Angled telescopic surgery , an approach for laryngeal diagnosis and surgery without suspension

There has been great progress in endoscopic larynx procedures since Babington’s first presentation of his laryngoscope over a hundred years ago. 1 The use of operating microscopes and telescopes in laryngeal surgery represents one of the most exciting advances in clinical otolaryngology in recent years since both systems provide good illumination, magnification and relative case of operation. Microlaryngeal surgery using telescopes or microscopes requires the use of some type of suspension apparatus or laryngoscope holder to maintain the laryngoscope in place. Due to anatomical difficulties the procedure may not be possible in cases where the surgeon is not able to look along a straight line from the upper teeth to the epiglottis when the suspension technique is employed. 2


INTRODUCTION
There has been great progress in endoscopic larynx procedures since Babington's first presentation of his laryngoscope over a hundred years ago. 1 The use of operating microscopes and telescopes in laryngeal surgery represents one of the most exciting advances in clinical otolaryngology in recent years since both systems provide good illumination, magnification and relative case of operation.Microlaryngeal surgery using telescopes or microscopes requires the use of some type of suspension apparatus or laryngoscope holder to maintain the laryngoscope in place.Due to anatomical difficulties the procedure may not be possible in cases where the surgeon is not able to look along a straight line from the upper teeth to the epiglottis when the suspension technique is employed.F3: force directed onto the upper alveolus or teeth.
In a study of 800 patients submitted to suspension laryngoscopy, Heiden et al 3 reported complications ranging from mild mucosal edema to problems that may compromise the cardiovascular system.The authors also stated that patients should be informed preoperatively concerning tooth damage and intubation lesions.Yanagisawa et al, 4 comparing patients submitted to endoscopic laryngeal procedures with the Kantor-Berci video microlaryngoscope and laryngoscopy using the Dedo laryngoscope, reported that the insertion of the first was not possible in 12.5% of the patients (3/24).The same procedure was considered difficult in 16.6% (4/24).Technical problems with the size of the laryngoscope and unfavorable patient anatomy were considered the main concerns.
The difficulties and complications related to suspension lar yngoscopy have been documented amply in otolaryngology literature since the description of the suspension apparatus by Killian almost one hundred years ago.Considering the problems with this technique we have developed an angled approach to laryngeal examination and surger y.This procedure is carried out with the patient in the normal supine position without flexion or extension of the cervical column and does not require suspension to distend and support the laryngeal structures.

TECHNIQUES
We have devised a fiber-optic telescope (Figure 2) with its 40mm distal portion deviated 60 degrees from the direction of the proximal portion.This angle was taken by measuring patients immediately before standard microlaryngeal surgery was performed.The surgical instruments have the same angle as the telescope, in order to work on the larynx.This technique provides an image that is not limited by the distal aperture of the laryngoscope and has an advantage in that magnification and illumination may be provided by changing the distance of the lesion from the tip of the instrument.
Four patients, two male and two female, ages ranging from 29 to 50 years old were operated on using this technique.One of the patients presented a polyp on the right true vocal cord that was fully removed with grasp forceps.The remaining three patients were submitted to biopsy of their glottic lesions.
Use of angled telescope and instruments enables the laryngologist to readily expose the larynx including the subglottic area and anterior commissure.Trauma to the teeth and the "difficult patient", a constant preoccupation when performing surgery with common laryngoscopes and suspension, are now a minor concern.We believe that this technique may help in larynx surgery especially in patients that cannot be submitted to the common endoscopic laryngeal approach with suspension.

Figure 1 -Figure 2 -
Figure 1 -Vectorial forces applied to the patient by the standard laryngoscope holder.F1: Force applied to the long lever arm F2: Force within the larynx and tongue F3: Force directed onto the upper alveolus or teeth