Volume 69 September 1976
667
Joint Meeting No. S
Section of Laryngology President Kenneth Harrison FRCS
with Section of Anaesthetics President R Bryce-Smith DM
Meeting 6 February 1976
Anaesthesia for Endoscopy
[Abridged] Mr R Pracy and Dr Gordon H Bush (Alder Hey Children's Hospital, West Derby, Liverpool, L12 2AP)
The Importance of Cooperation in Paediatric Endoscopy [Abstract] The prime consideration in all endoscopy must be safety. This can only be achieved if both the surgeon and the anxsthetist pay particular attention to the maintenance of a patent airway. Standardization of the procedure is all important. The anesthetist should be able to vary his technique to make this possible. Local and general anesthesia are combined and this ensures rapid recovery which is essential. The anesthetic technique should permit the carrying out of an endoscopic operation if this is found to be necessary. It is essential that proper records should be kept.
Mr David E Whittam (St George's Hospital, London SWJ7 OQT)
Adult Endoscopy The Concise Oxford Dictionary defines an endoscope as an instrument for viewing internal parts of the body. Laryngoscopes, bronchoscopes and cesophagoscopes are all specialized speculums which enable the endoscopist to visualize cavities of the body which, because of their depth and anatomical relations, cannot otherwise be seen. In the study and management of conditions involving the larynx, respiratory tract and cesophagus in patients of any age, endoscopic procedures are essential, but it must be stressed that they form only part of the total examination of the patient whose symptoms indicate an apparent disorder of the larynx, airway or oesophagus. The functions of the larynx are to control and protect the airway and also to produce sound.
The quality and pitch of the voice may be altered by inflammatory disease, obstruction of the airway by tumours or trauma or by neurological malfunction, and direct laryngoscopy may be needed to determine the etiology of the condition and permit endoscopic procedures to be carried out. After direct laryngoscopy in the investigation of a patient who presents with hkmoptysis, chronic cough, a wheeze or dyspncea, bronchoscopy should also be performed; its omission amounts almost to criminal neglect. Prior to bronchoscopy chest X-rays, including anteroposterior and lateral views, may reveal evidence of disease in the major bronchi or in the lung tissue itself. Radiological evidence of mediastinal enlargement can be invaluable, especially when cesophagoscopy is indicated. More dramatically, bronchoscopy allows removal of foreign material from the bronchial tree. The endoscopic aspects of cesophageal disease are mainly to be found in the field of the otolaryngologist. The problems of diagnosis, foreign bodies, the nonsurgical management of caustic and inflammatory strictures and the palliative management of malignant lesions constitute a broad field for the endoscopist. Symptoms of cesophageal disease include dysphagia or complete inability to swallow, pain on swallowing, regurgitation of food or himatemesis. More often than not the first symptom is that of a lump in the throat, for which the patient seeks a diagnosis and treatment by the otolaryngologist. In some cases pulmonary symptoms are the earliest signs of cesophageal disease. Systemic disease such as anoemias, and neurological disorders such as disseminated sclerosis, syringomyelia and other bulbar lesions may first present with cesophageal symptoms. CEsophagoscopy is an adjunct to and not a substitute for other means of studying cesophageal disease. X-ray examination should always precede endoscopy. This should consist of an AP and lateral chest film and a lateral film of the neck for soft tissue density which may reveal
668 Proc. roy. Soc. Med. Volume 69 September 1976
