separated from the edge of the ostoma and occupies part of the tracheal lumen.
It must be corrected by pulling it from its outer branch and then fixing it in the proper position with its retaining ring.

Internal view of a Tutor who, correctly, supports his wings on the edge of the ostoma.

The ostoma tutor is a tube that is inserted through the tracheostomy and fixed inside the trachea with two small wings that prevent accidental removal.

It is used as an intermediate step to decannulation to avoid the spontaneous closure of a tracheostomy whose utility is unknown and to ensure that breathing by the natural route is possible and satisfactory.

Aneumatosis of the right inferior lobe with evolution to atelectasis due to a carcinoma that occludes its bronchus.

The fissure in this lobe will move towards the vertebral column during collapse.

The indication of stents in distal or lobar bronchi was controversial (Journal of Bronchology & Interventional Pulmonology 24: 3; 211-215.2017).

Here from the inside of a prosthesis in the intermediate bronchus a small cone-shaped stent implanted after resection of the tumor and allowing the re-expansion of the right lower lobe is observed.

German Hospital

Punctate stenosis of the left source bronchus.

Sequela of extra primary pulmonary tuberculosis (photograph already exposed in tuberculosis and its sequels).

Proper position: these stents of the tracheal stenosis model were «embraced» by the stenosis and their ends «float» in the trachea avoiding contact with their mucosa and anticipate a stay free of complications.

Cured stenosis: just a thin fibrous arch on the floor of the trachea (upper area of the image) and a slight reduction of the light is the result of the repeated dilation treatment.

Dilated mucous glands also appear in the foreground of the image.

The incrustation of secretions occurs more frequently in prostheses of tracheal location and forces their replacement.

This stent avoids the restenosis of the surgical reimplantation of the left source bronchus in the trachea, after a severe trauma to the thorax by accident.

Several keloids on surgical scars on the neck.

Keloids are strikingly common in cases where benign tracheal stenosis develops in patients who have been subjected to orotracheal intubation.

External appearance of the trachea in the area of the stenosis.

Resection and end-to-end anastomosis as the definitive solution for a recurrent stenosis.

Very thick secretions occupy a stent implanted in a left main bronchus that was sectioned and reinserted in the trachea, away from the carina.

Side cut scissors in «penguin head» ready to make a window in the wall of a silicone stent implanted in the left source bronchus.

A positional defect caused the stent to partially obstruct the entry of the ipsilateral upper lobe bronchus, despite several attempts to reposition the prosthesis.

Now a metal spike with the hooked end takes the edge of the stent and offers it to the scissors to make the first cut.

View of the metal spike with a hooked end.

Arrangement in «omega» of a stent released inside the bronchial lumen.

Different maneuvers will be necessary to complete its expansion.

This task will be rewarded by the absence of migration that occurs after the implantation of stents that do not expand spontaneously and immediately.

This occurs when prostheses of a wide diameter are chosen in relation to the light of the airway to be treated.

Here the alligator clamp takes the edge of a stent.

By rotating the clamp, the silicone stent is folded, thus eliminating its radial force, and can be easily extracted.

Stringy mucus secretion on the end of a silicone stent in the left bronchus.

Due to the anatomical diameter of this bronchus, the 13mm stents are very appropriate for the left source.

«Punctiform» light in a tracheal stenosis after intubation.

The small diameter of the light produces a distressing situation for the patient; only tolerable because the length of the narrowness is also very short, thus relieving the airflow resistance through the narrow orifice.

A cutting «loop» about to act on the fibrous arch of a tracheal stenosis.

Incrustation of secretions in the walls of a bronchial stent.

This drawback is presented with a variable frequency and often the microbial flora is coincident with the one that exists in the dental pieces in poor condition of the patient.

After a year of implantation, this stent has migrated and now, free, rests in the intrathoracic trachea, as seen in the center and the bottom of the image.

In the foreground the stenosis presents a wide light, with its two fibrous arches that give it a stable and consolidated appearance.

Alejandro Posadas Hospital

Although it could be confused with an enlarged carina, this curious formation in the extrathoracic trachea consists of a medial septum that, as a bridge, joins the anterior wall with the posterior wall and divides the trachea into two conduits, contoured by fibrous arches.

Unusual evolution of post-intubation stenosis in a 21-year-old male.

Isidoro R., Debais M. Divided Trachea, report of a case. RAMR 2014; 1: 51-52.

This tracheal stent remains very close to the chordal movement without making contact with them.

Retention of secretions inside this stent, aggravated by the reduction of the light produced by the presence of the distal granuloma observed at the bottom of the image. This indicates contact of the prosthesis with the mucosa, excessive cough, or both.

The distal end of this stent rests very close to a spur in the lower lobe.

The maximum expiration can reduce the distance between both and allow contact between the stent and the spur, producing an irritative cough that is difficult to suppress, with possible damage to the bronchial mucosa.

Stent implanted in intermediate bronchus.

Note the uneven widening of the spur of the right upper lobe.

