Atlas of Head and Neck Surgery E-Book

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Atlas of Head and Neck Surgery, by Drs. James I. Cohen and Gary L. Clayman, delivers unparalleled visual guidance and insight to help you master the most important and cutting-edge head and neck procedures. Clear, consistent black-and-white drawings and detailed text lead you through each step of all standard operations, while commentary from leading experts presents alternative techniques – complete with explanations about the differences, nuances, pearls, and pitfalls of each approach. Concise yet complete, this easily accessible text captures groundbreaking techniques such as video-assisted thyroid and parathyroid surgeries; transoral laser surgeries; and robotic surgeries. This surgical technique reference is an ideal resource for planning and performing successful head and neck surgery or preparing for the head and neck portion of the Otolaryngology boards.

  • Understand how to proceed thanks to an abundance of explicit illustrations and detailed text that take you from one step to the next.
  • Quickly find the information you need to make confident decisions. Relevant indications/contraindications, pre-operative considerations, and post operative management are presented in an easily accessible format.
  • Discern the nuances and understand the differences between standard operations and alternate techniques. Experts debate each procedure offering insightful explanations, rationale, and tips for avoiding complications.
  • Master new procedures such as video-assisted thyroid and parathyroid surgeries; transoral laser surgeries; and robotic surgeries. Section editor F. Christopher Holsinger, MD, FACS, is at the forefront of many of these techniques, some of which are being illustrated for the first time here.
  • Learn from some of the very best - Experts from the MD Anderson Cancer Center and the Oregon Health & Science University (OHSU) share their innovative approaches to the surgical techniques and complications management most frequently seen in practice.
  • Understand specific variations in anatomy as they apply to each procedure.

Subjects

Books
Savoirs
Medicine
Médecine
Miastenia gravis
Cricopharyngeal Myotomy
Surgical incision
Oncology
Robotics
Stoma (disambiguation)
Hand
Parathyroid adenoma
Lymph node dissection
Surgical suture
Thyroid nodule
Bronchoscopy
Laryngotracheal stenosis
Branchial cleft cyst
Subglottic stenosis
Long terminal repeat
Ligation
Logic
Ranula
Reinnervation
Sentinel lymph node
Sentinel node
Dehiscence
Electrocoagulation
Pseudocyst
Lobectomy
Primary hyperparathyroidism
Gastrostomy
Neck dissection
Rhytidectomy
Microsurgery
Paraganglioma
Mediastinum
Lymphadenectomy
Neoplasm
Percutaneous endoscopic gastrostomy
Craniotomy
Surgical oncology
Parathyroidectomy
Thymectomy
Laryngectomy
Thyroglossal cyst
Skin grafting
Melanoma
Hyperparathyroidism
Esophagogastroduodenoscopy
Tracheal tube
Review
Osteotomy
Hypercalcaemia
Pedicle
Physician assistant
Angiography
Parathyroid hormone
Laryngoscopy
Wound
Tonsillectomy
Anastomosis
Cauterization
Tracheotomy
Tetralogy of Fallot
Thyroidectomy
Endoscopy
Barrett's esophagus
Cyst
List of surgical procedures
Trachea
Mucous membrane
Reconciliation
Human pharynx
X-ray computed tomography
Philadelphia
Infection
Positron emission tomography
Paralysis
Neurosurgery
Magnetic resonance imaging
General surgery
Chemotherapy
Carbon dioxide
Abscess
Perforation
Button
Diverticulum
Mirror
Neck
Dissection
Cornus
Viewpoint
Release
Ring
Surface
Copyright