bony abnormalities of the vertebral column, for example osteophytes, which may all too easily be dislodged by a poor endoscopic technique. Radioopaque studies are of vital importance, including cine radiography with video replays available to give both the radiologist and the endoscopist the maximum information as to the motility of the cesophagus and, more precisely, permit orientation and accurate localization of the disease. In recent years otolaryngologists have become more and more involved in the treatment of malignant disease in the head and neck and especially important is the role of the endoscopist in the investigations of these patients who present with a lump in the neck. A carefully planned and executed endoscopy will often reveal the site of the primary disease, thus making it possible to plan the treatment in order to give the patient the best possible prognosis. All too often, however, patients are referred for endoscopies after some over-zealous surgical registrar has removed the lump and have been told by the histopathologist that the probable site of the primary lesion is within the field of the otolaryngologist. Time and further education of some of our surgical colleagues are still required in order to convince them that these lumps are there as a sign of disease and not as a target for the scalpel of the registrar. Instrumentation for Endoscopy Instruments for endoscopy have been constantly changing over the years. Laryngoscopes now vary widely from the conventional type to the more modern Kleinsasser type for microlaryngeal surgery. Bronchoscopes and cesophagoscopes have changed relatively little over the last few years. The major recent change has been the introduction of fibre-optics for illumination in all types of endoscopes. The light source, no longer in the endoscope itself, is contained in its own unit, the light from this being carried through a bundle of flexible glass strands to the light carrier of the scope. Following the introduction of fibre-optics for illumination came the flexible fibre-optic instruments which have added another dimension to the instrumentarium of the endoscopist. These can be introduced easily under local anesthesia although quite a large proportion of endoscopies performed in the United Kingdom appear to be under general anesthesia. It is essential for the endoscopist to have a large variety of sizes and lengths of scopes, and a variety of shape of forceps. The maximum size of the surgical field in most endoscopic procedures in adults is less than 12 mm, and in infants may be no more than 3 mm and the length to reach these fields may vary from 50 cm in adults to less than 10 cm in infants. It is therefore obvious that for maximum efficiency
instruments of all gradations must be available, not just endoscopes but forceps and suckers also. Few other procedures are so dependent on an adequate selection of instruments.
Operative Techniquefor Endoscopy Techniques of endoscopic procedures vary widely in different clinics. Proper positioning of the patient is essential for ease of introduction of the scopes. The examination is performed with the patient in the recumbent position. Ideally his head should be held in the midline, elevated above the level of the table top until the chin and nose are horizontal. In this position there is a straight line from the open mouth to the larynx and then through the larynx into the trachea; or, for cesophagoscopy, through the cesophageal entrance into the upper thoracic cesophagus. After the instrument is introduced the head is rotated posteriorly as the lower airway or cesophagus is inspected. Careful attention to position of the head is vital to avoid damage to the oral cavity, oropharynx, the larynx itself and, more seriously, in the cesophagus and bronchus with perforating injuries resulting in mediastinitis.
Mediastinoscopy is not an investigation to be carried out by the amateur; it requires skill and a first-class knowledge of the anatomy of the mediastinum and in most cases is carried out by the thoracic surgeon. Following endoscopy it is important to make a careful record of all that was seen paying special attention to the site and size of the lesions, and motility of the area concerned. It is essential to make concise records so that anyone else involved in the subsequent care of the patient has all the information he requires.
