Atlas of Head and Neck Surgery

 

 Atlas of 

HEAD & NECK SURGERY James I. Cohen, MD, PhD, FACS Professor, Department of Otolaryngology/Head and Neck Surgery Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center Oregon Health and Science University Portland, Oregon

Gary L. Clayman, MD, DMD, FACS  Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery Professor of Surgery and Cancer Biology Director of Interdisciplinary Program in Head and Neck Oncology Chief, Section of Head and Neck Endocrine Surgery Deputy Head Division of Surgery University of Texas MD Anderson Cancer Center Houston, Texas

 

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

ATLAS OF HEAD & NECK SURGERY

ISBN: 978-1-41 978-1-4160-336860-3368-4 4

Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions . This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden understanding, changes in research methods, professional practices, or medical treatmentour may become necessary necessary. . Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Atlas of head & neck surgery / [edited by] James I. Cohen, Gary L. Clayman.—1st ed.   p. ; cm.   Atlas of head and neck surgery   Includes bibliographical references and index.   ISBN 978-1-4160-3368-4 (hardcover : alk. paper) 1. Head—Surgery—Atlases. Head—Surgery—Atlases. 2. Neck— Surgery—Atlases. I. Cohen, James I. II. Clayman, Gary L. III. Title: Atlas of head and neck surgery.   [DNLM: 1. Head—surgery—At Head—surgery—Atlases. lases. 2. Neck—surgery—Atla Neck—surgery—Atlases. ses. WE 17]   RD521.A843 2011   617.5 1059—dc22 2011010051 ′

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This book is dedicated to the concept that the wisdom and humility essential to the practice of medicine are best acquired by rejecting dogma and instead exploring the controversy that surrounds much of what we do every day. My lifelong pursuit of this ideal has required constant nurturing. For this, I am forever indebted to my father who instilled it in me at an early age by design and example, to three decades of residents who have helped me learn and teach in this context, and especially to my wife, Sherry, and my children, Alex and Adam, who have always supported me with love and affection.  James I. Cohen How we develop as individuals is shaped by both our genetics and our environment. I dedicate this book to those who have directly and indirectly shaped my life, and although I am hesitant to make too long of a list, such an opportunity comes too infrequently. My parents provided encouragement, support, and love for which I am forever grateful. I have had the honor to be educated by and to refer to as colleagues, several surgeons who have been icons in the field of head and neck surgery. These men inspired me with their wisdom, surgical art form, and humility and have remained within me throughout my career. They notably include Drs. Helmuth Goepfert, Alando  J. Ballantyne, Robert Byers, and Oscar Guillamondegui. Inspiration has also come from the honor and joy of training immensely talented and brilliant residents and fellows during the past 20 years. Finally, my family, including my loving wife, Mikyung, my beautiful children, Beau and Elizabeth, and my brothers, Lawrence and Marty, and my dear friends have provided endless love and care and the smiles, joy, and laughter that give my life meaning. Gary L. Clayman

 

 Associate Editors Peter E. Andersen, MD Professor, Department of Otolaryngology/ Head and Neck Surgery Professor, Department of Neurosurgery Director of Head and Neck Surgery Oregon Health and Science University

William M. Lydiatt, MD, FACS Professor and Vice Chair, Department of Otolaryngology Director of Head and Neck Surgery University of Nebraska Medical Center Professor, Department of Head and Neck Surgery Nebraska Methodist Hospital

Portland, Oregon

Omaha, Nebraska

Ehab Hanna, MD, FACS Professor and Vice Chairman Director of Skull Base Surgery Department of Head and Neck Surgery Medical Director, Head and Neck Center University of Texas MD Anderson Cancer Center Houston, Texas

Joshua S. Schindler, MD Assistant Professor, Department of Otolaryngology Medical Director, OHSU-Northwest Clinic for Voice and Swallowing Oregon Health and Science University Portland, Oregon

F. Christopher Holsinger, MD, FACS Associate Professor, Department of Head and Neck Surgery Director, Program in Minimally Invasive and Endoscopic Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Mark K. Wax, MD, FACS, FRCSC Professor, Otolaryngology/Head and Neck Surgery Professor, Oral and Maxillofacial Surgery Program Director Director, Microvascular Reconstruction Coordinator, Education, AAOHNS(F) Department of Otolaryngology/Head and Neck Surgery Oregon Health Sciences University Portland, Oregon

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Contributors Peter E. Andersen, MD Professor, Department of Otolaryngology/ Head and Neck Surgery Professor, Department of Neurosurgery Director of Head and Neck Surgery Oregon Health and Science University

Ehab Hanna, MD, FACS Professor and Vice Chairman Director of Skull Base Surgery Department of Head and Neck Surgery Medical Director, Head and Neck Center University of Texas MD Anderson Cancer Center

Portland, Oregon

Houston, Texas

Mihir K. Bhayani, MD Fellow, Department of Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

F. Christopher Holsinger, MD, FACS Associate Professor, Department of Head and Neck Surgery Director, Program in Minimally Invasive and Endoscopic Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