After implanting this «Y» shaped stent, the advance of tumor growth into the stent makes it emerge through its right bronchial branch.

As an undesired consequence of the subocclusion of this source bronchus, there is an accumulation of secretions at its entrance, indicating a precarious airflow and an ineffective cough.

Central and critical tracheal stenosis.

Smooth and tense appearance due to congestive edema of the mucosa.

Cetrángolo Hospital

Double stent: after the endo-surgical resection of an extensive carcinoma, two silicone stent were applied in the tracheal bifurcation, leaving the carina «enclosed» between them.

In the image, the generalized edema dominates the field and very abundant mucopurulent secretions accumulate around the prosthesis and inside one of them, in which a bubble has formed at the time of photographic exposure.

Appearance of the tracheal mucosa after the removal of a stent.

There is an arch of residual stenosis, still congestive, and a mucosal bed with bulging edema due to prolonged contact with the prosthesis in that area.

The metallic olive crosses the narrowness of the stenosis gently, forcing the opening of the tracheal lumen.

The central hole of the instrument allows the passage of air preventing the complete interruption of ventilation during the procedure.

A dilation balloon full of saline solution, exerts circumferential pressure during dilation of a stenosis.

The appearance of the tracheal wall, edematous and congestive, can be appreciated after decompression of the elastic balloon.
Note the distance between the balloon and the mucosa as a result of the progressive dilation maneuver.

These smooth protrusions that seem to pile on the posterior tracheal wall or mucous membrane, correspond to granulomas originated by a fearsome situation: the «tracheal cannula tip injury».

The lack of stable fixation of the pavilion of the tracheostomy cannula against the neck, allows movements of the device that tends to swing on its support in the stoma causing its end or tip of the cannula to damage the tracheal mucosa.
The phenomenon is particularly true when it has been connected to a mechanical ventilation system, adding weight and unwanted movement to the cannula.

Alejandro Posadas Hospital

A rare form of complex stenosis is double stenosis.

Their treatment differs considerably according to their anatomical location: very separate, close together or even worse, as seen in the reconstruction image: «neither together nor separated».

Tracheal Stent after 10 months remain implanted.

The walls of the endoprosthesis are free of secretions and incrustations, but several granulomas have developed in the mucosa close to its distal end.
One, very bulky and bulgy, sits on the entire back wall.

«Ideal» position for a tracheal stent in the treatment of unresectable stenosis.

The device is «trapped» in the area of the stenosis and its anterior end is «floating» in the tracheal lumen.
Thus, this position reduces the possibility of the appearance of granulomas.

The distal end of the prosthesis is still somewhat folded.
The defect can be corrected manually with a long clamp, or spontaneously in the days following the implant.

Silicone stent acting as a support in a tracheal stenosis at the level of the first rings.

The vocal cords are somewhat thickened and with obvious congestion in the mucosa in its posterior third, close to the arytenoids.

Complex tracheal stenosis after endo-surgical treatment.

Image taken one month after a stent, that remained for 2 years, was removed.

There is sufficient tracheal light and some changes in its relief due to the presence of granulomas on the left wall.

The edema erases the longitudinal folds and the silhouette of the cartilages.

Radial cuts at hours 3 and 9, performed with electrocautery.
Procedure prior to dilation of a simple tracheal stenosis.

The radial cut is also a safety measure reducing the risks of rupture of the posterior membrane during the dilation maneuvers.

The light from the left source bronchus is greatly reduced due to a stricture established after a complete bronchial rupture due to chest trauma.

The reduction of the bronchial diameter is concentric and progressive or «infundibuliform».

The edema thickens the mucosa and the cartilaginous reliefs and also the linear folds of the posterior wall of the bronchus are lost.

X-ray of the previous case: «opaque hemithorax».

The entire left field is completely opaque, homogeneously and from base to vertex.

The «sign of the naked spine» and a posteroinferior pneumonocele are present due to retraction, as well as the rise of the gastric chamber, indicating pulmonary atelectasis.

Tracheal stenosis that forms a double diaphragm of fibrous tissue.

At the distance, a second stenosis can be seen with little punctate light, the only way available for ventilation.

Strangely, a «T» tube has lost its alignment with the trachea.

Inspection from the glottis identifies its end that rests on inflamed tissue in the posterior wall, full of secretions.

Alejandro Posadas Hospital

Consolidated stenosis, central and short, below the prominence of the first tracheal ring.

Asymptomatic, because its diameter exceeds 8mm.
(Isidoro, R. Prolonged prolonged implant prosthesis: 10 years, RAMR 2016; 3: 250-257)

Central benign tracheal stenosis, with several fibrous arches.

Its thin edges together with its pallor indicate an absent inflammatory state.

Condition very suitable for open surgical treatment.

Subglottis: at short distance from the vocal cords a simple stenosis, in diaphragm, considerably reduces the light.

Ventilation is possible thanks to a central and circular hole, with a small marginal nodule.