Microlaryngeal Surgery During the past ten years, microlaryngoscopy and endolaryngeal microsurgery have gained worldwide recognition. This is in no small way due to the pioneering work of Oscar Kleinsasser. In 1958 Stortz supplied him with what he described as 'a relatively crude instrument made up on a monocular lens system connected to a simple,_ laryngoscope' (Kleinsasser 1968). It was not until 1962 that he used the Zeiss microscope with a 400 mm objective lens and this, by simply changing one lens of the otologist's operating microscope, becomes instantly available to the laryngologist. Microlaryngoscopy has many indications both diagnostic and therapeutic. In 1974 Kleinsasser published a review of 2500 microlaryngoscopic procedures in 2090 patients which showed that 30 % were performed for the diagnosis, treatment and control of tumours, 37 % were performed to
Section ofLaryngology with Section of Anesthetics 669 improve the voice in benign lesions and the remaining third of the cases were for different inflammatory lesions, trauma, pareses and rare disease of the larynx. This excellent review also contains 191 references to the literature as an Indication of the growing interest in this topic. Microsurgery of the larynx does present some technical difflculties. In comparison with ear surgery, the larynx Is far from microscopic, in fact the laryngologist views the larynx through the microscope and laryngoscope from a distance of some 35-40 cm. Magnification allows a more accurate evaluation of small lesions on the vocal cords, the extent of the lesions, their texture, consistency and spread to vital structures. The differential diagnosis of chronic disease of the larynx is greatly aided by microscopic examination of the epithelium of the vocal cords. The appearance of the capillaries in the normal epithelium of thb vocal cords Is in contrast to the inflammatory lesions, where the epithelium appears thick and hypermmic, the capillaries being indistinct, patchy and engorged. In precancerous or malignant lesions the epithelium is lrregular with horny patches, the capillaries lose their normal appearance with ramlflcations which bear no relation to their normal network. Microlaryngoscopy has contributed to an important step forward In the early diagnosis of vocal cord cancer. In the treatment of benign lesions of the vocal cords, the microscope allows for precision surgery which Is essential for maximum functional results. In these cases, in order to restore the voice to normal, It requires complete removal of all the pathological lesion without injury to the adjoining, vocal ligament, vocalis muscle or the perichondrium of the vocal process. These operations require skill and dexterity as well as a wide range of microsurgical instruments. In the field of functional surgery, I.e. surgery for improvement of the voice, the microscope is essential for success either via the endoral approach or via a laryngofissure. Reconstructive procedures, Including the Injection of Teflon paste, nerve trahsplants, nerve shunts and cqpposite flaps, can be carried out only by using the microscope. Laryngeal tumours can now be more accurately assessed and In some cases treated endoscopically as also the often more diflicult problems of stenosis. As more experience Is gained In endolaryngeal microsurgery there will be further advances in techniques. We all have our own methods which we have found by experience to give good results. In this type of surgory the working relationship between surgeon and anmthetist Is of paramount Importance. When one has this ansthotic skill and cooperation life Is made so much easier for all concerned.
