Endoscopy 1 (1979) 51-59
REVIEW
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck Endoscopy of Ear, Cerebellopontine Angle, Nose, Paranasal Sinuses, Larynx, Oro- and Hypopharynx W. Steiner
Endoscopy of the Ear
Tympanoscopy
The routine examination of the auditory meatus and the eardrum in the ENT practice is carried out with an ear speculum and the head mirror. For improved assessment of the eardrum, a magnifying glass or microscope can also be employed. Practitioners and pediatricians, for example, frequently use otoscopes. Endoscopy of the ear using a fine, short, forward viewing endoscope (Hopkins or Lumina optics), makes it possible to carry
out a reliable inspection of the auditory meatus and the eardrum (Fig. 1) " and, if perforations (Fig. 2) present, the tympanic cavity, too. This painless endoscopic techni-
que can be used even in children, without anaesthesia and repeated whenever necessary (4). In the last few years Eichner (1978) (3) drew attention to the value of endoscopy of
the ear including the possibility of photographic documentation, and developed a "mother-baby-endoscope" for the endoscopic inspection of the middle ear. Cisternoscopy of the Cerebellopontine Angle This new examination technique was developed by Prott (1974) (13). Via the transmastoidal-retrolabyrinthine approach such
important structures as the internal auditory pore and the cerebral nerves III to VII can be seen. With the aid of this additional examina-
All endoscopic photographs were taken with Lumina-optics, Fa. R. Wolf GmbH, 7134 Knittlingen, West Germany 0013-726 X/79
1300-0051
$ 02.00 © 1979
tion not only can small lesions be observed but also recordings of nerve-potentials and neurectomies may be performed Endoscopy of the Nose
Endoscopy of the nose methodically worked out by Messerklinger (1970/78) (12) is being used more and more by the otorhino-laryngologist.
With the aid of Hopkins or Lumina endoscopes (110° and 1550, 3-4 mm 0), not only can the entire nose of the conscious patient be inspected, but also the pharyngeal opening of the Eustachian tube, the roof of the pharynx, and also previously operated paranasal sinuses (5, 21).
The main fields of nasal endoscopy are pretherapeutic and posttherapeutic diagnosis and the documentation of benign (Fig. 3) and malignant (Fig. 4) diseases in the nose and nasopharynx. Wigand (1978) (25) draws attention to the possibilities of performing endonasal ethmoidectomy and infundibulotomy under endoscopic control. A new field of application
for nasal endoscopy is the endonasal application of laser light (10). Endoscopy of the Nasopharynx Indirect post-rhinoscopy with small mirrors is still the routine method for examination of
"" Recently Ehrenberger reported on the endoscopy of the cerebellopontine angle (Endoscopy 10: 1978, 260)
Georg Thieme Publishers
Downloaded by: University of British Columbia. Copyrighted material.
Departnnent of Otorhinolaryngology, University of Erlangen-Nuremberg
52
W. Ste ner
become unnecessary. The use of rigid endo-
scopes with a 90°-angle Hopkins optic ", developed by Ward and Berci (1974) (23), was recommended by Jung (1975/76) (7),
optic with a variable magnification up to fivefold became available. Its excellent qualities have definitely enhanced the early detec-
Fig. 1 Normal eardrum, right (11-y., m.) The eardrum shows no signs of pathology and is almost transparent. The manubrium of the malleus can be clearly recognized.
tion of tumours of the pharynx and larynx (Steiner 1976) (15). With the aid of zoomendoscopy, a practical examination technique, every part of the nasopharynx (Fig. 6 and 7) can accurately be inspected in the conscious patient under magnification, with-
Fig. 2a and b Traumatic perforation of the eardrum, right (22-y., f.) The eardrum was perforated during an attempt to clean the external meatus with a "cotton bud". a) The external acoustic meatus reveals a slight epithelial lesion. In the depths, the perforation ( ) with its blood-tinged margins can be seen. Anteriorly, the remaining portion of the eardrum showing the light reflection. b) Further advancement of the ear endoscope made it possible to look into the tympanic cavity.
the nasopharynx. Since 90°-angle optics are now available, the examination with the mir-
ror and microscope, mouth-gag and veloretractor under general anaesthesia has
Fa. K. Storz KG, 7200 Tuttlingen, West-Germany
Fa. R. Wolf GmbH, 7134 Knittlingen, West Germany
Downloaded by: University of British Columbia. Copyrighted material.
who emphasized the improved exposure and the possibility of carrying out photographic documentation, and minor endoscopic procedures in the nasopharynx. This instrument is mostly used in combination with auxiliary instruments e. g. for velotraction (9). In 1975, the zoom laryngo-epipharyngoscope " "- developed by v. Stuckrad (1975) (20) (Fig. 5 and 6) a 90-degree Lumina
Nasal polyp, right (25-y., m.) On endoscopic inspection, the yellowish polyp in the posterior part of the nose can be seen. Fig. 3
Fig. 4
53
Glomus tumour in the right side of the
nose (66-y., m.) Between the middle nasal concha
and the nasal septum, a reddish tumour (1) the size of a cherry stone; cause of recurrent unilateral bleeding from the nose.