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Published 06 June 2011
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EAN13 9781455728473
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Atlas of Head & Neck
Surgery
James I. Cohen, MD, PhD, FACS
Professor, Department of Otolaryngology/Head and Neck
Surgery; Chief Otolaryngology/Assistant Chief Surgery,
Portland VA Medical Center; Oregon Health and Science
University, Portland, Oregon
Gary L. Clayman, MD, DMD, FACS
Alando J. Ballantyne Distinguished Chair of Head and Neck
Surgery; Professor of Surgery and Cancer Biology; Director of
Interdisciplinary Program in Head and Neck Oncology; Chief,
Section of Head and Neck Endocrine Surgery; Deputy Head
Division of Surgery, University of Texas MD Anderson Cancer
Center, Houston, Texas
S a u n d e r sFront Matter
Atlas of Head & Neck Surgery
James I. Cohen, MD, PhD, FACS
Professor, Department of Otolaryngology/Head and Neck Surgery
Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical
Center
Oregon Health and Science University
Portland, Oregon
Gary L. Clayman, MD, DMD, FACS
Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery
Professor of Surgery and Cancer Biology
Director of Interdisciplinary Program in Head and Neck Oncology
Chief, Section of Head and Neck Endocrine Surgery
Deputy Head Division of Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas?
?
Copyright
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF HEAD & NECK SURGERY ISBN: 978-1-4160-3368-4
Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights
reserved.
No part of this publication may be reproduced or transmitted in any form or
by any means, electronic or mechanical, including photocopying, recording, or
any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency, can be found
at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this eld are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should
be mindful of their own safety and the safety of others, including parties for
whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identi ed, readers are
advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify
the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Atlas of head & neck surgery / [edited by] James I. Cohen, Gary L. Clayman.
—1st ed.
p. ; cm.
Atlas of head and neck surgery
Includes bibliographical references and index.
ISBN 978-1-4160-3368-4 (hardcover : alk. paper) 1. Head—Surgery—
Atlases. 2. Neck—Surgery—Atlases. I. Cohen, James I. II. Clayman, Gary L.
III. Title: Atlas of head and neck surgery.
[DNLM: 1. Head—surgery—Atlases. 2. Neck—surgery—Atlases. WE 17]
RD521.A843 2011
617.5′1059—dc22
2011010051
Acquisitions Editor: Stefanie Jewell-Thomas
Developmental Editor: Roxanne Halpine Ward
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Designer: Louis Forgione
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1 Dedication
This book is dedicated to the concept that the wisdom and humility essential to
the practice of medicine are best acquired by rejecting dogma and instead
exploring the controversy that surrounds much of what we do every day. My
lifelong pursuit of this ideal has required constant nurturing. For this, I am forever
indebted to my father who instilled it in me at an early age by design and
example, to three decades of residents who have helped me learn and teach in this
context, and especially to my wife, Sherry, and my children, Alex and Adam, who
have always supported me with love and affection.
James I. Cohen
How we develop as individuals is shaped by both our genetics and our
environment. I dedicate this book to those who have directly and indirectly shaped
my life, and although I am hesitant to make too long of a list, such an opportunity
comes too infrequently. My parents provided encouragement, support, and love
for which I am forever grateful. I have had the honor to be educated by and to
refer to as colleagues, several surgeons who have been icons in the field of head
and neck surgery. These men inspired me with their wisdom, surgical art form,
and humility and have remained within me throughout my career. They notably
include Drs. Helmuth Goepfert, Alando J. Ballantyne, Robert Byers, and Oscar
Guillamondegui. Inspiration has also come from the honor and joy of training
immensely talented and brilliant residents and fellows during the past 20 years.
Finally, my family, including my loving wife, Mikyung, my beautiful children,
Beau and Elizabeth, and my brothers, Lawrence and Marty, and my dear friends
have provided endless love and care and the smiles, joy, and laughter that give my
life meaning.
Gary L. ClaymanAssociate Editors
Peter E. Andersen, MD, Professor, Department of
Otolaryngology/Head and Neck Surgery
Professor, Department of Neurosurgery
Director of Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Ehab Hanna, MD, FACS, Professor and Vice Chairman
Director of Skull Base Surgery
Department of Head and Neck Surgery
Medical Director, Head and Neck Center
University of Texas MD Anderson Cancer Center
Houston, Texas
F. Christopher Holsinger, MD, FACS, Associate Professor,
Department of Head and Neck Surgery
Director, Program in Minimally Invasive and Endoscopic
Head and Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
William M. Lydiatt, MD, FACS, Professor and Vice Chair,
Department of Otolaryngology
Director of Head and Neck Surgery
University of Nebraska Medical Center
Professor, Department of Head and Neck Surgery
Nebraska Methodist Hospital
Omaha, Nebraska
Joshua S. Schindler, MD, Assistant Professor,
Department of Otolaryngology
Medical Director, OHSU-Northwest Clinic for Voice and
Swallowing
Oregon Health and Science University
Portland, OregonMark K. Wax, MD, FACS, FRCSC, Professor,
Otolaryngology/Head and Neck Surgery
Professor, Oral and Maxillofacial Surgery
Program Director
Director, Microvascular Reconstruction
Coordinator, Education, AAOHNS(F)
Department of Otolaryngology/Head and Neck Surgery
Oregon Health Sciences University
Portland, OregonContributors
Peter E. Andersen, MD, Professor, Department of
Otolaryngology/Head and Neck Surgery
Professor, Department of Neurosurgery
Director of Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Mihir K. Bhayani, MD, Fellow, Department of Head and
Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
Apostolos Christopoulos, MD, MSc, FRCSC, Assistant
Professor, Department of Otorhinolaryngology
Centre Hospitalier de l’Université de Montréal
Montréal, Québec, Canada
Woong Youn Chung, MD, PhD, Associate Professor,
Department of Surgery
Yonsei University College of Medicine
Seoul, Republic of Korea
Gary L. Clayman, MD, DMD, FACS, Alando J. Ballantyne
Distinguished Chair of Head and Neck Surgery
Professor of Surgery and Cancer Biology
Director of Interdisciplinary Program in Head and Neck
Oncology
Chief, Section of Head and Neck Endocrine Surgery
Deputy Head Division of Surgery, University of Texas MD
Anderson Cancer Center
Houston, Texas
James I. Cohen, MD, PhD, FACS, Professor, Department
of Otolaryngology/Head and Neck Surgery
Chief Otolaryngology/Assistant Chief Surgery, PortlandVA Medical Center
Oregon Health and Science University
Portland, Oregon
Robert L. Ferris, MD, PhD, FACS, Professor and
ViceChair of Clinical Operations
Departments of Otolaryngology, Radiation Oncology,
and Immunology
Eye & Ear Institute
Pittsburgh, Pennsylvania
Paul W. Gidley, MD, FACS, Associate Professor, Head and
Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
Neil D. Gross, MD, FACS, Assistant Professor,
Otolaryngology/Head and Neck Surgery
Oregon Health and Science University
Attending Surgeon, Operative Care Division
Portland VA Medical Center
Portland, Oregon
Ehab Hanna, MD, FACS, Professor and Vice Chairman
Director of Skull Base Surgery
Department of Head and Neck Surgery
Medical Director, Head and Neck Center
University of Texas MD Anderson Cancer Center
Houston, Texas
F. Christopher Holsinger, MD, FACS, Associate Professor,
Department of Head and Neck Surgery
Director, Program in Minimally Invasive and Endoscopic
Head and Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
Kitti Jantharapattana, MD, Postdoctoral Fellow, Head
and Neck Surgery
MD Anderson Cancer Center
Houston, TexasInstructor, Otolaryngology Head and Neck Surgery
Prince of Songkla University
Songkhla, Thailand
Ollivier Laccourreye, MD, Professor, Department of
Otorhinolaryngology–Head and Neck Surgery
University Descartes-Paris V
Hôpital Européen Georges Pompidou
Member, Académie Nationale de Chirurgie
Paris, France
Daniel D. Lydiatt, MD, DDS, FACS, Professor and Interim
Chair, Otolaryngology/Head and Neck Surgery
University of Nebraska Medical Center
Medical Director, Head and Neck Surgery
Nebraska Methodist Hospital
Omaha, Nebraska
William M. Lydiatt, MD, FACS, Professor and Vice Chair,
Department of Otolaryngology
Director of Head and Neck Surgery
University of Nebraska Medical Center
Professor, Department of Head and Neck Surgery
Nebraska Methodist Hospital
Omaha, Nebraska
Henry A. Milczuk, MD, Associate Professor
Chief, Pediatric Otolaryngology
Department of Otolaryngology–Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Raul Pellini, MD, Attending Surgeon, Department of
Otolaryngology–Head and Neck Surgery
National Cancer Institute “Regina Elena”
Rome, Italy
Greg Reece, MD, Professor of Plastic Surgery
Department of Plastic Surgery
University of Texas MD Anderson Cancer Center
Houston, TexasPaolo Ruscito, MD, Attending Surgeon, Department of
Otolaryngology–Head and Neck Surgery
National Cancer Institute “Regina Elena”
Rome, Italy
Joshua S. Schindler, MD, Assistant Professor,
Department of Otolaryngology
Medical Director, OHSU-Northwest Clinic for Voice and
Swallowing
Oregon Health and Science University
Portland, Oregon
Giuseppe Spriano, MD, Chief, Department of
Otolaryngology–Head and Neck Surgery
Director, Department of Neuroscience
National Cancer Institute “Regina Elena”
Rome, Italy
Mark K. Wax, MD, FACS, FRCSC, Professor,
Otolaryngology/Head and Neck Surgery
Professor, Oral and Maxillofacial Surgery
Program Director
Director, Microvascular Reconstruction
Coordinator, Education, AAOHNS(F)
Department of Otolaryngology/Head and Neck Surgery
Oregon Health Sciences University
Portland, Oregon
Gregory S. Weinstein, MD, Professor and Vice Chair,
Otorhinolaryngology: Head and Neck Surgery
University of Pennsylvania
Philadelphia, Pennsylvania
Mark E. Zafereo, MD, Fellow, Head and Neck Surgery
MD Anderson Cancer Center
Houston, TexasReviewers
Peter E. Andersen, MD, Professor, Department of
Otolaryngology/Head and Neck Surgery
Professor, Department of Neurosurgery
Director of Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
William B. Armstrong, MD, Professor of Clinical
Otolaryngology and Chair, Otolaryngology–Head and
Neck Surgery
University of California–Irvine
Irvine, California
Leon A. Assael, DMD, Professor and Chair of Oral and
Maxillofacial Surgery
Medical Director, Hospital Dentistry
Oregon Health and Science University
Portland, Oregon
Stephen W. Bayles, MD, FACS, Deputy Chief of Surgery
Section Head-Otolaryngology
Director of Head and Neck Oncology
Virginia Mason Medical Center
Seattle, Washington
Peter C. Belafsky, MD, PhD, Associate Professor and
Director, Center for Voice and Swallowing
University of California–Davis
Sacramento, California
Manuel Bernal-Sprekelsen, MD, PhD, Head of Ear, Nose
and Throat Department, Otorhinolaryngology, Hospital
Clinic
Tenure Professor for Otorhinolaryngology, Department
for Surgical Specialties
University of Barcelona
Barcelona, Spain
Privatdozent for ORLRuhr-University
Bochum, Germany
Nasir I. Bhatti, MD, FACS, Associate Professor,
Department of Otolaryngology Head and Neck Surgery
Johns Hopkins University School of Medicine
Baltimore, Maryland
Brian B. Burkey, MD, FACS, Section Head, Head and Neck
Surgery and Oncology
Head and Neck Institute
Cleveland Clinic Foundation
Cleveland, Ohio
Adjunct Professor, Department of Otolaryngology
Vanderbilt University Medical Center
Nashville, Tennessee
Bruce H. Campbell, MD, FACS, Professor, Department of
Otolaryngology and Communication Sciences
Medical College of Wisconsin
Milwaukee, Wisconsin
William R. Carroll, MD, Professor and Director of Head
and Neck Oncology
Department of Surgery
University of Alabama–Birmingham
Birmingham, Alabama
Salvatore M. Caruana, MD, Assistant Professor,
Department of Otolaryngology–Head and Neck Surgery
Columbia University
New York, New York
Claudio R. Cernea, MD, Associate Professor of Surgery,
Department of Head and Neck Surgery
University of Sao Paulo Medical School
Sao Paulo, Brazil
Francisco J. Civantos, MD, FACS, Associate Professor
Co-Director, Division of Head and Neck Surgery
Department of Otolaryngology
Sylvester Cancer Center/University of Miami Hospitaland Clinics
Miami, Florida
Gary L. Clayman, MD, DMD, FACS, Alando J. Ballantyne
Distinguished Chair of Head and Neck Surgery
Professor of Surgery and Cancer Biology
Director of Interdisciplinary Program in Head and Neck
Oncology
Chief, Section of Head and Neck Endocrine Surgery
Deputy Head Division of Surgery, University of Texas MD
Anderson Cancer Center
Houston, Texas
James I. Cohen, MD, PhD, FACS, Professor, Department of
Otolaryngology/Head and Neck Surgery
Chief Otolaryngology/Assistant Chief Surgery, Portland
VA Medical Center
Oregon Health and Science University
Portland, Oregon
Seth M. Cohen, MD, MPH, Assistant Professor, Duke Voice
Care Center
Division of Otolaryngology–Head and Neck Surgery
Duke University Medical Center
Durham, North Carolina
Ted A. Cook, MD, FACS, Professor, Facial Plastic and
Reconstructive Surgery
Department of Otolaryngology/Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Robin T. Cotton, MD, FACS, FRCSC, Director, Pediatric
Otolaryngology–Head and Neck Surgery
Director, Aerodigestive and Sleep Center
Cincinnati Children’s Hospital
Professor, Otolaryngology–Head and Neck Surgery
University of Cincinnati College of Medicine
Cincinnati, Ohio
Mark S. Courey, MD, Professor, Otolaryngology–Head
and Neck SurgeryUCSF Medical Center
Director, Division of Laryngology
University of California–San Francisco
San Francisco, California
Bruce J. Davidson, MD, Professor and Chairman,
Department of Otolaryngology–Head and Neck Surgery
Georgetown University Medical Center
Washington, District of Columbia
Terry A. Day, MD, Professor and Clinical Vice Chairman,
Department of Otolaryngology–Head and Neck Surgery
Medical University of South Carolina
Charleston, South Carolina
Daniel G. Deschler, MD, FACS, Director, Division of Head
and Neck Surgery
Department of Otolaryngology–Head and Neck Surgery
Massachusetts Eye and Ear Infirmary
Associate Professor, Department of Otology and
Laryngology
Harvard Medical School
Boston, Massachusetts
Gianlorenzo Dionigi, MD, FACS, Associate Professor of
Surgery, Department of Surgical Sciences
University of Insubria
Varese, Italy
Paul James Donald, MD, FRCSC, Professor and Vice
Chair, Otolaryngology–Head and Neck Surgery
University of California, Davis
Sacramento, California
David W. Eisele, MD, FACS, Professor and Chairman,
Department of Otolaryngology–Head and Neck Surgery
Irwin Mark Jacobs and Joan Klein Jacobs Endowed Chair
in Head and Neck Cancer
UCSF Helen Diller Family Comprehensive Cancer Center
University of California–San Francisco
San Francisco, CaliforniaD. Gregory Farwell, MD, FACS, Associate Professor,
Otolaryngology–Head and Neck Surgery
University of California–Davis
Sacramento, California
Fred G. Fedok, MD, FACS, Professor and Chief, Section of
Facial Plastic and Reconstructive Surgery
Division of Otolaryngology/Head and Neck Surgery
Department of Surgery
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania
Robert L. Ferris, MD, PhD, FACS, Professor and Vice-Chair
of Clinical Operations
Departments of Otolaryngology, Radiation Oncology,
and Immunology
Eye & Ear Institute
Pittsburgh, Pennsylvania
Paul W. Flint, MD, Professor and Chair,
Otolaryngology/Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Jeremy L. Freeman, MD, FRCSC, FACS, Professor,
Department of Otolaryngology–Head and Neck Surgery
Professor, Department of Surgery
University of Toronto
Temmy Latner/Dynacare Chair in Head and Neck
Oncology
Mount Sinai Hospital/University of Toronto
Otolaryngologist in Chief, Department of
Otolaryngology–Head and Neck Surgery
Mount Sinai Hospital
Toronto, Ontario, Canada
Paul L. Friedlander, MD, FACS, Chairman, Department of
Otolaryngology
Tulane Medical Center
New Orleans, Louisiana
Neal Futran, MD, DMD, Professor and Chair,Otolaryngology–Head and Neck Surgery
University of Washington
Seattle, Washington
Markus Gapany, MD, Associate Professor,
Otolaryngology–Head and Neck Surgery
University of Minnesota
Minneapolis, Minnesota
C. Gaelyn Garrett, MD, Professor, Department of
Otolaryngology
Vanderbilt Medical Center
Medical Director, Vanderbilt Voice Center
Vanderbilt Bill Wilkerson Center for Otolaryngology and
Communication Sciences
Nashville, Tennessee
Eric M. Genden, MD, FACS, Professor and Chairman,
Department of Otolaryngology–Head and Neck Surgery
Professor of Neurosurgery
Mount Sinai School of Medicine
New York, New York
Helmuth Goepfert, MD, Professor Emeritus, Head and
Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
Andrew N. Goldberg, MD, MSCE, FACS, Professor,
Director, Division of Rhinology and Sinus Surgery
Department of Otolaryngology–Head and Neck Surgery
University of California–San Francisco
San Francisco, California
Neil D. Gross, MD, FACS, Assistant Professor,
Otolaryngology–Head and Neck Surgery
Oregon Health and Science University
Attending Surgeon, Operative Care Division
Portland VA Medical Center
Portland, Oregon
Patrick J. Gullane, MD, CM, FRCSC, FACS, FRACS (Hon),FRCS (Hon), Otolaryngologist-in-Chief, University Health
Network
Wharton Chair Head and Neck Surgery–Princess
Margaret Hospital
Professor and Chair, Department of Otolaryngology Head
and Neck Surgery
University of Toronto
Department of Otolaryngology–Head and Neck Surgery
University Health Network
Toronto, Ontario, Canada
Gady Har-El, MD, FACS, Chairman, Department of
Otolaryngology–Head and Neck Surgery
Lenox Hill Hospital
New York, New York
Professor, Departments of Otolaryngology and
Neurosurgery
State University of New York–Downstate Medical Center
Brooklyn, New York
Adjunct Professor, Otolaryngology–Head and Neck
Surgery
New York University
New York, New York
Amy C. Hessel, MD, Associate Professor and Surgeon,
Department of Head and Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
Peter A. Hilger, MD, Professor, Division of Facial Plastic
Surgery
Department of Otolaryngology
University of Minnesota
Minneapolis, Minnesota
Frans J.M. Hilgers, MD, PhD, Chairman-Emeritus, Head
and Neck Oncology and Surgery
The Netherlands Cancer Institute–Antoni van
Leeuwenhoek Hospital
Professor, Oncology-Related Voice and Speech Disorders
Institute of Phonetic Sciences
Amsterdam Center for Language and Communication–University of Amsterdam
Consultant, Head and Neck Oncology and Surgery,
Otorhinolaryngology
Academic Medical Center–University of Amsterdam
Amsterdam, The Netherlands
Henry T. Hoffman, MD, FACS, Professor
Director, Voice Clinic
Department of Otolaryngology
University of Iowa Hospitals and Clinics
Iowa City, Iowa
F. Christopher Holsinger, MD, FACS, Associate Professor,
Department of Head and Neck Surgery
Director, Program in Minimally Invasive and Endoscopic
Head and Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
David B. Hom, MD, FACS, Professor, Director, Division of
Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
University of Cincinnati College of Medicine and
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
David Howard, MD, Professor of Head and Neck Oncology
Imperial College London
Consultant Head and Neck Surgeon
Charing Cross Hospital
London, United Kingdom
Jonathan Irish, ND, FRCSC, Chief, Department of Surgical
Oncology
Princess Margaret Hospital
University Health Network
Toronto, Ontario, Canada
Jonas T. Johnson, MD, Professor and Chairman,
Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, PennsylvaniaLarry R. Kaiser, MD, President, The University of Texas
Health Science Center at Houston
Houston, Texas
Emad Kandil, MD, FACS, Assistant Professor of Surgery,
Department of Surgery
Tulane University School of Medicine
New Orleans, Louisiana
Dennis Kraus, MD, Attending Surgeon, Head and Neck
Surgery Service
Department of Surgery
Memorial Sloan-Kettering Cancer Center
Professor, Department of Otorhinolaryngology–Head and
Neck Surgery
Cornell University Medical Center
New York, New York
Ronald B. Kuppersmith, MD, MBA, FACS, Texas Ear, Nose,
and Throat and Allergy
College Station, Texas
Ollivier Laccourreye, MD, Professor, Department of
Otorhinolaryngology–Head and Neck Surgery
University Descartes-Paris V
Hôpital Européen Georges Pompidou
Member, Académie Nationale de Chirurgie
Paris, France
Eric S. Lambright, MD, Assistant Professor of Thoracic
Surgery
Surgical Director of Lung Transplant
Vanderbilt Thoracic Surgery
Vanderbilt University Medical Center
Nashville, Tennessee
Jeffrey E. Lee, MD, Professor of Surgery, Department of
Surgical Oncology
University of Texas MD Anderson Cancer Center
Houston, Texas
John P. Leonetti, MD, Professor and Vice-Chairman,Neurotology, Otology, and Skull Base Surgery
Co-Director of the Loyola Center for Cranial Base
Surgery
Department of Otolaryngology–Head and Neck Surgery
Loyola University Medical Center
Maywood, Illinois
Celestino Pio Lombardi, MD, Endocrine Surgery
Department
Università Cattolica Del Sacro Cuore Policlinico Gemelli
Rome, Italy
William M. Lydiatt, MD, FACS, Professor and Vice Chair,
Department of Otolaryngology
Director of Head and Neck Surgery
University of Nebraska Medical Center
Professor, Department of Head and Neck Surgery
Nebraska Methodist Hospital
Omaha, Nebraska
Jeffery Scott Magnuson, MD, Associate Professor of
Surgery, Residency Program Director, Department of
Surgery
Division of Otolaryngology
University of Alabama at Birmingham
Birmingham, Alabama
Robert H. Maisel, MD, FACS, Professor, Department of
Otolaryngology–Head and Neck Surgery
University of Minnesota
Chief, Department of Otolaryngology–Head and Neck
Surgery
Hennepin County Medical Center
Minneapolis, Minnesota
Rosario Marchese-Ragona, MD, Assistant Professor,
Department of Medical and Surgical Specialties
Section of Otolaryngology Head and Neck Surgery
University of Padova
Padova, Italy
Robert G. Martindale, MD, PhD, Professor and Chief,Division of General Surgery
Department of Surgery
Oregon Health and Science University
Portland, Oregon
Sam J. Marzo, MD, Professor, Residency Program
Director
Director, Parmly Hearing Institute
Department of Otolaryngology–Head and Neck Surgery
Division of Otology, Neurotology, and Skull Base Surgery
Loyola University Health System
Maywood, Illinois
Timothy M. McCulloch, MD, Professor and Chairman,
Division of Otolaryngology Head and Neck Surgery
University of Wisconsin Hospital and Clinics
Madison, Wisconsin
Andrew J. McWhorter, MD, Director of Voice Center
Assistant Professor, Department of Otolaryngology–Head
and Neck Surgery
Louisiana State University Health Sciences Center
New Orleans, Louisiana
Jesus E. Medina, MD, FACS, Paul and Ruth Jonas
Professor, Department of Otorhinolaryngology
University of Oklahoma Health Sciences Center
Oklahoma City, Oklahoma
Eduardo Méndez, MD, MS, Assistant Professor,
Department of Otolaryngology–Head and Neck Surgery
University of Washington
Assistant Member, Clinical Research Division
Fred Hutchinson Cancer Research Center
Seattle, Washington
Albert L. Merati, MD, FACS, Associate Professor and
Chief, Laryngology
Department of Otolaryngology–Head and Neck Surgery
University of Washington School of Medicine
Adjunct Associate Professor, Department of Speech and
Hearing SciencesCollege of Arts and Sciences
University of Washington
Seattle, Washington
Tanya K. Meyer, MD, Assistant Professor
Department of Otolaryngology
University of Washington
Seattle, Washington
Paolo Miccoli, MD, Professor of Surgery
Head of the Department of Surgery
University of Pisa
Pisa, Italy
Henry A. Milczuk, MD, Associate Professor
Chief, Pediatric Otolaryngology
Department of Otolaryngology–Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Oleg Militsakh, MD, FACS, Assistant Professor, Director
Head and Neck Reconstructive Surgery
Division of Head and Neck Surgery
Department of Otolaryngology
University of Nebraska Medical Center
Assistant Professor, Director Head and Neck
Reconstructive Surgery
Department of Head and Neck Surgery
Nebraska Methodist Hospital–Estabrook Cancer Center
Omaha, Nebraska
Eric J. Moore, MD, Consultant, Otorhinolaryngology–
Head and Neck Surgery
Mayo Clinic
Associate Professor of Otolaryngology
Mayo College of Medicine
Rochester, Minnesota
Meijin Nakayama, MD, Associate Professor,
Otorhinolaryngology
Kitasato University School of Medicine
Sagamihara, Kanagawa, JapanRoger C. Nuss, MD, FACS, Assistant Professor of Otology
and Laryngology
Harvard Medical School
Children’s Hospital
Boston, Massachusetts
Kerry D. Olsen, MD, Professor, Otolaryngology Head and
Neck Surgery
Mayo Clinic
Rochester, Minnesota
Steven M. Olsen, MD, Resident, Otolaryngology Head and
Neck Surgery
Mayo Clinic
Rochester, Minnesota
Lisa A. Orloff, MD, FACS, Robert K. Werbe Distinguished
Professor of Head and Neck Cancer
Director, Division of Head and Neck and Endocrine
Surgery
Department of Otolaryngology, Head and Neck Surgery
University of California–San Francisco
San Francisco, California
Robert H. Ossoff, MD, DMD, Guy M. Maness Professor of
Laryngology and Care of the Voice
Department of Otolaryngology
Assistant Vice-Chancellor, Office of Compliance and
Corporate Integrity
Vanderbilt Medical Center
Nashville, Tennessee
Giorgio Peretti, MD, Associate Professor, Department of
Otorhinolaryngology–Head and Neck Surgery
University of Brescia
Brescia, Italy
Nancy D. Perrier, MD, FACS, Professor of Surgery,
Department of Surgical Oncology
University of Texas MD Anderson Cancer Center
Houston, TexasCesare Piazza, MD, Assistant Professor, Department of
Otorhinolaryngology–Head and Neck Surgery
University of Brescia
Brescia, Italy
Joe B. Putnam, Jr., MD, Professor of Surgery and
Chairman, Department of Thoracic Surgery
Ingram Professor of Cancer Research
Vanderbilt Ingram Cancer Center
Professor of Biomedical Informatics
Vanderbilt University Medical Center
Nashville, Tennessee
Gregory W. Randolph, MD, FACS, Director of General,
Thyroid, and Parathyroid Surgical Divisions
Massachusetts Eye and Ear Infirmary
Member, Division of Surgical Oncology and Endocrine
Surgical Service
Massachusetts General Hospital
Boston, Massachusetts
Associate Professor of Otology and Laryngology
Harvard Medical School
Cambridge, Massachusetts
Marc Remacle, MD, PhD, Professor, Associate Head,
Otorhinolaryngology–Head and Neck Surgery
Louvain University Hospital of Mont-Godinne
Mont-Godinne, Belgium
Alan T. Richards, MD, FACS, Associate Professor,
Otolaryngology–Head and Neck Surgery
University of Nebraska Medical Center
Associate Professor, Head and Neck Surgery
Nebraska Methodist Hospital
Omaha, Nebraska
William J. Richtsmeier, MD, PhD, Director, Clinician
Research, Department of Otolaryngology–Head and Neck
Surgery
Bassett Healthcare Network
Cooperstown, New YorkJohn A. Ridge, MD, PhD, Professor, Senior Member, and
Chief, Head and Neck Surgery Section
Departments of Surgery and Developmental Therapeutics
Fox Chase Cancer Center
Professor, Departments of Surgery and Otolaryngology–
Head and Neck Surgery
Temple University
Philadelphia, Pennsylvania
Clark A. Rosen, MD, FACS, Professor, Department of
Otolaryngology
University of Pittsburgh School of Medicine
Director, University of Pittsburgh Voice Center
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Eben L. Rosenthal, MD, Julius Hicks Professor of Surgery,
Division of Otolaryngology–Head and Neck Surgery
University of Alabama at Birmingham
Birmingham, Alabama
John R. Saunders, Jr., MD, MBA, Executive
VicePresident, Chief Medical Director
Medical Director, Milton J. Dance, Jr. Head and Neck
Center
Greater Baltimore Medical Center
Associate Professor, Otolaryngology–Head and Neck
Surgery
Surgery, Plastic Surgery
Johns Hopkins School of Medicine
Baltimore, Maryland
Joshua S. Schindler, MD, Assistant Professor, Department
of Otolaryngology
Medical Director, OHSU-Northwest Clinic for Voice and
Swallowing
Oregon Health and Science University
Portland, Oregon
David E. Schuller, MD, Vice President, Medical Center
Expansion and Outreach
Otolaryngology–Head and Neck SurgeryJohn W. Wolfe Chair in Cancer Research
College of Medicine
CEO Emeritus, Arthur G. James Cancer Hospital and
Richard J. Solove Research Institute
The Ohio State University
Columbus, Ohio
Aniel Sewnaik, MD, PhD, Head and Neck Surgeon,
Otorhinolaryngology Head and Neck Surgery
Erasmus MC-Daniel Den Hoed Cancer Center
Rotterdam, The Netherlands
Ashok R. Shaha, MD, FACS, Jatin P. Shah Chair in Head
and Neck Surgery
Head and Neck Service
Department of Surgery
Memorial Sloan-Kettering Cancer Center
Professor of Surgery, Department of Surgery
Weill Cornell Medical College
Cornell University
New York, New York
Maisie Shindo, MD, FACS, Professor, Otolaryngology
Thyroid and Parathyroid Division
Oregon Health and Science University
Portland, Oregon
William W. Shockley, MD, FACS, W. Paul Biggers
Distinguished Professor
Chief, Division of Facial Plastic and Reconstructive
Surgery
Department of Otolaryngology/Head and Neck Surgery
University of North Carolina School of Medicine
Attending Physician, Department of
Otolaryngology/Head and Neck Surgery
UNC Hospitals
Chapel Hill, North Carolina
James Sidman, MD, Director of Cleft and Craniofacial
Programs
Co-Director of Vascular Anomalies Program
Department of OtolaryngologyChildren’s Hospitals and Clinics of Minnesota
Professor of Otolaryngology and Pediatrics
University of Minnesota
Minneapolis, Minnesota
C. Blake Simpson, MD, Professor, Department of
Otolaryngology–Head and Neck Surgery
Director, The University of Texas Voice Center
University of Texas Health Science Center at San
Antonio
San Antonio, Texas
Catherine F. Sinclair, MD, FRACS, Instructor/Fellow Head
and Neck Surgery
Department of Surgery
Division of Otolaryngology Head and Neck Surgery
University of Alabama at Birmingham
Birmingham, Alabama
James D. Smith, MD, Professor Emeritus, Otolaryngology
Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Timothy L. Smith, MD, MPH, Professor and Chief,
Rhinology and Sinus Surgery
Department of Otolaryngology–Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
Carl Henry Snyderman, MD, Professor, Department of
Otolaryngology
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Robert A. Sofferman, MD, Professor of Surgery and Chief
Emeritus
Department of Surgery
Division of Otolaryngology
University of Vermont School of Medicine
Burlington, VermontJeffrey D. Spiro, MD, Professor of Surgery, Division of
Otolaryngology/Head and Neck Surgery
University of Connecticut School of Medicine
Farmington, Connecticut
Wolfgang Steiner, MD, Professor Emeritus, Department of
Otorhinolaryngology–Head and Neck Surgery
University of Goettingen
Goettingen, Germany
David J. Terris, MD, FACS, Porubsky Professor and
Chairman
Surgical Director, MCG Thyroid/Parathyroid Center
Department of Otolaryngology–Head and Neck Surgery
Medical College of Georgia
Augusta, Georgia
Ralph P. Tufano, MD, FACS, Associate Professor,
Department of Otolaryngology–Head and Neck Surgery
Director of the Johns Hopkins Hospital Multidisciplinary
Thyroid Tumor Center
Director, Thyroid and Parathyroid Surgery
Johns Hopkins School of Medicine
Baltimore, Maryland
Joseph Valentino, MD, Professor, Department of Surgery
Division Of Otolaryngology–Head and Neck Surgery
University of Kentucky College of Medicine
Chief of Head and Neck Surgery
Department of Surgery
Lexington Kentucky Veterans Medical Center
Lexington, Kentucky
Isabel Vilaseca, MD, PhD, Consultant,
Otorhinolaryngology
Hospital Clinic
Associate Professor of Otorhinolaryngology
Department for Surgical Specialties
University of Barcelona
Barcelona, Spain
Stephen J. Wang, MD, FACS, Associate Professor,Department of Otolaryngology–Head and Neck Surgery
University of California–San Francisco
San Francisco, California
Mark K. Wax, MD, FACS, FRCSC, Professor,
Otolaryngology–Head and Neck Surgery
Professor, Oral and Maxillofacial Surgery
Program Director
Director, Microvascular Reconstruction
Coordinator, Education, AAOHNS(F)
Department of Otolaryngology–Head and Neck Surgery
Oregon Health Sciences University
Portland, Oregon
Randal S. Weber, MD, Professor and Chair, Head and
Neck Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
Richard J. Wong, MD, Associate Attending Surgeon,
Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, New York
Steven M. Zeitels, MD, FACS, Eugene B. Casey Professor
of Laryngeal Surgery
Department of Surgery
Harvard Medical School
Director, Center for Laryngeal Surgery
Department of Surgery
Massachusetts General Hospital
Boston, Massachusetts


