Ann Otol 88 :1979
OTOSCOPY AND PHOTOGRAPHY A NEW METHOD BENJAMIN CHEN
TERRY
L.
NEWTON
FRY
D.
FISCHER
CHAPEL HILL, NORTH CAROLINA
A new hand-held otoscope photographic system, convenient and suitable for clinical application, is introduced. This instrument allows clear otoscopic examination in stenotic or tortuous ear canals, and photographs the subject in one procedure. The instrument consists of a rodlens optical system, a fiberoptic light source, a camera, and exchangeable speculum and a strobe light. Color photographs of tympanic membranes and middle ear pathology are presented.
Anatomical variations that hamper visual examination of the tympanic membrane and the middle ear have been long recognized. Shining a light through the meatus onto the tympanic membrane is sometimes a difficult task, especially in tortuous or stenotic canals. The normal external auditory canal consists of a cartilaginous portion, which is slightly concave anteriorly, and a bony portion, within the temporal bone which is slightly concave posteriorly.' The canal as a whole looks like a stretched S-shaped tube. Conventional otoscopes arrange the light source behind the speculum, reflecting and scattering much of the light. The speculum is not designed for guiding the light beam onto the drum membrane. Therefore, illumination of the drum membrane is not optimal. Conventional otoscopes deliver enough light for routine observation but not for close scrutiny or for photography. Photography of the tympanic membrane and middle ear pathology has been a challenge over many years. Numerous new instruments have been devised.v" Color photographs in this area have required time-consuming elaborate methods, yet good results are rare. Otomicroscopic phototechnique was introduced by Lundborg and Linzander in 1970.4 The photoequipment consisted of a Zeiss operating microscope equipped with a 250 W halogen lamp, high speed Ektachrome® type B color film, Siegle's speculum, etc, for evaluation and photo-
graphy. The burden of photographic documentation of psthology, as well as pre- and postoperative findings, can be alleviated with reliable hand-held photographic equipment. Valuable otoscopic findings can be accurately presented during conferences and as a good teaching aid. METHODS AND MATERIALS The need for a new type of otoscope which is applicable not only for normal ear canals but also for stenotic or tortuous ear canals and for convenience in photography is obvious. The otoscope (patent pending) which is reported here, is designed to accommodate a self-rewind camera, a flash unit for photography, viewing optics, and a set of specula, as one functionally integrated compact system (Fig. 1). This hand-held otoscope photographic system ( OPS) overcomes the illumination problem by sending the light source via a fiberoptic bundle to the very tip of a speculum, facilitating photography and observation. The light is located beneath the objective lens and is delivered to the subject without the interference of the speculum, unlike the conventional otoscopes. The OPS utilizes the advantages of a Hopkins rod-lens system as viewing optics (Fig. 2). In rod-lens viewing optics, the total amount of light transmitted by the optical lens relay system is proportional to the square of the index of refraction of the space between the relay lenses, and the fourth power of the inner radius of the relay lens supporting tube. The losses of light by absorption in the glass or by reflection at the air glass interface, in practice, can be made very small. Therefore, in the Hopkins rod-lens system, the glass rods replace the air spaces of a conventional scope, and the relay lenses replace the air gaps. The immediate effect of such replacement is that the total light transmission in the system increases by 2.5 fold (the refractive index of glass is 1.6 and
From the Division ot Otolaryngology, Department or Surgery, University or North Carolina Chapel HUl. North Carolina. '
771
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
CHEN ETAL
772
A
B
DRUM MEMBRANE
Fig. 2. Schematic diagram illustrates the relationship between the speculum and viewing optics for otoscopy. A Eyepiece; B - Rod-lens relay system; C Air gap; D - Objectives. Fig. 1. Otoscope photographic system (OPS). of air is 1). Secondly, the rod-lens system has a finely ground outer surface which prevents the reflection of light at glancing incidence and permits a radius of clear aperture. By increasing the inner radius and refractive index, the light transmission of a Hopkins rod-lens system can be increased as much as nine times that of the conventional lens relay system of the same outer diameter. In addition, it has a wide viewing angle, good depth of field and a small outer diameter. A commercially made Hopkins rod-lens system of 6 em in length, 2.7 mm in diameter with zero degree viewing angle and illumination is adapted as the viewing optics of the otoscope. e The light is supplied by a 150 W halogen lamp coupled with a 4.8 mm x 180 em fiberoptic cable. A. flash generator supplies the power to the flash unit which is triggered by a self-rewind camera for photography. The exposure time is 1/125 second. A 35-mm high speed Kodacolore negative film (ASA 400) and Ektachrome color slide film (ASA 200) were used for the study. Operation of the DPS can be accomplished single handedly. Observation is direct through the eyepiece. The image can be zoomed closer by changing the focal range step by step from f= 70 to 130 mm. The light intensity is reduced slightly at higher focal range, but the visibility does not deteriorate. RESULTS