The same volume of inhaled air must increase its speed to enter through a narrow light, becoming turbulent, which causes visible hyperemia in the mucosa.

Enlarged photograph of the case.
Note the thin and taut edges of the central diaphragm hole.
Almost always yield immediately to the dilation maneuvers.

Laryngeal stenosis that has evolved towards the total closure of light at the level of the subglottis.

The patient suffers a post-intubation rash with damage to the laryngeal cartilages.

It develops a subglottic stenosis that, when it becomes symptomatic or critical, receives the relief of the tracheostomy at the hands of the surgeon. However, this «defunctionalization» of the larynx is what precedes its complete closure.

When it occurs at a lower level and affects the initial trachea, it constitutes the «blind trachea«.

a) View of the glottis in abduction.
The tracheal lumen is missing at the bottom of the image due to a stenosis.

b) Same case.

c) Same case: view of the laryngotracheal junction where the complete closure of the light or «blind trachea» can be seen at the level of the first ring.

Chest x-ray with loss of volume of the middle lobe in patient with sequelae of tuberculosis and a bronchoscopy that finds the stenosis of the bronchus (upper left quadrant of the image).

Brock syndrome or middle lobe syndrome.

Triangular light at the site of the old tracheostomy, where the damage or ablation of the cartilage causes a local malacia with total collapse during cough.

This fairly compact clot of incredible size was lodged in the right source bronchus, with the consequent pulmonary atelectasis.

In spite of its volume, it was expelled by the pressures generated by the cough.

This small «bronchial plug» of rolled gauze allows to stop a serious hemorrhage when the bronchus is occluded with it.
It is applied directly with the rigid bronchoscopy clamp.

The long linen thread that holds it will come out through the patient’s mouth and at the moment of removing it, it is only necessary to pull it to extract the plug.

Haemostasis balloon with its mooring to the flexible bronchoscope channel, which will guide it to the bronchus to occlude.

Although the title exaggerates its condition, large blood clots that are not removed in time suffer from drying and hardening that require a rigid bronchoscopy for removal.

Most commonly occurs in patients who are under respiratory assistance with insufficiently humidified gaseous mixture.

Line of blood that discovers the bronchus that causes hemoptysis.

Sometimes the bronchoscopy can establish the anatomical origin of the hemoptysis, although a trace as clear as the one of the photograph should not be expected. Usually the fresh blood is distributed by the cough and the oldest one coagulates and fragments, so it is seen in different areas of the airway. Then the bronchoscopist makes silence. To ensure the origin of hemoptysis, it is imperative to observe the production and reproduction of blood from the same bronchus.

After a few days, the clot begins to fade, gradually abandoning its original burgundy color.

A few more days: before being spontaneously eliminated, the clot, now pale yellowish, retracts, losing volume and increasing its consistency, so that it can be confused with a neoformation.

In the flexible bronchoscopy of the previous case, the entrance to the cavity is found through two bronchi separated by its spur, producing a double sign of the «black hole«.

Hospital Francisco Muñiz

The chest radiograph was taken without the necessary centering, as shown by the asymmetry between the clavicles and the transverse processes, generating a false image of left pulmonary retraction, (sign of the «naked column»).

A confusing destructive pattern occupies all that hemithorax in which a system of several lung cavities is hidden.

Francisco Muñiz Hospital

It is one of the three ways in which it affects the lung.

View of the interior of a cavity with colonies of Aspergillus fumigatus.
The fungus produces a local disorder of coagulation and can cause serious and fatal hemoptysis.

CT scan of the previous case in which the aspergilloma is observed as a prominence in the posterior wall of the cavity.

On the right, the presence of the «black hole» sign announces the existence of the cavity.

The mucosa is edematized and the division spur has lost its edge, becoming blunt.

View of the entrance to the cavity

Inspection of the interior of a cave is an infrequent act.

Small bronchi with tiny spurs may appear on its wall.

Punctate stenosis of the left source bronchus.

Sequela of bronchial tuberculosis.

This circular area over-raised and whitish center is easily impacted during the biopsy revealing the appearance of caseum.

Future tuberculous gangliobronchial fistula.

View from the intrathoracic trachea.
These source bronchi are «reunited».

Note that the separation angle has been reduced, giving a singular aspect of parallelism.
The posterior tracheal wall is also modified.

The changes are due to a thoracoplasty of six ribs, which has included the first, as a complementary surgical treatment for multidrug-resistant pulmonary tuberculosis.

Bulging formation in the bronchial wall that hides the outlet of the fistula.

The medial wall of the right source bronchus shows an anfractuous and irregular opening as a result of a tuberculous lymphadenitis that discharges its caseous content into the bronchial lumen.

Bulging of the wall at the entrance to the right source bronchus that ends in a formation reminiscent of the pustules.

The biopsy of this mamelon is followed by the appearance of caseum, which is the beginning of the development of a tuberculous gangliobronchial fistula.

View of the very swollen laryngeal crown.