 Apostolos Christopoulos, MD, MSc, FRCSC Assistant Professor, Department of Otorhinolaryngology Centre Hospitalier de l’Université de Montréal Montréal, Québec, Canada Woong Youn Chung, MD, PhD Associate Professor, Department of Surgery Yonsei University College of Medicine Seoul, Republic of Korea Gary L. Clayman, MD, DMD, FACS Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery Professor of Surgery and Cancer Biology Director of Interdisciplinary Program in Head and Neck Oncology Chief, Section of Head and Neck Endocrine Surgery Deputy Head Division of Surgery, University of Texas MD Anderson Cancer Center Houston, Texas James I. Cohen, MD, PhD, FACS Professor, Department of Otolaryngology/Head and Neck Surgery Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center Oregon Health and Science University Portland, Oregon Robert L. Ferris, MD, PhD, FACS Professor and Vice-Chair of Clinical Operations Departments of Otolaryngology, Radiation Oncology, and Immunology Eye & Ear Institute Pittsburgh, Pennsylvania

Kitti Jantharapa Jantharapattana, ttana, MD Postdoctoral Fellow, Fellow, Head and Neck Surgery MD Anderson Cancer Center Houston, Texas Instructor, Otolaryngology Head and Neck Surgery Prince of Songkla University Songkhla, Thailand Ollivier Laccourreye, MD Professor, Department of Otorhinolaryngology–Head and Neck Surgery University Descartes-Paris V Hôpital Européen Georges Pompidou Member, Académie Nationale de Chirurgie Paris, France Daniel D. Lydiatt, MD, DDS, FACS Professor and Interim Chair, Otolaryngology/Head and Neck Surgery University of Nebraska Medical Center Medical Director, Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska William M. Lydiatt, MD, FACS Professor and Vice Chair, Department of Otolaryngology Director of Head and Neck Surgery University of Nebraska Medical Center Professor, Department of Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska

Paul W. Gidley, MD, FACS Associate Professor, Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Henry A. Milczuk, MD Associate Professor Chief, Pediatric Otolaryngol Otolaryngology ogy Department of Otolaryngology–Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Neil D. Gross, MD, FACS Assistant Professor, Otolaryngology/Head and Neck Surgery Oregon Health and Science University Attending Surgeon, Operative Care Division

Raul Pellini, MD Attending Surgeon, Department of Otolaryngolog Otolaryngology–Head y–Head and Neck Surgery National Cancer Institute “Regina Elena”

Portland Medical Center Portland,VA Oregon

Rome, Italy

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Contributors

Greg Reece, MD Professor of Plastic Surgery Department of Plastic Surgery University of Texas MD Anderson Cancer Center Houston, Texas Paolo Ruscito, MD Attending Surgeon, Department of Otolaryngolog Otolaryngology–Head y–Head and Neck Surgery National Cancer Institute “Regina Elena” Rome, Italy Joshua S. Schindler, MD Assistant Professor, Department of Otolaryngology Medical Director, OHSU-Northwest Clinic for Voice and Swallowing Oregon Health and Science University Portland, Oregon Giuseppe Spriano, MD Chief, Department of Otolaryngology–Head and Neck Surgery Director, Department of Neuroscience National Cancer Institute “Regina Elena” Rome, Italy

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Mark K. Wax, MD, FACS, FRCSC Professor, Otolaryngology/Head and Neck Surgery Professor, Oral and Maxillofacial Surgery Program Director Director, Microvascular Reconstruction Coordinator, Education, AAOHNS(F) Department of Otolaryngology/Head and Neck Surgery Oregon Health Sciences University Portland, Oregon Gregory S. Weinstein, MD Professor and Vice Chair, Otorhinolaryngology: Head and Neck Surgery University of Pennsylvania Philadelphia, Pennsylvania Mark E. Zafereo, MD Fellow, Head and Neck Surgery MD Anderson Cancer Center Houston, Texas

 

Reviewers Peter E. Andersen, MD Professor, Department of Otolaryngology/Head and Neck Surgery Professor, Department of Neurosurgery Director of Head and Neck Surgery Oregon Health and Science University

William R. Carroll, MD Professor and Director of Head and Neck Oncology Department of Surgery University of Alabama–Birmingham Birmingham, Alabama

Portland, Oregon

Salvatore M. Caruana, MD Assistant Professor, Department of Otolaryngology–Head and Neck Surgery Columbia University New York, New York

William B. Armstrong, MD Professor of Clinical Otolaryngology and Chair, Otolaryngology–Head Otolaryngolog y–Head and Neck Surgery University of California– California–Irvine Irvine Irvine, California Leon A. Assael, DMD Professor and Chair of Oral and Maxillofacial Surgery Medical Director, Hospital Dentistry Oregon Health and Science University Portland, Oregon Stephen W. Bayles, MD, FACS Deputy Chief of Surgery Section Head-Otolaryn Head-Otolaryngology gology Director of Head and Neck Oncology Virginia Virgini a Mason Medical Center Seattle, Washington Peter C. Belafsky Belafsky,, MD, PhD Associate Professor and Director, Center for Voice and Swallowing University of California– California–Davis Davis Sacramento, California Manuel Bernal-Sprekelsen, MD, PhD Head of Ear, Nose and Throat Department, Otorhinolaryngology, Hospital Clinic Tenure Professor for Otorhinolaryngology, Department for Surgical Specialties University of Barcelona Barcelona, Spain Privatdozent for ORL Ruhr-University Bochum, Germany Nasir I. Bhatti MD, FACS Associate Professor, Department of Otolaryngology Head and Neck Surgery  Johns Hopkins University School of Medicine Baltimore, Maryland Brian B. Burkey, MD, FACS Section Head, Head and Neck Surgery and Oncology Head and Neck Institute Cleveland Clinic Foundation Cleveland, Ohio Adjunct Professor, Department of Otolaryngology Vanderbilt University Medical Center Nashville, Tennessee Bruce H. Campbell, MD, FACS Professor,, Department of Otolaryngol Professor Otolaryngology ogy and Communication Sciences Medical College of Wisconsin Milwaukee, Wisconsin