Under clinical scrutiny, the OPS shows remarkable results. It replaces the operating microscope for observation and photography of the tympanic membrane. The hand-held OPS is simple to operate and the reliability of each photograph is predictable. The image size on the negatives is 13
mm in diameter. A standard Kodacolor 3R print enlarges the circular image to 67 mm in diameter, more than fivefold enlargement, with good resolution. The color in the slides is less vivid than the negative film. The light intensity is sufficient for the exposure of the color slides. Three cases of middle ear pathology are documented with color pictures taken during routine ENT clinic visits. The first case demonstrates a normal tympanic membrane and a red area on the underlying promontory, clearly documenting a small glomus tympanicum tumor (Fig. 3). The second case shows the bubbles and serous fluid secondary to eustachian tube dysfunction in typical serous otitis media (Fig. 4). Finally, a case of bullous myringitis is documented (Fig. 5). The composition of Figure 5 illustrates the inadvertent inclusion of the undesirable external ear canal. Minimal practice can avoid such an undesirable inclusion in the photograph. The accompanying schematic sketches illustrate the relevant anatomical landmarks (Figs. 3-5). The OPS is also a valuable instrument for middle ear research in laboratory animals too small for conventional techniques. Three color pictures illustrate the utility of the OPS in documenting the status of the guinea pig tympanic membrane during a study of otic drops," Figure 6 shows the tympanic membrane of a normal guinea pig ear before surgical intervention. A total tympanic membrane perforation was surgically created without damage to the malleus (Fig. 7). Subsequent healing of the
*Hopkins straight forward telescope no. 1218A, camera no. 565, electronic flash unit no. 55Q and flash unit tube no. 555B. Storz Instrument Co, St. Louis, MO.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
11
Fig. 4. Serous otitis media. Schematic sketch - 1 - Manubrium; 3 - Fibrous annulus; 11 - Bubbles.
Fig. 3. Glomus tyrnpanicum tumor on the underlying promontory. Schematic sketch - 1 - Manubrlum; 2 - Umbo; 3 - Fibrous annulus; 4 - Light reflection; 5 - Glomus tympan!cum; 6 - Tympanic membrane; 7 - Promontory; 8 - Round window; 9 - Lenticular process of Incus; 10 - Chorda tymparrl.
16
Fig. 6. Tympanic membrane, malleus and underlying cochlea of a normai guinea pig are visible. Schematic sketch 1 - Manubrium of the malleus; 15 - Tympanic membrane; 16 - Cochlea.
Fig. 5. Bullous myringitis. Schematic sketch - 12 - Red blood cell sediment; 13 - Bulla; 14- External auditory canal; 15 - Tympanic membrane.
Fig. 7. After surgical removal of the TM. the malleus Is " intact. The round window and pigmentary stria vascularles In the scala media of the 3rd and 4th turn of the otic capsule are clearly displayed. Schematic sketch - 1 - Manubrium of the malleus: 8 - Round window: 14 Ext. aud, canal: 16 - Cochlea: 17 - Scala media of the 3rd and 4th turn.
19
Fig. 8. Trapped white otic drops debris Is observable 28 days following removal of the guinea pig tympanic membrane. Schematic sketch - 1 - Manubrium of the malleus; 18 - Trapped white otic drop debris; 19 - Middle ear space.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
OTOSCOPY AND PHOTOGRAPHY
guinea pig tympanic membrane results in slight opacification as well as trapped white debris in the middle ear space (Fig. 8). The corresponding schematic sketches (Figs. 6, 7 and 8) illustrate the relevant anatomical landmarks of the middle ear of a guinea pig. CONCLUSION
Numerous middle ear problems, such as traumatic or congenital middle ear lesions, recurrent infection, etc, require close examination with an otoscope. Good photographic documents enhance case presentation. This OPS offers many advantages: 1) It provides enough light for visual examination of the ear canal,
773
tympanic membrane and the middle ear. If desired, it photographs the subject at the same time. 2) It incorporates the Hopkins rod-lens system and camera to the otoscope. 3) The integrated system can be operated by one hand. It makes photographic procedure simple, compact, and reliable. 4) It accepts a set of specula (24 mm OD). The small diameter facilitates pediatric otoscopy. Removal of the speculum allows examination in stenotic as well as small laboratory animal ear canals. The OPS is limited in usefulness to observation and photography. The operating microscope is still the instrument of choice for operative procedures.