It has lost the usual relief of its cartilaginous skeleton and a disseminated granulation is irregularly distributed in the mucosa.
The vocal cords also affected, are asymmetrically thickened and deformed.

View of the precarinal trachea with bulging of the posterior wall.

Its folds are well marked and «tensed» to surround the carina, grossly enlarged on its edge and its slopes.

The congestion of the mucosa is irregular because its nutrient vessels were trapped by regional tumor growth.

Alejandro Posadas Hospital

Carina in «saddle» or «book spine».

The tracheal wall and the main bronchi are displaced forward.

There is moderate congestion of the mucosa.
The border of the carina has disappeared due to the involvement of the subcarinal lymph nodes of group 7, due to a carcinoma.

Different forms of widening of the main carina, without disruption of the mucosa:

a) Widening at the expense of the carinal edge.

b) Widening at the expense of the anterior triangle.

c) At the expense of the right slope.

d) At the expense of both sides.

e) Total widening of the carina.

f) Combined broadening, with deformation of the light and distortion of the longitudinal folds. All changes without disruption of the mucosa.

Trachea severely affected by a carcinoma that sits on the posterior wall of the intrathoracic and precarinal portion with 50% light reduction.

This voluminous formation seems to occupy all the light and deprives us of explaining how distal pulmonary ventilation is achieved.

The reason is that before the muscle relaxation caused by general anesthesia, the tracheal diameter was greater and thus allowed air passage through the periphery of this large occupant lesion.

Tumor of smooth surface and circumscribed aspect occupies the center of the tracheal lumen, reaching the height of its first ring.

Irregular edema in «street cobblestones» of the tracheal wall due to neoplastic embolisms in the submucosal lymphatics.

In this case, a cystic lymphangioma in the neck barely deflects the trachea.

At hour 4 and 5, the imprint of the rings has been lost by the smooth and regular edema of the mucosa.

Osteochondroplastic tracheopathy: tracheal aspect very different from its usual anatomical conformation.

Multiple hard nodular excrescences, irregularly distributed over the tracheal cartilages, upholstered by normal mucosa.

Osteoplastic tracheopathy is an infrequent and asymptomatic condition.

Alejandro Posadas Hospital

Photograph of a tracheal pseudomembrane extracted under rigid bronchoscopy, in a patient with obstructive symptoms and a history of recent orotracheal intubation.

Trachea in «saber scabbard».

Notable reduction of its transverse diameter, due to the compression exerted by paratracheal adenomegalies of group 2 and 4.

The mucosa is thickened by regular edema.

Severe distortion of the precarinal trachea by compression that elevates the folds and deforms the entrance of the main bronchi.

The carina, although very asymmetric, remains fine.

On the compression of the posterior wall protrudes a submucous and smooth protrusion.

Towards the bottom of the image, one can guess the great widening of the tracheal carina.

Low light in «half moon», by strong compression on the tracheal posterior wall.

Severe compression on the tracheal posterior wall that advances it toward the light.

General and regular edema of the mucosa.

Slight lateral compression and folds that curve and accentuate as a sign of affection adjacent to the posterior tracheal wall.

Actinic necrosis: The trachea presents a reduction of its transverse diameters as a consequence of the acute necrosis of its mucosa, which has allowed the detachment of the tracheal rings at their ends.

The organ is disordered in inspiration, narrowing its posterior mucous membrane and deepening intercartilaginous spaces.

Reduction of tracheal light of combined cause.

Visible right posterolateral compression and intramural lesion in the opposite wall that begins to protrude towards the light.

Voluminous and solitary, a pale smooth surface granuloma observes the trachea from its insertion at the edge of the ostoma.

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Montevideo, Uruguay

Lobulated compression on the mucous membrane of the posterior wall of the extrathoracic trachea.

Tracheal carina enlarged and fixed.

The entrance to the source bronchi is asymmetric due to unequal reduction in its diameters, due to compression and regular edema.

Left lateral compression on the trachea that can only be appreciated by the asymmetry at the source of the bronchial foramen, towards which appears a formation that emerges from the right lateral wall of the trachea and subocludes the entrance to the main bronchus on the same side.

Observe the bulging of the posterior mucous membrane upon entering the left source.

Trachea in «saber scabbard».

Appropriate analogy for this severe and prolonged compression of the trachea by an endothoracic goiter.

The cartilaginous reliefs have been lost and the edema gives a regular appearance to the entire mucosa.
The rear wall is now a narrow and straight corridor that leads to the carina.

Alejandro Posadas Hospital

In chronic bronchitis, the atrophy of the mucosa gives it a tense and bright appearance, with wide glandular holes and sharp reliefs on the spurs and cartilages.

Multiple depressions of the bronchial mucosa in the right upper lobe, with anthracotic macules in them.

Dilated bronchial glands at the entrance of the left source bronchus, at the junction of its lateral wall with the posterior or mucous membrane.

Chronic bronchitis

Forward displacement of the posterior wall of the right source bronchus during inspiration.