Zoom-endoscopic examination nasopharyngeal area (schematic) Fig. 5
of
the
Normal nasopharyngeal area (72-y., m.) Zoom endoscopic "overview". Fig. 6
Downloaded by: University of British Columbia. Copyrighted material.
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck
54
W. Steiner
tubal torus Fig. 7
(13-y., m.)
The glassy, spherical polyp
) hangs into the nasopharynx from the right side of the nose.
Fig. 8
Nasopharyngeal carcinoma TiNoMo (74-y., m.) The reddish tumour ( ) (histology: lymphoepithelial carcinoma, Schminke-Regaud) had led to a compression of the Eustachian tube with consecutive soundconduction hearing loss.
out auxiliary instruments. Biopsies can be taken (Fig. 8), and excisions of small lesions
under local anaesthesia in the office or ambulance (Witten 1970, Hellmich and Her-
can be carried out with appropriate optical
berhold 1971, Illum 1972, Draf 1973/78,
control (Jaumann and Steiner 1978) (5).
Buiter 1976, Terrier 1976/78) ". When considering a revision operation of the maxillary sinus, transnasal endoscopy employing angle optics if required supplemented by tomois very important graphic examinations
Endoscopy of the Paranasal Sinuses Maxillary Sinus Endoscopy of the maxillary sinus (Fig. 9) has been known since the beginning of this century (Hirschmann 1903, Reichert 1902) ".
Because of the development of improved
(21).
There is evidence that endonasal surgery of the maxillary sinus under endoscopic control
endoscopes it has, since the beginning of the 1970's, become an established routine procedure, which can be carried out in outpatients
(Wigand and Steiner 1977) (24) closed a
" For references see W. Draf "Endoskopie der
mucosa (with nasal window) according to
Nasennebenhöhlen". Springer, Berlin 1978
Caldwell-Luc. A new concept of performing
therapeutic gap between sinoscopic removal of solitary cysts and polyps (without nasal window) and the radical removal of the sinus
Downloaded by: University of British Columbia. Copyrighted material.
Choanal polyp on the right
Fig. 9 Retention cyst in the maxillary sinus, right (32-y., m.)
At the medial wall of the sinus, caudal to the physiological and accessory ostium, a small yellowish epithelial cyst (T) can be seen.
Fig. 10
55
Foreign body in the right frontal sinus
(37-y., m.) On the floor of the right frontal sinus, glass splinters (T) prior to their endoscopic extraction.
Fig. 11
Microlaryngoscopy after Kleinsasser under intubation anaesthesia (schematic).
surgery on the paranasal sinuses under endoscopic control with conservation of the
mucosae has been reported by Wigand (25) recently in this journal. Frontal sinus The inspection of the frontal sinus is carried out under local anaesthesia using endoscopes of small diameter (Boenninghaus 1974 (1),
Draf 1975/78 (2), Mann and Beck 1976) (11). The main indications for endoscopy of the frontal sinus are uncertain equivocal Xray findings in the presence of headache of unknown etiology. Posttraumatic endoscopy of the paranasal sinuses is helpful for adequate presurgery assessment or for the endoscopic extraction of glass splinters (Fig. 10) from the frontal sinus (16).
Downloaded by: University of British Columbia. Copyrighted material.
Techniques of Diagnost c and Operative Endoscopy of the Head and Neck
W. S e ner
Hyperkeratosis of the left vocal cord (44-y., m.) Circumscribed hyperkeratosis (T) histology: medium grade dysplasia of the middle and anterior left vocal cord (microlaryngoscopic aspect). Fig. 12
L
Fig. 13
Zoom endoscopic examination of the
larynx and pharynx (schematic).
Fig. 14
epiglottis
Sphenoid sinus The indication for endoscopy of the sphenoid sinus via the transnasal route under endoscopic vision is generally restricted to the
histological identification of a tumour as malignant or benign and the extent of its spread or to the identification of sphenoidal fractures (Draf 1978) (2).
Normal endolarynx (56-y., f.) Zoom endoscopic "overview".
