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A different way of seeing the larynx and nasopharynx
A different way of seeing the larynx and nasopharynx Stanley Taub, MD
An improved and simplified method of observation and photography of the larynx and nasopharynx has been needed for quite some time. This has prompted me to develop an oral panendoscope to facilitate direct observation and photography of the larynx and nasopharynx during phonation. Prior to this time our technology had not vastly improved since Ludwig Turck popularized the use of the laryngeal mirror in 1806, and Alfred Kirstein introduced the direct method of laryngoscopy in 1896. The Taub oral panendoscope was originally developed for use in cleft palate research and speech pathology. Because of its uniqueness as a diagnostic instrument and its simplicity of use in the direct examination of the larynx and nasopharynx, the inStanlJy
Taub,
MD, i s a clinical associate pro-
fessor i n the department of surgery a t N e w York M e d i c a l College-Flower Fifth Avenue Hospitals. H e is a graduate of N e w York University, Bronx, and N e w York M e d i c a l College, N e w York Ci+y.
50
strument is widely used in operating rooms a t the request of anesthesiologists for preoperative and postoperative laryngoscopy. Formerly the anesthesiologist had to call upon an ENT specialist for routine indirect laryngoscopy. The anesthesiologist can now save the patient time and money by performing a direct examination of the larynx that is no more complicated than the insertion of a tongue depressor in the patient’s mouth. Since the oral panendoscope is a telescopic instrument, the image is upright and not inverted as when seen with the laryngeal mirror. In effect, this examination constitutes a direct laryngoscopy.
Its application in the field of diagnostic and photographic laryngoscopy soon became apparent. This device permits a more leisurely examination and panoramic viewing of the larynx and nasopharynx and at the same time enables the observer by a
AORN Journal
simple camera attachment to1 make excellent photographic records of what has been seen. Examination of the larynx with the laryngeal mirror can become a frustrating procedure because of unreliable illumination and repeated fogging of the mirror. The view of the larynx through the mirror is a partial one with a very narrow visual field. Patient discomfort caused by pulling of the tongue often results in an incomplete examination. These problems have been practically eliminated with the use of the Taub oral panendoscope. The oral panendoscope is an integrally illuminated tubular optical device. A newly designed lens system transmits the image received at the distal end to the viewer and camera at the proximal end. A high intensity incandescent lamp adjacent to the objective lens illuminates the target surfaces a t levels of light required for direct observation and for motion picture and still photography. An eyepiece is provided with a glare shield for clinical use and a threaded adapter for camera mounting. Light intensity is controlled by a variable output transformer, which operates from a standard 110 volt 60 cycle AC power source. A clear plastic removable heat shield protects exposed tissue from contact with the lamp bulb. The heat from the bulb prevents the objective lens from fogging after the light has been turned on and kept at clinical level of intensity for approximately one minute. The instrument is in focus from ‘7/” to infinity, and so it does not have to be refocused during use. The field of vision is an approximate 50 degree cone, having its apex near the surface of the objective
December 1972
lens. The axis of vision is a t right angles to the instrument tube axis. With the subject seated, the instrument is inserted into the oral cavity to the posterior pharynx with the objective lens up, and is manipulated for viewing the nasopharynx while the patient recites various combinations of vowel consonant vowel sounds. In this manner the activity of the palato pharyngeal sphincter mechanism may be observed during phonation. The optical tube is rotated 180 degrees for viewing the larynx during the production of various vowel sounds in natural, falsetto, and singing voice. A 16 mm single lens reflex motion picture camera can be attached to the instrument for simultaneous viewing and color motion picture photography at sound speeds (24 frames per second) using high speed EHB film. Individual color transparencies of excellent quality can be made with a 35 mm single lens reflex camera using a 50 mm lens. Larger transparencies, 33 mm in diameter, have been obtained with a 2% by 23,4 single lens reflex camera using a 135 mm lens. Fine quality 8” by 10” enlargements of the larynx and nasopharynx in color and black and white have been produced from the larger negatives. For still color photography, EHB film is recommended. Shutter speeds may vary from 1/4 second to 1/15 second depending upon the focal distance of the lens and the film speed. The ASA rating of the film may be pushed to 250 if custom processed. For color motion picture photography, the single lens 16 mm reflex camera is recommended. The lenses may be the wide angle 16 mm or
51
How it all works
A demonstration of the use of the oral panendoscope and the equipment involved. The physician sees the larynx through the view finder. The TV camera transfers t h e view t o the monitor so other parties can g e t t h e same view while the video tape recorder simultaneously records the scene
for later refer-
ence.
O n e view seen through t h e panendoscope.