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Preface
Learning how to do an operation can be a daunting task, whether as a rst-year
resident preparing the night before a case never previously encountered or as a
surgeon in a busy practice faced with incorporating a new technique or
technology into his or her surgical repertoire. This book acknowledges the realities
of how this process occurs. Initially, “rote” learning of the steps involved may be
all that can be expected. Over time, it is hoped that an increased understanding of
the logic behind these steps and their sequence will be acquired, and this is where
most surgical atlases stop. We know, however, that di erent surgeons perform the
same operations in different ways, and these different techniques can work equally
well. Although this can be confusing and disconcerting to early trainees as they
work with di erent attending sta or preceptors, ultimately, being able to
reconcile the success of these di erent approaches requires a rm grasp of the
unifying concepts behind any procedure. Helping the reader reach this level while
still supporting the early phases of learning is the goal of this book.
The book is designed to be read in the same way it is assembled. We selected
authors with a known expertise in given procedures and asked them to break
down the operations into their component steps, much as they would direct an
early learner the rst time through the procedures in the operating room. We then
asked the authors to provide their logic, for both their technique and the sequence
of these steps. This information was interposed into the initial “step sequence” in a
separately identifiable way. Key references are provided, where needed.
With the chapters assembled with their artwork, each chapter was then sent to
two to four surgeons with known expertise in the subject matter. They were asked
to interject commentary into the chapter wherever they thought appropriate,
whether to provide emphasis, clari cation, or alternate strategies. This
commentary is provided in essentially unedited form, interposed in the original
author’s text, because we thought that this would best simulate a “virtual
conversation” taking place around an operation, such as one that would occur at a
surgical technique meeting session where a panel is asked to discuss a given
operation. We were surprised and grati ed to see the enthusiasm with which the
commentators approached the task. Finally, at the end of many of the chapters,
we have provided summary comments, when applicable, that seek to clarify
common themes, reconcile significant conflicts, or emphasize critical issues.%
Through the use of di erent fonts, color schemes, and paragraph structure, the
publisher has preserved the concept of the sequence of the writing process. This
allows the reader, depending on his or her knowledge base or time constraints, to
read (or reread) the operation at the most appropriate level for his or her need at
that point in time. We think that it allows a logical sequence of knowledge
acquisition, whether it be rudimentary memorization, review of the steps, a more
in-depth understanding of the logic of these steps, or an analysis of the guiding
principles that underpin the operation as a whole, through the commentary.
We hope the reader enjoys this approach as much as we have enjoyed
assembling it. We think that the discipline of the framework it provides is valid not
only for the operations outlined here but also for a lifelong learning process that
will allow for the newer techniques and technology that we all will and must
confront over the course of our professional lives.
James I. Cohen
Gary L. Clayman
Editors in ChiefTable of Contents
Front Matter
Copyright
Dedication
Associate Editors
Contributors
Reviewers
Preface
Unit I: Benign Upper Aerodigestive Disease
Section A: Adult Endoscopy
Chapter 1: Clinical Diagnostic Nasopharyngoscopy
Chapter 2: Diagnostic Clinical Pharyngoscopy and Laryngoscopy
Chapter 3: Operative Pharyngoscopy and Laryngoscopy
Chapter 4: Operative Esophagoscopy and Percutaneous Gastrostomy
Chapter 5: Operative Bronchoscopy
Section B: Airway Operations
Chapter 6: Tracheotomy
Chapter 7: Laryngotracheal Reconstruction for Subglottic and Proximal
Tracheal Stenosis
Chapter 8: Cricotracheal Resection for Subglottic Stenosis
Chapter 9: Surgery for Unilateral Vocal Fold Paralysis
Chapter 10: Excision of Saccular Cysts and Laryngoceles
Section C: Neck
Chapter 11: Drainage of Deep Space Neck Infections
Chapter 12: Thyroglossal Duct Cyst Excision (Sistrunk Procedure)
Chapter 13: Branchial Cleft Cyst ExcisionSection D: Pharyngeal Operations
Chapter 14: Operations on the Cervical Esophagus and Cervical Spine
Chapter 15: Cricopharyngeal Myotomy and Surgical Management of
Zenker’s Diverticulum
Chapter 16: Defatting Tracheotomy
Unit II: Neck and Salivary Gland
Section A: Neck Dissection
Chapter 17: Radical Neck Dissection
Chapter 18: Modified Radical Neck Dissection
Chapter 19: Selective Neck Dissection, Levels I-III (Supraomohyoid Neck
Dissection)
Chapter 20: Selective Neck Dissection, Levels I-IV and II-IV (Anterolateral
and Lateral Neck Dissection)
Chapter 21: Posterolateral Neck Dissection
Chapter 22: Retropharyngeal Lymph Node Dissection
Chapter 23: Sentinel Lymph Node Biopsy
Section B: Salivary Gland Operations
Chapter 24: Superficial Parotidectomy
Chapter 25: Submandibular Gland Excision
Chapter 26: Excision of Ranula
Chapter 27: Parapharyngeal Space Tumor
Chapter 28: Resection of Carotid Body Tumor
Unit III: Oral Cavity and Oropharyngeal Operations
Section A: Transoral
Chapter 29: Transoral Resections
Chapter 30: Extended Approaches to the Oropharynx
Chapter 31: Transoral Robotic Surgery
Section B: Operations on the Mandible and Maxilla
Chapter 32: Composite Resection with Segmental Mandibulectomy
Chapter 33: Transhyoid and Lateral Pharyngotomy
Unit IV: Laryngopharyngeal OperationsSection A: Laryngectomy
Chapter 34: Exam Under Anesthesia for the Patient with Cancer
Chapter 35: Horizontal Supraglottic Laryngectomy
Chapter 36: Supracricoid Partial Laryngectomy with Cricohyoidopexy or
Cricohyoidoepiglottopexy
Chapter 37: Total Laryngectomy
Chapter 38: Stomaplasty for Hands-Free Voice with Tracheoesophageal
Puncture
Chapter 39: Tracheoesophageal Puncture in the Clinic via Transnasal
Esophagoscopy
Section B: Transoral Endoscopic Head and Neck Surgery
Chapter 40: Transoral Laser Microsurgery
Chapter 41: Transoral Laser Resection of Glottic Tumors
Unit V: Skull Base
Section A: Paranasal Sinus Operations
Chapter 42: Transfacial Approaches
Chapter 43: Maxillectomy
Chapter 44: Craniofacial Resection
Chapter 45: Lateral and Subtotal Temporal Bone Resection
Unit VI: Thyroid and Parathyroid
Section A: Thyroid Operations
Chapter 46: Thyroid Lobectomy and Isthmusectomy
Chapter 47: Subtotal and Total Thyroidectomy
Chapter 48: Video-Assisted Thyroidectomy
Chapter 49: Robotic Thyroidectomy
Chapter 50: Paratracheal and Superior Mediastinal Dissection
(Transcervical)
Chapter 51: Transcervical Thymectomy and Superior Mediastinal
Dissection
Section B: Parathyroid Operations
Chapter 52: Targeted Parathyroidectomy
Chapter 53: Open ParathyroidectomyChapter 54: Video-Assisted Parathyroidectomy
Unit VII: Basic Reconstructive Flaps
Section A: Skin Grafts
Chapter 55: Split-Thickness Skin Graft
Section B: Pedicled Flaps
Chapter 56: Cervicofacial Rotation Flap
Chapter 57: Deltopectoral Flap
Chapter 58: Pectoralis Major Myocutaneous Flap
Chapter 59: Trapezius Flap
Chapter 60: Latissimus Dorsi Myocutaneous Flap
Section C: Neural Reconstruction
Chapter 61: Neural Reconstruction
IndexUnit I
Benign Upper Aerodigestive
DiseaseSection A
Adult EndoscopyCHAPTER 1
Clinical Diagnostic Nasopharyngoscopy
Author Joshua S. Schindler
Commentary by Andrew N. Goldberg, Timothy L. Smith
Positioning
The procedure should be performed with the patient in the seated position with the head
supported from behind. The chin should be in a neutral position with the chin centered
between the shoulders.
Although the procedure can be performed in any position, secretion management is
easiest with the head elevated. A headrest prevents withdrawal by the patient during the
procedure. A centered chin prevents apparent asymmetries in the nasopharynx from
rotation of the cervical spine.
Indirect Nasopharyngoscopy
Nasopharyngoscopy may be performed transorally with a small mirror. The physician
gently grasps the tongue and, using a head mirror or headlight, directs focused light to
the mirror placed just beneath and behind the soft palate (Figure 1-1).
FIGURE 1-1 Indirect mirror nasopharyngoscopy.
The patient’s saliva on the buccal mucosa can be used to defog the mirror prior toinsertion in the nasopharynx. TLSmith
Although nasopharyngoscopy may be performed this way, mirror nasopharyngoscopy
yields a comparatively limited view of the nasopharynx. It is technically challenging and
cannot provide an adequate examination in all patients. We therefore defer mirror
laryngoscopy for flexible fiberoptic examination in most cases.
In fact, I have not performed indirect nasopharyngoscopy for years given the ready
availability and superior visualization of the nasopharyngoscope. TLSmith
Fiberoptic Nasopharyngoscopy
The nasal cavity is treated with topical nasal decongestant and local anesthetic using an
aerosolizer. The physician stands in front of the patient and directs the scope into the
nasal cavity (Figure 1-2A).FIGURE 1-2 A, Flexible ) beroptic nasopharyngoscopy. B, Fiberoptic view of anterior
nasal cavity.
During ) beroptic nasopharyngoscopy, patients often attempt to tilt the head
backward to “assist” the entry of the scope into the nose but this generally increases the
di. culty of passing the scope through the nasal cavity. The head should be in a neutral
position. TLSmith
Studies have failed to demonstrate a signi) cant patient bene) t from topicalization of
the nasal cavity. Despite this, we ) nd that the decongestant spray (oxymetazoline or
phenylephrine [Neo-Synephrine]) does facilitate placement of the ) beroptic scope.
Anesthetic (e.g., lidocaine, tetracaine [Pontocaine], mepivacaine [Carbocaine]) should
take e4ect within 90 seconds and may be mixed with the nasal decongestant; 2%
watersoluble lidocaine jelly also may be used and can facilitate ) beroptic scope placement. We
typically treat both nasal cavities to allow placement of the ) beroptic scope through
either passageway.
For a right-handed examiner, standing in front of and slightly to the patient’s right
allows the examiner to stand closer to the patient in a more comfortable position.
Although there is controversy over the utility of topicalization in the nose, use of
decongestant and anesthetic is common practice.
Although anesthetics begin to take e4ect in 90 seconds, anesthesia is optimal between
5 and 10 minutes. Timing your topicalization and examination will increase comfort of
the examination.
Warning the patient in advance that application of topical anesthetic may make it feel
di. cult to swallow or may make the front teeth feel numb allays some patients’ anxiety
if these sensations occur. Noting that the e4ects typically last less than an hour similarly
provides information that many patients appreciate. ANGoldberg
The ) beroptic scope is passed transnasally to the nasopharynx. Continuous
visualization is performed to determine the widest and most comfortable transnasal
approach (see Figure 1-2B).
We prefer to use the ; oor of the nasal cavity to pass the ) beroptic scope because this is
the least sensitive to pain and is commonly the widest passage. If the bilateral nasal ; oors
are impassable, we approach the nasopharynx between the middle meatus and septum.
This approach is directly below the middle turbinate and commonly used in my
experience. TLSmith
Diagnostic nasopharyngoscopy examination begins at the choana. A thorough
examination includes inspection of the choana, the eustachian tube ori) ce, the torus
tubarius, and the fossa of Rosenmueller on each side. Midline structures including the
adenoid pad, the roof of the nasopharynx, Passavant’s ridge and the posterior mucosa of
the soft palate should also be inspected. Motion and closure of the soft palate should alsobe tested by asking the patient to say “cake” or “kitty cat” (Figure 1-3).
FIGURE 1-3 Nasopharynx view through flexible fiberoptic scope.
In most cases, all of these structures may be visualized through unilateral nasal cavity
placement. Other functional testing, such as Mueller’s maneuver to test for pharyngeal
airway collapse with inspiration, may be performed with ) beroptic nasopharyngoscopy.
The examiner should take note of relatively subtle asymmetries in the nasopharynx
because many lesions in this area are submucosal.
Although nasopharyngoscopy begins at the choana, the opportunity to examine the
nasal cavity during the same examination should not be missed. Administration of
topical anesthetic and decongestant to both sides of the nose and examination of the
nasal cavity provides a complete endoscopic examination with minimal additional
morbidity. ANGoldberg
Editorial Comment
Fiberoptic technology has signi) cantly improved the odds of complete examination of
the nasopharynx compared with mirror examination alone—the issue is not whether the
nasopharynx can be well seen with a mirror but rather that the technique requires
considerable experience, and even with this is poorly tolerated in the majority of
patients.
As pointed out the use of topical decongestant with or without topical
anesthetic is not mandatory but probably preferred by most clinicians. The key if
it is used is to wait su. ciently for both decongestion and anesthesia to take
e/ ect. Plan your o. ce visit/examination and patient 3ow in such a way that the
necessary time (5 to 10 minutes) is built in without rushing this. JICohenSuggested Readings
Burkey BB, Ossoff RH. Endoscopy of nasopharyngeal cancer. Diagn Ther Endosc.
1994;1:6368.
Ritter CT, Trudo FJ, Goldberg AN, Welch KC, Maislin G, Schwab RJ. Quantitative evaluation
of the upper airway during nasopharyngoscopy with the Muller maneuver. Laryngoscope.
1999;109:954-963.
Strauss RA. Flexible endoscopic nasopharyngoscopy. Atlas Oral Maxillofac Surg Clin North Am.
2007;15:111-128.
$



CHAPTER 2
Diagnostic Clinical Pharyngoscopy and Laryngoscopy
Author Joshua S. Schindler
Comments by Robert H. Maisel, Albert L. Merati
Positioning
Indirect laryngoscopy and pharyngoscopy should be performed with the patient in the
seated position with the back straight and exed forward about 20 degrees from
perpendicular. The chin should be in a “sni ng” position with the chin centered between
the shoulders and slightly elevated.
This position may be used for all types of laryngoscopy (mirror, exible beroptic, or
rigid). The head exion and extension may be adjusted to facilitate visualization of
laryngeal and pharyngeal structures with different visualization techniques.
Successful endoscopy begins with correct positioning and verbal preparation of the
patient. All the endoscopic skill and topical anesthesia in the world can’t overcome a
poorly positioned or ill-prepared patient. This cannot be overemphasized. ALMerati
Mirror Examination
Transoral laryngopharyngoscopy may be performed with a mirror. The physician gently
grasps the tongue and, using a head mirror or headlight, directs focused light to the
mirror placed onto or just beneath the soft palate. The soft palate is gently elevated and
the mirror is angled inferiorly to perform the examination (Figure 2-1).$
FIGURE 2-1 Indirect mirror laryngoscopy.
In contrast to nasopharyngoscopy, mirror laryngoscopy can yield a magni cent view of
the larynx and pharynx without topical anesthesia. Procedures such as vocal cord
injection and laryngeal or pharyngeal biopsy may be performed with this technique if the
patient grasps his or her own tongue to free the physician’s second hand. Warming the
mirror to body temperature or applying a detergent-based defogging solution facilitates
visualization.
Telescopic Examination
Transoral laryngopharyngoscopy may also be performed with a rigid angled telescope.
The physician grasps the patient’s tongue and passes the telescope transorally to the
vallecula. The larynx may be visualized by then asking the patient to phonate while
adjusting the telescope to see the endolarynx (Figure 2-2).$

FIGURE 2-2 Indirect rigid telescope laryngoscopy.
Rigid, telescopic laryngopharyngoscopy o0ers one of the best views of the posterior
upper aerodigestive tract. The telescopes may be magni ed (up to 10×) and provide
unparalleled clarity. Most patients will tolerate this procedure without anesthesia, but
topical application of local anesthetic (benzocaine/butyl aminobenzoate/tetracaine
[Cetacaine]) may be performed to diminish gagging. Relaxation of the jaw and tongue
with retraction by the examiner will prevent elevation of the base of tongue that prevents
visualization. Asking the patient to smile widely facilitates elevation of the soft palate.
Both 70- and 90-degree telescopes are available to achieve optimal visualization in the
widest number of patients.
Flexible Examination
Transnasal laryngopharyngoscopy may be performed with a exible laryngoscope. The
procedure is performed as in nasopharyngoscopy (see Chapter 1). Once in the
nasopharynx, the scope is passed through the velopalatal closure while asking the patient
to gently sniff (Figure 2-3).