Endoscopy of the Larynx
For more than 100 years, the larynx has been inspected with a mirror. In view of the endoscopic examination available today, this procedure, with all its disadvantages, represents a compromise which, in the absence of a better method, has long been tolerated. During the last 20 years, microlaryngoscopy as
Downloaded by: University of British Columbia. Copyrighted material.
56
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck
57
Oropharyngeal carcinoma on the right T2N3M0 (46-y., m.) Exulcerated tumour (ls ) in the right vallecula epiglottica, invading the lingual epiglottis and the pharyngo-epiglottic fold.
Fig. 16 Hypopharyngeal carcinoma on the right T1N3M0 (38-y., m.) Tumour ( ) the size of a pinhead
(histology: poorly keratinizing squamous cell carcinoma) at the medial wall of the piriform sinus.
developed by Kleinsasser (1960/76) (8) (Fig. 11) for diagnostic and therapeutic
approach to the larynx under general anaesthesia, has found widespread acceptance. In endolaryngeal microsurgery (Fig. 12), numerous diagnostic and therapeutic techniques can be employed during microlaryngoscopy. In the last few years, endolaryngeal laser surgery
has been gaining in importance (Strong and Jako 1972) (19). Non-intubation microlaryngoscopy with jet ventilation (Stange 1973) (14) represents a technical enrichment of the endoscopic possibilities even though its indication is limited. In 1968, for the first time, Sawashima and
Hirose (1968) (26) reported on the use of flexible fiberscopes in the larynx. Since that
time, few reports on experiences with this method have been published (Williams, 1975)
(26). In 1974 we, too, tested flexible fiberscopes, manufactured by Olympus, for use in
the inspection of the pharynx and larynx However, we found that the rigid endoscopes are superior for diagnostic inspection of the pharynx and larynx (wider viewing field, better resolution, more reliable biopsy, brighter
image with high quality photographic and film documentation.
The laryngoscope with a 90°-angle Hop-
kins optic developed by Ward and Berci (1974) (23), has considerable advantages over
mirror examination, but is used largely for photographic documentation. By using an
Downloaded by: University of British Columbia. Copyrighted material.
Fig. 15
58
W. Steiner
(1975) (20). This 90°-angle Lumina optic
(Fig. 13) allows a thorough inspection of the larynx (Fig. 14) and pharynx in the conscious patient, without the need of auxiliary instruments. It has proved very suitable for the early detection of cancer of the pharyngolarynx in screening programs (Steiner, 1976) (15) "Direct" vision and magnification facilitate the removal of biopsy specimens and excision of tissue under topical spray anaesthesia with high safety and reliability. Photographic, video and film documentation can easily be carried out by fitting the camera directly to the instrument's eyepiece (18). Zoom endoscopy enabled the introduction and establishment of new diagnostic methods for laryngeal
diseases, such as electromyography in the conscious patient with selective recording of action potentials from single laryngeal muscles (22) and needle biopsy for the histological examination of tumours growing beneath the mucosa in the pharynx and larynx (17).
Zoom endoscopy may be considered a routine examination method capable of
replacing the mirror. In many cases microlaryngoscopic examinations under general
anaesthesia can be replaced by this single procedure.
Endoscopy of the Oro-Hypopharynx The modern endoscopic examination techniques, such as zoom-endoscopy in the conscious patient and microlaryngoscopy under general anaesthesia as described for the larynx also permit reliable evaluation of the oropharynx (Fig. 15) and hypopharynx (Fig. 16) in the majority of the cases (Jaumann and Steiner, 1978) (6). Oesophagoscopy would be necessary to exclude a malignant tumour in a patient presenting swallowing problems, or to establish the extent of a carcinoma in the piriform sinus or in the postcricoid region. References 1 Boenninghaus, H.-G.: Rhinochirurgische Aufgaben bei der Chirurgie des an die Schädelbasis angrenzenden Gesichtsschädels. Arch. Oto-Rhino-Laryng. 207 (1974) 1