Conclusion In all endoscopic surgery, discomfort and complications often relate directly to the procedures. A carefully taken history and pre.endoscopic assessment of each patient is essential, with particular attention to the dentition, vertebral column irregularities and respiratory function. The endoscopist must be prdpared to abandon the operation at any stage if so requested by the anesthetist. The elimination of unnecessary delay through the establishment of a previously agreed routine is of prime importance. The acquiring and maintainance of an adequate instrument Inventory is vital. Finally, and perhaps most Important of all, Is the need for cooperation and understanding between surgeon and anesthetist. It is only by following a strict routine that the endoscopist can avoid serious complications. REPERENCES KI.ldnsar 0
(1963) Journal oathe Otolaryngological Society qfAsustralIa 2, 3 (1974) H.N.O. (Berlin) 22, 69-13
Dr M P Coplans (St George's Hospital, London SW17 OQT)
Ansthesiafor Endoscopy In Adults: A Technique and Special Tube for Microlaryngsal Surgey Anesthesia for microlaryngeal surgery In adults presents the anesthetist with the difficult choice between unimpeded surgical access without intubation, and full airway protection and control with intubation. Gordon & Sellars (1971), Oulton & Donald (1971) and Sanchez (1971), and many others since, have described techniques which do not entail tracheal intubation and which doubtless provide the surgeon with excellent operating conditions. However, Tonkin (1967), of Sydney, drew attention to the extra degree of safety provided by the presence of a cuffed endotracheal tube. Particularly when biopsies were taken or tumours removed, complete protection of the lungs could be guaranteed only by the use of such a tube, and this Is especially true If a head-up tilt Is used to facilitate laryngeal exposure and examination. The presence of a cuffed tube will also prevent fogging of the microscope lons. Tonkin found that no tube then available was satisfactory and pointed out that the smalllumen children's tubes were never long enough for use In the adult. In 1968 Pollard, also of Sydney, described his specially designed tube which consisted of a. narrow cuffed tracheal portion (5, 6 and 7 mm) and a wide-bore oral segment. Pollard showed that the pressure tracings produced by artificial ventilation through
667
Joint Meeting No. S
Section of Laryngology President Kenneth Harrison FRCS
with Section of Anaesthetics President R Bryce-Smith DM
Meeting 6 February 1976
Anaesthesia for Endoscopy
[Abridged] Mr R Pracy and Dr Gordon H Bush (Alder Hey Children's Hospital, West Derby, Liverpool, L12 2AP)
The Importance of Cooperation in Paediatric Endoscopy [Abstract] The prime consideration in all endoscopy must be safety. This can only be achieved if both the surgeon and the anxsthetist pay particular attention to the maintenance of a patent airway. Standardization of the procedure is all important. The anesthetist should be able to vary his technique to make this possible. Local and general anesthesia are combined and this ensures rapid recovery which is essential. The anesthetic technique should permit the carrying out of an endoscopic operation if this is found to be necessary. It is essential that proper records should be kept.
