“External Counterpressure” and “Internal Distention” for Optimal Laryngoscopic Exposure of the Anterior Glottal Commissure

External laryngeal counterpressure and internal laryngeal distention produce forces that are helpful for enhancing laryngoscopic exposure of the anterior glottis. These principles were formally described in the early 20th century, but are seldom used today. Hand pressure has been the typical source for external counterpressure. Since this maneuver is unstable if provided by an assistant and wasteful if provided by the surgeon, it is often neglected. Current phonomicrosurgical techniques require wider glottal exposure; therefore, a reexamination of the value of external counterpressure and internal distention is worthwhile. During the last 2 years, 125 microlaryngoscopic procedures were performed for a variety of benign, premalignant, and malignant lesions. All patients were placed in the Boyce-Jackson position and sustained with a modified Killian gallows, with resulting elevated-vector suspension. Internal distention was achieved by placing the largest-lumen glottiscope possible between the endotracheal tube and the infrapetiole region. Exposure was also improved by using silk adhesive tape to apply external counterpressure to the lower laryngeal framework. The use of both external counterpressure and internal distention as an adjunct to microlaryngoscopy was most helpful for the surgical management of lesions located near the anterior commissure. Seemingly, the two resultant forces are in opposition to each other, but in fact they are complementary, both to each other and to the orthodox laryngoscopic principle of elevated-vector suspension.