2 Draf, W.: Therapeutic Endoscopy of the Paranasal Sinuses. Endoscopy 10 (1978) 247
3 Eichner, H.: Eine Mother-and-Baby-scope Optik zur Trommelfell- und Mittelohr-Endoskopie. Laryng. Rhinol. 57 (1978) 872 4 Jaumann, M. P., W. Steiner: Moderne otorhinolaryngologische Endoskopie beim Kind. 1. Endoskopie am wachen Kind. Pädiat. Prax. 20 (1978) 229 5 Jaumann, M. P., W. Steiner: Endoscopy of the Nose and Nasopharynx. Endoscopy 10 (1978) 240
6 Jaumann, M. P., W. Steiner, H.-J. Pesch: Leitsymptom Globusgefühl. Endoskopische, röntgenologische und histomorphologische Differentialdiagnose von Proliferanten in Oro- und Hypopharynx. Dtsch. Ärztebl. 75 (1978) 479 7 Jung, H.: lndikation zur operativen Eingriffen im Bereich des Nasenrachenraumes und der mittleren Schädelbasis. Laryng. Rhino]. 55 (1976) 932 8 Kleinsasser, O.: Mikrolaryngoskopie und endolaryngeale Mikrochirurgie. F. K. Schattauer Verlag Stuttgart (1976)
9 Kuske, I., A. Karduck, W. Bartholomé: Diagnostic Value of Nasopharyngeal Endoscopy for the Early Recognition of Tumours. Endoscopy 9 (1977) 199 10 Lenz, H., J. Eichler, J. Knopf, J. Salk, G. Schafer: Endonasales Argon-Laser-Strahlfiihrungssystem und erste klinische Anwendungen bei der Rhinopathia vasomotorica. Laryng. Rhinol. 56 (1977) 749 11 Mann, W., C. Beck: Stirnhöhlenendoskopie. Fortschritte in der Endoskopie (1976) 101; Herausg. W. Rösch, Perimed Verlag Erlangen
12 Messerklinger, W.: Endoscopy of the Nose. Urban & Schwarzenberg, Miinchen (1978)
13 Prott, W.: Möglichkeiten einer Endoskopie des Kleinhirnbrückenwinkels auf transpyramidalem-retrolabyrinthärem Zugangsweg Cisternoskopie. HNO 22 (1974) 337
14 Stange, G., E. Gebert, P. Pedersen: Eine neue Methode zur Injektionsanästhesie bei der direkten Laryngoskopie. Arch. klin. exp. Ohren-, Nasen- und Kehlk. Heilk. 204 (1973) 285
15 Steiner, W.: Krebsfriiherkennung in Mund, Rachen und Kehlkopf. Dtsch. Arztebl. 73 (1976) 3159 16 Steiner, W., M. P. Jaumann, M. E. Wigand, C. Gammert: Operative Endoscopy of the Upper Respiratory System. Endoscopy 9 (1977) 121 17 Steiner, W. M. P. Jaumann, H.-J. Pesch: Endoskopische Nadelbiopsie in Rachen und Kehlkopf. HNO 26 (1978) 168
18 Steiner, W., M. P. Jaumann: Endoscopic Diagnosis and Therapy of the Trachea. Endoscopy 10 (1978) 149 19 Strong, M. S., G. J. Jako: Laser Surgery in the Larynx. Early clinical Experience with continous CO2-Laser. Ann. Otol. Rhinol. Laryngol. 81 (1972) 791 20 v. Stuckrad, H., I. Lakatos: Ober ein neues Lupenlaryngoskop (Epipharyngoskop). Laryng. Rhinol. 54 (1975) 336 21 Thumfart, W., W. Steiner, M. P. Jaumann: Diagnose und Indikation zur Revision der radikal voroperierten Kiefer-
höhle. HNO 26 (1978) 289 22 Thumfart, W., W. Steiner, M. P. Jaumann: Lupenendoskopische Elektromyographie des M. crico-arytaenoideus dorsalis am wachen Patienten. HNO 27 (1979) in press 23 Ward, P. H., G. Berci, T. Calcaterra: Advances in Endoscopic Examination of the Respiratory System. Ann. Otol. Rhinol. Laryngol. 83 (1974) 754 24 Wigand, M. E., W. Steiner: Endonasale Kieferhöhlenoperation mit endoskopischer Kontrolle. Laryng. Rhinol. 56 (1977) 421
Downloaded by: University of British Columbia. Copyrighted material.
appropriate variable objective, magnification can be obtained. A decisive step forward in oto-rhino-laryngological endoscopy was the development of the laryngo-epipharyngoscope by v. Stuckrad
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck 25 Wigand, M. E., W. Steiner, M. P. Jaumann: Endonasal Sinus Surgery with Endoscopical Control: From Radical Operation to Rehabilitation of the Mucosa. Endoscopy 10 (1978) 255
59
26 Williams, G. T., J. M. Farquharson, J. Anthony: Fibreoptic Laryngoscopy in the Assessment of Laryngeal Disorders. J. Laryngol. Otol. 89 (1975) 299
Downloaded by: University of British Columbia. Copyrighted material.
