What Is a Laryngoscope?

A laryngoscope is a medical instrument used to view the inside of the throat, specifically the larynx (voice box) and the vocal cords. The word comes from "larynx" (voice box) and "skopein" (to look). In simple terms, it is a lighted tool that allows healthcare professionals to look deep into the airway.

In children, the airway is much smaller, narrower, and more delicate than in adults. For this reason, pediatric laryngoscopes are designed in specific sizes and shapes suited for newborns, infants, toddlers, and older children. The device plays a critical role in both emergency situations and planned medical procedures.

Purpose and Where It Is Used

A laryngoscope is used in two broad ways: for diagnosis (looking at the airway) and for procedures (helping place a breathing tube or remove something from the airway).

Common Medical Uses

• Endotracheal intubation: Placing a breathing tube into the windpipe (trachea) when a patient cannot breathe on their own. This is the most common use in pediatric emergencies, surgeries, and intensive care.
• Airway assessment: Examining the larynx, vocal cords, epiglottis (the flap that covers the airway during swallowing), and upper airway for abnormalities.
• Foreign body removal: When a child inhales or swallows an object that gets stuck in the upper airway, a laryngoscope is used to locate and remove it.
• Diagnosis of voice and swallowing problems: Hoarseness, noisy breathing (stridor), swallowing difficulties, or chronic cough may require a laryngoscopy to find the cause.
• Biopsy and minor procedures: Collecting tissue samples, laser treatment of vocal cord lesions, or removal of benign growths (papillomas).
• Resuscitation: During cardiopulmonary resuscitation (CPR) in newborns and children, a laryngoscope helps secure the airway quickly.

Settings Where It Is Used

Types of Laryngoscopes

There are several types of laryngoscopes used in pediatric care. Each type is suited to different clinical situations. Understanding the types helps in choosing the right tool for the right situation.

1. Direct Laryngoscope (Most Common)

This is the standard laryngoscope. It has two parts: a handle (which contains the battery and powers the light) and a blade (the part inserted into the mouth). The user looks directly through the device to see the airway. It requires good alignment of the head and neck to get a clear view.

Blade Shapes: Straight vs. Curved

Blade Size Selection by Age

2. Video Laryngoscope

A video laryngoscope has a tiny camera built into the blade tip. The image is displayed on a separate screen or monitor in real time. This allows the user to see the airway without needing a straight line of sight from the mouth to the vocal cords. It is especially useful for difficult airways — children with unusual jaw, neck, or throat anatomy.

• Advantages: Better visualization, more success on first attempt in difficult cases, the whole team can see the screen simultaneously (useful for teaching).
• Examples: GlideScope (Verathon), C-MAC (Karl Storz), McGrath, AirwayScope
• Limitation: Requires familiarity with screen-guided hand movements; the tube must be guided with visual coordination looking at a monitor rather than directly into the airway.

3. Flexible Laryngoscope (Fiberoptic)

A flexible laryngoscope is a long, thin, bendable instrument with a light and a lens at the tip. It can be passed through the nose (nasally) or mouth and gently guided to view the larynx without requiring a straight path. It is used primarily for diagnosis and awake airway assessments in outpatient or clinic settings.

• Use: Diagnosing hoarseness, stridor, laryngomalacia, vocal cord palsy, or airway tumours
• Anaesthesia: Usually done with only local numbing spray; can be done without any anaesthesia in older children
• Duration: Typically 5 to 10 minutes

4. Rigid Laryngoscope (Suspension Laryngoscopy)

This type involves a metal tube-like instrument that is held in place by a suspension device attached to the operating table. It is always done in an operating room under general anaesthesia. It provides a wide, stable view and is used for more complex procedures such as laser surgery on vocal cords, biopsy, dilation of airway narrowing (stenosis), or removal of lesions.

5. Indirect Laryngoscope

In this older technique, a small angled mirror is placed at the back of the throat and a light is used to reflect a view of the larynx. It is used in outpatient ENT clinics and is less commonly used in children as it requires cooperation. Flexible laryngoscopes have largely replaced mirror-based indirect laryngoscopy in pediatric practice.

How to Use a Laryngoscope: Step-by-Step Guide

The following describes the standard process for direct laryngoscopy for intubation, which is the most commonly performed procedure using this device in pediatric emergency and critical care settings.

