clinic in Germany, the DEUTSCHE STIMMKLINIK (, which is located in Hamburg on the grounds of the UKE. mklinik unterbringen. THE AUTHORS.

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3 2 CONTENTS 4.6. Examination of Children .. 66 4.6.1. General Remarks .. 66 4.6.2. Transoral Rigid Endoscopy of Children . 67 4.6.3. Transnasal Flexible Endoscopy of Children . 68 4.6.4. Transnasal and Transoral Endoscopy of Babies (Flexible and Rigid) . 69 5 RECOMMENDED SEQUENCE OF PROCEDURES .. 71 6 TIPS AND TRICKS 77 6.1. How to Solve Problems with Poor Image Quality . 78 6.2. Patient-Related Problems: Secretions and Gag Response .. 85 6.3. Special Maneuvers 87 6.4. Special Positioning of Endoscope or Patient . 93 7 STROBOSCOPY .. 109 8 OFFICE-BASED PHONOSURGERY .. 115 8.1. Phonosurgery, Rigid Transoral Procedure .. 117 8.2. Phonosurgery, Flexible Transnasal Procedure .. 118 8.3. Phonosurgery, Percutaneous Procedure with Transnasal Visualization .. 119 9 ACKNOWLEDGEMENTS / DISCLOSURE / THE AUTHORS . 121 10 SPECIALIZED TECHNICAL EQUIPMENT 125 11 PREPARATION, CLEANING, AND HYGIENE . 129 12 PRODUCT INFORMATION .. 139 1 INTRODUCTION . 5 2 EQUIPMENT FOR IMAGE ACQUISITION 9 2.1. Arrangement of the Examination Room 10 2.2. Image Acquisition and Processing . 11 2.2.1. General Remarks . 11 2.2.2. Preparing the Equipment .. 12 2.3. Examples of Poor Image Quality . 14 2.4. Endoscopes for Laryngoscopy 15 2.4.1. General Remarks . 15 2.4.2. Rigid Endoscopes 18 2.4.3. Flexible Endoscopes .. 24 3 ANESTHESIA 31 3.1. General Remarks .. 32 3.2. Anesthetizing the Oropharyngeal Region . 33 3.3. Anesthetizing the Nasal Cavity . 34 3.4. Anesthetizing the Larynx. .. 35 4 ENDOSCOPY .. 37 4.1. Considerations Before Starting Endoscopy 38 4.2. Position of Patient and Examiner 39 4.3. Transoral Rigid Laryngoscopy Œ Handling the Endoscope 46 4.3.1. Left Hand: Holding the Patient™s Tongue .. 46 4.3.2. Right Hand: Inserting the Endoscope 48 4.3.3. The Examiner™s Head Position . 49 4.4. Transnasal Flexible Laryngoscopy Œ Handling the Endoscope 50 4.4.1. Insertion of the Endoscope 50 4.4.2. Rotation of the Endoscope 51 4.4.3. Flexible Endoscopy Œ How NOT to Do It . 52 4.4.4. Transnasal Passage and Sequence of Endoscope Positions .. 53 4.5. Special Maneuvers for Flexible Endoscopy . 58 4.5.1. Endolaryngeal Dipping Maneuver .. 58 4.5.2. Transstomal Flexible Endoscopy of Subglottis and Trachea 60 4.5.3. Transnasal Flexible Endoscopic Examination of Swallowing (FEES) 62 4.5.4. Transnasal Flexible Esophagoscopy (TNE) . 64

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INTRODUCTION 1 OLYMPUS DISCLAIMER The information presented here is for your general knowledge and background only. Please thoroughly review the relevant Users Manual(s) for instructions, warnings and cautions. The information presented here comes from sources considered to be dependable. However, we make no representations, warranties or other expressed or implied warranties or guarantees regarding the accuracy, reliability or completeness of the information. To the maximum extent permitted by applicable law, under no circumstance shall Olympus or its employees, consultants, agents or representatives be liable for any costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with the information provided or any use thereof. This limitation of liability shall not apply to acts of willful intent or gross negligence or to claims for culpable caused damages to life, body and health and to claims arising from the German Act on Product Liability (Produkthaftungsgesetz).