Dr. med. habil. W. Steiner, University of Erlangen-Nuremberg, Department of Otorhinolaryngology, Waldstr. 1, D-8520 Erlangen, West Germany
REVIEW
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck Endoscopy of Ear, Cerebellopontine Angle, Nose, Paranasal Sinuses, Larynx, Oro- and Hypopharynx W. Steiner
Endoscopy of the Ear
Tympanoscopy
The routine examination of the auditory meatus and the eardrum in the ENT practice is carried out with an ear speculum and the head mirror. For improved assessment of the eardrum, a magnifying glass or microscope can also be employed. Practitioners and pediatricians, for example, frequently use otoscopes. Endoscopy of the ear using a fine, short, forward viewing endoscope (Hopkins or Lumina optics), makes it possible to carry
out a reliable inspection of the auditory meatus and the eardrum (Fig. 1) " and, if perforations (Fig. 2) present, the tympanic cavity, too. This painless endoscopic techni-
que can be used even in children, without anaesthesia and repeated whenever necessary (4). In the last few years Eichner (1978) (3) drew attention to the value of endoscopy of
the ear including the possibility of photographic documentation, and developed a "mother-baby-endoscope" for the endoscopic inspection of the middle ear. Cisternoscopy of the Cerebellopontine Angle This new examination technique was developed by Prott (1974) (13). Via the transmastoidal-retrolabyrinthine approach such
important structures as the internal auditory pore and the cerebral nerves III to VII can be seen. With the aid of this additional examina-
All endoscopic photographs were taken with Lumina-optics, Fa. R. Wolf GmbH, 7134 Knittlingen, West Germany 0013-726 X/79
1300-0051
$ 02.00 © 1979
tion not only can small lesions be observed but also recordings of nerve-potentials and neurectomies may be performed Endoscopy of the Nose
Endoscopy of the nose methodically worked out by Messerklinger (1970/78) (12) is being used more and more by the otorhino-laryngologist.
With the aid of Hopkins or Lumina endoscopes (110° and 1550, 3-4 mm 0), not only can the entire nose of the conscious patient be inspected, but also the pharyngeal opening of the Eustachian tube, the roof of the pharynx, and also previously operated paranasal sinuses (5, 21).
The main fields of nasal endoscopy are pretherapeutic and posttherapeutic diagnosis and the documentation of benign (Fig. 3) and malignant (Fig. 4) diseases in the nose and nasopharynx. Wigand (1978) (25) draws attention to the possibilities of performing endonasal ethmoidectomy and infundibulotomy under endoscopic control. A new field of application
for nasal endoscopy is the endonasal application of laser light (10). Endoscopy of the Nasopharynx Indirect post-rhinoscopy with small mirrors is still the routine method for examination of
"" Recently Ehrenberger reported on the endoscopy of the cerebellopontine angle (Endoscopy 10: 1978, 260)
Georg Thieme Publishers
Downloaded by: University of British Columbia. Copyrighted material.
Departnnent of Otorhinolaryngology, University of Erlangen-Nuremberg
52
W. Ste ner
become unnecessary. The use of rigid endo-
scopes with a 90°-angle Hopkins optic ", developed by Ward and Berci (1974) (23), was recommended by Jung (1975/76) (7),
optic with a variable magnification up to fivefold became available. Its excellent qualities have definitely enhanced the early detec-
Fig. 1 Normal eardrum, right (11-y., m.) The eardrum shows no signs of pathology and is almost transparent. The manubrium of the malleus can be clearly recognized.
tion of tumours of the pharynx and larynx (Steiner 1976) (15). With the aid of zoomendoscopy, a practical examination technique, every part of the nasopharynx (Fig. 6 and 7) can accurately be inspected in the conscious patient under magnification, with-
Fig. 2a and b Traumatic perforation of the eardrum, right (22-y., f.) The eardrum was perforated during an attempt to clean the external meatus with a "cotton bud". a) The external acoustic meatus reveals a slight epithelial lesion. In the depths, the perforation ( ) with its blood-tinged margins can be seen. Anteriorly, the remaining portion of the eardrum showing the light reflection. b) Further advancement of the ear endoscope made it possible to look into the tympanic cavity.
the nasopharynx. Since 90°-angle optics are now available, the examination with the mir-
ror and microscope, mouth-gag and veloretractor under general anaesthesia has
Fa. K. Storz KG, 7200 Tuttlingen, West-Germany
Fa. R. Wolf GmbH, 7134 Knittlingen, West Germany
Downloaded by: University of British Columbia. Copyrighted material.
who emphasized the improved exposure and the possibility of carrying out photographic documentation, and minor endoscopic procedures in the nasopharynx. This instrument is mostly used in combination with auxiliary instruments e. g. for velotraction (9). In 1975, the zoom laryngo-epipharyngoscope " "- developed by v. Stuckrad (1975) (20) (Fig. 5 and 6) a 90-degree Lumina
Nasal polyp, right (25-y., m.) On endoscopic inspection, the yellowish polyp in the posterior part of the nose can be seen. Fig. 3
Fig. 4
53
Glomus tumour in the right side of the
nose (66-y., m.) Between the middle nasal concha
and the nasal septum, a reddish tumour (1) the size of a cherry stone; cause of recurrent unilateral bleeding from the nose.