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Claudio R. Cernea, MD Associate Professor of Surgery, Department of Head and Neck Surgery University of Sao Paulo Medical School Sao Paulo, Brazil Francisco J. Civantos, MD, FACS Associate Professor Co-Director, Division of Head and Neck Surgery Department of Otolaryngol Otolaryngology ogy Sylvester Cancer Center/University Center/University of Miami Hospital and Clinics Miami, Florida Gary L. Clayman, MD, DMD, FACS Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery Professor of Surgery and Cancer Biology Director of Interdisciplinary Program in Head and Neck Oncology Chief, Section of Head and Neck Endocrine Surgery Deputy Head Division of Surgery, University of Texas MD Anderson Cancer Center Houston, Texas James I. Cohen, MD, PhD, FACS Professor, Department of Otolaryngology/Head and Neck Surgery Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center Oregon Health and Science University Portland, Oregon Seth M. Cohen, MD, MPH Assistant Professor, Duke Voice Care Center Division of Otolaryngology–Head Otolaryngology–Head and Neck Surgery Duke University Medical Center Durham, North Carolina Ted A. Cook, MD, FACS Professor, Facial Plastic and Reconstructive Surgery Department of Otolaryngology/Head and Neck Surgery Oregon Health and Science University Portland, Oregon Robin T. Cotton, MD, FACS, FRCSC Director, Pediatric Otolaryngology–Head Director, Aerodigestive and Sleep Center and Neck Surgery Cincinnati Children’s Hospital Professor, Otolaryngology–Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati, Ohio

 

Reviewers

Mark S. Courey, MD Professor, Otolaryngology–Head and Neck Surgery UCSF Medical Center Director, Division of Laryngology University of California– California–San San Francisco San Francisco, California Bruce J. Davidson, MD Professor and Chairman, Department of Otolaryngology–Head and Neck Surgery Georgetown University Medical Center Washington, District of Columbia Terry A. Day, MD Professor and Clinical Vice Chairman, Department of Otolaryngology–Head Otolaryngolog y–Head and Neck Surgery Medical University of South Carolina Charleston, South Carolina Daniel G. Deschler, MD, FACS Director, Division of Head and Neck Surgery Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear Infirmary Associate Professor, Department of Otology and Laryngology Harvard Medical School Boston, Massachusetts Gianlorenzo Gianlorenz o Dionigi, MD, FACS Associate Professor of Surgery, Department of Surgical Sciences University of Insubria Varese, Italy

Paul James Donald, MD, FRCSC Professor and Vice Chair, Chair, Otolaryngology–Head Otolaryngology– Head and Neck Surgery University of California, Davis Sacramento, California David W. Eisele, MD, FACS Professor and Chairman, Department of Otolaryngology–Head and Neck Surgery Irwin Mark Jacobs and Joan Klein Jacobs Endowed Chair in Head and Neck Cancer UCSF Helen Diller Family Comprehensive Cancer Center University of California– California–San San Francisco San Francisco, California D. Gregory Farwell, MD, FACS Associate Professor, Otolaryngology–Head and Neck Surgery University of California–Davis Sacramento, California Fred G. Fedok, MD, FACS Professor and Chief, Section of Facial Plastic and Reconstructive Surgery Division of Otolaryngology/Head Otolaryngology/Head and Neck Surgery Department of Surgery Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania Robert L. Ferris, MD, PhD, FACS Professor and Vice-Chair of Clinical Operations Departments of Otolaryngology, Radiation Oncology, and Immunology Eye & Ear Institute Pittsburgh, Pennsylvania Paul W. Flint, MD Professor and Chair, Otolaryngology/Head and Neck Surgery Oregon Health and Science University Portland, Oregon

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Jeremy L. Freeman, MD, FRCSC, FACS Professor, Department of Otolaryngology–Head and Neck Surgery Professor, Department of Surgery University of Toronto Temmy Latner/Dynacare Chair in Head and Neck Oncology Mount Sinai Hospital/University of Toronto Otolaryngologist Otolaryngolo gist in Chief, Department of Otolaryngolo Otolaryngology–Head gy–Head and Neck Surgery Mount Sinai Hospital Toronto, Ontario, Canada Paul L. Friedlander Friedlander,, MD, FACS Chairman, Department of Otolaryngol Otolaryngology ogy Tulane Medical Center New Orleans, Louisiana Neal Futran, MD, DMD Professor and Chair, Otolaryngology–Head and Neck Surgery University of Washington Seattle, Washington Markus Gapany, MD Associate Professor, Otolaryngology–Head and Neck Surgery University of Minnesota Minneapolis, Minnesota C. Gaelyn Garrett, MD Professor, Department of Otolaryngology Vanderbilt Medical Center Medical Director, Vanderbilt Voice Center Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Communicati on Sciences Nashville, Tennessee