$

$
FIGURE 2-3 Flexible fiberoptic laryngoscopy.
Flexible transnasal laryngopharyngoscopy may be performed in all patients and is
generally well tolerated. It a0ords the most access (including the subglottis and cervical
trachea, in some cases) and allows for both structural and functional examination of the
larynx, oropharynx and upper portion of the hypopharynx.
Even in very experienced hands, there are patients in whom exible beroptic
laryngoscopy is di cult, nearly impossible, and even impossible. This is usually the
result of a combination of the following: (1) patient physical sensitivities such as an
extreme gag re ex; (2) poor preparation of the patient, that is, talking through the
examination, informing the patient about the process, positioning, and anesthesia; (3)
patient psychologic preparation. Although they may intrinsically be limited in their
capacity to tolerate this simple examination, many patients have become
“unexaminable” following a previous traumatic examination. This latter situation is best
handled by addressing it directly, and doing so prior to any attempt to examine the
patient. ALMerati
Comprehensive exible beroptic laryngoscopic examination should include
examination of the base of tongue, vallecula, epiglottis, aryepiglottic folds,
glossoepiglottic fold, superior hypopharynx, posterior pharyngeal wall, arytenoids, false
vocal folds, true vocal folds, and immediate subglottis. Functional examination should
include true vocal fold abduction and adduction (Figure 2-4).
$

FIGURE 2-4 View of larynx through flexible fiberoptic laryngoscope.
With the exible endoscope in place, a number of techniques can be used to facilitate
visualization. Protrusion of the patient’s tongue will often demonstrate the vallecula and
may show the lingual surface of the epiglottis. InsuB ation of the cheeks may be used to
open the pharynx in some patients and allow visualization of the hypopharynx.
Alternatively, left and right head turn usually allows inspection of the contralateral
piriform sinus—sometimes to the apex.
Flexible scopes are available to the operator in several di0erent sizes by diameter of
tip cross section, allowing more patient comfort, pediatric examination, and suction or
biopsy channel. The pediatric scope is 1.5 mm, the adult exible scopes are 3.6 mm, and
the channeled scope is 6.1 mm in diameter. The video scope with “chip in tip” is 3.9 mm,
and other scopes have a tip diameter of 3.2 mm. Decision on which scopes t the
internal anatomy is achieved actively during the procedure. RHMaisel
The glottis is generally quite easy to see in relaxed voicing and respiration. Sni0 can be
used to demonstrate maximal vocal fold abduction and is useful in patients with
laryngeal stenosis and true vocal fold motion impairment. Some patients have pressed,
hyperfunctional voicing with closure of their false vocal folds during phonation, known as
plica ventricularis. Visualization of the true vocal folds and glottic closure may be
obtained in such patients by asking them to phonate on inspiration.
Functional examinations, such as videostroboscopy and functional endoscopic
evaluation of swallowing, may also be performed using basic laryngopharyngoscopy
techniques.
Video and still photo capture is possible for patient education during a consultation
and can be archived to compare with the direct laryngoscopic view and subsequent office
examination to permit objective observation of the e0ects of the medication or speech
therapy. RHMaisel/
/
/
Editorial Comment
The odds of success in o- ce-based comprehensive examination of the upper
aerodigestive tract have been greatly enhanced by beroptic technologies so that
now not only is visualization improved but a more complete assessment of
function is possible. However, for the reasons mentioned, mirror examination and
rigid beroptic telescopes still have a place and can provide views not achievable
with the smaller 2exible telescopes. All techniques require practice, a cooperative
and well-prepared patient, and a structured approach to ensure that all necessary
information is specifically sought out.
A planned examination under anesthesia in no way should be seen as a
substitute for what can be seen in the o- ce but rather should be viewed as
complementary to what is already known from the o- ce visit. In most
circumstances with modern technology the majority of information is gleaned
from the o- ce examination; the clinician should make a speci c “checklist” of
the unique additional information still needed and achievable by examination
under anesthesia before a decision to go forward with this is made. JICohen
Suggested Readings
Hiss SG, Postma GN. Fiberoptic endoscopic evaluation of swallowing. Laryngoscope.
2003;113:1386-1393.
Rosen CA, Amin MR, Sulica L, Simpson CB, Merati AL, Courey MS, et al. Advances in
officebased diagnosis and treatment in laryngology. Laryngoscope. 2009;119:S185-S212.
Verikas A, Uloza V, Bacauskiene M, Gelzinis A, Kelertas E. Advances in laryngeal imaging.
Eur Arch Otorhinolaryngol. 2009;266:1509-1520.!
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CHAPTER 3
Operative Pharyngoscopy and Laryngoscopy
Author Joshua S. Schindler
Commentary by Robert H. Ossoff, Clark A. Rosen, Steven M.
Zeitels
General Considerations
Direct laryngoscopy and pharyngoscopy are procedures fundamental to the practice of
otolaryngology and essential components of a complete head and neck examination. The
ability to obtain direct line-of-sight visualization of the entire upper aerodigestive tract is
as critical as it is challenging. Although exible examination provides a tremendous
amount of information and may obtain tissue for biopsy, direct examination allows the
surgeon to palpate the tissue, to assess characteristics of lesions such as depth and
adherence to deeper tissues, and visualize regions of the upper aerodigestive tract that
cannot be seen in the o ce (e.g., lateral extent of the ventricle, the undersurface of the
vocal folds, the piriform sinuses).
Laryngoscopy and pharyngoscopy are somewhat unique among head and neck
procedures in that they are both diagnostic and therapeutic. As such, it is not uncommon
for the surgeon to identify unexpected pathology or to &nd that the pathology is di erent
than that anticipated by previous clinical and radiographic examinations. This
uncertainty mandates that the surgeon have broad experience in techniques and a wide
array of instruments to manage whatever he or she finds at the time of the procedure.
Of particular importance in the performance of laryngoscopy is the ability of the
surgeon to manage and maintain an adequate airway before, during, and after the
procedure. All laryngoscopy procedures should be considered airway procedures. Before
proceeding to the operative suite, the surgeon should have the requisite skill, support, and
equipment necessary to manage the most di cult airway safely. Emergencies do happen
and advance preparation is the only defense against catastrophe. This preparation
includes a careful preoperative assessment of the patient’s airway anatomy and
respiratory requirements, an honest assessment of the surgeon’s skill, thorough discussion
and close communication with supporting anesthesia and nursing sta , inspection of the
operative equipment for completeness and proper function, and multiple plans for
managing a difficult airway.
The role of preoperative communication and planning with the anesthesia and nursing
teams cannot be overemphasized. This should include not only initial airway
management strategies but also several backup options. This sequence of airway
“management options” should be determined preoperatively. Similarly, an'
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intraoperative and postoperative airway plan should be discussed and agreed on by the
anesthesia, nursing, and surgical teams. This discussion typically focuses on issues such
as endotracheal tube size and placement, use of jet ventilation, placement of
tracheotomy, and use of apneic technique. This type of discussion should also ensure that
emergency airway equipment, jet ventilation equipment, heliox, and a Combitube are
available and agreed on by all members of the operative team. CARosen
I am in complete agreement with the points raised by Dr. Schindler and elaborated on
by Dr. Rosen regarding preoperative and intraoperative communication. There is no
such thing as an easy “airway” case. RHOssoff
In most situations the lesions of greatest concern to the otolaryngologist are
malignancies of the larynx, oropharynx, and hypopharynx, and evaluation for such
lesions should be performed during all direct laryngoscopy procedures. That said, there
are many reasons to perform direct laryngoscopy including evaluation and removal of
masses, acquiring and maintaining an airway, removal of foreign bodies, improvement in
glottic competence, assessment and management of scar tissue and stenosis, and
improving swallowing function. Although many of these aims require different techniques
and instrumentation, the basic procedures of laryngoscopy and pharyngoscopy should be
performed in the same fashion, order, and method in all patients to ensure that the
surgeon performs an adequate examination and does not overlook any unexpected
pathology.
The usual and customary sequence of performing laryngoscopy and pharyngoscopy
also allows the perioperative team to better support the surgeon. RHOssoff
Equipment for Laryngoscopy and Pharyngoscopy
Considerations on Scopes
Adequate instrumentation is essential to ensure a safe, complete, and e ective
laryngoscopy procedure. Instruments can be divided into two basic groups: (1) those
aimed at evaluation and exposure of the patient’s anatomy and (2) those needed to
perform the expected procedure. Although it is important to plan ahead for laryngoscopy
and have the equipment needed to perform the expected procedure, it is not uncommon
to &nd unexpected pathology and require additional equipment for the evaluation and
management of whatever the surgeon &nds. In addition, having instruments available for
alternate methods of both examination and treatment is essential to prevent the added
risk of future procedures.
We maintain all of the necessary equipment in a standardized location. Although a
surgical tray or two may be used to hold the equipment while not in use, we strongly
recommend a surgical cart with multiple drawers that can be brought to the surgical
suite. This a ords the surgeon immediate access to all of the equipment that might be
needed to perform the expected procedure as well as any additional procedures that may
be required without contaminating multiple sets of instruments. In addition, the cart'
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allows organization of the instruments in order to quickly determine if all of the necessary
equipment is available and ensure rapid delivery of the necessary instruments to the
surgeon if necessary.
Access to an adequate and appropriate endoscopic armamentarium cannot be
overemphasized. Lack of availability of proper instrumentation can lead to all sorts of
misadventures in the upper aerodigestive tract including less-than-favorable
outcomes. RHOssoff
Diagnostic laryngoscopy and pharyngoscopy in their purest form require only a scope,
a suction, a light source, and a tooth protector. Although this may seem simple, the
options for all of these items are vast. There is signi&cant debate over the most useful
laryngoscopes and technique, and preferences vary from institution to institution. Simply
put, any technique and scope that provides adequate exposure in a safe fashion is useful.
The surgeon should have familiarity with many options in order to obtain a successful
result in a wide variety of patients. Laryngoscopes and pharyngoscopes come in many
shapes and sizes designed to obtain di erent views of the laryngeal anatomy in di erent
patients. Although a comprehensive discussion of laryngoscope design and options is well
beyond the scope of this chapter, a brief description of some of the more common scopes
is warranted to allow familiarity and a frame of reference for the reader.
After becoming familiar with the laryngoscopes available at their institution, the reader
is encouraged to learn about other brands and models by inspecting laryngoscopes at
vendor stands at meetings and obtaining catalogs from several of the manufacturers. It is
important to remember that no single laryngoscope is optimal for all patients and all
procedures.
Probably the two most commonly encountered laryngoscopes in the United States for
adult procedures are the Holinger anterior commissure (AC) scope (Figure 3-1) and the
Dedo microlaryngoscope (Figure 3-2). Although many surgeons are facile with these two
models and can perform diagnostic procedures in nearly all patients, both scopes have
limitations that make them unsuitable in some situations.
FIGURE 3-1 The Holinger anterior commissure (AC) hourglass laryngoscope.
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FIGURE 3-2 The Dedo microlaryngoscope.
Although they are commonly requested and described by name, each of these
laryngoscopes actually comes in several di erent forms and may be available from more
than one manufacturer. Despite subtle differences, the basic features are preserved.
The Holinger AC scope has a very narrow shaft and a ared distal end to allow
maximal exposure of the anterior commissure. These features allow a monocular view of
the anterior-most surfaces of the larynx and subglottis in even the most di cult to expose
patients. As such, this is an excellent scope to have available for both diagnostic
examinations and obtaining an airway in patients whose larynx is di cult to visualize.
Unfortunately, its advantages come at the cost of a very limited field of view and inability
to a ord binocular vision for microlaryngoscopy procedures or bimanual
instrumentation.
It is important to note that the Holinger AC scope is not appropriate for most
operative procedures of the pharynx and larynx other than for viewing only. In most
situations this laryngoscope should not be suspended and used for biopsy, given a lack of
binocular vision, increased ability to be disoriented, and poor exposure at the operative
site in case of bleeding. CARosen
The Holinger laryngoscope 1 was introduced in 1960 in an era when the assistant
functioned as the head holder to alter the position of the line-of-sight vector for the
1laryngoscopist. This allowed for distal viewing despite the narrow central hourglass
waist. The narrow central region was designed to accommodate the common restriction
of large scope placement by the posterior oor of mouth along with the insertion of the
palatoglossus and palatopharygeus muscles with the tongue. The Holinger laryngoscope
was designed for performing visual examination and one-handed surgery without
magnification as it was introduced prior to the era of microlaryngoscopy. SMZeitels
The Holinger AC laryngoscope can be suspended and used with telescopes and
microlaryngeal instruments in otherwise difficult to expose individuals. RHOssoff
The Dedo laryngoscope was designed in an e ort to allow binocular visualization and
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bimanual instrument use following introduction of the operating microscope in direct
microlaryngoscopy. The shaft is much wider and tapers only gently toward the tip. There
is little anterior are. Some models have bilateral light carriers and suction ports for
aspirating smoke plumes in laser-assisted laryngoscopy. Although this laryngoscope is
tremendously useful because it yields wide laryngeal exposure, it may not be suitable for
patients with an anteriorly positioned or high larynx.
The Dedo laryngoscope expanded the caliber of the Holinger design to accommodate
the surgical microscope and the 400-mm front lens; however, the hourglass shape
continued to partially restrict binocular stereoscopic microlaryngoscopic viewing. For
2this reason we introduced the Universal Modular Glottiscope, which was designed
speci&cally to examine and perform glottic surgery. It provides a full binocular glottal
&eld, and the distal lumen is conformed as a lancet arch to accommodate the inner
contours of the thyroid laminae, which is especially valuable for treating glottic cancer.
This feature distracts the vestibular folds to provide enhanced viewing of the superior
3vocal fold region, a concept initially introduced by Jackson in the 1920s as
4 3laryngostasis. Killian and Jackson both recognized decades ago that an “inverted V”
distal contour optimally exposed the glottis given its intrinsic shape. SMZeitels
Although a thorough discussion of all available laryngoscopes is not possible, it is
useful to know that there is an instrument designed to overcome almost all exposure
problems in laryngoscopy and allow optimal performance of di erent procedures.
Procedure-speci&c laryngoscopes are designed for visualization of the supraglottis,
posterior commissure, anterior commissure, and subglottis.
A primary advantage of bivalve laryngoscopes is that the surgeon has substantially
greater degrees of freedom while angulating hand instruments. SMZeitels
Other scopes are designed for evaluation of the oropharynx and hypopharynx.
Laryngoscopes have numerous features such as multiple light carriers, suction ports, jet
ventilation ports, and telescopic video ports. Some laryngoscopes have sliding channels to
allow placement of an endotracheal tube and greater range of motion for instruments,
distending distal and proximal tips to allow optimal exposure of the larynx and greater
instrument access, and removable handles to facilitate placement and suspension.
I agree that the Holinger AC scope is a good “starting” laryngoscope and can be
important from a diagnostic perspective, and the Dedo laryngoscope is often a
“workhorse” for simple pharyngoscopy and laryngoscopy procedures. However, it is
important to note that neither of these laryngoscopes is appropriate for high-quality
detailed microlaryngoscopy procedures if a larger laryngoscope can be used. Multiple
manufacturers make laryngoscopes larger than the Dedo laryngoscope, and these
laryngoscopes can be suspended above the area of interest and provide signi&cantly
greater exposure and operative ease, thus increasing surgeon precision and improving
operative outcome. The take-home point must be emphasized that the largest possible
laryngoscope that can be safely inserted and suspended above the operative site in
question should be used, as opposed to a surgeon settling for the view obtained from the
Holinger AC scope or a Dedo laryngoscope. CARosen
4-7True laryngeal suspension requires a gallows that suspends the patient with the
primary force being exerted at the tongue base, supraglottis, and mandible. This is in
contradistinction of what most surgeons use, which are chest-support laryngoscope
holders/stabilizers that exert force on the maxilla. True suspension force on the mandible
4 9as demonstrated by Kirstein (written communication, 1897), Killian, and Jackson
allows for the largest-caliber speculum to be positioned. This is a key strategic goal
because optimizing laryngoscopic exposure frequently in uences the precision of a
surgical procedure. SMZeitels
Having a selection of operative microlaryngoscopes is essential. At this point in my
career, I have drifted back to a more centrist position regarding scope selection as it
speci&cally relates to size of the scope. By that I mean that I will choose a
microlaryngoscope that adequately exposes the surgical &eld but typically not the largest
scope. To me the key is adequate and good exposure, and the largest possible
laryngoscope is not always required to achieve that. RHOssoff
Direct Laryngoscopy and Pharyngoscopy with or Without Biopsy
Preoperative Considerations
The indications for direct laryngoscopy and pharyngoscopy are myriad and generally
include abnormality or mass, noted or suspected, in the oropharynx, supraglottis, glottis,
subglottis, or hypopharynx; trauma or burn to upper aerodigestive tract structures;
stridor; dysphagia with symptoms or &ndings suspicious for lesion or stricture of the
upper aerodigestive tract; throat pain without obvious source; need to obtain an adequate
airway; evaluation for second primary lesion with known upper aerodigestive tract
malignancy; and obtaining and maintaining a stable airway for endoscopic
tracheobronchial procedures.
There are few contraindications to laryngoscopy and pharyngoscopy, but strict
contraindications should include cardiopulmonary instability with a stable airway, neck
instability (e.g., fracture), and immobility of the mandible precluding adequate jaw
excursion.
Although operative endoscopy may be performed under sedative/local anesthesia,
optimal control, precision, and evaluation are attained under general anesthesia.
Judicious use of intermediate-length nondepolarizing paralytic agents can facilitate
exposure and maintain an immobile field.
Endotracheal intubation with as small a tube as can be used for adequate ventilation
(usually 5 to 6 Fr) will facilitate the procedure if it can be performed safely and without
significantly disturbing the pathology of interest.
The surgeon should habitually be present during endotracheal intubation to observe as'
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the anesthesia team places the endotracheal tube, noting the blade size and ease or
di culty with the exposure for intubation. This ensures that the otolaryngologist is
present at the time of airway establishment and may predict the ease of placement of
the operating laryngoscope. CARosen
A Hunsaker jet-ventilation catheter can be valuable with laryngeal stenosis patients or
when working in the periarytenoid and interarytenoid regions. SMZeitels
The surgeon should be ready to take over the intubation if he or she senses any
di culty by the anesthesia team. Traumatic intubation needs to be minimized to prevent
trauma to the delicate tissues of the larynx. RHOssoff
Close communication with anesthesia sta and preparation for alternative means of
ventilation are essential to safe induction and intubation. Imaging studies should be
available during the procedure and reviewed with the anesthesia sta prior to induction.
It is the surgeon’s responsibility to con&rm availability and proper function of all
laryngoscopy equipment prior to induction.
Before starting direct operative pharyngoscopy and laryngoscopy, the surgeon should
con&rm total muscle paralysis with the anesthesia sta . No twitches on peripheral nerve
monitoring ensures optimal relaxation prior to laryngoscope insertion and minimizes the
chance of injury to surrounding structures during the procedure. CARosen
The surgical suite is often small and, depending on the procedure planned, may
contain numerous pieces of bulky, unwieldy equipment. Preoperative consideration of the
location of this equipment and its order of use is essential to e cient use of operating
room time. Although many con&gurations work well, a simple set of principles may allow
the surgeon to configure any available room rapidly (Figure 3-3).'
FIGURE 3-3 Room configuration.
First, the anesthesiologist must have immediate access to intravenous lines and
ventilating circuits. Typically the patient should not be turned more than 90 degrees
away from the anesthesiologist and one arm should be available for blood pressure,
oxygen saturation, and emergency intravenous access. Multiple light sources should be
available and may be positioned in a number of places around the surgeon with attention
paid to cables and obstruction. If a video cart is to be used, it is often most convenient to
place this at the patient’s feet. The instrument cart should be placed in the room for rapid
access to additional instruments by a noncontaminated circulating assistant.
In my practice, the assistant is on the right-hand side of the surgeon, given that most
surgeons are right-handed. CARosen
Operative Steps
STEP 1. Position the patient with the head as close as possible to the head of the
bed.
STEP 2. Induce general anesthesia as per management plan with anesthesia
staff.
In most cases induction of general anesthesia and endotracheal intubation may be
performed by quali&ed anesthesia sta prior to performing upper airway endoscopy.'
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Once intubated, the tube is taped to the left lower lip and corner of mouth (for a
righthanded surgeon).
After the anesthesia team has successfully intubated the patient, the surgeon should
ensure that the endotracheal tube is placed to the left side of the base of the tongue prior
to taping the endotracheal tube at the left corner of the mouth. Given that most
intubations are done with the right hand, this naturally places the endotracheal tube on
the right side of the base of the tongue, and for the right-handed surgeon, this places the
endotracheal tube in a “competing” position for direct pharyngoscopy and laryngoscopy.
The most e ective way to reposition the endotracheal tube to the left base of the tongue
is not to use a tongue blade, but instead to use a gloved index &nger, manually placing
the endotracheal tube to the left aspect of the patient’s base of tongue prior to securing
the tube. CARosen
When performing laser-assisted operative microlaryngoscopy, the tube should not be
taped so that it can be rapidly removed should an airway fire occur. RHOssoff
STEP 3. Turn the head of the bed toward the surgeon and drape the operative
field.
The eyes are carefully taped closed and protected to prevent corneal abrasions or other
injuries. Plastic eye shields are available, but gauze eye pads are generally su cient.
Typically these are soaked in water prior to application to maintain safety in the event
the laser is later used.
The arm opposite the anesthesiologist is padded and tucked and the patient is draped
in a clean fashion such that the ventilator circuit can be seen and monitored by the
anesthesiologist.
STEP 4. Perform a careful bimanual examination while the patient is under
general anesthesia (Figure 3-4).
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FIGURE 3-4 Bimanual examination.
With wet gloves to facilitate examination, digital palpation of the lips, gingivolabial
and gingivobuccal sulci, oor of mouth, anterior tongue, and retromolar trigones should
be performed.
Deeper palpation of the soft palate, tonsils, posterior pharyngeal wall, base of tongue,
and vallecula should be performed to assess for submucosal lesions not appreciated
during o ce examination. The lingual and palatine tonsils are often involved in cases of
occult malignancy, and palpation is surprisingly sensitive in identifying such lesions if
performed carefully. In cases of laryngeal cancer, the preepiglottic space and base of
tongue can often be palpated for signs of invasion.
The long &nger should be used to palpate the palatoglossal folds and piriform sinuses
to the level of the hyoid bone if possible. Also, any discrete suspicious masses should be
biopsied with cup forceps either through the laryngoscope or by direct visualization.
Once oropharyngeal examination is completed, the neck may be carefully palpated
with the patient under general anesthesia to feel for lymphadenopathy, particularly deep
to the sternocleidomastoid muscles.
It is very important to perform digital and bimanual palpation of the structures of the
oral cavity, oropharynx, and hypopharynx. RHOssoff
STEP 5. Prepare the patient’s head and oral cavity for direct laryngoscopy andpharyngoscopy.
Preparation for direct laryngoscopy and pharyngoscopy begins with dental protection
and head positioning. Standard positioning for unassisted laryngoscopy places the
patient’s neck flexed and atlanto-occipital joint extended (Figure 3-5).
FIGURE 3-5 Patient positioning for laryngoscopy and pharyngoscopy.
If the patient has maxillary dentition, a Silastic or rubber tooth protector is applied. If
the maxillary dentition is absent, a saline-soaked gauze or towel may be used. In cases in
which the maxillary dentition is poor or loose, extreme caution must be used. Dental
impression putty may be placed in the tooth protector to help maintain support if some of
the dentition is absent or suspect.
Saline-soaked gauze can often cause signi&cant mucosal trauma to the edentulous
alveolar ridge. A superior alternative is to use a small piece of high-density foam such as
is found in otologic or neurosurgical head rests. A strip of high-density foam
(approximately 1-2 cm × 3-4 cm × 0.5 cm) can be placed inside a small plastic bag and
then placed between the laryngoscope and the alveolar ridge. CARosen
Rolling a wet surgical sponge and placing it between the maxillary alveolus and labial
surface of the upper lip as well as using another to protect the maxillary alveolar ridge
will usually protect the patient’s tissues in edentulous patients, in my!