Zoom-endoscopic examination nasopharyngeal area (schematic) Fig. 5
of
the
Normal nasopharyngeal area (72-y., m.) Zoom endoscopic "overview". Fig. 6
Downloaded by: University of British Columbia. Copyrighted material.
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck
54
W. Steiner
tubal torus Fig. 7
(13-y., m.)
The glassy, spherical polyp
) hangs into the nasopharynx from the right side of the nose.
Fig. 8
Nasopharyngeal carcinoma TiNoMo (74-y., m.) The reddish tumour ( ) (histology: lymphoepithelial carcinoma, Schminke-Regaud) had led to a compression of the Eustachian tube with consecutive soundconduction hearing loss.
out auxiliary instruments. Biopsies can be taken (Fig. 8), and excisions of small lesions
under local anaesthesia in the office or ambulance (Witten 1970, Hellmich and Her-
can be carried out with appropriate optical
berhold 1971, Illum 1972, Draf 1973/78,
control (Jaumann and Steiner 1978) (5).
Buiter 1976, Terrier 1976/78) ". When considering a revision operation of the maxillary sinus, transnasal endoscopy employing angle optics if required supplemented by tomois very important graphic examinations
Endoscopy of the Paranasal Sinuses Maxillary Sinus Endoscopy of the maxillary sinus (Fig. 9) has been known since the beginning of this century (Hirschmann 1903, Reichert 1902) ".
Because of the development of improved
(21).
There is evidence that endonasal surgery of the maxillary sinus under endoscopic control
endoscopes it has, since the beginning of the 1970's, become an established routine procedure, which can be carried out in outpatients
(Wigand and Steiner 1977) (24) closed a
" For references see W. Draf "Endoskopie der
mucosa (with nasal window) according to
Nasennebenhöhlen". Springer, Berlin 1978
Caldwell-Luc. A new concept of performing
therapeutic gap between sinoscopic removal of solitary cysts and polyps (without nasal window) and the radical removal of the sinus
Downloaded by: University of British Columbia. Copyrighted material.
Choanal polyp on the right
Fig. 9 Retention cyst in the maxillary sinus, right (32-y., m.)
At the medial wall of the sinus, caudal to the physiological and accessory ostium, a small yellowish epithelial cyst (T) can be seen.
Fig. 10
55
Foreign body in the right frontal sinus
(37-y., m.) On the floor of the right frontal sinus, glass splinters (T) prior to their endoscopic extraction.
Fig. 11
Microlaryngoscopy after Kleinsasser under intubation anaesthesia (schematic).
surgery on the paranasal sinuses under endoscopic control with conservation of the
mucosae has been reported by Wigand (25) recently in this journal. Frontal sinus The inspection of the frontal sinus is carried out under local anaesthesia using endoscopes of small diameter (Boenninghaus 1974 (1),
Draf 1975/78 (2), Mann and Beck 1976) (11). The main indications for endoscopy of the frontal sinus are uncertain equivocal Xray findings in the presence of headache of unknown etiology. Posttraumatic endoscopy of the paranasal sinuses is helpful for adequate presurgery assessment or for the endoscopic extraction of glass splinters (Fig. 10) from the frontal sinus (16).
Downloaded by: University of British Columbia. Copyrighted material.
Techniques of Diagnost c and Operative Endoscopy of the Head and Neck
W. S e ner
Hyperkeratosis of the left vocal cord (44-y., m.) Circumscribed hyperkeratosis (T) histology: medium grade dysplasia of the middle and anterior left vocal cord (microlaryngoscopic aspect). Fig. 12
L
Fig. 13
Zoom endoscopic examination of the
larynx and pharynx (schematic).
Fig. 14
epiglottis
Sphenoid sinus The indication for endoscopy of the sphenoid sinus via the transnasal route under endoscopic vision is generally restricted to the
histological identification of a tumour as malignant or benign and the extent of its spread or to the identification of sphenoidal fractures (Draf 1978) (2).
Normal endolarynx (56-y., f.) Zoom endoscopic "overview".