The depth of the longitudinal folds is maintained and does not disappear, as occurs when the wall is «stretched» by extrinsic compression.

Here the alteration is dynamic and is due to the flaccidity of the mucosa and the elastic bands.

Chronic bronchitis

Thin secretion of mucous aspect in the left source bronchus.

On the right side wall there are several cartilaginous prominences that in some cases can acquire a triangular or «spur» shape.
No pathological value.

Triangular aspect of the tracheal lumen, permanent deformation due to chronic cough.

«Black hole sign»

The bronchus that appears in hour 2 leads to a cavity.

The light emitted by the endoscope is not refracted or reflected in the walls so the bronchus looks like a dark hole.

«Black hole sign»

The left lower lobe bronchus does not reflect the light of the endoscope.

It appears with a central twilight, because the light is lost inside a cavity with which the bronchus is communicated.

«Sign of the Bubble» positive

At hour 11: bubbles are observed in the lateral segmental of the middle lobe (RB4).
No bubbles in the medial (RB5), at hour 7 of the photograph: they report the distal obstruction of this bronchus.

It indicates that in segment RB5 the bronchoscopist must introduce the biopsy clamp to reach the tumor that obstructs it.

The bubble sign was described by Dr. Ricardo Isidoro in 2005, and published much later. (Rev. amer.respiratory med vol.12 no.4 CABA oct./Dec. 2012).

«Positive bubble sign»

The lack of bubbles in one of these two segments of the lingula, after instilling physiological solution, indicates that it is occluded distally.

«Bubble sign»

The lack of bubble formation in a segmental bronchus during breathing and after the instillation of saline, suggests that this bronchus is obstructed in its distal course.

Sign of Bence

Bence A. E. Bronchoscopy, its indications, El día Med 1942, 25: 634

Inflammatory signs dominate the image, but here the light has been lost and the longitudinal folds meet giving this upper lobe a «funnel» aspect: «Bence sign».

This indirect sign linked to bronchogenic carcinoma was described in Buenos Aires in 1942 by Dr. Alvaro Bence, in charge of the bronchoscopy service at the Guillermo Rawson hospital since 1938 and a disciple of Haslinguer in Vienna and of Chevalier Jackson in Philadelphia. (Fiorino, A. Historical evolution of bronchoscopy, Rev. Arg of tuberculosis, pulmonary diseases and public health 1987, 3:48)

View of the trachea with reduction of the light by left lateral compression of its wall, which contains an «intramural, endoluminal and infiltrating» lesion.

«Direct and indirect» signs of severe neoplastic process that protrudes towards the tracheal lumen from its posterior wall in the proximity of the bifurcation.

Irregular and bulky thickening of the entire mucosa that surrounds an asymmetric tracheal lumen, whose deformation increases when entering the main bronchi.

The carnal edge has been lost and its widening is complete.

Mucopurulent secretions.
In patients prostrated or with bronchial immobility due to the passive atelectasis that accompanies the effusions, the secretions can fill the lower bronchi, flooding them.

You can see the secretions «retained» within the adynamic bronchi that accumulate there due to their decline.

Soft, very circumscribed superelevation in the intermediate bronchial mucosa that does not go unnoticed due to its noticeable change in coloration that contrasts with superficial vessels.

Intramural lesion that in its growth advances into the interior of a trachea with «triangular light» zones, as is usually the case in some cases of chronic cough.

Another case of intramural injury (at 10 o’clock), next to an abnormally widened spur.

Example of «intramural» injury.

The tumor deforms the light by occupying the wall without destroying the mucosa yet.

Positive biopsy.
Undifferentiated carcinoma.

This carcinoma occurs in the trachea with a very smooth surface which will suspect a carcinoid tumor.

Note the intense mucosal vascularization that with a more or less parallel disposition is directed to the tumor.

Partial view of the right lower lobe, with segmental basal lines aligned.

At hour 11 and in the distance the paracardiac (RB7) is observed, occluded by a smooth and vascularized formation.

Remarkable pallor of this bronchial wall that contrasts with the superficial vessels that form small islands.

Thickening and rigidity conferred by an adenocarcinoma that has invaded the mediastinum.

Another form of presentation of the endobronchial tumor that occurs frequently: only whitish formation.
It is no more than necrotic tissue on the surface because it is the furthest point from its base of vascularized implantation.

The secretions cover it and can dry out due to the disturbance in the airflow produced by the tumor.

Vegetative tumoral formation that occludes the right upper lobe, which also shows a noticeable widening of its spur.

The lesion appears with freshly emitted blood due solely to the cough that occurred during the endoscopic exploration.

Insufficient local anesthesia will trigger coughing during the examination and spontaneous bleeding will make it difficult to see and accurately during the biopsy.

Close-up image of a bulky tumor that completely obstructs the bronchial lumen.
Note the particular arrangement of the surface vasculature.
Some vessels interrupt their journey intermittently.

It is another expression of the «vascular stop» because of the tumoral infiltration of its wall.