Equipment Required Before Starting

• Laryngoscope handle (with working batteries and light source)
• Correct blade — type and size selected based on child's age and weight
• Endotracheal tube (ETT) in the correct size, plus one size smaller and one larger
• Bag-valve-mask (BVM) and oxygen source for pre-oxygenation
• Suction device (Yankauer suction tip) — turned on and within reach
• Stylet (for shaping the ETT, if needed)
• Pulse oximeter and cardiac monitor running
• Medications (if rapid sequence intubation is being performed)
• Tape or tube-holder to secure the ETT after placement

Step-by-Step Procedure

1. 1
   Check and Assemble Equipment Attach the selected blade to the handle. Open the blade to 90 degrees — the light should turn on automatically. Confirm the light is bright and white (not dim or yellow). A dim light is a common cause of failed first attempts.
2. 2
   Pre-oxygenate the Child Before inserting any device, deliver 100% oxygen via a face mask for at least 30-60 seconds (or longer, up to 3 minutes if the situation allows). This fills the lungs with oxygen and gives a safety window for the procedure. In newborns, the safe apnoea time is very short (under 30 seconds), so this step is critical.
3. 3
   Position the Child Correctly Correct positioning is essential for a clear view.

   • Infants and small children: Lay flat with no pillow. The large occiput (back of the head) naturally brings the airway into alignment. Sometimes a small folded towel under the shoulders helps open the neck.
   • Older children (over 3 years): Place the head in the "sniffing position" — slight neck extension with the head elevated on a small pillow (about 7-10 cm). This aligns the mouth, throat, and trachea into a straight line.
4. 4
   Hold the Laryngoscope Always hold the laryngoscope in the left hand, regardless of whether the user is right-handed or left-handed. The handle is gripped firmly but not tightly. The right hand is kept free to pass the breathing tube or handle suction.
5. 5
   Open the Mouth and Insert the Blade Gently open the child's mouth using the right hand (scissor technique: thumb pushes down on the lower teeth/gum, index finger lifts upper teeth/gum). Insert the blade from the right side of the mouth, gently sweeping the tongue to the left as the blade moves toward the midline.
6. 6
   Advance and Identify Landmarks Advance the blade slowly. Look for the uvula, then the epiglottis (a small leaf-shaped structure). The vocal cords appear as two white or pale structures beyond the epiglottis, shaped like an upside-down V.

   • With straight blade (Miller): Advance the tip under and past the epiglottis, then gently lift it directly to expose the vocal cords.
   • With curved blade (Macintosh): Place the tip in the vallecula (the space between the base of the tongue and the epiglottis). Lift upward and forward — the epiglottis rises indirectly to reveal the vocal cords.
7. 7
   Lift, Do Not Lever Lift the laryngoscope upward and forward in the direction the handle points. Do not use the upper teeth or gums as a fulcrum or pivot point. Levering backwards against the teeth is a common error that causes dental injury and worsens the view.
8. 8
   Pass the Endotracheal Tube Once the vocal cords are clearly visible, pass the breathing tube through the right side of the mouth (not through the blade in most cases), and guide it between the vocal cords under direct vision. Advance until the cuff (if present) or the depth marking for the age is just below the cords.
9. 9
   Confirm Correct Placement Remove the laryngoscope blade carefully. Ventilate with the bag-mask attached to the tube. Confirm tube placement by:

   • Rise and fall of the chest
   • Equal breath sounds on both sides (auscultate left and right chest)
   • No air entry sound over the stomach
   • Rising oxygen saturation on the pulse oximeter
   • Carbon dioxide detection (colorimetric CO2 detector turns yellow, or waveform capnography)
10. 10
    Secure the Tube Mark the tube depth at the lip or gum line. Secure firmly with adhesive tape or a commercial tube holder. Document the tube size and depth. Get a chest X-ray to confirm final position when time allows.

The 30-30-30 Rule (General Reference)

A widely used teaching guideline for emergency intubation in children: no more than 30 seconds per attempt, stop at 30% oxygen saturation drop, and allow 30 seconds of bag-mask ventilation before retrying. (Local protocols may vary.)

Precautions and Potential Dangers

Laryngoscopy in children carries specific risks due to the small size and sensitivity of the pediatric airway. Awareness of these risks is essential for safe practice.

Risks During the Procedure

Special Precautions in Infants and Newborns

• The infant airway is at the level of C3-C4 vertebrae (higher than in adults, which is at C4-C5), making it more anterior — the cords are harder to see with the same angle used for adults.
• The infant's epiglottis is omega-shaped and floppy — direct lifting with a straight blade is usually needed.
• The smallest airways (premature infants) have a trachea that is only a few millimetres wide — blade placement must be extremely gentle.
• Oxygen levels fall much faster in infants than in adults — time is critical.
• A prominent occiput in infants means the head should not be extended; slight or no extension is usually correct.