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experience. RHOssoff
Contrary to popular anesthesia and otolaryngology teaching, substantial pressure may
be applied to the maxillary dentition so long as the pressure is applied gradually and
directly into the maxilla over stable teeth. Any rapid acceleration in the anteroposterior
dimension can lead to dental injury or loss.
With a simple set of basic precautions, the skilled surgeon can obtain excellent direct
visualization of nearly all regions of the oropharynx, larynx, and hypopharynx. Of
greatest concern is injury to the teeth. Although the tooth protector helps reduce the
likelihood of injury, damage to the dentition can still occur through carelessness.
Most commonly, injuries occur when the surgeon attempts to inspect anterior structures
and the wrist exes to reduce the angle between the line of the scope and the oor. This
places the proximal end of the laryngoscope against the teeth and uses them as a fulcrum
to raise the distal tip of the laryngoscope into the base of tongue. Proper technique
applies anterior pressure against the base of tongue with the laryngoscope, without using
it or the teeth as a fulcrum, and keeps the proximal end of the laryngoscope o of the
teeth. One usually knows that the technique is correct when the patient’s head comes o
the table.
One method to reduce the risk of dental injury during laryngoscopy is to ensure the
use of proper upward force by monitoring the surgeon’s arm muscle use or activation.
Inappropriate “fulcrum” use of the laryngoscope involves bicep muscle use and suggests
that the surgeon is not providing the appropriate forces on the laryngoscope to achieve
exposure. In contrast, to achieve the appropriate upward and forward force on the
laryngoscope during pharyngoscopy and laryngoscopy, signi&cant tricep and deltoid
muscle activation should be used. This is especially helpful when training and
monitoring students of laryngoscopy. CARosen
Proper head positioning for direct laryngoscopy is famously controversial and hotly
debated among laryngologists. In general, head position is largely dependent on the
patient’s anatomy and the region the surgeon wishes to inspect. If an operative table with
adjustable head position is used, a shoulder roll is generally not required.
The examination may begin in the “sni ng” position with the atlanto-occipital joint
extended and the neck gently exed. This position is suitable for careful inspection of the
oropharynx and hypopharynx. Often the larynx may also be exposed adequately in this
position.
Greatest anterior exposure of the larynx with little or no dental pressure can be
obtained with the neck exed and the atlanto-occipital joint exed (Figure 3-6). Raising
the head of the operating table facilitates this positioning. Although this view is excellent
for diagnostic examinations, it is often cumbersome for the surgeon because the
laryngoscope is pointed near vertically and the patient cannot be placed in suspension in
this position easily.

FIGURE 3-6 Greatest anterior exposure of the larynx with little or no dental pressure
can be obtained with the neck flexed and the atlanto-occipital joint flexed.
To optimize exposure of the pharynx and larynx for direct examination, the basic
principle of neck exion and head extension is not controversial and is an essential tenet
for pharyngoscopy and laryngoscopy. Neck exion is easily achieved using an elevated
head pillow, with or without upward rotation of an articulated head of the operating
table. Head extension can be achieved during laryngoscopy (especially during
suspension of the laryngoscope). Any unfavorable angle of the suspended laryngoscope
for microlaryngoscopy can be overcome easily by placing the operating room table in
Trendelenburg position or using articulated eyepieces of the microscope. CARosen
In contrast, the distal hypopharynx and cervical esophagus can be visualized most
easily with both the atlanto-occipital joint and neck extended (Figure 3-7). This position
is often used for rigid esophagoscopy and is readily obtained by lowering the head of the
bed.
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FIGURE 3-7 The distal hypopharynx and cervical esophagus can be visualized most
easily with both the atlanto-occipital joint and neck extended.
Remarkably, the sni ng position is widely espoused as the optimal position for
exposure of the glottis and therefore intubation. In fact, exion of the neck and
atlantooccipital joint (see Figure 3-6) provides optimal viewing in a di cult laryngoscopic
10 11,12exposure, which was recognized by Johnson a century ago. Endotracheal
13,14intubation was done approximately 15 years after the conventional introduction of
direct laryngoscopy, and anesthesiologists copied the surgeons’ sni ng position using
similar viewing vectors from the head of the bed. However, surgeons required this
viewing vector to perform substantial instrumentation of soft tissues while
anesthesiologists could easily intubate patients in exion- exion position (see Figure
36). SMZeitels
The surgeon may need to adjust his or her body and head position to obtain direct line
of sight down the laryngoscope. Additional extension of the atlanto-occipital joint and
neck is improper and may lead to dental injury as the laryngoscope contacts the teeth.
Reverse Trendelenburg position adjustments typically allow for more comfortable
head and neck position of the surgeon. SMZeitels
The surgeon must be aware of his or her body, head and neck alignment. Great care
should be exercised to avoid sticking one’s chin out too far or extending one’s neck too
much. Careful positioning by the surgeon is essential to avoid acquiring long-termcervical spine degenerative changes. Do not be afraid to ask your assistant, nurse, or
other member of the operative team if your “head is situated over your
shoulders.” RHOssoff
Injuries to the pharyngeal mucosa and tongue can occur through aggressive
manipulation of the laryngoscope. The best means to avoid these injuries is to know the
location of and maintain precise control over the distal tip of the laryngoscope. It is not
uncommon for the surgeon to be inspecting mucosa, but not be entirely certain where the
mucosa is within the oropharynx or hypopharynx. The natural reaction is to start looking
side to side and deeper to see if more landmarks come into view to allow orientation. This
tendency must be avoided and the surgeon should gently withdraw the laryngoscope
until known anatomic structures come into view. Once reoriented to the position of the
distal tip of the laryngoscope, the surgeon may then advance the scope carefully and
attempt to identify the next landmark. Useful landmarks include the uvula, the epiglottis,
the arytenoids, and the endotracheal tube itself. Poorly oriented attempts to perform
laryngoscopy will lead to mucosal injury and bleeding, which only compounds the
difficulty of the examination.
The importance of orientation should contribute to the surgeon’s decision on which
laryngoscope to use because small scopes allow only a limited view of critical landmarks.
In general, the surgeon should choose the largest laryngoscope that can be used to
evaluate all portions of the anatomy.
STEP 6. Perform oropharyngeal examination.
Endoscopic evaluation typically begins with examination of the oropharynx (Figure
38). For a right-handed surgeon, pharyngoscopy and laryngoscopy begin with a scissoring
motion of the left thumb and fore&nger to open the jaw. The structures that should be
identi&ed discretely and carefully inspected include the soft palate, the tonsils, the
palatoglossal folds, the base of tongue and vallecula, the lingual surface of the epiglottis,
the lateral pharyngeal walls, the posterior pharyngeal walls, the walls and apex of the
piriform sinuses, the postcricoid mucosa, the esophageal introitus, the laryngeal surface
of the epiglottis, the aryepiglottic folds, the arytenoids, the interarytenoid space, the false
vocal folds, the ventricles, the true vocal folds, and the immediate subglottis.FIGURE 3-8 Examination of the oropharynx.
The surgeon should develop his or her own methodical system that evaluates all of the
anatomy and is repeated in the same order and manner with every examination to ensure
that all areas of the anatomy are inspected thoroughly. The following is one method for
inspecting all of these structures.
The scope is inserted with the right hand and the surgeon immediately begins the
process of orientation. The surgeon should pay careful attention to the lower lip and
corner of mouth as he or she passes the laryngoscope because it easy to pinch between
the teeth and the scope. Insertion in the midline rapidly yields a view of the uvula and
soft palate (Figure 3-9). The posterior pharyngeal wall may be visualized at this point. In
returning the laryngoscope to the uvula, the surgeon may trace the soft palate laterally to
the right tonsillar fossa. At the inferior pole of the tonsil, the surgeon may proceed to the
palatoglossal fold and base of tongue. As the surgeon draws the tip of the scope medially,
the vallecula and lingual surface of the epiglottis come into view and may be inspected
(Figure 3-10). The same structures on the left may be visualized as the surgeon draws the
scope to the left palatoglossal fold and inferior tonsil pole. As the surgeon draws the scope
up the left tonsillar fossa and, palate the uvula again comes into view.!
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FIGURE 3-9 View of the uvula and soft palate, as well as the posterior pharyngeal wall.
FIGURE 3-10 The vallecula and lingual surface of the epiglottis come into view.
Some patients release copious saliva following induction of anesthesia. If this causes
any di culty with visualization, the surgeon or anesthesia sta may administer a small
dose of glycopyrrolate (Robinul). Typically 0.2 mg is e ective. Glycopyrrolate can cause
significant urinary retention, particularly in older men.
There is a substantive time delay (about 20 minutes) between the administration of
glycopyrrolate and decreased salivation; therefore, this medicine should be given
preoperatively for patients undergoing direct pharyngoscopy and/or laryngoscopy,
unless there is a medical contraindication. CARosenSTEP 7. Perform hypopharyngeal examination.
With the uvula in view, the distal tip of the laryngoscope is pressed into the tongue and
tongue base. This should bring the tip of the epiglottis into view with little or no rotation
of the laryngoscope. Careful direction of the laryngoscope laterally will demonstrate the
palatoglossal fold. Keep the proximal end of the laryngoscope off the teeth; the scope may
be gently passed into the superior aspect of the piriform sinus.
To facilitate the examination the surgeon may direct the shaft of the laryngoscope into
the lingual sulcus, thus displacing the tongue away from the side being inspected. This
usually allows continued anterior passage of the laryngoscope without rotation of the
laryngoscope. As the piriform sinus is entered, the surgeon will note that there are no
landmarks in this cone of mucosa leading to the apex. This is an easy region to lose
orientation.
The hyoid bone laterally and the pharyngoepiglottic fold anteriorly demarcate the
oropharynx from the hypopharynx, which can be helpful in de&ning and mapping the
geography of cancer in this region. The pharyngoepiglottic fold is the surface mucosal
structure overlying the hyoepiglottic ligament. SMZeitels
Gentle passage of the scope should continue to yield a potential space that ends in a
blind pouch (Figure 3-11). This is the apex of the piriform sinus and may be con&rmed
by gentle palpation of the distal tip of the scope medially against the cricoid cartilage.
The esophageal introitus should be viewed with slight medial observation and con&rms
orientation. As the scope is drawn medially, the postcricoid mucosa and posterior
hypopharyngeal wall may be inspected. Once the examination is completed, the
laryngoscope may be withdrawn to the uvula and the sequence may be repeated on the
opposite side.
FIGURE 3-11 The apex of the piriform sinus.!
'
STEP 8. Perform laryngeal examination.
From the uvula, the laryngoscope is again pressed into the tongue to visualize the tip of
the epiglottis. Rotation of the tip of the laryngoscope superiorly and gentle advancement
allows passage of the tip posterior and superior to the tip of the epiglottis. This allows
inspection of the aryepiglottic folds and some of the laryngeal surface of the epiglottis.
The surgeon should note that the laryngeal surface of the epiglottis is parallel to the tip of
the laryngoscope and complete inspection of this region often requires an angled
telescope.
The aryepiglottic folds should be followed on both sides to the arytenoid cartilages.
These may be gently palpated with a suction or blunt probe to con&rm mobility, if
indicated.
If arytenoid joint &xation and the subsequent diagnosis of arytenoid ankylosis and/or
dislocation is a preoperative clinical concern, then during the direct laryngoscopy, it is
best to perform palpation of the arytenoids and subsequent cricoarytenoid joints either
as an awake, in-o ce procedure, or before the endotracheal tube is in place and/or the
laryngoscope is suspended. Optimal visualization of the posterior glottis and the
arytenoids should be achieved prior to an endotracheal tube being inserted. Each
arytenoid should be independently palpated just anterior to the vocal process of the
arytenoid cartilage. One should be looking for decreased motion or “sti ness” of the
cricoarytenoid joint during lateral traction applied to the arytenoid. In addition, careful
examination of the posterior commissure should be done during this maneuver to fully
evaluate the possibility of posterior glottic stenosis (a common cause of bilateral vocal
fold motion impairment). CARosen
The interarytenoid space should be inspected. If the endotracheal tube is taped to the
patient’s left lower lip, the surgeon should inspect the interarytenoid space from the right
arytenoid cartilage. With this cartilage in view, the scope tip should be directed
posteriorly and placed behind the endotracheal tube. The tip may then be advanced
inferiorly and the interarytenoid space will come into view as the endotracheal tube is
moved gently into the anterior glottis (Figure 3-12). The immediate posterior subglottis,
often to the level of the &rst or second tracheal ring, may also be viewed from this
position.!