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7 6 INTRODUCTION Recent progress in the development of optical systems means that there are now several ways to obtain great laryngeal images in the consulting room. As a general rule, combining different methods, i.e. rigid or ˜exible endoscopy with stroboscopy, or NBI, etc., helps to gather an extended amount of information about laryngeal structure and function. In this manual, we show practical routine procedures and special maneuvers for laryngoscopy as well as the manner in which they are performed. The aim of this is to improve imaging quality while making the procedure tolerable for patients. Because special maneuvers are needed to examine some functions in voice, swallowing, and breathing, we have summarized these examination techniques in a newly coined term: functional endoscopy. Before starting the examination, it is advisable to familiarize yourself with the equipment. In the ˚rst part (chapter 2) the most important features of the endoscopes and the technical equipment with helpful handling techniques are explained. Because good anesthesia is of crucial importance for every examination, procedures for providing effective anesthesia are discussed in chapter 3. In chapter 4, endoscopy with rigid and ˜exible endoscopes is discussed Œ together with pre-conditions such as positioning of the patient and the examiner. Its emphasis is the accurate description of handling skills because these are an essential prerequisite for good imaging. This chapter also includes further indications for endoscopy, such as FEES and TNE, and a separate section describing how to examine children. In chapter 5 we have made several suggestions about an effective order in which the various procedures may be carried out. Some special maneuvers, tips, and tricks are described in chapter 6. We outline stroboscopy (chapter 7) and of˚ce-based phonosurgery (chapter 8). Tables have been provided within the chapters summarizing useful maneuvers, procedures, and techniques at a glance. For most procedures we tried to include all the information within the image, thus avoiding long text passages. Olympus provides information about the special technique of NBI as well as about the preparation and cleaning of the endoscopes and delivers some product information (chapters 10Œ12). It is obvious that a small booklet on practical of˚ce- based endoscopy cannot cover all features, prerequisites, and special cases that endoscopy requires. The endoscopist can only acquire the necessary skills and experience through daily practice and continued learning. We intentionally excluded endoscopy under general anesthesia. This would have in˜ated the manual too much. We hope that this manual is of some help for those who want to get familiar and skilled in of˚ce-based laryngoscopy. Hamburg, December 2015 Susanne Fleischer, MD Markus Hess, MD 1 INTRODUCTION 1 INTRODUCTION

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11 10 2.1. Arrangement of the Examination Room When arranging an of˚ce for laryngeal endoscopy there are some important aspects to consider. · The room has to be large enough to place the necessary equipment while leaving enough space for the patient and the examiner(s) as well as for any assistants who may need to move around the examiner and patient. · When examinations or of˚ce-based operations are performed with the patient lying supine even more space will be required. · The chair for the patient should be placed so as to allow placing the equipment and instrumentation within easy reach and without cables to stumble across. · Place the video monitor next to the patient, so that the examiner can view both patient and monitor in a relaxed manner, either when sitting or standing. · Choose height-adjustable chairs for both the patient and the examiner. · The examiner should not be blinded by a light source or with a daylight window during the examination. Criteria for the Examination Room: · Enough space for a patient, examiner and assistant. · Enough space for a patient lying on a stretcher. · Endoscope equipment and ENT instruments within easy reach of the examiner. · Choose a monitor position that permits the clinician to view both the screen and the patient in reasonable comfort. · Avoid loose cabling on the ˜oor to avoid tripping accidents. · Window light and room light should be dimmed. 