Eric M. Genden, MD, FACS Professor and Chairman, Department of Otolaryngology–Head and Neck Surgery Professor of Neurosurgery Mount Sinai School of Medicine New York, New York Helmuth Goepfert, MD Professor Emeritus, Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas  Andrew N. Goldberg, MD, MSCE, FACS Professor, Director, Division of Rhinology and Sinus Surgery Department of Otolaryngology–Head and Neck Surgery University of California–S California–San an Francisco San Francisco, California Neil D. Gross, MD, FACS Assistant Professor, Otolaryngology–Head and Neck Surgery Oregon Health and Science University Attending Surgeon, Operative Care Division Portland VA Medical Center Portland, Oregon Patrick J. Gullane, MD, CM, FRCSC, FACS, FRACS (Hon), FRCS (Hon)

Otolaryngologist-in-Chief, University Health Network Otolaryngologist-in-Chief, Wharton Chair Head and Neck Surgery–Princess Margaret Hospital Professor and Chair, Department of Otolaryngology Head and Neck Surgery University of Toronto Department of Otolaryngology–Head and Neck Surgery University Health Network Toronto, Ontario, Canada

 

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Reviewers

Gady Har-El, MD, FACS Chairman, Department of Otolaryngolog Otolaryngology–Head y–Head and Neck Surgery Lenox Hill Hospital New York, New York Professor, Departments of Otolaryngology and Neurosurgery State University of New York–Downstate Medical Center Brooklyn, New York Adjunct Professor, Otolaryngology–Head and Neck Surgery New York University New York, New York  Amy C. Hessel, MD Associate Professor and Surgeon, Department of Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas Peter A. Hilger, MD Professor, Division of Facial Plastic Surgery Department of Otolaryngolog Otolaryngology y University of Minnesota Minneapolis, Minnesota

Jonas T. Johnson, MD Professor and Chairman, Department of Otolaryngolo Otolaryngology gy University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Larry R. Kaiser, MD President, The University of Texas Health Science Center at Houston Houston, Texas Emad Kandil, MD, FACS Assistant Professor of Surgery, Department of Surgery Tulane University School of Medicine New Orleans, Louisiana Dennis Kraus, MD Attending Surgeon, Head and Neck Surgery Service Department of Surgery Memorial Sloan-Kettering Cancer Center Professor, Department of Otorhinolaryngology–Head and Neck Surgery Cornell University Medical Center New York, New York

Frans J. M. Hilgers, MD, PhD Chairman-Emeritus, Chairman-Em eritus, Head and Neck Oncology and Surgery The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital

Ronald B. Kuppersmith, MD, MBA, FACS Texas Ear, Nose, and Throat and Allergy College Station, Texas

Professor, Oncology-Related Voice and Speech Disorders Institute of Phonetic Sciences Amsterdam Center for Language and Communication Communication– – University of Amsterdam Consultant, Head and Neck Oncology and Surgery, Otorhinolaryngology Academic Medical Center–University of Amsterdam Amsterdam, The Netherlands

Ollivier Laccourreye, MD Professor, Department of Otorhinolaryngology–Head and Neck Surgery University Descartes-Paris V Hôpital Européen Georges Pompidou Member, Académie Nationale de Chirurgie Paris, France

Henry T. Hoffman, MD, FACS Professor Director, Voice Clinic Department of Otolaryngolog Otolaryngology y University of Iowa Hospitals and Clinics Iowa City, Iowa F. Christopher Holsinger, MD, FACS Associate Professor, Department of Head and Neck Surgery Director, Program in Minimally Invasive and Endoscopic Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas David B. Hom, MD, FACS Professor, Director, Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology–Head and Neck Surgery University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio David Howard, MD Professor of Head and Neck Oncology Imperial College London Consultant Head and Neck Surgeon Charing Cross Hospital London, United Kingdom

Jonathan Irish, ND, FRCSC Chief, Department of Surgical Oncology Princess Margaret Hospital University Health Network Toronto, Ontario, Canada

Eric S. Lambright, MD Assistant Professor of Thoracic Surgery Surgical Director of Lung Transplant Vanderbilt Thoracic Surgery Vanderbilt University Medical Center Nashville, Tennessee Jeffrey E. Lee, MD Professor of Surgery, Department of Surgical Oncology University of Texas MD Anderson Cancer Center Houston, Texas

John P. Leonetti, MD Professor and Vice-Chairman, Neurotology, Otology, and Skull Base Surgery Co-Director of the Loyola Center for Cranial Base Surgery Department of Otolaryngology–Head and Neck Surgery Loyola University Medical Center Maywood, Illinois Celestino Pio Lombardi, MD Endocrine Surgery Department Università Cattolica Del Sacro Cuore Policlinico Gemelli Rome, Italy William M. Lydiatt, MD, FACS Professor and Vice Chair, Department of Otolaryngology Director of Head and Neck Surgery University of Nebraska Medical Center Professor, Department of Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska

 