Macroscopic appearance very common in neoplastic processes.

The sub-occlusion of the bronchus is formed by tissue that develops in the light (center of the image), and in its upper part the proliferation still respects the mucosa, at least on its surface.
The vessels are engorged, with the typical changes in their color.

On this enlarged bronchial spur, the engorged vessels that form «islands» in their tortuous path are observed.

Biopsy: adenocarcinoma.

Alejandro Posadas Hospital

All signs present: Vegetative tissue, with whitish necrotic areas, mamelons, edema, changes in vascularization and coloration with more or less congestive areas, in this carcinoma that occludes the intermediate bronchus.

In this tracheal compression, the magnitude is such that there is no light in the right source bronchus and a large reduction in crescent in the left.

The «Y» stent is indicated to recover light and threatened ventilation.

Severe left lateral compression that gives curvature to the trachea in addition to the reduction of the transverse diameter.

«Infundibuliform stenosis»

All the planes of the bronchial walls meet at a point where the bronchial light no longer exists.

«Light in cleft»

In this case bilateral compression is quite symmetrical and produces a linear narrowing of the bronchial lumen.
In the image the affected segment is the upper part of the lingula (LB4).

«Light in half moon»

Aspect that adopts the bronchial light due to uneven extrinsic compression.

Irregular roughness in the walls of the trachea dominated by the bulging edema, which is missing in the mucous membrane that forms the posterior wall, with its deep folds and loss of its usual parallelism.

Carina notoriously pathological.
Very wide and surely «fixed».

Distortion of the folds that are exaggeratedly marked.

On the left, a small submucous protrusion appears at the entrance of the bronchus source.

Locoregional neoplastic disease.

Although there is no lesion of endoluminal growth, the bronchial mucosa is decidedly affected by irregular edema and visible thickening.

The rigidity and decreased mobility are other signs that can be seen during endoscopy when the bronchus is «fixed» to the tumor that surrounds it.

As a solitary boulder, this carcinoma sits in the center of the right source bronchus, interrupting the normal course of the longitudinal folds.

Full of semiology, the neoplastic repercussion in the interior of the trachea shows deformation of the light at the entrance to the main bronchi, very marked in the left.

The carina is widened, with a submucosal protrusion.
The folds have deviated and the superficial coloration combines pale areas with congestive ones, in which the full and tortuous vessels denounce the local circulatory difficulty.

View of the entrance to the left source bronchus. In addition to the small protrusion in its right lateral wall, a fine puntilled of submiliar size is observed in the mucosa of the carinal slope.

Bronchial light is greatly reduced and deformed by irregular edema of the mucosa in which several mamelons appear on its surface.

Tracheal carina enlarged at the expense of both paths. The biopsy can reveal neoplastic embolisms of the submucosal lymphatics in 11% of the cases.

The longitudinal folds are preserved parallel but very accentuated and somewhat «separated» in this pulmonary atelectasis by extrinsic compression. Recall that in the trachea only the malignant conditions contiguous to its posterior wall «accentuate and separate» their folds, while the compressions of nonmalignant causes produce the bulge of the wall and the folds can be separated but not accentuated or «sink» in the mucosa, because it is not infiltrated but has only been pushed towards the tracheal lumen.

Asymmetry, stenosis and deviation of the marked folds, are the findings in this obstruction of the right source bronchus due to a contiguous extrinsic affection.

The irregularity of the mucosa, with a granular surface characterizes this neoplastic development in the wall, almost in the center of the image and close to the entrance of the basal segmental bronchi.

Threadlike secretion that crosses the bronchial lumen as if it indicated the area of irregular and mamelonated edema of the mucosa at hour 7: infiltrating carcinoma of the bronchial wall.

Carina with a rounded edge and widened sheds that give it a «saddle» look. The deformation occurs after the regional ganglion enlargement of different etiologies.

«Hidden carina.» Extensive compression in the tracheal route that produces the prolapse of the posterior wall. Towards the bifurcation deforms the light from the bronchi, losing the right bronchus. The carina it is hidden due to the compression.

«Stoned edema». Typical aspect in the left area of the image, where the mucosa, although retaining its homogeneous coloration, is presented as an irregular street on its surface and reminds the stoned of the pavements. It leads here to the anterior segmental of the right upper lobe (RB3) and must be differentiated from the «regular» edema that is smooth, and in which its biopsy does not usually clarify the origin. It is common to find neoplastic cells in samples of stoned edema, since the etiology of the rule is infiltration of the mucosa by bronchogenic carcinoma.

View from the intermediate bronchus. Distortion of the folds at the entrance to the lower lobe, which can be seen at hour 6 of the image. Submucosal miliary infiltration, close to the paracardiac segmental. Habitual aspect in «slit» of its entrance hole.

Widening of the left secondary carina: widened and rigid division spur. Local congestion with a sinuous and engorged vessel in the upper part of the image. Distortion of the folds that reach the lower lobe and deformation of its entrance. On the left, the orifice of the lingual bronchus can be seen and the culminar farther.