REFERENCES microscopic observation and its clinical application. Acta Otolaryngol (Stockh) Suppl 266: 3-36, 1970 5. Hopkins HH: Optical principles of the endoscope, in Berci G (ed): Endoscopy. New York, Appleton-Century-Crofts, 1976, p 3 6. Fry TL, Chen B, Fischer ND, et al: Evaluation of otic drops on infection and healing of traumatic tympanic membrane perforations. Laryngoscope 89:818-821, 1979
1. Hollingshead WH: Anatomy for Surgeons, ed 2. New York, Harper & Row Publishers Inc, 1968, vol 1, p 184 2. Konard HR: Otoscope, in Berci G (ed ): Endoscopy. New York, Appleton-CenturyCrofts, 1976, p 645 3. Smith WH, Rosnagle RS, Yanagisawa E: Tympanic membrane photography. Arch Otolaryngol 99:125-127, 1974 4. Lundborg T, Linzander S: The oto-
REPRINTS - Benjamin Chen, Division of Otolaryngology, Department of Surgery, School of Medicine, University of North Carolina, Clinical Sciences Bldg. 229 H, Chapel Hill, NC 27514.
,..., ,...,
AWARDS In September 1979 Dr. [uergen Tonndorf was presented the Guyot Prize from the University of Groningen (Netherlands). The prize given every five years was established in honor of Dr. Guyot who was the founder of the first Deaf School in the Netherlands in 1790. Also in September, he received the George Shambaugh Prize from the Collegium ORLAS at its annual meeting in Budapest, Hungary. This award was established in 1949 and is given biennially. On January 21, 1980, he is slated to receive the Award of Merit from the Association for Research in Otolaryngology. Dr. Harold Schuknecht was the first award winner in 1977 and Dr. Merle Lawrence was the recipient in 1978.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
OTOSCOPY AND PHOTOGRAPHY A NEW METHOD BENJAMIN CHEN
TERRY
L.
NEWTON
FRY
D.
FISCHER
CHAPEL HILL, NORTH CAROLINA
A new hand-held otoscope photographic system, convenient and suitable for clinical application, is introduced. This instrument allows clear otoscopic examination in stenotic or tortuous ear canals, and photographs the subject in one procedure. The instrument consists of a rodlens optical system, a fiberoptic light source, a camera, and exchangeable speculum and a strobe light. Color photographs of tympanic membranes and middle ear pathology are presented.
Anatomical variations that hamper visual examination of the tympanic membrane and the middle ear have been long recognized. Shining a light through the meatus onto the tympanic membrane is sometimes a difficult task, especially in tortuous or stenotic canals. The normal external auditory canal consists of a cartilaginous portion, which is slightly concave anteriorly, and a bony portion, within the temporal bone which is slightly concave posteriorly.' The canal as a whole looks like a stretched S-shaped tube. Conventional otoscopes arrange the light source behind the speculum, reflecting and scattering much of the light. The speculum is not designed for guiding the light beam onto the drum membrane. Therefore, illumination of the drum membrane is not optimal. Conventional otoscopes deliver enough light for routine observation but not for close scrutiny or for photography. Photography of the tympanic membrane and middle ear pathology has been a challenge over many years. Numerous new instruments have been devised.v" Color photographs in this area have required time-consuming elaborate methods, yet good results are rare. Otomicroscopic phototechnique was introduced by Lundborg and Linzander in 1970.4 The photoequipment consisted of a Zeiss operating microscope equipped with a 250 W halogen lamp, high speed Ektachrome® type B color film, Siegle's speculum, etc, for evaluation and photo-
graphy. The burden of photographic documentation of psthology, as well as pre- and postoperative findings, can be alleviated with reliable hand-held photographic equipment. Valuable otoscopic findings can be accurately presented during conferences and as a good teaching aid. METHODS AND MATERIALS The need for a new type of otoscope which is applicable not only for normal ear canals but also for stenotic or tortuous ear canals and for convenience in photography is obvious. The otoscope (patent pending) which is reported here, is designed to accommodate a self-rewind camera, a flash unit for photography, viewing optics, and a set of specula, as one functionally integrated compact system (Fig. 1). This hand-held otoscope photographic system ( OPS) overcomes the illumination problem by sending the light source via a fiberoptic bundle to the very tip of a speculum, facilitating photography and observation. The light is located beneath the objective lens and is delivered to the subject without the interference of the speculum, unlike the