Reviewers

Jeffery Scott Magnuson, MD Associate Professor of Surgery, Residency Program Director, Department of Surgery Division of Otolaryngolog Otolaryngology y University of Alabama at Birmingham Birmingham, Alabama Robert H. Maisel, MD, FACS Professor, Department of Otolaryngology–Head and Neck Surgery University of Minnesota Chief, Department of Otolaryngology–Head and Neck Surgery Hennepin County Medical Center Minneapolis, Minnesota Rosario Marchese-Ragona, MD Assistant Professor Professo r, Department of Medical and Surgical Specialties Section of Otolaryngology Head and Neck Surgery University of Padova Padova, Italy Robert G. Martindale, MD, PhD Professor and Chief, Division of General Surgery Department of Surgery Oregon Health and Science University Portland, Oregon Sam J. Marzo, MD Professor, Residency Program Director Director, Parmly Hearing Institute Department of Otolaryngology–Head and Neck Surgery Division of Otology, Neurotology, and Skull Base Surgery Loyola University Health System Maywood, Illinois

Timothy M. McCulloch, MD Professor and Chairman, Division of Otolaryngol Otolaryngology ogy Head and Neck Surgery University of Wisconsin Hospital and Clinics Madison, Wisconsin  Andrew J. McWhorter, MD Director of Voice Center Assistant Professor, Department of Otolaryngology–Head and Neck Surgery Louisiana State University Health Sciences Center New Orleans, Louisiana

Jesus E. Medina, MD, FACS Paul and Ruth Jonas Professor, Department of Otorhinolaryngology University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Eduardo Méndez, MD, MS Assistant Professor, Department of Otolaryngology–Head and Neck Surgery University of Washington Assistant Member, Clinical Research Division Fred Hutchinson Cancer Research Center Seattle, Washington  Albert L. Merati, MD, FACS Associate Professor and Chief, Laryngology Department of Otolaryngology–Head and Neck Surgery University of Washington School of Medicine Adjunct Associate Professor, Professor, Department of Speech and Hearing Sciences College of Arts and Sciences University of Washington Seattle, Washington

Tanya K. Meyer, MD Assistant Professor Department of Otolaryngolo Otolaryngology gy University of Washington Seattle, Washington Paolo Miccoli, MD Professor of Surgery Head of the Department of Surgery University of Pisa Pisa, Italy Henry A. Milczuk, MD Associate Professor Chief, Pediatric Otolaryngolo Otolaryngology gy Department of Otolaryngology–Head and Neck Surgery Oregon Health and Science University Portland, Oregon Oleg Militsakh, MD, FACS Assistant Professor, Professor, Director Head and Neck Reconstructive Surgery Division of Head and Neck Surgery Department of Otolaryngolo Otolaryngology gy University of Nebraska Medical Center Assistant Professor, Professor, Director Head and Neck Reconstructive Surgery Department of Head and Neck Surgery Nebraska Methodist Hospital–Estabrook Cancer Center Omaha, Nebraska

Eric J. Moore, MD Consultant, Otorhinolaryngology–Head Otorhinolaryngology–Head and Neck Surgery Mayo Clinic Associate Professor of Otolaryngolo Otolaryngology gy Mayo College of Medicine Rochester, Minnesota Meijin Nakayama, MD Associate Professor, Otorhinolaryngology Kitasato University School of Medicine Sagamihara, Kanagawa, Japan Roger C. Nuss, MD, FACS Assistant Professor of Otology and Laryngology Harvard School Children’sMedical Hospital Boston, Massachusetts

Kerry D. Olsen, MD Professor, Otolaryngology Head and Neck Surgery Mayo Clinic Rochester, Minnesota Steven M. Olsen, MD Resident, Otolaryngology Otolaryngology Head and Neck Surgery Mayo Clinic Rochester, Minnesota Lisa A. Orloff, MD, FACS Robert K. Werbe Distinguished Professor of Head and Neck Cancer Director, Division of Head and Neck and Endocrine Surgery Department of Otolaryngology, Head and Neck Surgery University of California–S California–San an Francisco San Francisco, California

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Reviewers

Robert H. Ossoff, MD, DMD Guy M. Maness Professor of Laryngology and Care of the Voice Department of Otolaryngolog Otolaryngology y Assistant Vice-Chancellor, Office of Compliance and Corporate Integrity Vanderbilt Medical Center Nashville, Tennessee Giorgio Peretti, MD Associate Professor, Department of Otorhinolaryngology–Head and Neck Surgery University of Brescia Brescia, Italy Nancy D. Perrier, MD, FACS Professor of Surgery, Department of Surgical Oncology University of Texas MD Anderson Cancer Center Houston, Texas Cesare Piazza, MD Assistant Professor, Department of Otorhinolaryngology–Head and Neck Surgery University of Brescia Brescia, Italy Joe B. Putnam, Jr., MD Professor of Surgery and Chairman, Department of Thoracic Surgery Ingram Professor of Cancer Research Vanderbilt Ingram Cancer Center Professor of Biomedical Informatics Vanderbilt University Medical Center Nashville, Tennessee

Gregory W. Randolph, MD, FACS Director of General, Thyroid, and Parathyroid Surgical Divisions Massachusetts Eye and Ear Infirmary Member, Division of Surgical Oncology and Endocrine Surgical Service Massachusetts General Hospital Boston, Massachusetts Associate Professor of Otology and Laryngology Harvard Medical School Cambridge, Massachusetts

Marc Remacle, MD, PhD Professor, Associate Head, Otorhinolaryngology–Head and Neck Surgery Louvain University Hospital of Mont-Godinne Mont-Godinne, Belgium  Alan T. Richards, MD, FACS Associate Professor, Otolaryngology–Head and Neck Surgery University of Nebraska Medical Center Associate Professor, Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska William J. Richtsmeier, MD, PhD Director, Clinician Research, Department of Otolaryngology– Head and Neck Surgery Bassett Healthcare Network Cooperstown, New York