FIGURE 3-12 The interarytenoid space comes into view.
This is the technique that I use to visualize the posterior commissure, arytenoids and
vocal process area. RHOssoff
Withdraw the scope to the epiglottis, maintaining the tip of the scope inferior to the tip
of the epiglottis. Applying pressure into the base of tongue with the shaft of the
laryngoscope will gently lift the patient’s head from the operating table. The false vocal
folds should come into view. These may be inspected and the vocal processes should also
be seen.
Continued gentle application of pressure into the base of tongue should yield a view of
the vocal folds and anterior commissure. If this region is di cult to expose, the surgeon
may try elevating the head of the operating table 4 to 7 cm, applying gentle posterior
pressure to the cricoid cartilage, or switching to a smaller laryngoscope. Sometimes the
surgeon must make all of these changes in order to obtain an adequate view. One of the
most common mistakes is to pass the laryngoscope tip too deep, which prevents full view
of the anterior commissure. As a rule, if visualization is poor, the surgeon should &rst
attempt to improve the exposure by gently withdrawing the laryngoscope before
advancing it.
To further improve anterior exposure during direct laryngoscopy, the clinician should
ensure that the patient’s head and neck are positioned in neck exion and head
extension. Also consider applying gentle anterior neck downward pressure in the area of
the upper trachea and/or cricoid to maximize anterior commissure visualization during
laryngoscopy and microlaryngoscopy. CARosen
With the anterior commissure in view, the ventricles may be carefully inspected by
pressing the false folds laterally with the tip of the laryngoscope (Figure 3-13).!
FIGURE 3-13 False versus true vocal folds.
The distal aperture of most tubular laryngoscopes (through 1960) is round posteriorly
to expose the interarytenoid region (see Figure 3-12) because they were designed before
the era of endotracheal tube placement during surgical laryngoscopy. Laryngoscopes
15 16 17such as the Jako, Kleinsasser, and Dedo unnecessarily adopted that feature from
18earlier designs. Davis and associates clearly demonstrated that glottic cancer
resections often failed in the anterior commissure and posterolateral paraglottic region
due to limitations in laryngoscopic exposure from the circular-oval laryngoscope
speculum. However, the optimal shape of a distal laryngoscope lumen to expose the
2neoplasm in Figures 3-12 and 3-13 is triangular. SMZeitels
Complete examination of the ventricular mucosa requires a sharply angled telescope
(usually 70 degrees).
Use of telescopes (5 mm diameter, 30 cm in length) during direct laryngoscopy and
microlaryngoscopy is essential and should be a routine part of all pharyngoscopy and
laryngoscopy procedures, most notably after the laryngoscope has been suspended.
Zero, 30-, and 70-degree telescopes provide a “three-dimensional” view of many areas of the
larynx and pharynx that are di cult to visualize with direct laryngoscopy and binocular
microlaryngoscopy. These areas include the posterior commissure, the infraglottis,
subglottis, anterior commissure, and the laryngeal ventricles. The use of angled
telescopes through a suspended laryngoscope provides the surgeon important staging
and “mapping” information that complements and supplements the information
obtained from binocular, high-powered microlaryngoscopy. CARosen
I completely agree that today telescopic evaluation using 0-, 30-, and 70-degree
telescopes is an integral part of diagnostic and therapeutic microlaryngoscopy. I alsoroutinely use these same telescopes to monitor operative progress as needed and to
evaluate my results following completion of the case. RHOssoff
Inspection of the immediate subglottis may be performed through the vocal folds or the
laryngoscope may be gently passed through the vocal folds for improved visualization.
Again, angled telescopes may be very useful to view the entire mucosa of the subglottis.
STEP 9. Biopsy suspicious pharyngeal and laryngeal lesions (Figure 3-14).
FIGURE 3-14 Biopsy.
If any lesions are encountered during the examination, they should be noted and, after
the entire examination is completed, the lesion(s) should be viewed again for
consideration of biopsy.
An operative diagram of the larynx should be used in the operating room to document
lesions seen during pharyngoscopy and laryngoscopy and location of biopsies.
Preferably this is a standardized diagram that is placed in the medical record. CARosen
If biopsy is indicated, the lesion and surrounding mucosa should be treated with topical