Endoscopy of the Larynx
For more than 100 years, the larynx has been inspected with a mirror. In view of the endoscopic examination available today, this procedure, with all its disadvantages, represents a compromise which, in the absence of a better method, has long been tolerated. During the last 20 years, microlaryngoscopy as
Downloaded by: University of British Columbia. Copyrighted material.
56
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck
57
Oropharyngeal carcinoma on the right T2N3M0 (46-y., m.) Exulcerated tumour (ls ) in the right vallecula epiglottica, invading the lingual epiglottis and the pharyngo-epiglottic fold.
Fig. 16 Hypopharyngeal carcinoma on the right T1N3M0 (38-y., m.) Tumour ( ) the size of a pinhead
(histology: poorly keratinizing squamous cell carcinoma) at the medial wall of the piriform sinus.
developed by Kleinsasser (1960/76) (8) (Fig. 11) for diagnostic and therapeutic
approach to the larynx under general anaesthesia, has found widespread acceptance. In endolaryngeal microsurgery (Fig. 12), numerous diagnostic and therapeutic techniques can be employed during microlaryngoscopy. In the last few years, endolaryngeal laser surgery
has been gaining in importance (Strong and Jako 1972) (19). Non-intubation microlaryngoscopy with jet ventilation (Stange 1973) (14) represents a technical enrichment of the endoscopic possibilities even though its indication is limited. In 1968, for the first time, Sawashima and
Hirose (1968) (26) reported on the use of flexible fiberscopes in the larynx. Since that
time, few reports on experiences with this method have been published (Williams, 1975)
(26). In 1974 we, too, tested flexible fiberscopes, manufactured by Olympus, for use in
the inspection of the pharynx and larynx However, we found that the rigid endoscopes are superior for diagnostic inspection of the pharynx and larynx (wider viewing field, better resolution, more reliable biopsy, brighter
image with high quality photographic and film documentation.
The laryngoscope with a 90°-angle Hop-
kins optic developed by Ward and Berci (1974) (23), has considerable advantages over
mirror examination, but is used largely for photographic documentation. By using an
Downloaded by: University of British Columbia. Copyrighted material.
Fig. 15
58
W. Steiner
(1975) (20). This 90°-angle Lumina optic
(Fig. 13) allows a thorough inspection of the larynx (Fig. 14) and pharynx in the conscious patient, without the need of auxiliary instruments. It has proved very suitable for the early detection of cancer of the pharyngolarynx in screening programs (Steiner, 1976) (15) "Direct" vision and magnification facilitate the removal of biopsy specimens and excision of tissue under topical spray anaesthesia with high safety and reliability. Photographic, video and film documentation can easily be carried out by fitting the camera directly to the instrument's eyepiece (18). Zoom endoscopy enabled the introduction and establishment of new diagnostic methods for laryngeal
diseases, such as electromyography in the conscious patient with selective recording of action potentials from single laryngeal muscles (22) and needle biopsy for the histological examination of tumours growing beneath the mucosa in the pharynx and larynx (17).
Zoom endoscopy may be considered a routine examination method capable of
replacing the mirror. In many cases microlaryngoscopic examinations under general
anaesthesia can be replaced by this single procedure.
Endoscopy of the Oro-Hypopharynx The modern endoscopic examination techniques, such as zoom-endoscopy in the conscious patient and microlaryngoscopy under general anaesthesia as described for the larynx also permit reliable evaluation of the oropharynx (Fig. 15) and hypopharynx (Fig. 16) in the majority of the cases (Jaumann and Steiner, 1978) (6). Oesophagoscopy would be necessary to exclude a malignant tumour in a patient presenting swallowing problems, or to establish the extent of a carcinoma in the piriform sinus or in the postcricoid region. References 1 Boenninghaus, H.-G.: Rhinochirurgische Aufgaben bei der Chirurgie des an die Schädelbasis angrenzenden Gesichtsschädels. Arch. Oto-Rhino-Laryng. 207 (1974) 1