John A. Ridge, MD, PhD Professor, Senior Member, and Chief, Head and Neck Surgery Section Departments of Surgery and Developmental Therapeutics Fox Chase Cancer Center Professor, Departments of Surgery and Otolaryngology–Head and Neck Surgery Temple University Philadelphia, Pennsylvania Clark A. Rosen, MD, FACS Professor, Department of Otolaryngology University of Pittsburgh School of Medicine Director, University of Pittsburgh Voice Center University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Eben L. Rosenthal, MD  Julius Hicks Professor of Surgery, Surgery, Division of Otolaryngology– Head and Neck Surgery University of Alabama at Birmingham Birmingham, Alabama John R. Saunders, Jr., MD, MBA  Executive Vice-President, Chief Medical Director Medical Director, Milton J. Dance, Jr. Head and Neck Center Greater Baltimore Medical Center Associate Professor, Otolaryngology–Head and Neck Surgery Surgery, Plastic Surgery  Johns Hopkins School of Medicine Baltimore, Maryland

Joshua S. Schindler, MD Assistant Professor, Department of Otolaryngology Medical Director, OHSU-Northwest Clinic for Voice and Swallowing Oregon Health and Science University Portland, Oregon David E. Schuller, MD Vice President, Medical Center Expansion and Outreach Otolaryngology–Head Otolaryngol ogy–Head and Neck Surgery  John W. W. Wolfe Chair in Cancer Research College of Medicine CEO Emeritus, Arthur G. James Cancer Hospital and Richard  J. Ohio SoloveState Research Institute The University Columbus, Ohio

 Aniel Sewnaik, MD, PhD Head and Neck Surgeon, Otorhinolaryngology Head and Neck Surgery Erasmus MC-Daniel Den Hoed Cancer Center Rotterdam, The Netherlands  Ashok R. Shaha, MD, FACS  Jatin P. P. Shah Chair in Head and Neck Surgery Head and Neck Service Department of Surgery Memorial Sloan-Kettering Cancer Center Professor of Surgery, Department of Surgery Weill Cornell Medical College Cornell University New York, New York Maisie Shindo, MD, FACS Professor, Otolaryngology Thyroid and Parathyroid Division Oregon Health and Science University Portland, Oregon

 

Reviewers

William W. Shockley, MD, FACS W. Paul Biggers Distinguished Professor Chief, Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology/Head and Neck Surgery University of North Carolina School of Medicine Attending Physician, Department of Otolaryngolog Otolaryngology/Head y/Head and Neck Surgery UNC Hospitals Chapel Hill, North Carolina James Sidman, MD Director of Cleft and Craniofacial Programs Co-Director of Vascular Anomalies Program Department of Otolaryngol Otolaryngology ogy Children’s Hospitals and Clinics of Minnesota Professor of Otolaryngology and Pediatrics University of Minnesota Minneapolis, Minnesota C. Blake Simpson, MD Professor, Department of Otolaryngology–Head and Neck Surgery Director, The University of Texas Voice Center University of Texas Health Science Center at San Antonio San Antonio, Texas

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David J. Terris, MD, FACS Porubsky Professor and Chairman Surgical Director, MCG Thyroid/Parathyroid Center Department of Otolaryngology–Head and Neck Surgery Medical College of Georgia Augusta, Georgia Ralph P. Tufano, MD, FACS Associate Professor, Department of Otolaryngology–Head and Neck Surgery Director of the Johns Hopkins Hospital Multidisciplinary Thyroid Tumor Center Director, Thyroid and Parathyroid Surgery  Johns Hopkins School of Medicine Baltimore, Maryland Joseph Valentino, MD Professor, Department of Surgery Division Of Otolaryngology–Head Otolaryngology–Head and Neck Surgery University of Kentucky College of Medicine Chief of Head and Neck Surgery Department of Surgery Lexington Kentucky Veterans Medical Center Lexington, Kentucky

Catherine F. Sinclair, MD, FRACS Instructor/Fellow Instructor/Fello w Head and Neck Surgery

Isabel Vilaseca, MD, PhD Consultant, Otorhinolary Otorhinolaryngology ngology Hospital Clinic

Department of Surgery Division of Otolaryngology Head and Neck Surgery University of Alabama at Birmingham Birmingham, Alabama

Associate Professor of Otorhinolary Otorhinolaryngology ngology Department for Surgical Specialties University of Barcelona Barcelona, Spain

James D. Smith, MD Professor Emeritus, Otolaryngology Otolaryngology Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Stephen J. Wang, MD, FACS Associate Professor, Department of Otolaryngology–Head and Neck Surgery University of California–S California–San an Francisco San Francisco, California

Timothy L. Smith, MD, MPH Professor and Chief, Rhinology and Sinus Surgery Department of Otolaryngology–Head and Neck Surgery Oregon Health and Science University Portland, Oregon Carl Henry Snyderman, MD

Mark K. Wax, MD, FACS, FRCSC Professor, Otolaryngology–Head and Neck Surgery Professor, Oral and Maxillofacial Surgery Program Director Director, Microvascular Reconstruction Coordinator, Education, AAOHNS(F)