Intense congestive edema of the mucosa that widens the dividing spurs and reduces the light of the segmentals. Also, the longitudinal folds have deepened. Although not exclusive, the finding is common in acute and subacute bronchial inflammatory conditions and the contiguous lung parenchyma.

«Bronchial parallelism». More common in elders than in the rest of the population, in the parallelism the source bronchi «look straight» to the bronchoscopist.

«Bronchoscopy of minimum changes»: In the center of the image, the submucosal vessels are observed abnormally engorged. Some vascular «stops» can be appreciated usually present in the early infiltration of the bronchial wall.

«Bronchoscopy of the minimum changes»: In the distance, on the posterior wall, a small submucosal protrusion dominates among others that look out the tracheal light.

«Bronchoscopy of the minimum changes»: «Submillary» protrusions with creases accentuated of the mucosa and division spur widened at the entrance of the segmental basals.

«Bronchoscopy of the minimum changes»: roughness of the mucosa with turgid vessels in the proximity of a spur of the segmental basals.

«Bronchoscopy of the minimum changes»: Entry of the right lower lobe. A circular area of pale mucosa is observed under the spur of the middle lobe, in hour 11. A biopsy will be necessary to investigate carcinoma in situ.

At hour 11, a slight bulge of the apical segmental wall of the upper lobe (RB1) is the only endoluminal manifestation of a contiguous pulmonary nodule.

Invagination of the mucosa between the birth of two bronchi.

Distribution anomaly: in hour 3 appear two segmental bronchi. The outermost of the image it’s the apical of the right lower lobe (RB6) and below it there is an accessory subapical.

«Star» distribution for the segments of the right upper lobe, which are presented as five bronchi.

Left tracheal bronchus: infrequent variant of ventilation of the apicoposterior segment(LB1 + 2) of the left upper lobe, which now does it directly from
trachea.

Distribution anomaly: Tracheal bronchus. It is the most common congenital anomaly of the tracheobronchial tree. In this case is missing the upper right lobe as branch of the source bronchus and It is also called porcine bronchus, because it is the normal distribution in the pig.

Distribution anomaly: tracheal bronchus. An additional bronchus is born in the right side wall and heads to the homolateral upper lobe. Depending on its location, the tracheal bronchus can cause exclusive atelectasis of the superior lobe during anesthetic intubation.

Distribution anomaly: Tracheal bronchus.

Part of the right upper lobe is ventilated thanks to a bronchus that has shifted during the embryonic phase of lung development so that it is born directly from the trachea.

Sometimes, this bronchus only leads to the apical segment of the right upper lobe and is, in these cases, a «supernumerary» bronchus.

It can be associated to the fusion of cervical vertebrae (syndrome of Klippel Feil).

Sometimes the atrophy of the mucosa is so marked that it allows to explore bronchi of 4th and 5th order.

Another variant very common in the lower left lobe, its division into two small trunks containing the three basal.

Accustomed distribution «in line» of the three left basal: anterior (LB8) here at 12 o’clock and partially hidden by the bronchial wall, medial (LB9) in the center and posterior segmental (LB10) below.

Close view at hour 3 of the entrance to the apical segment of the left upper lobe (LB6).
In its natural position, it is the first one that appears when leaving the upper left lobe bronchus.

A view of the lingular bronchus and its divisions in superior (LB4) at hour 11 and to its right the inferior (LB5).

From left to right: segmental medial (RB5) and lateral (RB4) of the middle lobe bronchus.

Division between the anterior segment (LB3) at hour 3 and the apicoposterior (LB1+2) at hours 8 and 10) of the left upper lobe.

Entrance to the left upper lobe.

In the background on the right, the bronchus of the lingula and on its left, at 10 o’clock, the small bronchial passage culminate, until its division, which is not observed here, in anterior segmental (LB3) and apicoposterior (LB1+2).

Image of the secondary carina that separates the upper and lower left lobular.
The area is also called a crossroads or «carrefour».

View of the left main bronchus, with its separation angle from the midline of about 70° and its normal length from 20 to 55 millimeters.

Cytological brush about to enter a segmental bronchus to obtain a cellular sample by abrasion, for study.

Basal segmental rights: previous (RB8) at hour 12, medial (RB9) at the center and the later (RB10) at hour 5.

View of the lower right lobe.

In order of appearance: apical of the inferior (RB6) in hour 3, paracardiac (RB7) in hour 8 and in the center the trunk that goes to the three basal, anterior (RB8), medium (RB9) and posterior (RB10).

Entrance to the right upper lobe and its three segmental: anterior (RB3), apical (RB1) and posterior (RB2), at hours 9-12 and 3 respectively.

From left to right: segmental medial (RB5) and lateral (RB4) of the middle lobe bronchus.

Entry of the middle lobe in hour 11. The trunk of the basal ones in the center with its segment RB 6 or apical in the hour 4.