Mr David E Whittam (St George's Hospital, London SWJ7 OQT)
Adult Endoscopy The Concise Oxford Dictionary defines an endoscope as an instrument for viewing internal parts of the body. Laryngoscopes, bronchoscopes and cesophagoscopes are all specialized speculums which enable the endoscopist to visualize cavities of the body which, because of their depth and anatomical relations, cannot otherwise be seen. In the study and management of conditions involving the larynx, respiratory tract and cesophagus in patients of any age, endoscopic procedures are essential, but it must be stressed that they form only part of the total examination of the patient whose symptoms indicate an apparent disorder of the larynx, airway or oesophagus. The functions of the larynx are to control and protect the airway and also to produce sound.
The quality and pitch of the voice may be altered by inflammatory disease, obstruction of the airway by tumours or trauma or by neurological malfunction, and direct laryngoscopy may be needed to determine the etiology of the condition and permit endoscopic procedures to be carried out. After direct laryngoscopy in the investigation of a patient who presents with hkmoptysis, chronic cough, a wheeze or dyspncea, bronchoscopy should also be performed; its omission amounts almost to criminal neglect. Prior to bronchoscopy chest X-rays, including anteroposterior and lateral views, may reveal evidence of disease in the major bronchi or in the lung tissue itself. Radiological evidence of mediastinal enlargement can be invaluable, especially when cesophagoscopy is indicated. More dramatically, bronchoscopy allows removal of foreign material from the bronchial tree. The endoscopic aspects of cesophageal disease are mainly to be found in the field of the otolaryngologist. The problems of diagnosis, foreign bodies, the nonsurgical management of caustic and inflammatory strictures and the palliative management of malignant lesions constitute a broad field for the endoscopist. Symptoms of cesophageal disease include dysphagia or complete inability to swallow, pain on swallowing, regurgitation of food or himatemesis. More often than not the first symptom is that of a lump in the throat, for which the patient seeks a diagnosis and treatment by the otolaryngologist. In some cases pulmonary symptoms are the earliest signs of cesophageal disease. Systemic disease such as anoemias, and neurological disorders such as disseminated sclerosis, syringomyelia and other bulbar lesions may first present with cesophageal symptoms. CEsophagoscopy is an adjunct to and not a substitute for other means of studying cesophageal disease. X-ray examination should always precede endoscopy. This should consist of an AP and lateral chest film and a lateral film of the neck for soft tissue density which may reveal
668 Proc. roy. Soc. Med. Volume 69 September 1976
bony abnormalities of the vertebral column, for example osteophytes, which may all too easily be dislodged by a poor endoscopic technique. Radioopaque studies are of vital importance, including cine radiography with video replays available to give both the radiologist and the endoscopist the maximum information as to the motility of the cesophagus and, more precisely, permit orientation and accurate localization of the disease. In recent years otolaryngologists have become more and more involved in the treatment of malignant disease in the head and neck and especially important is the role of the endoscopist in the investigations of these patients who present with a lump in the neck. A carefully planned and executed endoscopy will often reveal the site of the primary disease, thus making it possible to plan the treatment in order to give the patient the best possible prognosis. All too often, however, patients are referred for endoscopies after some over-zealous surgical registrar has removed the lump and have been told by the histopathologist that the probable site of the primary lesion is within the field of the otolaryngologist. Time and further education of some of our surgical colleagues are still required in order to convince them that these lumps are there as a sign of disease and not as a target for the scalpel of the registrar. Instrumentation for Endoscopy Instruments for endoscopy have been constantly changing over the years. Laryngoscopes now vary widely from the conventional type to the more modern Kleinsasser type for microlaryngeal surgery. Bronchoscopes and cesophagoscopes have changed relatively little over the last few years. The major recent change has been the introduction of fibre-optics for illumination in all types of endoscopes. The light source, no longer in the endoscope itself, is contained in its own unit, the light from this being carried through a bundle of flexible glass strands to the light carrier of the scope. Following the introduction of fibre-optics for illumination came the flexible fibre-optic instruments which have added another dimension to the instrumentarium of the endoscopist. These can be introduced easily under local anesthesia although quite a large proportion of endoscopies performed in the United Kingdom appear to be under general anesthesia. It is essential for the endoscopist to have a large variety of sizes and lengths of scopes, and a variety of shape of forceps. The maximum size of the surgical field in most endoscopic procedures in adults is less than 12 mm, and in infants may be no more than 3 mm and the length to reach these fields may vary from 50 cm in adults to less than 10 cm in infants. It is therefore obvious that for maximum efficiency
instruments of all gradations must be available, not just endoscopes but forceps and suckers also. Few other procedures are so dependent on an adequate selection of instruments.
Operative Techniquefor Endoscopy Techniques of endoscopic procedures vary widely in different clinics. Proper positioning of the patient is essential for ease of introduction of the scopes. The examination is performed with the patient in the recumbent position. Ideally his head should be held in the midline, elevated above the level of the table top until the chin and nose are horizontal. In this position there is a straight line from the open mouth to the larynx and then through the larynx into the trachea; or, for cesophagoscopy, through the cesophageal entrance into the upper thoracic cesophagus. After the instrument is introduced the head is rotated posteriorly as the lower airway or cesophagus is inspected. Careful attention to position of the head is vital to avoid damage to the oral cavity, oropharynx, the larynx itself and, more seriously, in the cesophagus and bronchus with perforating injuries resulting in mediastinitis.
Mediastinoscopy is not an investigation to be carried out by the amateur; it requires skill and a first-class knowledge of the anatomy of the mediastinum and in most cases is carried out by the thoracic surgeon. Following endoscopy it is important to make a careful record of all that was seen paying special attention to the site and size of the lesions, and motility of the area concerned. It is essential to make concise records so that anyone else involved in the subsequent care of the patient has all the information he requires.