Professor, Otolaryngology University Department of PittsburghofMedical Center Pittsburgh, Pennsylvania

Department of Otolaryngology–Head and Neck Surgery Oregon Health Sciences University Portland, Oregon

Robert A. Sofferman, MD Professor of Surgery and Chief Emeritus Department of Surgery Division of Otolaryngolog Otolaryngology y University of Vermont School of Medicine Burlington, Vermont

Randal S. Weber, MD Professor and Chair, Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Jeffrey D. Spiro, MD Professor of Surgery, Division of Otolaryngology/Head and Neck Surgery University of Connecticut School of Medicine Farmington, Connecticut Wolfgang Steiner, MD Professor Emeritus, Department of Otorhinolary Otorhinolaryngology–Head ngology–Head and Neck Surgery University of Goettingen Goettingen, Germany

Richard J. Wong, MD Associate Attending Surgeon, Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Steven M. Zeitels, MD, FACS Eugene B. Casey Professor of Laryngeal Surgery Department of Surgery Harvard Medical School Director, Center for Laryngeal Surgery Department of Surgery Massachusetts General Hospital Boston, Massachusetts

 

Preface Learning how to do an operation can be a daunting task, whether as a first-year resident preparing the night before a case never previously encountered or as a surgeon in a busy practice faced with incorporating a new technique or technology into his or her surgical

they thought appropriate, whether to provide emphasis, clarification, or alternate strategies. This commentary is provided in essentially unedited form, interposed in the original author’s text, because we thought that this would best simulate a “virtual conversation” taking

repertoire. This book acknowledges the realities of how this process occurs. Initially, Initially, “rote” learning of the steps involved may be all that can be expected. Over time, it is hoped that an increased understanding of the logic behind these steps and their sequence will be acquired, and this is where most surgical atlases stop. We know, however, that different surgeons perform the same operations in different ways, and these different techniques can work equally well. Although this can be confusing and disconcerting to early trainees as they work with different attending staff or preceptors, ultimately, ultimately, being able to reconcile the success of these different approaches requires a firm grasp of the unifying concepts behind any procedure. Helping the reader reach this level while still supporting the early phases of learning is the goal of this book. The book is designed to be read in the same way it is assembled. We selected authors with a known expertise in given procedures and asked them to break down the operations into their component steps, much as they would direct an early learner the first time through the procedures in the operating room. We then asked the authors to provide their logic, for both their technique and the sequence of these steps. This information was interposed into the initial “step sequence” in a separately identifiable way. Key references are provided, where needed. With the chapters assembled with their artwork, each chapter was then sent to two to four surgeons

place around an operation, such as one that would occur at a surgical technique meeting session where a panel is asked to discuss a given operation. We were surprised and gratified to see the enthusiasm with which the commentators approached the task. Finally, at the end of many of the chapters, we have provided summary comments, when applicable, that seek to clarify common themes, reconcile significant conflicts, or emphasize critical issues. Through the use of different fonts, color schemes, and paragraph structure, the publisher has preserved the concept of the sequence of the writing process. This allows the reader, depending on his or her knowledge base or time constraints, to read (or reread) the operation at the most appropriate level for his or her need at that point in time. We think that it allows a logical sequence of knowledge acquisition, whether it be rudimentary memorization, review of the steps, a more in-depth understanding of the logic of these steps, or an analysis of the guiding principles that underpin the operation as a whole, through the commentary. We hope the reader enjoys this approach as much as we have enjoyed assembling it. We think that the discipline of the framework it provides is valid not only for the operations outlined here but also for a lifelong learning process that will allow for the newer techniques and technology that we all will and must confront over the course of our professional lives.  James I.  I.  Cohen

with known expertise in the subject matter. They were asked to interject commentary into the chapter wherever

Gary L.  L.  Clayman Editors in Chief 

xvii

 

SECTION A  Adult

Endoscopy

CHAPTER

Clinical Diagnostic Nasopharyngoscopy

1

 Author Joshua S. Schindler Commentary by  Andrew N. Goldberg and Timothy L. Smith

Positioning

Fiberoptic Nasopharyngoscopy 

The procedure should be performed with the patient in the seated position with the head supported from behind. The chin should be in a neutral position with

The nasal cavity is treated with topical nasal decongestant and local anesthetic using an aerosolizer aerosolizer.. The physician stands in front of the patient and directs the scope

the Although chin centered thecan shoulders. the between procedure be performed in any position, secretion management is easiest with the head elevated. A headrest prevents withdrawal by the patient during the procedure. A centered chin prevents apparent asymmetries in the nasopharynx from rotation of the cervical spine.

into the nasal cavity (Figure 1-2A). During fiberoptic nasopharyngoscopy, patients often attempt to tilt the head backward to “assist” the entry of the scope into the nose but this generally increases the difficulty of passing the scope through the nasal cavity. The head should be in a neutral position. TLSmith

Indirect Nasopharyngoscopy  Nasopharyngoscopy may be performed transorally with a small mirror. The physician gently grasps the tongue and, using a head mirror or headlight, directs focused light to the mirror placed just beneath and behind the soft palate (Figure 1-1). The patient’s saliva on the buccal mucosa can be used to defog the mirror prior to insertion in the nasopharynx. TLSmith