conventional otoscopes. The OPS utilizes the advantages of a Hopkins rod-lens system as viewing optics (Fig. 2). In rod-lens viewing optics, the total amount of light transmitted by the optical lens relay system is proportional to the square of the index of refraction of the space between the relay lenses, and the fourth power of the inner radius of the relay lens supporting tube. The losses of light by absorption in the glass or by reflection at the air glass interface, in practice, can be made very small. Therefore, in the Hopkins rod-lens system, the glass rods replace the air spaces of a conventional scope, and the relay lenses replace the air gaps. The immediate effect of such replacement is that the total light transmission in the system increases by 2.5 fold (the refractive index of glass is 1.6 and
From the Division ot Otolaryngology, Department or Surgery, University or North Carolina Chapel HUl. North Carolina. '
771
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
CHEN ETAL
772
A
B
DRUM MEMBRANE
Fig. 2. Schematic diagram illustrates the relationship between the speculum and viewing optics for otoscopy. A Eyepiece; B - Rod-lens relay system; C Air gap; D - Objectives. Fig. 1. Otoscope photographic system (OPS). of air is 1). Secondly, the rod-lens system has a finely ground outer surface which prevents the reflection of light at glancing incidence and permits a radius of clear aperture. By increasing the inner radius and refractive index, the light transmission of a Hopkins rod-lens system can be increased as much as nine times that of the conventional lens relay system of the same outer diameter. In addition, it has a wide viewing angle, good depth of field and a small outer diameter. A commercially made Hopkins rod-lens system of 6 em in length, 2.7 mm in diameter with zero degree viewing angle and illumination is adapted as the viewing optics of the otoscope. e The light is supplied by a 150 W halogen lamp coupled with a 4.8 mm x 180 em fiberoptic cable. A. flash generator supplies the power to the flash unit which is triggered by a self-rewind camera for photography. The exposure time is 1/125 second. A 35-mm high speed Kodacolore negative film (ASA 400) and Ektachrome color slide film (ASA 200) were used for the study. Operation of the DPS can be accomplished single handedly. Observation is direct through the eyepiece. The image can be zoomed closer by changing the focal range step by step from f= 70 to 130 mm. The light intensity is reduced slightly at higher focal range, but the visibility does not deteriorate. RESULTS
Under clinical scrutiny, the OPS shows remarkable results. It replaces the operating microscope for observation and photography of the tympanic membrane. The hand-held OPS is simple to operate and the reliability of each photograph is predictable. The image size on the negatives is 13
mm in diameter. A standard Kodacolor 3R print enlarges the circular image to 67 mm in diameter, more than fivefold enlargement, with good resolution. The color in the slides is less vivid than the negative film. The light intensity is sufficient for the exposure of the color slides. Three cases of middle ear pathology are documented with color pictures taken during routine ENT clinic visits. The first case demonstrates a normal tympanic membrane and a red area on the underlying promontory, clearly documenting a small glomus tympanicum tumor (Fig. 3). The second case shows the bubbles and serous fluid secondary to eustachian tube dysfunction in typical serous otitis media (Fig. 4). Finally, a case of bullous myringitis is documented (Fig. 5). The composition of Figure 5 illustrates the inadvertent inclusion of the undesirable external ear canal. Minimal practice can avoid such an undesirable inclusion in the photograph. The accompanying schematic sketches illustrate the relevant anatomical landmarks (Figs. 3-5). The OPS is also a valuable instrument for middle ear research in laboratory animals too small for conventional techniques. Three color pictures illustrate the utility of the OPS in documenting the status of the guinea pig tympanic membrane during a study of otic drops," Figure 6 shows the tympanic membrane of a normal guinea pig ear before surgical intervention. A total tympanic membrane perforation was surgically created without damage to the malleus (Fig. 7). Subsequent healing of the
*Hopkins straight forward telescope no. 1218A, camera no. 565, electronic flash unit no. 55Q and flash unit tube no. 555B. Storz Instrument Co, St. Louis, MO.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
11
Fig. 4. Serous otitis media. Schematic sketch - 1 - Manubrium; 3 - Fibrous annulus; 11 - Bubbles.