Frequently Asked Questions (FAQ)

How to Keep a Laryngoscope Safe and Ready

Proper storage, cleaning, and maintenance of a laryngoscope is essential for patient safety and device reliability. A malfunctioning laryngoscope in an emergency can be life-threatening.

Daily Equipment Check

• Attach the blade to the handle and open it to 90 degrees. The light should turn on immediately and appear bright white.
• Check for a firm "click" when attaching the blade — a loose blade can fall off during use.
• Inspect the blade for any cracks, chips, or damaged edges.
• Check battery level; replace batteries if the light is dim or yellow.
• Ensure all required blade sizes for the clinical area are present and accounted for.

Cleaning and Sterilization

Storage Guidelines

• Store sterilized blades in sealed sterile packaging until use.
• Keep laryngoscopes in designated resuscitation trolleys, emergency bags, or airway management kits — always organized, visible, and accessible.
• Store in a dry, dust-free environment. Avoid areas with high humidity which can damage battery contacts and light bulbs.
• Organize blades by size in a clearly labelled tray so the correct size can be identified instantly in an emergency.
• Do not store laryngoscopes in drawers where blades can accidentally open (which drains the battery) — blade open position activates the light.

Battery and Light Maintenance

• Standard handles use AA or C batteries. Replace on a scheduled basis — do not wait for failure.
• Fibre-optic handles transmit light from the handle through a glass fibre bundle in the blade — if the bundle is damaged, light transmission fails. Check for dark spots in the blade light.
• LED light sources (now standard in most modern laryngoscopes) are more reliable and longer-lasting than older halogen bulbs and do not require bulb replacement.
• Some handles use rechargeable batteries — follow the charging schedule as specified by the manufacturer.

Additional Considerations

Pediatric Airway Anatomy: Why It Is Different from Adults

Understanding why children require different techniques and equipment is important background knowledge.

• The pediatric airway is smaller overall and narrower at the subglottis (below the vocal cords) — this is the narrowest point in children under 8 years, unlike in adults where the narrowest point is at the glottis (vocal cords).
• The larynx is positioned higher in the neck (C3-C4) in infants, making it more anterior and harder to visualize with adult positioning techniques.
• The tongue is relatively larger in proportion to the mouth in infants, making blade insertion more challenging.
• The epiglottis is omega-shaped, floppy, and angled more steeply in infants — this is why straight blades are preferred in young children.
• Infants are obligate nose-breathers until about 4-6 months of age, which has implications when placing nasal airways or scopes.

Video Laryngoscopy: Growing Standard of Care

Internationally, video laryngoscopy is increasingly being recommended as the preferred approach for intubation, including in pediatric patients. The 2025 Difficult Airway Society guidelines and the International Liaison Committee on Resuscitation (ILCOR) have updated recommendations supporting the use of video laryngoscopy as a first-choice tool for tracheal intubation where trained users and equipment are available. In pediatric difficult airways, GlideScope video laryngoscopy has been associated with higher first-attempt success rates in registry data.

Rapid Sequence Intubation (RSI) in Children

In emergency situations, intubation is often performed as RSI — a method that involves giving sedative and muscle relaxant medications in quick succession to allow safe intubation in an awake, distressed, or at-risk child. Laryngoscopy is the central tool in RSI. Specific drug choices, doses, and protocols vary by institution and region, and RSI should only be performed by trained practitioners in a monitored setting.

Difficult Airway in Children

Some children have anatomical or medical conditions that make intubation more challenging. These include conditions such as Pierre Robin sequence, Treacher Collins syndrome, Down syndrome, tracheal stenosis, epiglottitis, large tonsils, or post-surgical scarring. In such cases, video laryngoscopy, fiberoptic intubation, or specialized rigid laryngoscope designs may be used. A difficult airway plan and backup equipment should always be prepared before any elective procedure in a child with known airway challenges.

Training and Competency

Pediatric laryngoscopy and intubation is a skill that requires formal hands-on training, supervised practice, and regular maintenance of competency. Simulation-based training using mannequins and airway trainers is widely used. Most international resuscitation programs (NRP for neonates, PALS for older children, APLS) include structured training in pediatric airway management. Competency should be assessed periodically, especially in settings where intubation is infrequent.