Microlaryngeal Surgery During the past ten years, microlaryngoscopy and endolaryngeal microsurgery have gained worldwide recognition. This is in no small way due to the pioneering work of Oscar Kleinsasser. In 1958 Stortz supplied him with what he described as 'a relatively crude instrument made up on a monocular lens system connected to a simple,_ laryngoscope' (Kleinsasser 1968). It was not until 1962 that he used the Zeiss microscope with a 400 mm objective lens and this, by simply changing one lens of the otologist's operating microscope, becomes instantly available to the laryngologist. Microlaryngoscopy has many indications both diagnostic and therapeutic. In 1974 Kleinsasser published a review of 2500 microlaryngoscopic procedures in 2090 patients which showed that 30 % were performed for the diagnosis, treatment and control of tumours, 37 % were performed to
Section ofLaryngology with Section of Anesthetics 669 improve the voice in benign lesions and the remaining third of the cases were for different inflammatory lesions, trauma, pareses and rare disease of the larynx. This excellent review also contains 191 references to the literature as an Indication of the growing interest in this topic. Microsurgery of the larynx does present some technical difflculties. In comparison with ear surgery, the larynx Is far from microscopic, in fact the laryngologist views the larynx through the microscope and laryngoscope from a distance of some 35-40 cm. Magnification allows a more accurate evaluation of small lesions on the vocal cords, the extent of the lesions, their texture, consistency and spread to vital structures. The differential diagnosis of chronic disease of the larynx is greatly aided by microscopic examination of the epithelium of the vocal cords. The appearance of the capillaries in the normal epithelium of thb vocal cords Is in contrast to the inflammatory lesions, where the epithelium appears thick and hypermmic, the capillaries being indistinct, patchy and engorged. In precancerous or malignant lesions the epithelium is lrregular with horny patches, the capillaries lose their normal appearance with ramlflcations which bear no relation to their normal network. Microlaryngoscopy has contributed to an important step forward In the early diagnosis of vocal cord cancer. In the treatment of benign lesions of the vocal cords, the microscope allows for precision surgery which Is essential for maximum functional results. In these cases, in order to restore the voice to normal, It requires complete removal of all the pathological lesion without injury to the adjoining, vocal ligament, vocalis muscle or the perichondrium of the vocal process. These operations require skill and dexterity as well as a wide range of microsurgical instruments. In the field of functional surgery, I.e. surgery for improvement of the voice, the microscope is essential for success either via the endoral approach or via a laryngofissure. Reconstructive procedures, Including the Injection of Teflon paste, nerve trahsplants, nerve shunts and cqpposite flaps, can be carried out only by using the microscope. Laryngeal tumours can now be more accurately assessed and In some cases treated endoscopically as also the often more diflicult problems of stenosis. As more experience Is gained In endolaryngeal microsurgery there will be further advances in techniques. We all have our own methods which we have found by experience to give good results. In this type of surgory the working relationship between surgeon and anmthetist Is of paramount Importance. When one has this ansthotic skill and cooperation life Is made so much easier for all concerned.
Conclusion In all endoscopic surgery, discomfort and complications often relate directly to the procedures. A carefully taken history and pre.endoscopic assessment of each patient is essential, with particular attention to the dentition, vertebral column irregularities and respiratory function. The endoscopist must be prdpared to abandon the operation at any stage if so requested by the anesthetist. The elimination of unnecessary delay through the establishment of a previously agreed routine is of prime importance. The acquiring and maintainance of an adequate instrument Inventory is vital. Finally, and perhaps most Important of all, Is the need for cooperation and understanding between surgeon and anesthetist. It is only by following a strict routine that the endoscopist can avoid serious complications. REPERENCES KI.ldnsar 0
(1963) Journal oathe Otolaryngological Society qfAsustralIa 2, 3 (1974) H.N.O. (Berlin) 22, 69-13
Dr M P Coplans (St George's Hospital, London SW17 OQT)
Ansthesiafor Endoscopy In Adults: A Technique and Special Tube for Microlaryngsal Surgey Anesthesia for microlaryngeal surgery In adults presents the anesthetist with the difficult choice between unimpeded surgical access without intubation, and full airway protection and control with intubation. Gordon & Sellars (1971), Oulton & Donald (1971) and Sanchez (1971), and many others since, have described techniques which do not entail tracheal intubation and which doubtless provide the surgeon with excellent operating conditions. However, Tonkin (1967), of Sydney, drew attention to the extra degree of safety provided by the presence of a cuffed endotracheal tube. Particularly when biopsies were taken or tumours removed, complete protection of the lungs could be guaranteed only by the use of such a tube, and this Is especially true If a head-up tilt Is used to facilitate laryngeal exposure and examination. The presence of a cuffed tube will also prevent fogging of the microscope lons. Tonkin found that no tube then available was satisfactory and pointed out that the smalllumen children's tubes were never long enough for use In the adult. In 1968 Pollard, also of Sydney, described his specially designed tube which consisted of a. narrow cuffed tracheal portion (5, 6 and 7 mm) and a wide-bore oral segment. Pollard showed that the pressure tracings produced by artificial ventilation through