Intermediate bronchus. It only exists in the right lung, with a diameter of 12 mm and length of 20, leads to the middle lobe, which  is at hour 9 in this image, and to the  lower lobe, towards the bottom.

Fluid and translucent appearance acquired by bronchial secretions during the endoscopy examination when diluted in instilled solutions during the procedure.

View from the right source bronchus: insinuates in hour 4 the entrance of the upper lobe and towards the bottom, the intermediate bronchus.

A) A and B different aspects of normal carina,

B)… in which its edge and angle can vary discreetly.

Sharp carina with slopes so sharp that can hardly be seen at the tracheal bifurcation level. It can clearly be seen the edges of the bronchial cartilages due to some senile atrophy. In the posterior wall, the elastic fibers compose the longitudinal folds that, like rails that bifurcate, lead to the source bronchi in the first great division of the airway.

The trachea extends in front of the esophagus from the 6th cervical vertebra to the 4th or 5th dorsal, measures about 12 cm in length and has between 16 to 20 cartilages.

Bronchoscope that enters the trachea. Splendid rigid and elastic organ at the same time. It can be appreciated the fine vascular network of the mucosa and the relief of the rings between the intercartilaginous grooves. The longitudinal folds of the posterior mucous membrane barely appear.

Images of a normal trachea. It can be noticed when following the path of the rings, that some lose the relief as if they were interrupted. No pathological value.

Diffuse granular arrangement throughout the mucosa in the laryngeal crown: moniliasis is more frequent in patients who make incorrect use of inhaled steroids.

Carcinoma in situ in the posterior third of the left vocal chord.

Irregular and roughed appearance of the chordal surface with depression in the anterior third of the right vocal chord compatible with surcus vocalis.

Mid-anterior synechia that brings together the vocal chords and fixes them in the midline with loss of glottal light

Warty carcinoma of the right vocal chord.

Carcinoma that sits on the right vocal chord and affects the anterior commissure, but mobility is normal. (T1a). (Montevideo, Uruguay).

Contact granuloma.

Bilateral chordal papilloma.

Contact pachydermia.

Small granuloma in the posterior third of the left vocal chord as a result of prolonged contact with an endotracheal tube of ventilation.

Cyst of the ventricular band, prolapsed out of the ventricle.

The mucosa continues and advances on the surface of this cyst on the right chord.

The cysts they are due to retention and are produced by occlusion from the mouth of the glands.

Small nodule in the junction of the anterior third and the middle of the left vocal chord and its opponent.

Papillary warty epiglottis cancer.

Papilloma on the epiglottis.

Epiglottitis. Notice the intense edema that rounds the epiglottis and forms an acute angle in his pharyngeal face that remembers the epiglottis in «omega».

Large chordal hematoma that hides the anterior commissure and contrasts with pallor general of the laryngeal mucosa. The chordal hematoma usually presents with sudden dysphonia in professional singers.

Although the most common arrangement of papillomas is «cluster», in this case it is presented with a more or less smooth surface and occupies the anterior third of the left vocal chord.

Voluminous laryngeal cyst in the arytenoepiglottic fold. (Juan P. Pediatric Hospital Garraham).

Inspiratory laryngeal dystonia in adduction: infiltration of botulinum toxin into the right vocal chord.

Pseudopolyp that sits in the commissure and anterior third of the right vocal chord.

Asymmetry of the glottic lumen due to left chordal paralysis.

Gelatinous and bichordal Reinke’s edema.

Gelatinous and bilateral chordal thickening: Reinke’s edema with its characteristic appearance.

Subglottal laryngeal angioma. (Juan P. Garraham Pediatric Hospital).

Telangiectatic polyp.

Typical gelatinous polyp.

Bilateral chordal paralysis in adduction. It is the most frequent congenital paralysis and in 50% of the cases is associated with other neurological alterations The remaining 50% is idiopathic and reverses in the first year of life. (Hospital Pediatrics Juan P. Garraham).

Bilateral thoracic thickening that seems to occlude the Morgagni ventricles.

Varices on vocal chords.

Throat thickening and edema. Rugged appearance of the posterior commissure. Common finding in patients with reflux of gastroesophageal acid.

View of the larynx. The bronchoscope has been located in the midline, raising the free edge of the epiglottis and remains supported on its pharyngeal side. The vocal cords are in abduction. The first tracheal ring can be visualized through the glottic cleft.

View of the normal laryngeal crown, with the vocal chords in an abduction position.

Larynx: it can be clearly seen the arytenoepiglottic folds and vocal cords in adduction. The edge of the left vocal cord isirregular in its middle third.

The bronchoscope has overcome the epiglottis and the arytenoids, now facing the vocal cords, here in a paramedian position. Third anatomical repair for intubation. It is the right time to start the 90º rotation of the bronchoscope to separate the vocal cords with the bevel and allow smooth entry into the trachea.

After the uvula, the free edge of the epiglottis is the second point of reference for a bronchoscopist during orotracheal intubation.