52
AORN Journal
standard 25 mm. A camera with a reflex viewing system is recommended. The 8 mm camera may be adapted to the oral panendoscope. For teaching purposes, the instrument may be attached to a television camera for video tape recording. When the optical tube is in the down position, the entire laryngeal mechanism is brought into striking full view. The true and false vocal cords, the base of the epiglottis, the anterior commissure, the posterior surface of the vertical wall of the epiglottis and ventricles are clearly observed. The arytenoid cartilages, aryepiglottic folds and the pyriform fossa are brightly illuminated and clearly visible at or slightly greater than life size. Approximately 2 cm of the tracheal lumen is visible below the glottis. When viewing the nasopharynx, the torus and mouth of the eustachian tube, the posterior edge of the nasal septum and choanae are readily visible. The relationship of structure to function during phonation is clearly observed.
Not all subjects react favorably to the introduction of the device into the
oral cavity. In most instances this negative reaction can be overcome by the application of a topical anesthetic into the posterior pharynx. In some patients, gentle tongue traction may be necessary for the proper placement of the instrument. Once in place, the tongue may be released and the patient instructed to phonate as may be required for viewing the larynx or nasopharynx. The Taub oral panendoscope creates the opportunity for improved diagnosis, treatment and research by providing a simple method of direct visual observation, photography and television demonstration of the laryngeal and nasopharyngeal areas. Clinical direct laryngoscopy without alteration of the natural position of the larynx is greatly facilitated. Its use in the operating room by the anesthesiologist greatly facilitates preoperative as well as postoperative laryngoscopy for airway evaluation. [7 REFERENCES Lederer,
FL: "Laryngic Descriptive Discrepancy",
Ann&
of Otology, Rhinology, and Laryngofogy 72396-41 5, 1963.
Taub, S: "The Taub O r a l Panendoscope: New Technique", Cleft Pa/& Journal 3, 1966.
A
Nurse fraining granfs and confracfs During the fiscal year ending June 30, 1972, 3,439 grants and contracts totaling more than $125,800 were awarded t o schools of nursing and health concerned agencies under the provisions of the Nurse Training A c t of 1971. The grants and contracts t o improve the quality of nursing education, provide a i d to nursing students, and encourage recruitment and upper mobility in nursing were awarded by the Division of Nursing o f HEW. Awards were made t o nursing schools under the new provisions for financial distress and capitation grants t o help schools increase enrollments and prepare nurses for primary care responsibilities. Grants and contracts were awarded for projects t o encourage f u l l utilization of educational talent for nursing among minority groups, the male population, and auxiliary nursing personnel. Tables listing the grant and contract awards may be obtained by calling (301) 496-1 143 or writing t o the Division o f Nursing, Bureau of Health Manpower Education, National Institutes of Health, 9000 Rockville Pike, Bethesda, Md 20014.
December 1972
53
An improved and simplified method of observation and photography of the larynx and nasopharynx has been needed for quite some time. This has prompted me to develop an oral panendoscope to facilitate direct observation and photography of the larynx and nasopharynx during phonation. Prior to this time our technology had not vastly improved since Ludwig Turck popularized the use of the laryngeal mirror in 1806, and Alfred Kirstein introduced the direct method of laryngoscopy in 1896. The Taub oral panendoscope was originally developed for use in cleft palate research and speech pathology. Because of its uniqueness as a diagnostic instrument and its simplicity of use in the direct examination of the larynx and nasopharynx, the inStanlJy
Taub,
MD, i s a clinical associate pro-
fessor i n the department of surgery a t N e w York M e d i c a l College-Flower Fifth Avenue Hospitals. H e is a graduate of N e w York University, Bronx, and N e w York M e d i c a l College, N e w York Ci+y.
50
strument is widely used in operating rooms a t the request of anesthesiologists for preoperative and postoperative laryngoscopy. Formerly the anesthesiologist had to call upon an ENT specialist for routine indirect laryngoscopy. The anesthesiologist can now save the patient time and money by performing a direct examination of the larynx that is no more complicated than the insertion of a tongue depressor in the patient’s mouth. Since the oral panendoscope is a telescopic instrument, the image is upright and not inverted as when seen with the laryngeal mirror. In effect, this examination constitutes a direct laryngoscopy.