2 Draf, W.: Therapeutic Endoscopy of the Paranasal Sinuses. Endoscopy 10 (1978) 247
3 Eichner, H.: Eine Mother-and-Baby-scope Optik zur Trommelfell- und Mittelohr-Endoskopie. Laryng. Rhinol. 57 (1978) 872 4 Jaumann, M. P., W. Steiner: Moderne otorhinolaryngologische Endoskopie beim Kind. 1. Endoskopie am wachen Kind. Pädiat. Prax. 20 (1978) 229 5 Jaumann, M. P., W. Steiner: Endoscopy of the Nose and Nasopharynx. Endoscopy 10 (1978) 240
6 Jaumann, M. P., W. Steiner, H.-J. Pesch: Leitsymptom Globusgefühl. Endoskopische, röntgenologische und histomorphologische Differentialdiagnose von Proliferanten in Oro- und Hypopharynx. Dtsch. Ärztebl. 75 (1978) 479 7 Jung, H.: lndikation zur operativen Eingriffen im Bereich des Nasenrachenraumes und der mittleren Schädelbasis. Laryng. Rhino]. 55 (1976) 932 8 Kleinsasser, O.: Mikrolaryngoskopie und endolaryngeale Mikrochirurgie. F. K. Schattauer Verlag Stuttgart (1976)
9 Kuske, I., A. Karduck, W. Bartholomé: Diagnostic Value of Nasopharyngeal Endoscopy for the Early Recognition of Tumours. Endoscopy 9 (1977) 199 10 Lenz, H., J. Eichler, J. Knopf, J. Salk, G. Schafer: Endonasales Argon-Laser-Strahlfiihrungssystem und erste klinische Anwendungen bei der Rhinopathia vasomotorica. Laryng. Rhinol. 56 (1977) 749 11 Mann, W., C. Beck: Stirnhöhlenendoskopie. Fortschritte in der Endoskopie (1976) 101; Herausg. W. Rösch, Perimed Verlag Erlangen
12 Messerklinger, W.: Endoscopy of the Nose. Urban & Schwarzenberg, Miinchen (1978)
13 Prott, W.: Möglichkeiten einer Endoskopie des Kleinhirnbrückenwinkels auf transpyramidalem-retrolabyrinthärem Zugangsweg Cisternoskopie. HNO 22 (1974) 337
14 Stange, G., E. Gebert, P. Pedersen: Eine neue Methode zur Injektionsanästhesie bei der direkten Laryngoskopie. Arch. klin. exp. Ohren-, Nasen- und Kehlk. Heilk. 204 (1973) 285
15 Steiner, W.: Krebsfriiherkennung in Mund, Rachen und Kehlkopf. Dtsch. Arztebl. 73 (1976) 3159 16 Steiner, W., M. P. Jaumann, M. E. Wigand, C. Gammert: Operative Endoscopy of the Upper Respiratory System. Endoscopy 9 (1977) 121 17 Steiner, W. M. P. Jaumann, H.-J. Pesch: Endoskopische Nadelbiopsie in Rachen und Kehlkopf. HNO 26 (1978) 168
18 Steiner, W., M. P. Jaumann: Endoscopic Diagnosis and Therapy of the Trachea. Endoscopy 10 (1978) 149 19 Strong, M. S., G. J. Jako: Laser Surgery in the Larynx. Early clinical Experience with continous CO2-Laser. Ann. Otol. Rhinol. Laryngol. 81 (1972) 791 20 v. Stuckrad, H., I. Lakatos: Ober ein neues Lupenlaryngoskop (Epipharyngoskop). Laryng. Rhinol. 54 (1975) 336 21 Thumfart, W., W. Steiner, M. P. Jaumann: Diagnose und Indikation zur Revision der radikal voroperierten Kiefer-
höhle. HNO 26 (1978) 289 22 Thumfart, W., W. Steiner, M. P. Jaumann: Lupenendoskopische Elektromyographie des M. crico-arytaenoideus dorsalis am wachen Patienten. HNO 27 (1979) in press 23 Ward, P. H., G. Berci, T. Calcaterra: Advances in Endoscopic Examination of the Respiratory System. Ann. Otol. Rhinol. Laryngol. 83 (1974) 754 24 Wigand, M. E., W. Steiner: Endonasale Kieferhöhlenoperation mit endoskopischer Kontrolle. Laryng. Rhinol. 56 (1977) 421
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appropriate variable objective, magnification can be obtained. A decisive step forward in oto-rhino-laryngological endoscopy was the development of the laryngo-epipharyngoscope by v. Stuckrad
Techniques of Diagnostic and Operative Endoscopy of the Head and Neck 25 Wigand, M. E., W. Steiner, M. P. Jaumann: Endonasal Sinus Surgery with Endoscopical Control: From Radical Operation to Rehabilitation of the Mucosa. Endoscopy 10 (1978) 255
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26 Williams, G. T., J. M. Farquharson, J. Anthony: Fibreoptic Laryngoscopy in the Assessment of Laryngeal Disorders. J. Laryngol. Otol. 89 (1975) 299
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Dr. med. habil. W. Steiner, University of Erlangen-Nuremberg, Department of Otorhinolaryngology, Waldstr. 1, D-8520 Erlangen, West Germany