2.2. Image Acquisition and Processing 2.2.1. General Remarks In this section we want to stress the fact that video endoscopy relies on a series of well-attuned components. Although we cannot deal with cameras and image processing in this endoscopy manual, it needs to be said that the weakest component determines the image outcome. However, we address some aspects in the following sections. EQUIPMENT FOR IMAGE ACQUISITION · In most ENT of˚ces providing laryngoscopy, video or computer recording is usually available. · Video recording of the whole examination is recommended for comprehensive assessment and reevaluation as well as for documentation, demonstration to the patient, teaching and monitoring pre- and postoperative outcome. · Video editing saves data space, but requires extra time. In busy of˚ces, there might not be enough time to edit videos. · All components for video laryngoscopy and archiving be adjusted and balanced in order to optimize image quality: Endoscope, light source, camera, recorder, monitor, stroboscope, light ˚lters (e.g. NBI), printer, computer, server. · When video recording of huge data sets is mandatory, choose the best trade-off between image quality and compression ratio for digitized video. · We believe that in the near future one can expect easy image acquisition with mobile devices, e.g. with an adapter connected to a smart phone. Keep in Mind Which Parameters Determine the Quality of Your Images: · Optimum illumination · High resolution for the smallest structures · Image centered on region of interest (ROI) · Focus on ROI · No image rotation (see alignment) · Lens of endoscope should be clean; check with microscope 2 EQUIPMENT FOR IMAGE ACQUISITION IMAGE ACQUISITION AND PROCESSING 2 EQUIPMENT FOR IMAGE ACQUISITION ARRANGEMENT OF THE EXAMINATION ROOM · Optimal distance to ROI (optimal size) · Balanced colors (white balance) · Adequate color and contrast balance

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15 14 2.3. Examples of Poor Image Quality Acceptable image: Centered, not rotated, focussed, well illuminated, sufficient magnification, white-balanced, not blurred Here, reasons for poor image quality are shown. Laryngoscopic images with the same problems are shown in chapter 6.1. Traditional examination of the larynx with a mirror. Position of hands similar to rigid endoscopy. For 3D stroboscopy attach strobe light to microscope* and trigger with microphone (here: Neck microphone**). You can get stereoscopic 3D strobe imaging of vocal-fold vibrations. 2.4. Endoscopes for Laryngoscopy 2.4.1. General Remarks · It is important that the examiner is entirely familiar with all instruments and devices so he can concentrate fully on the examination itself and doesn™t have to struggle with problems with instrument handling. · In this chapter you can ˚nd some basic information about endoscopes, camera systems and video images. · Additionally, we describe some helpful tips and techniques for endoscopy. You can easily try these tricks before examining a patient. · With the perfect knowledge of your instrumentation it is easier to take advantage of all possibilities during endoscopy. Traditionally, examination of the larynx with a mirror was standard. Here, the examiner has to pay attention to the direction of the light beam Œ it should be in the same axis as his viewing axis. In some situations this technique can still be helpful, e.g. for assessment of level differences, for true 3D imaging or when you want to see the true colors of the larynx. Image too dark Not white-balanced Image overmodulated Region of interest not centered Image rotated Region of interest too far away Not well focussed Œ or fogged Image blurred due to fluid on lens Magnified view with microscope. Use 350 mm lens for the microscope. 2 EQUIPMENT FOR IMAGE ACQUISITION ENDOSCOPES FOR LARYNGOSCOPY 2 EQUIPMENT FOR IMAGE ACQUISITION EXAMPLES OF POOR IMAGE QUALITY