Its application in the field of diagnostic and photographic laryngoscopy soon became apparent. This device permits a more leisurely examination and panoramic viewing of the larynx and nasopharynx and at the same time enables the observer by a
AORN Journal
simple camera attachment to1 make excellent photographic records of what has been seen. Examination of the larynx with the laryngeal mirror can become a frustrating procedure because of unreliable illumination and repeated fogging of the mirror. The view of the larynx through the mirror is a partial one with a very narrow visual field. Patient discomfort caused by pulling of the tongue often results in an incomplete examination. These problems have been practically eliminated with the use of the Taub oral panendoscope. The oral panendoscope is an integrally illuminated tubular optical device. A newly designed lens system transmits the image received at the distal end to the viewer and camera at the proximal end. A high intensity incandescent lamp adjacent to the objective lens illuminates the target surfaces a t levels of light required for direct observation and for motion picture and still photography. An eyepiece is provided with a glare shield for clinical use and a threaded adapter for camera mounting. Light intensity is controlled by a variable output transformer, which operates from a standard 110 volt 60 cycle AC power source. A clear plastic removable heat shield protects exposed tissue from contact with the lamp bulb. The heat from the bulb prevents the objective lens from fogging after the light has been turned on and kept at clinical level of intensity for approximately one minute. The instrument is in focus from ‘7/” to infinity, and so it does not have to be refocused during use. The field of vision is an approximate 50 degree cone, having its apex near the surface of the objective
December 1972
lens. The axis of vision is a t right angles to the instrument tube axis. With the subject seated, the instrument is inserted into the oral cavity to the posterior pharynx with the objective lens up, and is manipulated for viewing the nasopharynx while the patient recites various combinations of vowel consonant vowel sounds. In this manner the activity of the palato pharyngeal sphincter mechanism may be observed during phonation. The optical tube is rotated 180 degrees for viewing the larynx during the production of various vowel sounds in natural, falsetto, and singing voice. A 16 mm single lens reflex motion picture camera can be attached to the instrument for simultaneous viewing and color motion picture photography at sound speeds (24 frames per second) using high speed EHB film. Individual color transparencies of excellent quality can be made with a 35 mm single lens reflex camera using a 50 mm lens. Larger transparencies, 33 mm in diameter, have been obtained with a 2% by 23,4 single lens reflex camera using a 135 mm lens. Fine quality 8” by 10” enlargements of the larynx and nasopharynx in color and black and white have been produced from the larger negatives. For still color photography, EHB film is recommended. Shutter speeds may vary from 1/4 second to 1/15 second depending upon the focal distance of the lens and the film speed. The ASA rating of the film may be pushed to 250 if custom processed. For color motion picture photography, the single lens 16 mm reflex camera is recommended. The lenses may be the wide angle 16 mm or
51
How it all works
A demonstration of the use of the oral panendoscope and the equipment involved. The physician sees the larynx through the view finder. The TV camera transfers t h e view t o the monitor so other parties can g e t t h e same view while the video tape recorder simultaneously records the scene
for later refer-
ence.
O n e view seen through t h e panendoscope.
52
AORN Journal
standard 25 mm. A camera with a reflex viewing system is recommended. The 8 mm camera may be adapted to the oral panendoscope. For teaching purposes, the instrument may be attached to a television camera for video tape recording. When the optical tube is in the down position, the entire laryngeal mechanism is brought into striking full view. The true and false vocal cords, the base of the epiglottis, the anterior commissure, the posterior surface of the vertical wall of the epiglottis and ventricles are clearly observed. The arytenoid cartilages, aryepiglottic folds and the pyriform fossa are brightly illuminated and clearly visible at or slightly greater than life size. Approximately 2 cm of the tracheal lumen is visible below the glottis. When viewing the nasopharynx, the torus and mouth of the eustachian tube, the posterior edge of the nasal septum and choanae are readily visible. The relationship of structure to function during phonation is clearly observed.
Not all subjects react favorably to the introduction of the device into the
oral cavity. In most instances this negative reaction can be overcome by the application of a topical anesthetic into the posterior pharynx. In some patients, gentle tongue traction may be necessary for the proper placement of the instrument. Once in place, the tongue may be released and the patient instructed to phonate as may be required for viewing the larynx or nasopharynx. The Taub oral panendoscope creates the opportunity for improved diagnosis, treatment and research by providing a simple method of direct visual observation, photography and television demonstration of the laryngeal and nasopharyngeal areas. Clinical direct laryngoscopy without alteration of the natural position of the larynx is greatly facilitated. Its use in the operating room by the anesthesiologist greatly facilitates preoperative as well as postoperative laryngoscopy for airway evaluation. [7 REFERENCES Lederer,
FL: "Laryngic Descriptive Discrepancy",
Ann&
of Otology, Rhinology, and Laryngofogy 72396-41 5, 1963.
Taub, S: "The Taub O r a l Panendoscope: New Technique", Cleft Pa/& Journal 3, 1966.
A
Nurse fraining granfs and confracfs During the fiscal year ending June 30, 1972, 3,439 grants and contracts totaling more than $125,800 were awarded t o schools of nursing and health concerned agencies under the provisions of the Nurse Training A c t of 1971. The grants and contracts t o improve the quality of nursing education, provide a i d to nursing students, and encourage recruitment and upper mobility in nursing were awarded by the Division of Nursing o f HEW. Awards were made t o nursing schools under the new provisions for financial distress and capitation grants t o help schools increase enrollments and prepare nurses for primary care responsibilities. Grants and contracts were awarded for projects t o encourage f u l l utilization of educational talent for nursing among minority groups, the male population, and auxiliary nursing personnel. Tables listing the grant and contract awards may be obtained by calling (301) 496-1 143 or writing t o the Division o f Nursing, Bureau of Health Manpower Education, National Institutes of Health, 9000 Rockville Pike, Bethesda, Md 20014.
December 1972
53