1 : 10,000 epinephrine for 2 to 3 minutes. Once vasoconstriction is initiated, the surgeon
may proceed with biopsy.
Most of the lesions of the oropharynx, larynx, and hypopharynx that require biopsy for
diagnostic purposes are mucosal and are amenable to simple biopsy with cup forceps
between 2 and 4 mm in diameter. Biopsy involves pressing the open forceps into the
lesion, closing the jaws, and rapidly withdrawing the forceps with a tearing action (see
Figure 3-14). In most cases several biopsies should be obtained to ensure adequate tissue
for diagnosis.
If the lesion appears to be submucosal, additional biopsies of the submucosa may be
taken following initial removal of the overlying mucosa.
If the lesion is noted within the palatine tonsil, strong consideration should be made to
unilateral tonsillectomy in order to ensure adequate tissue for biopsy and adequate
postprocedure hemostasis. Although unilateral tonsillectomy results in oropharyngeal
wall asymmetry which is annoying in subsequent surveillance for malignancy, routine
removal of the opposite tonsil is unnecessary and increases postoperative pain and risk of
bleeding.
Although biopsy in most regions is safe, special attention should be paid to lesions of
the membranous vocal fold. Super&cial lesions of the true vocal fold that are worrisome
for malignancy should be biopsied.
Because limited lesions may be treated with microsurgery or radiation therapy for
de&nitive management, the surgeon should pay very careful attention to biopsy
technique to avoid biopsy of any normal tissues. Although bulky tumors may be biopsied
with large-cup forceps without magni&cation, proper evaluation and biopsy of small
lesions of the vocal folds is best performed with an operating microscope and
microlaryngeal instruments to minimize the chance of permanent dysphonia following
definitive management.
Excessively deep biopsies may violate the vocal ligament, leading to sulcus formation.
Indiscriminant vocal fold “stripping” should be condemned because it can lead to
excessive loss of the lamina propria and profound dysphonia. Biopsy or stripping near the
anterior commissure can also lead to anterior glottic web formation and should be
performed with adequate magnification and great care.
It is also important to note that there is often a role for a micro ap approach for
removal of vocal fold lesions that allows for optimal and maximal precision of tissue
removal and orientation of the specimen. CARosen
Today proper care and respect for the tissues of the vocal folds represents the standard
of care. Use of the operating microscope with mid to high magni&cation similar to
otologic microsurgery of the middle ear is the expectation. The micro ap approach can
be used with good con&dence and is ideal to manage premalignant and super&cial
malignant lesions of the vocal folds. Vocal fold stripping is of historical signi&cance only
and should not be used as a technique for mucosal removal. RHOssoffSTEP 10. At the conclusion of laryngoscopy, treat the larynx with topical
anesthetic to reduce the chance of laryngospasm.
This can be easily accomplished with several milliliters of 4% lidocaine solution
sprayed onto the vocal folds.
STEP 11. Remove the laryngoscope and the dental protector.
STEP 12. Suction the patient’s oral cavity and oropharynx clear of blood and
secretions.
STEP 13. Return the patient to the anesthesia staff for extubation.
In order to prevent laryngospasm, extubation should be delayed until the patient is
awake and following commands.
Suggested Readings
Benjamin B, Lindholm CE. Systematic direct laryngoscopy: the Lindholm laryngoscopes. Ann
Otol Rhinol Laryngol. 2003;112(9 Pt 1):787-797.
Friedrich G, Kiesler K, Gugatschka M. Curved rigid laryngoscope: missing link between direct
suspension laryngoscopy and indirect techniques? Eur Arch Otorhinolaryngol.
2009;266(10):1583-1588.
Hochman II, Zeitels SM, Heaton JT. Analysis of the forces and position required for direct
laryngoscopic exposure of the anterior vocal folds. Ann Otol Rhinol Laryngol.
1999;108(8):715-724.
Zeitels SM. Atlas of phonomicrosurgery and other endolaryngeal procedures for benign and
malignant disease. San Diego: Singular; 2001. pp 23-36
Suggested References of Historical Interest Provided by Dr. Zeitels
1 Holinger PH. An hour-glass anterior commissure laryngoscope. Laryngoscope.
1960;70:1570-1571.
2 Zeitels SM. A universal modular glottiscope system: the evolution of a century of design
and technique for direct laryngoscopy. Ann Otol Rhinol Laryngol. 1999;108(Suppl
179):124.
3 Jackson C, Tucker G, Clerf LH. Laryngostasis and the laryngostat. Arch Otolaryngol.
1925;1:167-169.
4 Killian G. Die Schwebelaryngoskopie und ihre praktische Verwertung. Vienna: Urban &
Schwarzenberg; 1920.
5 Grundfast KM, Vaughan CW, Strong MS, De Vos P. Suspension microlaryngoscopy in the
Boyce position with a new suspension gallows. Ann Otol Rhinol Laryngol.
1978;87:560566.
6 Killian G. Die Schwebelaryngoskopie. Archr Laryngol Rhinol. 1912;26:277-317.
7 Zeitels SM, Burns JA, Dailey SH. Suspension laryngoscopy revisited. Ann Otol Rhinol
Laryngol. 2004;113:16-22.
8 Reference deleted in proofs.9 Jackson C. Position of the patient for peroral endoscopy, in peroral endoscopy and laryngeal
surgery. St. Louis: Laryngoscope Co; 1915. pp 77-88
10 Johnston RH. Some original endoscopic methods. Laryngoscope. 1913;23:607-617.
11 Hochman II, Zeitels SM, Heaton JT. An analysis of the forces and position required for
direct laryngoscopic exposure of the anterior vocal folds. Ann Otol Rhinolaryngol.
1998;108:715-724.
12 Hochman II, Zeitels SM. Exposure and visualization of the glottis for phonomicrosurgery.
Op Tech Otolaryngol Head Neck Surg. 1998;9:192-195.
13 Elsberg CA. Clinical experiences with intratracheal insufflation meltzer, with remarks
upon the value of the method for thoracic surgery. Ann Surg. 1910;LII:23-29.
14 Jackson C. Anesthesia for Peroral Endoscopy. Peroral Endoscopy and Laryngeal Surgery. St.
Louis: Laryngoscope Co; 1915. 54-72
15 Jako GJ. Laryngoscope for microscopic observation, surgery, and photography. Arch
Otolaryngol. 1970;91:196-199.
16 Kleinsasser O. Microlaryngoscopy and endolaryngeal microsurgery. Philadelphia: Saunders;
1968.
17 Dedo HH. A fiberoptic anterior commissure laryngoscope for use with the operating
microscope. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol. 1976;82:ORL91-92.
18 Davis RK, Jako GJ, Hyams VJ, Shapshay SM. The anatomic limitations of CO laser2
cordectomy. Laryngoscope. 1982;92:980-984.CHAPTER 4
Operative Esophagoscopy and Percutaneous
Gastrostomy
Author Joshua S. Schindler
Commentary by Nasir I. Bhatti, Robert G. Martindale, John R.
Saunders, Jr.
Transnasal Esophagoscopy
STEP 1. Unsedated, thin-caliber esophagoscopy is performed under local
anesthesia alone. The nasal cavity is prepared with topical nasal decongestant
(e.g., oxymetazoline, phenylephrine) and local anesthetic (e.g., lidocaine,
tetracaine [Pontocaine]) as in 2exible laryngoscopy; 2% lidocaine water-based
lubricant is then applied liberally to the nasal cavity on a cotton-tipped
applicator.
It is preferable if the patient fasts before the procedure for a brief period, although I
have not encountered problems if the patient has not done this. The surgeon is
performing esophagoscopy, not gastroscopy, and the esophagus should be devoid of food
that could obstruct visualization.
I instruct the patient not to eat solid food for at least 4 to 6 hours before the
procedure. NIBhatti
The application of the lidocaine in this manner allows the operator to assess which
nares will be most optimal to pass the endoscope. JRSaunders
STEP 2. The patient is positioned in a chair with the head comfortably
supported. A 60- or 100-cm 2exible esophagoscope is passed transnasally along
the floor of the nose (Figure 4-1).FIGURE 4-1 Transnasal esophagoscopy.
As a right-handed individual, I prefer to hold the scope in my right hand and advance
the scope with my left. If bony obstruction prevents passage along the oor, the “middle
road” just medial to the middle meatus entrance may be used. The scope is passed to the
nasopharynx and then to the oropharynx.
Because most transnasal scopes are designed for right-handed operators, they function
better by holding the endoscope with the left hand to manipulate the exion or
retro exion dial with the left thumb, freeing the right hand to rotate and direct the
scope. JRSaunders
STEP 3. With the scope positioned just over the piriform sinus, the patient is
asked to swallow forcefully. The scope is gently passed into the cervical esophagus
through the upper esophageal sphincter (UES).
Gagging is expected and typically modest.
As in all passages of endoscopes this should be done under direct vision particularly
because the passage through the lower esophageal sphincter (LES) can be somewhat
tortuous. JRSaundersPharyngeal anesthesia may make the patient very uncomfortable and may give a false
but alarming sensation of not being able to breathe! NIBhatti
STEP 4. Once in the cervical esophagus, the scope is gently passed to the
stomach.
STEP 5. The stomach is gently in2ated and inspected to a limited degree unless
the 100-cm scope is used. Retro2exion of the scope allows visualization of the
diaphragmatic hiatus and Z-line.
Patients tolerate unsedated, transnasal esophagoscopy extremely well. Although nasal
anesthesia is essential to the procedure, pharyngeal and hypopharyngeal anesthesia often
complicates the procedure because patients /nd it di0 cult to manage their own
secretions. In some circumstances, pharyngeal application of benzocaine/butyl
aminobenzoate/tetracaine (Cetacaine) may be used to diminish a strong gag reflex.
Patients should be warned and prepared for the gagging that occurs with passage of
the scope through the UES. With a gentle touch this is limited or absent and, once the
scope is in the cervical esophagus, usually extinguishes quickly.
Patients should be encouraged to belch any excess air that is insu6 ated during the
procedure. JRSaunders
STEP 6. After brie2y examining the stomach, the stomach is suctioned free of air
and the scope is withdrawn through the diaphragmatic hiatus to view the
gastroesophageal junction. Biopsies for lesions or Barrett’s esophagus may be
taken through the working channel.
Several passes are often necessary to adequately visualize the entire gastroesophageal
junction, or Z-line. Biopsies of the esophagus in the absence of sedation are challenging
because of the constant peristalsis, and the surgeon must ensure adequacy of the
specimen. Often, grasping the tissue with the forceps and pulling back and forth under
direct visualization will allow determination if the area to be biopsied has been captured
in the forceps. Lesions in the cervical esophagus are even more challenging because this
region is more sensitive to pain than is the distal esophagus.
I haven’t found this to be a problem. The main problem is the extremely small sample
that can be biopsied with each pass of the biopsy forceps. JRSaunders
STEP 7. The scope is gently withdrawn through the remainder of the esophagus,
noting structural and mucosal abnormalities. Once withdrawn into the
hypopharynx, the scope may be withdrawn completely.
The mucosa of the UES and lower hypopharynx cannot adequately be assessed with a
exible endoscope, and thus if a lesion is suspected in this area, sedated rigid
laryngoscopy and esophagoscopy are indicated to adequately view this region.
Operative Flexible EsophagoscopySTEP 1. Under general anesthesia 2exible esophagoscopy is performed by grasping
the patient’s jaw and lifting anteriorly. The scope is then placed transorally with a
gentle inferior curve. With the scope draped over the surgeon’s shoulder, the
surgeon gently passes the 2exible esophagoscope gently into the hypopharynx and
through the UES. This is done blindly by palpation (Figure 4-2).
FIGURE 4-2 Transoral exible esophagoscopy, with the patient under general
anesthesia.
Operative exible esophagoscopy can be performed with either sedative or general
anesthesia. For the head and neck surgeon, this is usually performed under general
anesthesia because of lesions in the oropharynx, hypopharynx, larynx, or esophagus and
the difficulties in assessing these areas adequately with flexible techniques.
If the surgeon encounters resistance to passage, the scope is withdrawn 1 to 2 cm,
rotated 5 degrees in either direction, and repassed.
Entering the cervical esophagus with a exible scope under general anesthesia is one of
the initial challenges of esophagoscopy. With practice it becomes very easy to place the
scope by this method and it is very fast. Many head and neck cancer patients have
strictures and altered anatomy in this region. This can complicate passage of the scope
and may prove to be impossible without visualization. In such cases, a Miller or
Macintosh laryngoscope from the anesthesia department can facilitate opening the
hypopharynx and passing the scope under direct visualization into the cervical?
esophagus. In some cases, dilation is necessary before the scope can be placed.
In our resident training program we have the attending sta pass the scope as the
resident steers the endoscope. It seems that about half the time the scope can be easily
passed as previously described; other times the opening through the UES should be
visualized before the scope is passed through. JRSaunders
If the surgeon/operator has performed direct operative laryngoscopy and has used a
shoulder roll, it should be removed to facilitate entry into the upper esophageal
sphincter. Dilation in the case of previous radiation can be risky, and extreme caution
and signi/ cant experience in esophageal endoscopy are warranted. Pulling the mandible
forward as depicted in Figure 4-2 is often necessary. NIBhatti
STEP 2. The surgeon passes the scope to the stomach and gently inflates it.
STEP 3. Once the scope is well into the midportion of the stomach lumen,
retro2exion of the scope allows visualization of the diaphragmatic hiatus and
Zline.
STEP 4. The stomach is inspected as required and on completion suctioned to
remove excess insufflated gas.
STEP 5. Visualization of the esophagus is done while withdrawing the scope.
Finger controls help keep the scope centered in the esophagus and allow visualization
of all mucosal surfaces.
Biopsies may be taken though the 2.3-mm working port. Once passed through the UES
into the hypopharynx, the scope is withdrawn.
Rigid Esophagoscopy
STEP 1. Rigid esophagoscopy is performed transorally under general anesthesia
with the patient completely relaxed. A tooth protector is placed on the maxillary
dentition and the neck is extended to bring the esophagus in line with the oral
cavity (Figure 4-3).FIGURE 4-3 Positioning for rigid esophagoscopy.
STEP 2. The scope is passed into the hypopharynx and then into the cervical
esophagus.
STEP 3. With gentle elevation of the tip of the scope and protection of the
maxilla with the thumb or foreCnger, the scope is gently passed through the
cervical esophagus (Figure 4-4).FIGURE 4-4 Initiating rigid esophagoscopy.
The surgeon must keep a lumen in view while advancing the scope (Figure 4-5).FIGURE 4-5 Advancing rigid esophagoscope.
Rigid esophagoscopy is tremendously valuable for evaluation of lesions in the
hypopharynx and their extension into the cervical esophagus. It is a particularly
dangerous technique in inexperienced hands, however. It is very easy to pass the scope
through a stricture, neoplasm, or Zenker’s diverticulum into the mediastinum.
Unrecognized, such injuries can be fatal. Prompt management of such complications with
cessation of oral intake, enteral bypass (feeding tube) placement, and mediastinal
drainage is critical. Proper positioning and depth of anesthesia are also important to help
prevent serious complications.
The rigid esophagoscope should ideally be advanced by traction using the thumb on
the undersurface of the scope. Rotating the patient’s head from side to side can facilitate
visualization of the lumen. JRSaunders
As otolaryngologists become more and more familiar with exible esophagoscopy,
experience with rigid esophagoscopy is diminishing. Extreme caution is therefore advised
to avoid passing a rigid esophagoscope into the mid- and especially lower esophagus.
Asking the anesthesiologist to help with muscle relaxation is always helpful. NIBhatti
STEP 4. The scope is advanced only to the mid- or upper portion of the distal
third of the esophagus.
It becomes increasingly di0 cult (and dangerous) to pass it to the distal esophagus.
Biopsies may be taken directly or with the use of an operating telescope.
STEP 5. The rigid esophagoscope is gently withdrawn under direct visualization.
Percutaneous GastrostomySTEP 1. Begin percutaneous gastrostomy tube placement by performing 2exible
esophagogastroduodenoscopy.
Percutaneous gastrostomy placement is a valuable skill for a head-and-neck surgeon.
With proper patient selection and attention to technique, it is extremely safe.
Prior to placement of a percutaneous gastrostomy, the surgeon should inspect the entire
upper gastrointestinal (GI) tract to at least the /rst portion of the duodenum. This is
important to exclude pathology in these sites and to understand the position and
geometry of the pylorus and lesser curvature of the stomach.
Percutaneous procedures should be considered with extreme caution in patients with
previous abdominal surgery and obesity. Relative contraindications include ascites and
the presence of malignant lesions of the esophagus, stomach, or duodenum.
During gastrostomy placement the greatest danger is malposition of the tube with
placement into or through the colon, small bowel, or liver edge. Thus patients with
previous intraabdominal surgery should be considered for referral for possible open
gastrostomy placement.
Patients with prior surgery for ventral hernia repairs with synthetic mesh are
especially at risk. Passing the gastrostomy tube through synthetic mesh will have a
disastrous result of abdominal wall infection and fasciitis. RGMartindale
A single dose of a broad-spectrum antibiotic is given prior to the procedure (see Jafri
et al, 2007). JRSaunders
STEP 2. The scope is passed to the stomach and through the pylorus to exclude
malignant or dangerous pathology (e.g., advanced duodenal ulcer) that might
require additional treatment or be a contraindication to gastrostomy placement.
In addition to the malignant lesions noted, patients with portal gastropathy will have
large venous structures noted in the submucosa. RGMartindale
STEP 3. With the stomach in2ated, an assistant palpates the epigastrum just
inferior to the costal margin with a single finger (Figure 4-6).FIGURE 4-6 Palpating for suitable position for gastrostomy.
This palpation should be seen endoscopically as a discrete projection into the anterior
stomach wall. Transillumination of the skin around the depression may be performed in a
darkened room. Placement of the gastrostomy tube too close to the pylorus can allow
natural passage of the balloon or bolster into the duodenum and lead to gastric outlet
obstruction.The procedure may be aborted in favor of open gastrostomy tube placement
if visualization of stomach anatomy is not perfect.
We like to start from lateral to medial until the area of maximum indentation is found.
For questionable sites, the Ponsky technique of passing a needle with an attached
saline/ lled syringe through the puncture site until it is visualized in the stomach, without other
air entering the syringe, signifying entry through another gas-filled viscus, can be helpful
(see Ponsky, 1998). Patients who have had prior gastric resection may have gastric
remnants that are too small to be insu6 ated to the abdominal wall. They may have a
retro-colic anastomosis, making the Ponsky syringe technique an important
addition. JRSaunders
Using a single / nger to palpate the epigastrium cannot be overstated. If a large
portion of the anterior wall of the stomach depresses with the / nger palpation, the
surgeon should continue to search the anterior abdominal wall for a point where the
stomach is easily noted to see projection onto the stomach wall with even mild pressure.
This will minimize the potential of passing a needle through the liver edge or
colon. RGMartindale
Otolaryngologists with limited experience should ensure seeing transillumination of
the abdominal wall. This will reduce the risk of misplacement of the tube into thecolon. NIBhatti
STEP 4. While keeping the stomach in2ated, the assistant chooses a site two
Cngerbreadths below the costal margin between the xiphoid process and the
anterior axillary line on the left (Figure 4-7).
FIGURE 4-7 Site selection for percutaneous gastrostomy.
Endoscopically, the point should be lateral to the lesser curvature so as to prevent
migration of the gastrostomy tube through the pylorus.
If a combination tube of gastrostomy and jejunostomy may be needed, the tube should
be placed near the antrum to allow easy placement of the jejunostomy portion of the
combination tubes. RGMartindale
STEP 5. The abdomen is prepped and draped in sterile fashion. A 1-cm vertical
incision is made at the site on the anterior abdominal wall.
The size of the incision is much more important than the orientation. JRSaunders
STEP 6. With the stomach fully in2ated, a needle catheter is passed into the
stomach.
An additional method to “test” for appropriate approximation of the anterior?
?
abdominal wall and stomach is to place a 1.5-inch 21- or 23-gauge needle through the
anterior abdominal wall and evaluate the location and angle of entry of needle into the
stomach. After this is con/ rmed, the larger 12- or 14-gauge needle catheter is
placed. RGMartindale
STEP 7. A wire is passed through the catheter and grasped with a snare through
the gastroscope.
The surgeon should be aware that there are di erent kits and methods to gastrostomy
tube placement (availability may vary substantially from institution to institution). The
Ponsky pull technique is described, but push techniques are common as well. It is the
surgeon’s obligation to full understand what kits are available and how these tubes are
placed.
Other commercially available choices for gastrostomy tube placement kits include the
technique of T-fasteners used to pexy the stomach to the anterior abdominal wall. The
Seldinger technique is then used to place the gastrostomy tube by / rst passing a needle,
followed by a guidewire. Dilators are then passed over the wire, followed by the tube,
with a balloon to secure it in the stomach. NIBhatti
STEP 8. The scope, snare, and wire are brought out through the mouth and a
gastrostomy pull-type tube secured to the wire (Figure 4-8).
FIGURE 4-8 Passing guidewire for percutaneous gastrostomy.
During the procedure, gentle insu6 ation of the stomach with complete e acement of
the normal rugae helps ensure that the stomach “ oats” up to the anterior abdominal
wall and displaces other organs that may be between it and the peritoneum.
Good visualization and control of the wire during the procedure are also critical to
prevent injury to the stomach.Too much air insu6 ation can push air into the jejunum and interfere with gastric
apposition to the abdominal wall. JRSaunders
STEP 9. The wire is then withdrawn from the abdomen side, pulling the
gastrostomy tube through the mouth and through the esophagus (Figure 4-9).
FIGURE 4-9 Pulling gastrostomy into stomach wall.
STEP 10. The gastrostomy tube is secured at the abdominal wall between 2 and
4 cm from the skin depending on the girth of the patient (Figure 4-10).
FIGURE 4-10 Securing gastrostomy tube to abdominal wall.
The tube should be secured snugly, but not tightly against the skin to prevent necrosis
and “buried bumper syndrome.”We don’t secure the tube in any way and prefer it to have some play rather than to be
snug. JRSaunders
Keeping the tube exiting the abdomen at a 90-degree angle will help prevent mucosal
and skin necrosis. When the tube is allowed to hang to one side or the other, the internal
bolster places excessive pressure on the mucosa and causes pressure necrosis, leading to
leakage and increased risk of infection. The tube can be easily kept at a 90-degree angle
by placing a Kerlix or small face towel placed at the base of the tube. RGMartindale
STEP 11. The tube is attached to a straight drainage bag and the gastroscope
removed.
Although feeding may begin immediately after placement, we /nd that many patients
do not tolerate feeding shortly following the procedure and we prefer to “rest” the
stomach and GI tract by connecting the new gastrostomy tube to a straight drainage bag
for 24 hours before feeding.
We allow administration of enteral medication in small volumes (<_50c2a0_ml29_
immediately="" after="" tube="">NIBhatti
We generally wait for the return of normal bowel sounds at 1 to 24 hours before
initiating feeding. JRSaunders
Postoperative Considerations for Percutaneous Gastrostomy
Late complications are rare following percutaneous gastrostomy placement.
Subdiaphragmatic air following the procedure is common on chest x-ray and should not
cause alarm.
The air can be noted under the diaphragm for approximately 4 to 5 days, and if
present over 5 days, concern of gastric leakage should increase. RGMartindale
Rebound tenderness, fever, bowel obstruction, and vomiting should be evaluated very
carefully following the procedure for perforation of the large or small bowel. Leakage
around the gastrostomy after resuming feeding is typically the result of gastric stasis
rather than breakdown of the gastrostomy site. Stimulation of the stomach motility
prokinetic agents may be helpful.
We recommend that patients rotate their tubes 360 degrees daily. This helps ensure
that the mushroom end of the tube has remained in the stomach rather than being
extruded into the tract. If there is a question regarding this, the bumper can be
withdrawn, and the tube should easily move back and forth into the stomach.
Gastrogra/ n tube studies can be misleading for tubes that are partially extruded but still
in communication with the gastric lumen. Extruded tubes are generally easily removed
using topical lidocaine gel and replaced with a balloon gastrostomy tube in an o0 ce
setting. JRSaundersPain at the gastrostomy site should be evaluated carefully. Buried bumper is a common
etiology. The occurrence is most common when the gastrostomy tube is pulled too tightly
to the abdominal wall. RGMartindale
Erythema and local skin excoriation around the gastrostomy site is common and often
best treated with gentle loosening of the skin ange. Antibiotics with activity against
gram-positive cocci (e.g., cephalexin) may be useful for erythema consistent with
cellulitis around the site. Yeast organisms are also a common cause of erythema under the
skin ange, particularly in patients who have regular leakage of tube feed around the
flange. Skin barriers and antifungal creams may be helpful in managing such problems.
The routine cleaning of the peritube site with mild soap and warm water will prevent
most gastrostomy tube site irritations and skin problems. RGMartindale
Seeding of the gastrostomy tube site with upper aerodigestive tract cancer has been
reported, but is incredibly rare. Although direct contact and transfer of tumor cells has
been suggested as a mechanism, other data suggest that hematogenous spread of
malignancy with subsequent seeding of the gastrostomy wound may play a greater role.
We do not consider the presence of upper aerodigestive tract malignancy a
contraindication to gastrostomy tube placement or the use of “pull-type” tubes, such as
those described in the technique described earlier.
Editorial Comment
Changes in technology (thin caliber esophagoscopes that can be passed
transnasally) and procedures (percutaneous versus open gastrostomy) have
greatly expanded the head-and-neck surgeon’s role and capability in the Celd of
esophagology. A familiarity with each of the techniques is important, and they
should be seen as complementary rather than competitive with respect to the
more traditional rigid esophagoscopy and open gastrostomy, which still have a
role. Most of the serious problems that arise from these procedures can be traced
to trying to push a given approach beyond its safe limitations rather than
choosing an alternate one. JICohen
Suggested Readings
Ghogomu NT, Kallogjeri D, Nussenbaum B, Piccirillo JF. Iatrogenic esophageal perforation in
patients with head and neck cancer: evaluation of the SEER-Medicare database. J
Otolaryngol Head Neck Surg. 2010;142:728-734.
Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis:
antibiotic prophylaxis to prevent peristomal infection following percutaneous
endoscopic gastrostomy. Aliment Pharmacol Ther. 2007;25:647-656.
Ponsky JL. Transilluminating percutaneous endoscopic gastrostomy. Endoscopy. 1998;30:656.
Postma GN. Transnasal esophagoscopy. Curr Opin Otolaryngol Head Neck Surg.
2006;14:156158.Schrag SP, Sharma R, Jaik NP, Seamon MJ, Lukaszczyk JJ, Martin ND, et al. Complications
related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical
review. J Gastrointestin Liver Dis. 2007;16:407-418.
CHAPTER 5
Operative Bronchoscopy
Author Joshua S. Schindler
Commentary by Seth M. Cohen, Paul W. Flint, Tanya K. Meyer
General Preoperative Considerations
For either exible or rigid bronchoscopy, the surgeon should have all available
information in the room prior to starting the procedure. In common cases, such as upper
aerodigestive tract tumors and airway stenosis, computed tomography (CT) scans of the
area of concern can be critically important in assessing the extent of a given lesion.
Unlike pulmonologists, otolaryngologists must perform bronchoscopy at times when
most indications mandate general anesthesia. This means that management of the airway
throughout the procedure is of paramount importance and the primary responsibility of
the otolaryngologist. Preoperative assessment of the patient’s oral, pharyngeal, laryngeal,
and tracheobronchial anatomy through physical examination, indirect laryngoscopy, and
radiographic imaging is critical to safely maintaining ventilation during the procedure.
The surgeon must consider the relative pulmonary health of each patient to understand
how that patient will tolerate periods of inadequate ventilation. In many cases the
pathology may not allow intubation or even adequate bag-mask ventilation, and the
surgeon must be prepared for multiple contingencies. Although a careful appraisal of the
surgeon’s comfort, skill, and available equipment for direct laryngoscopy (see Chapter 3)
is essential, bronchoscopy can add additional challenges to ventilation that must be
considered prior to inducing general anesthesia.
It is vitally important that the surgeon meet with the anesthesiologist prior to induction
to review the plan for managing the airway. Although this management should be
considered the responsibility of the surgeon, there are a number of airway measures with
which the anesthesiologist is more familiar that can be life-saving in emergencies.
One of the most important steps in operative airway management is preoperative
planning including discussions with anesthesia and having multiple plans for airway
management. SMCohen
In an average adult patient, assuming adequate preoxygenation, after cessation of
respiration there is approximately 3 minutes until desaturation, 6 minutes until asystole,
and 11 minutes until brain death (this varies by the age of the patient and
comorbidities). Thus it is critical to be prepared for contingency plans in case of failure
of the primary airway plan before the patient enters the operating room (OR). If the
contingency plan for securing the airway is a - beroptic intubation, that - beroptic scope