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17 16 Relation of Image to Larynx · When performing indirect laryngoscopy it is important to remember that the ˚nal image that is projected is dependent on the equipment being used. In practice, with modern camera systems, every orientation of anterior to posterior and right to left is possible. Get to know your instrumentation. · In the traditional view with (A) a mirror compared with (B) rigid endoscopy, the anterior and the posterior aspects of the larynx are reversed (vertical inversion). · For ˜exible endoscopy (B, C, D), depending on how the camera is connected and adjusted and how the examiner holds the endoscope, the image may be rotated by 180° or it may be mirrored vertically or horizontally. · Caveat: the left and right sides in (B) and (D) are switched. The Possibilities of Image Projection Are Illustrated Here: · Line 1 shows a scheme of the vocal folds with the speci˚cation of anterior to posterior and right to left. · Line 2 illustrates with the letter R what happens to a picture. · In Line 3 laryngoscopy was performed in that speci˚c way and the picture of the larynx is shown. Indication for Rigid and Flexible Laryngoscopy · There are numerous endoscopes available on the market for indirect laryngoscopy. · When choosing between rigid and flexible laryngoscopy, it is important to know the specific advantages of both techniques. · To obtain maximum information from the examination it is often best to use both techniques (see Table 2.1. and Table 5.1). · With the development of the distal-chip cameras the image quality of flexible endoscopy has improved dramatically. · Advantages of rigid endoscopy are less significant now than in former times when compared with glass-fiber flexible endoscopes. But rigid endoscopes can still provide high-quality images. · Controlling the position of the endoscope tip is easier when using a rigid endoscope rather than a flexible one. Symmetry and orientation of the image is easier to maintain during rigid endoscopy. · For rigid laryngoscopy, endoscopes with 70° and 90° angles have different advantages. Typically, 70° laryngoscopes are best examining of children and visualizing the anterior commissure. · In some countries flexible endoscopes must be cleaned in a time-consuming way. Rigid endoscopes are mostly cheaper and easier to clean. Thus, some examiners might prefer rigid endoscopes. · In the future, high-definition flexible chip-on-the-tip endoscopes may shift your choice to flexible endoscopy. Experience shows – · – that where a flexible chip-on-the-tip endoscope is available it will be used more and rigid endoscopy will be performed less frequently. · – that when no flexible chip-on-the-tip endoscope is available and a fiberscope must be used, rigid endoscopy will be performed more frequently as the image quality is significantly better than that of the glass-fiber instruments. Table 2.1: Applications for rigid and flexible endoscopes (see Table 5.1) Endoscope Advantage Special Application Rigid 70° Autofocus Children examination, anterior commissure 90° Zoom (bifocal) in some endoscopes Same magni˚cation as with 70° and close- up position Flexible All ˜exible endoscopes Patients with severe gag response Examination of subglottis/trachea Examination of arytenoid mobility Vocal tract con˚guration during running speech and singing Examination of swallowing Smallest size (<2 mm) to largest useable size (nearly 5 mm) <2 mm glass ˚berscope Very small diameter Babies and toddlers Transglottal examination in laryngeal stenosis Standard ˚berscope Adaptable to different light sources (CW, strobe) Bedside examination (because of portable pocket-sized light source) Chip-on-the-tip videoendoscope (smallest size 2.6 mm) High-quality images Looking for ˚ne structures With instrument channel ( ˝ 4.8 mm) Instrument channel allows operation, suction, etc. Of˚ce-based surgery Right Left Right Left A) View with a mirror B) Rigid endoscope or ˜exible endoscope, not rotated (standard) C) Flexible endoscope, same endoscope position as in (b) but camera rotated 180° D) Flexible endoscope, same endoscope position as in (b), but image digitally mirrored by camera system Right Left Posterior Anterior Right Left 2 3 1 Posterior Anterior Posterior Anterior Posterior Anterior 2 EQUIPMENT FOR IMAGE ACQUISITION ENDOSCOPES FOR LARYNGOSCOPY 2 EQUIPMENT FOR IMAGE ACQUISITION ENDOSCOPES FOR LARYNGOSCOPY PAGE - 10 ============ 19 18 2.4.2. Rigid Endoscopes Characteristics · Rigid endoscopes angled at either 70° or 90° are suitable for indirect laryngoscopy. · For both there are different versions on the market with different diameters and various handgrips. · In Europe rigid endoscopy was traditionally performed with a 90° endoscope. Now the 70° endoscope seems to increasingly be the instrument of choice. · The 90° rigid endoscopes may provide dual focus for zooming. · The 90° rigid endoscope may also have an antifog ventilation channel. 