Fig. 3. Glomus tyrnpanicum tumor on the underlying promontory. Schematic sketch - 1 - Manubrlum; 2 - Umbo; 3 - Fibrous annulus; 4 - Light reflection; 5 - Glomus tympan!cum; 6 - Tympanic membrane; 7 - Promontory; 8 - Round window; 9 - Lenticular process of Incus; 10 - Chorda tymparrl.
16
Fig. 6. Tympanic membrane, malleus and underlying cochlea of a normai guinea pig are visible. Schematic sketch 1 - Manubrium of the malleus; 15 - Tympanic membrane; 16 - Cochlea.
Fig. 5. Bullous myringitis. Schematic sketch - 12 - Red blood cell sediment; 13 - Bulla; 14- External auditory canal; 15 - Tympanic membrane.
Fig. 7. After surgical removal of the TM. the malleus Is " intact. The round window and pigmentary stria vascularles In the scala media of the 3rd and 4th turn of the otic capsule are clearly displayed. Schematic sketch - 1 - Manubrium of the malleus: 8 - Round window: 14 Ext. aud, canal: 16 - Cochlea: 17 - Scala media of the 3rd and 4th turn.
19
Fig. 8. Trapped white otic drops debris Is observable 28 days following removal of the guinea pig tympanic membrane. Schematic sketch - 1 - Manubrium of the malleus; 18 - Trapped white otic drop debris; 19 - Middle ear space.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
OTOSCOPY AND PHOTOGRAPHY
guinea pig tympanic membrane results in slight opacification as well as trapped white debris in the middle ear space (Fig. 8). The corresponding schematic sketches (Figs. 6, 7 and 8) illustrate the relevant anatomical landmarks of the middle ear of a guinea pig. CONCLUSION
Numerous middle ear problems, such as traumatic or congenital middle ear lesions, recurrent infection, etc, require close examination with an otoscope. Good photographic documents enhance case presentation. This OPS offers many advantages: 1) It provides enough light for visual examination of the ear canal,
773
tympanic membrane and the middle ear. If desired, it photographs the subject at the same time. 2) It incorporates the Hopkins rod-lens system and camera to the otoscope. 3) The integrated system can be operated by one hand. It makes photographic procedure simple, compact, and reliable. 4) It accepts a set of specula (24 mm OD). The small diameter facilitates pediatric otoscopy. Removal of the speculum allows examination in stenotic as well as small laboratory animal ear canals. The OPS is limited in usefulness to observation and photography. The operating microscope is still the instrument of choice for operative procedures.
REFERENCES microscopic observation and its clinical application. Acta Otolaryngol (Stockh) Suppl 266: 3-36, 1970 5. Hopkins HH: Optical principles of the endoscope, in Berci G (ed): Endoscopy. New York, Appleton-Century-Crofts, 1976, p 3 6. Fry TL, Chen B, Fischer ND, et al: Evaluation of otic drops on infection and healing of traumatic tympanic membrane perforations. Laryngoscope 89:818-821, 1979
1. Hollingshead WH: Anatomy for Surgeons, ed 2. New York, Harper & Row Publishers Inc, 1968, vol 1, p 184 2. Konard HR: Otoscope, in Berci G (ed ): Endoscopy. New York, Appleton-CenturyCrofts, 1976, p 645 3. Smith WH, Rosnagle RS, Yanagisawa E: Tympanic membrane photography. Arch Otolaryngol 99:125-127, 1974 4. Lundborg T, Linzander S: The oto-
REPRINTS - Benjamin Chen, Division of Otolaryngology, Department of Surgery, School of Medicine, University of North Carolina, Clinical Sciences Bldg. 229 H, Chapel Hill, NC 27514.
,..., ,...,
AWARDS In September 1979 Dr. [uergen Tonndorf was presented the Guyot Prize from the University of Groningen (Netherlands). The prize given every five years was established in honor of Dr. Guyot who was the founder of the first Deaf School in the Netherlands in 1790. Also in September, he received the George Shambaugh Prize from the Collegium ORLAS at its annual meeting in Budapest, Hungary. This award was established in 1949 and is given biennially. On January 21, 1980, he is slated to receive the Award of Merit from the Association for Research in Otolaryngology. Dr. Harold Schuknecht was the first award winner in 1977 and Dr. Merle Lawrence was the recipient in 1978.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 25, 2015