should be in the OR, and the optics, light source, and suction should be tested before the
patient arrives. If the contingency plan is a tracheotomy, the tracheotomy tray needs to
be open with the appropriate blade loaded on the scalpel. There is no time to search for
equipment when the operative team is moving from the primary to the contingency
airway plan.
It is important to ensure proper positioning of the patient on the OR table prior to the
start of anesthesia. Make sure that the head of the bed can ex superior and inferior to
facilitate placing the patient in the proper “sni0 ng” position for optimal laryngeal
exposure. Also make sure that the patient is positioned at the very head of the table so
that the surgeon or anesthesiologist does not have to reach an additional distance to
manipulate the airway. TKMeyer
In some cases, stabilization of the airway with an awake tracheotomy under local
anesthesia prior to induction of general anesthesia is the safest way to proceed with
airway evaluation.
It is useful to calculate the maximal dose and volume allowed for lidocaine for each
patient. During exible bronchoscopy in a sensitive patient, it is possible to get near the
toxic lidocaine dose, especially if the 4% topical lidocaine is used. It may be safer to use
1% or 2% plain lidocaine preparations in these cases. TKMeyer
Flexible Bronchoscopy Preoperative Considerations
Otolaryngologists most commonly perform exible bronchoscopy with the patient
intubated because the procedure is usually part of a comprehensive panendoscopy of the
upper aerodigestive tract. Because of this it is important to discuss the intubation with the
anesthesiologist prior to induction. The necessary diameter of the endotracheal tube
depends on the bronchoscope used and the intent of the procedure. Most diagnostic
procedures can be done with a 5.1-mm bronchoscope and 2-mm cup forceps for biopsies.
These will easily - t down a 7-mm endotracheal tube and even a 6.5-mm tube.
Therapeutic procedures, such as those performed for removal of large mucous plugs,
dilation, or stent placement, require a 7-mm bronchoscope with a 2.8-mm working
channel. These tubes - t best down a 7.5- to 8-mm endotracheal tube. Coordinating
intubation with the anesthesiologist is helpful to avoid delays for tube changes.
It is useful to “test” the sizing by making sure the chosen bronchoscope - ts through the
endotracheal tube or laryngeal mask airway. Make sure that you have enough room for
ventilation around the bronchoscope. TKMeyer
Rigid Bronchoscopy Preoperative Considerations
Rigid bronchoscopy is substantially di; erent from exible bronchoscopy and is almost
never performed in the absence of general anesthesia. In order to perform rigid
bronchoscopy, the surgeon must obtain direct line-of-sight access to the lower airway.
Although this is often easy in children because of their anatomy and particularly pliabletissues, obtaining line-of-sight access in adults can be di0 cult. As such, the surgeon may
consider a variety of methods to view and manipulate the lower airway, some of which
do not even require a rigid bronchoscope. Regardless of what method the surgeon uses,
having a full complement of equipment used for direct laryngoscopy is often useful.
It is essential to make sure that all equipment that may be needed is available and
working. Lighting for scopes and suction need to be checked prior to the patient entering
the OR. SMCohen
Flexible Bronchoscopy
STEP 1. Attach the swivel adaptor to the endotracheal tube (Table 5-1).
TABLE 5-1 Equipment for Flexible Bronchoscopy
• Bronchoscope
• Swivel adapter (Bodi connector)
• Silicone lubricant
• Anti-fog solution
• Biopsy forceps
STEP 2. Pass the bronchoscope through the endotracheal tube to the distal tip
(Figure 5-1).FIGURE 5-1 Flexible fiberoptic bronchoscopy through an endotracheal tube.
It is helpful to suction the endotracheal tube prior to advancing the bronchoscope to
avoid collecting mucus at the tip. If the scope becomes fogged or covered with mucus,
simply wipe the scope tip gently across the carina to clear the tip. Lavage of 2 to 3 mL of
respiratory-grade sterile saline may also help.
For most diagnostic procedures the surgeon should avoid the urge to suction patches of
mucus. These can clog smaller scopes and simply prolong the procedure.
STEP 3. Pass the scope to the carina and into the right mainstem bronchus. View
the visible portions of the lower airway.
Use a combination of - nger and wrist action for directional control of the distal tip of
the scope. The surgeon should stand tall and keep the scope as extended and straight as
possible. This allows the surgeon to “dance” using wrist rotation of the bronchoscope.
Doing so is critical to add the third degree of freedom at the tip of the scope and allow
atraumatic advancement into all air passages. If the scope is not extended, rotation of the
body of the scope will only result in coiling of the cable rather than movement of the tip.To further maintain visual orientation, it is helpful for the surgeon to turn slightly and
face the side being examined. PWFlint
Comprehensive bronchoscopy will inspect the mid and distal trachea, the carina, and
bronchi including the right upper lobe, right bronchus intermedius, right middle lobe,
right lower lobe, left upper lobe, left lingua, and left lower lobe. To enable the scope to
pass, each segment should be noted and inspected for lesions. The proximal trachea is
better visualized by direct laryngoscopy/tracheoscopy without an endotracheal tube in
place using a rigid telescope (see Chapter 3).
During the examination, apply frequent suction in all areas inspected to assess for
tracheomalacia. Collapse of anterior and lateral walls identi- es segments with loss of
cartilaginous support. PWFlint
Having a standard evaluation algorithm can help ensure that all areas are
inspected. SMCohen
STEP 4. Biopsy suspicious lesions by passing the forceps through the working
channel of the scope.
Most lesions in the lower airway can be biopsied. Although there can be a concern
about creating a bronchopleural - stula or pneumothorax, these problems are rare with
intraluminal lesions. The surgeon should exercise caution biopsying lesions that appear to
be outside of or through the cartilaginous lumen as well as particularly vascular lesions.
Flexible bronchoscopy can also be easily performed under general anesthesia using a
laryngeal mask airway (LMA) and spontaneous ventilation. The patient is induced and
the LMA is placed by the anesthesia team. The swivel adapter is placed. The
bronchoscope is introduced through the LMA. At the glottis, topical lidocaine can be
given to prevent laryngospasm and coughing. Additional topical lidocaine can be given
in the trachea—be careful to monitor total dose given. With this technique, vocal fold
motion, the status of the subglottis, the dynamic stability of the trachea with respiration
and cough (tracheomalacia), and the lower airways can all be assessed and
manipulated. TKMeyer
Equipment for Rigid Bronchoscopy (Table 5-2)
Bronchoscopes come in di; erent sizes and lengths. In most situations a 40-cm
bronchoscope is the appropriate length. A normal adult male airway will usually
accommodate a 9-mm-diameter scope easily. Smaller patients, airway stenosis, and
unusual anatomy may necessitate the use of smaller scopes.
TABLE 5-2 Equipment for Rigid Bronchoscopy
• Rigid bronchoscope• Light source
• Suction
• Anesthesia circuit adapter (Jolly tube)
• 45-cm Hopkins rod telescope
• Macintosh (or other) laryngoscope (if needed)
In many cases a rigid bronchoscope is not necessary or desirable. In such cases the
surgeon can establish the airway with a laryngoscope and suspension apparatus.
Ventilation may be performed with intermittent removal and replacement of an
endotracheal tube through the laryngoscope (intermittent apneic technique) or via jet
ventilation. The jet ventilator is often the most e0 cient because it allows the surgeon to
work with no endotracheal tube in the way and maintain ventilation. Again, a rigid
45cm Hopkins rod telescope is useful for visualizing the airway.
Rigid Bronchoscopy
STEP 1. Place the bronchoscope in the oropharynx with the longer end of the
beveled tip directed anteriorly.
STEP 2. Pass the scope behind the epiglottis and identify the glottis (Figure 5-2A).FIGURE 5-2 A, Rigid bronchoscope insertion to larynx.
The bronchoscope has a tiny distal aperture given its length, and it can often be
challenging to identify the glottis.
If secretions are a problem—which are cumbersome to suction from a 40-cm
bronchoscope—the anesthetist may administer glycopyrrolate (Robinul) to reduce these.
A sturdy tooth protector is often helpful to prevent dental injury.
If the glottis cannot be easily identi- ed, the surgeon may use a Macintosh or similar
laryngoscope to expose the glottic aperture and place the rigid bronchoscope (see Figure
5-2B).
A small amount of water-based lubricant on the outside of the bronchoscope can
facilitate passage through the lower airways.
STEP 3. Rotate the bronchoscope 180 degrees to advance the scope into the
cervical trachea (Figure 5-3).
FIGURE 5-3 Rotate rigid bronchoscope to pass through glottis.
The beveled end of the scope facilitates exposure throughout the procedure. Like a
laryngoscope, the longer end is adjacent to the epiglottis when exposing the larynx.
Before passing through the glottic aperture the bevel is rotated to better view the airway
as the surgeon passes the scope through the glottis.
Rotating the bevel is helpful to atraumatically lateralize one vocal fold to facilitate
passage through the glottis. SMCohen
Head position may change during this part of the procedure. It is often easiest to see
the glottis with the neck slightly exed, as in direct laryngoscopy. Once the glottis is
exposed, the airway will angle more anteriorly and the surgeon may need to extend the
neck substantially to safely advance the bronchoscope. A shoulder roll is rarely necessary
if the head of the bed can be lowered to flex the neck.
STEP 4. Attach the proximal glass, ventilator adapter, and the anesthesia circuit
to initiate ventilation.
Most rigid bronchoscopes have side holes that extend about 5 cm up from the tip.
Because of this the surgeon cannot e; ectively ventilate with positive pressure from the
anesthesia circuit until the scope tip is about 5 to 6 cm below the glottis.
Be aware that small-diameter bronchoscopes may leak substantially through glottic
apertures of normal caliber. E; ective ventilation is not possible unless the scope is closelysized to the airway lumen.
STEP 5. Carefully advance the bronchoscope to the carina.
With the bronchoscope in the cervical trachea, the surgeon “threads” the airway onto
the bronchoscope by gently advancing the scope through the open lumen.
The rigid bronchoscope can be extremely dangerous if it is not carefully advanced
through the airway. The junction of the membranous tracheal wall with the cartilaginous
rings of the tracheal is particularly easy to separate and cause a bronchopleural - stula.
The surgeon must always see an open lumen before advancing the scope and may need to
rotate the scope slightly in order to take advantage of the beveled end.
The left hand is used to advance the scope (see Figures 5-2A and 5-3) in controlled
increments while guiding with the right hand, thus minimizing the risk of injury. PWFlint
STEP 6. Rotate the patient’s head to gain access to the bronchi (Figure 5-4).
FIGURE 5-4 Turn patient’s head to the contralateral side to obtain straight line access
to the bronchus.Turning the head allows the surgeon to angle the scope into the right and left airways,
using the glottis as the pivot point. To view the right mainstem bronchus, the surgeon
should turn the patient’s head to the left and vice versa.
STEP 7. Biopsy suspicious lesions using a 2- to 4-mm cup forceps.
Bronchoscopy Without a Rigid Bronchoscope
STEP 1. Perform suspension laryngoscopy and expose the glottic aperture.
This is often the most useful way to perform airway evaluation and intervention. It
a; ords the surgeon unencumbered access to the entire lower airway from the vocal folds
to the lower lobe takeo; s. Without an endotracheal tube or rigid bronchoscope, the
surgeon has much more room to manipulate instruments and work in several areas of the
lower airway without adjusting the airway. The surgeon should use the largest
laryngoscope that will allow visualization of the glottis and jet ventilation. I prefer the
Lindholm laryngoscope when possible, but the Dedo laryngoscope will also work
effectively.
In select patients, total intravenous anesthesia (TIVA) can be used to allow
spontaneous ventilation. This works better in younger, thin patients without pulmonary
disease. TKMeyer
STEP 2. Establish jet ventilation.
Establishing jet ventilation can be tricky to those unfamiliar with the technique. Many
laryngoscopes have a side channel to allow attachment of a jet ventilator and direct the
air to the tip of the scope. Some laryngoscopes require small attachments for this. The
“Hunsaker” needle may also be used.
Keep in mind that the procedure may also be performed under brief apneic conditions
without the use of jet ventilation. PWFlint
The surgeon should monitor for chest rise and fall to assure adequate ventilation and
not simply oxygenation. Usually 20 to 30 mm Hg pressure is adequate for e; ective
ventilation. In obese patients, reverse Trendelenburg position may be helpful to improve
ventilation.
A suspension table (Mustard, Mayo, etc.) should always be used for jet ventilation
because using the patient’s chest as the suspension surface may prevent adequate
ventilation.
For this procedure, 100% oxygen may be used, and as long as nothing that can burn is
placed in the airway, there is no risk of laser or electrical fire.
At no time should the proximal end of the laryngoscope be substantially obstructed, to
avoid the risk of barotrauma.
The surgeon should wear eye protection during jet ventilation.
STEP 3. Perform bronchoscopy with a 45-cm by 5-mm 0- or 30-degree Hopkinsrod telescope (Figure 5-5).
FIGURE 5-5 Rigid telescope through laryngoscope for airway inspection.
A 70-degree telescope may also be useful. SMCohen
The surgeon may need to adjust the patient’s head position and laryngoscope position
to attain line-of-sight access through the trachea and bronchi. Use of a 30-degree
endoscope may preclude the need to take the patient out of suspension and turn the head
for visualization of the bronchi.
STEP 4. Biopsy suspicious lesions under close visualization using the telescope
and 2- to 4-mm cup forceps.
When the procedure is completed, the surgeon may place a No. 6 endotracheal tube
through the laryngoscope, withdraw the scope over the tube, and emerge the patient
from general anesthesia at the discretion of the anesthesiologist with a secure airway.
Interventional Bronchoscopy with Tracheal Balloon Dilation
STEP 1. The surgeon should perform suspension laryngoscopy and bronchoscopy
with jet ventilation and a 45-cm Hopkins rod telescope as described previously.
Rigid bronchoscopy can also be performed, but ventilation and visualization are both
compromised as a result of the bronchoscope.
Jet ventilation can be used e; ectively with even the smallest airways (3 to 4 mm) and
allows the greatest flexibility with instrumentation.
The stenosis should be inspected for position relative to the vocal folds and length

(both in cm). It may also be palpated for rigidity. Tracheal stenoses come in many
varieties. Cartilaginous collapse from previous tracheotomy is often “A-shaped” in
con- guration. In my experience, these are rarely ameliorated with dilation for long and
typically require resection because they lack structural support for durable dilation.
Membranous stenoses have normal and stable cartilaginous rings surrounding a
circumferential - brous and mucosal band in the airway. In the trachea, these are more
common in in ammatory disorders, such as Wegener’s granulomatosis, and less severe
endotracheal tube injuries. These are generally quite amenable to simple dilation. More
comprehensive, and possibly more durable treatment, may be a; orded by using radial
incisions cut with a laser or definitive resection.
Biopsy of the stenosis is important to facilitate diagnosis. SMCohen
As discussed under exible bronchoscopy, it is important to identify tracheomalacia. In
this situation, pass a rigid telescope and suction through the glottic aperture and apply
suction. Collapse of anterior and lateral wall identi- es segments with loss of
cartilaginous support. PWFlint
STEP 2. Dilate the stenosis using a continuous radial expansion (CRE) balloon
(Figure 5-6).
FIGURE 5-6 Balloon dilation of tracheal stenosis.
The balloon is in ated to dilate the stenosis and subsequently removed. The procedure
may be repeated with a larger balloon, if desired. There is no great science for
determining how much to dilate the patient’s airway stenosis. The risk, of course, is
airway disruption with bronchopleural - stula and subcutaneous or mediastinal
emphysema. Soft stenoses with cartilaginous collapse can often be dilated widely (18 to
20 mm), but will relax back to at least partially obstructed shortly following the
procedure. Firm, - xed stenoses may be at greater risk of disruption during dilation. I
have become more aggressive with dilating these with time and will generally dilate to
about three times larger than the stenotic aperture. Most will accept dilation with a 15- to
18-mm balloon. Serial dilation in ever-increasing diameters of balloon from the original
stenosis does not seem to yield any advantage over simply using the - nal 15- to 18-mm
balloon.
Other methods of dilation, including serially increasing semirigid bougies, Jackson




laryngeal dilators, and rigid bronchoscopes, may be used for simple dilation. I prefer the
CRE balloons because they in ate within the airway and do not have the limitation of
passing through the glottis. I would not try to pass an 18-mm bougie through the glottis.
The CRE (controlled radial expansion) balloons are also gentle on the surrounding
mucosa and may limit further airway injury.
New noncompliant balloons are available for tracheal dilation. I prefer to make radial
incisions through areas with a large “shelf” of stenosis prior to balloon dilation with a
noncompliant balloon. I typically use a 10- or 14-mm balloon. Adjuvant treatments such
as mitomycin C may be applied after dilation. SMCohen
Following dilation, redundant tissue extruding into the airway may be removed using
laser ablation or excised with a 27.5-cm microdebrider with a 4-mm Tricut
blade. PWFlint
Once completed, the surgeon should be able to place a No. 6 endotracheal tube
without di0 culty, remove the laryngoscope, and return the patient to the anesthesiologist
for emergence.
Tracheal balloon dilation can additionally be performed using exible bronchoscopy
through an LMA with spontaneous ventilation. It is important to check the length of the
bronchoscope in relation to the balloon catheter. Some exible bronchoscopes allow
introduction of the balloon catheter through the working channel. Other bronchoscopes
either do not have a working channel that is large enough, or the balloon catheter is not
long enough to pass entirely out of the working channel. It is important not to in ate
the balloon in the channel or the scope will be severely damaged. If there is a length
discrepancy, a guidewire can be introduced through the working channel and into the
distal tracheobronchial tree. The bronchoscope is removed leaving the wire in place. The
balloon is introduced over the wire, and the bronchoscope is reintroduced alongside the
balloon for visual con- rmation of placement. The balloon can be in ated to allow
dilation and then deflated to allow ventilation. TKMeyer
Postoperative Considerations
Bronchoscopy is most commonly performed as an outpatient procedure. Even in cases of
airway stenosis, the surgeon should be con- dent that the airway is larger than it was
before the patient arrived.
Postoperative chest x-ray is not typically necessary.
Rarely, patients with substantial airway compromise can develop postobstructive
pulmonary edema following airway interventions. Hypoxemia in the postoperative period
with continued supplemental oxygen requirement and di; use rales in the chest are
characteristic. Chest x-ray will demonstrate di; use pulmonary edema. This typically
resolves with diuretics in 24 to 48 hours, but may require hospitalization. In rare
circumstances, reintubation with positive pressure ventilation and slow wean may be
necessary.Hemoptysis is common following bronchoscopy, but rarely of consequence.
Largevolume hemoptysis should prompt close observation and consideration of repeat
bronchoscopy. Often hemoptysis occurs from tears of the pharyngeal mucosa and resolves
without further intervention.
Suggested Readings
Andrews BT, Graham SM, Ross AF, Barnhart WH, Ferguson JS, McLennan G. Technique,
utility, and safety of awake tracheoplasty using combined laser and balloon dilation.
Laryngoscope. 2007;117:2159-2162.
Daumerie G, Su S, Ochroch EA. Anesthesia for the patient with tracheal stenosis. Anesthesiol
Clin. 2010;28:157-174.
Gaissert HA, Burns J. The compromised airway: tumors, strictures, and tracheomalacia. Surg
Clin North Am. 2010;90:1065-1089.
Gardner GM, Courey MS, Ossoff RH. Operative evaluation of airway obstruction. Otolaryngol
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Airway Operations