70° (left) and 90° (right) rigid endoscopes Œ different position for same vertical optical axis Tip of 70° (left) and 90° (right) rigid endoscope 0° 70° 90° Optical Axis for Various Rigid Endoscopes: Magni˚cation Possibilities with Rigid Endoscopes · Magni˚cation can be determined by the distance to the object. · Some rigid endoscopes have the option of a bifocal zoom. · In some camera systems you can additionally zoom with the camera (see chapter 2.2.2.) · The zoom can either be optical (within the endoscope or the camera) or digital (using image processing within camera). 90° rigid endoscope with manual (finger) dual focus for zooming; endoscope is attached to camera A) Test chart with normal focus of 90° rigid endoscope B) Test chart, same distance from lens to object as in (A), but digitally zoomed. Image resolution is changed when zoom is used. Zoom in camera D) Same setting as in C) but with a distance of 3 cm C) 70° rigid endoscopes, distance to test chart of 6 cm 2 EQUIPMENT FOR IMAGE ACQUISITION ENDOSCOPES FOR LARYNGOSCOPY 2 EQUIPMENT FOR IMAGE ACQUISITION ENDOSCOPES FOR LARYNGOSCOPY PAGE - 11 ============ 21 20 Rigid Endoscope and Camera Alignment Alignment is de˚ned as the process of adjusting parts so that they are in the proper position relative to one another. · For rigid endoscopes correct camera alignment is important. · When the image is rotated, laryngeal cartilage frame asymmetry is difficult to diagnose. · When the image is rotated, assessment of arytenoid movements may be difficult. · The patient™s anteriorŒposterior (i.e. sagittal) axis should be aligned with the vertical axis of the image. · Most adapters permit rotation of the camera, enabling manual alignment as seen in the following pictures. How Alignment Can Influence Your Imaging Alignment: In clinical practice when performing laryngoscopy, it is assumed that the larynx is symmetrical and the vocal folds form a V. When a rigid endoscope is in an ideal median laryngoscopic position, it is in a fiperfect sagittalfl direction as well. In order to achieve a perfect V on the monitor it is mandatory that the camera and adaptor are aligned with the endoscope (see examples, page 21). Corrective Alignment: Intentional correction for (monitor) image alignment: The camera is intentionally rotated to compensate an oblique position of the rigid endoscope. The resulting image on the screen is perfectly adjusted (perfect V). Corrective alignment can be used to rectify and adjust a monitor image by rotation of the camera attached to the endoscope™s eyepiece (see examples, page 22). Attaching of endoscope and camera. Here, a clip-on adapter is shown. Most adapters allow rotation of the camera, enabling manual alignment as well as ficorrective alignment,fl seen in the following figures and photos. Alignment of endoscope with camera, with and without rotation. A) If the camera is rotated clockwise, as illustrated with arrow, then the image is rotated counterclockwise. B) Perfect alignment. C) If camera is rotated counterclockwise (see arrow), then the image is rotated clockwise. Monitor Image Endoscope Image rotated Image rotated Ocular Camera 0 0 0 0 Perfect alignment OK 0 0 Alignment of endoscope with camera, with and without rotation: The rotated image cannot be satisfactorily corrected simply by altering the endoscope position. On the other hand, you can compensate for an oblique endoscope position with a corrective alignment of the camera. 2 EQUIPMENT FOR IMAGE ACQUISITION ENDOSCOPES FOR LARYNGOSCOPY 2 EQUIPMENT FOR IMAGE ACQUISITION ENDOSCOPES FOR LARYNGOSCOPY A B C 383 KB – 74 Pages