Although nasopharyngoscopy may be performed this way, mirror nasopharyngoscopy yields a comparatively limited view of the nasopharynx. It is technically challenging and cannot provide an adequate examination in all patients. We therefore defer mirror laryngoscopy for flexible fiberoptic examination in most cases. In fact, I have not performed indirect nasopharyngoscopy for years given the ready availability and superior visualization of the nasopharyngoscope. TLSmith

Studies have failed to demonstrate a significant patient benefit from topicalization of the nasal cavity. Despite this, we find that the decongestant spray (oxymetazoline or phenylephrine [Neo-Synephrine]) does facilitate placement of the fiberoptic scope. Anesthetic (e.g., lidocaine, tetracaine [Pontocaine], mepivacaine [Carbocaine]) should take effect within 90 seconds and may be mixed with the nasal decongestant; 2% watersoluble lidocaine jelly also may be used and can facilitate fiberoptic scope placement. We typically treat both nasal cavities to allow placement of the fiberoptic scope through either passageway passageway..

For a right-handed examiner, standing in front of and slightly to the patient’s right allows the examiner to stand closer to the patient in a more comfortable position.  Although there is controversy over the utility of topicalization in the nose, use of decongestant and anesthetic is common practice.  Although anesthetics begin to take effect in 90 seconds, anesthesia is optimal between 5 and

3

 

4

UNIT I  I  Benign Upper Aerodigestive Disease

FIGURE 1-1.  1-1.  Indirect mirror nasopharyngoscopy.

10 minutes. Timing your topicalization and examination will increase comfort of the examination. Warning the patient in advance that application of topical anesthetic may make it feel difficult to swallow or may make the front teeth feel numb allays some patients’ anxiety if these sensations occur. Noting that the effects typically last less than an hour similarly provides information that many patients appreciate.  ANGoldberg

The fiberoptic scope is passed transnasally to the nasopharynx. Continuous visualization is performed to determine the widest and most comfortable transnasal approach (see Figure 1-2B). We prefer to use the floor of the nasal cavity to pass the fiberoptic scope because this is the least sensitive to pain and is commonly the widest passage. If the bilateral nasal floors are impassable, we approach the nasopharynx between the middle meatus and septum. This approach is directly below the middle turbinate and commonly used in my experience. TLSmith

Diagnostic nasopharyngoscopy examination begins at the choana. A thorough examination includes

inspection of the choana, the eustachian tube orifice, the torus tubarius, and the fossa of Rosenmueller on each side. Midline structures including the adenoid pad, the roof of the nasopharynx, Passavant’s ridge and the posterior mucosa of the soft palate should also be inspected. Motion and closure of the soft palate should also be tested by asking the patient to say “cake” or “kitty cat” (Figure 1-3). In most cases, all of these structures may be visualized through unilateral nasal cavity placement. Other functional testing, such as Mueller’s maneuver to test for pharyngeal airway collapse with inspiration, may be performed with fiberoptic nasopharyngoscopy. The examiner should take note of relatively subtle asymmetries in the nasopharynx because many lesions in this area are submucosal.

 Although nasopharyngoscopy begins at the choana, the opportunity to examine the nasal cavity during the same examination should not be missed.  Administration of topical anesthetic and decongestant to both sides of the nose and examination of the nasal cavity provides a complete endoscopic examination with minimal additional morbidity.  ANGoldberg

 

CHAPTER 1  1  Clinical Diagnostic Nasopharyngoscopy

5

A

Middle turbinate

Superior meatal passage (“High road”)

Inferior turbinate Nasal septum

Inferior meatal passage (“Low road”)

B

FIGURE 1-2.  1-2.   A, Flexible fiberoptic nasopharyngoscopy. B, Fiberoptic view of anterior nasal cavity.

 

6

UNIT I  I  Benign Upper Aerodigestive Disease Nasopharynx roof Torus tubarius

Adenoid pad Fossa of Rosenmueller

Uvula

Eustachian tube

Soft palate

FIGURE 1-3.  1-3.  Nasopharynx view through flexible fiberoptic scope.

EDITORIAL COMMENT:  COMMENT:  Fiberoptic technology has significantly improved the odds of complete examination of the nasopharynx compared with mirror examination alone—the issue is not whether the nasopharynx can be well seen with a mirror but rather that the technique requires considerable experience, and even with this is poorly tolerated in the majority of patients.  As pointed out the use of topical decongestant with or without topical anesthetic is not mandatory but probably preferred by most clinicians. The key if it is used is to wait sufficiently for both decongestion and anesthesia to take effect. Plan  your office visit/examination and patient flow in such a way that the necessary time (5 to 10 minutes) is built in without rushing this.  JICohen

Suggested Readings Burkey BB, Ossoff RH: Endoscopy of nasopharyngeal cancer. Diagn Ther Endosc 1:63-68, 1994. Ritter CT, Trudo FJ, Goldberg AN, Welch KC, Maislin G, Schwab RJ: Quantitative evaluation of the upper airway during nasopharyngoscopy with the Muller maneuver. Laryngoscope 109:954-963, 1999. Strauss RA: Flexible endoscopic nasopharyngoscopy. Atlas Oral Maxillofac Surg Clin North Am 15:111-128, 2007.

 

CHAPTER

2

Diagnostic Clinical Pharyngoscopy and Laryngoscopy  Author Joshua S. Schindler Comments by

Robert H. Maisel and Albert L. Merati 

Positioning

Telescopic Examination

Indirect laryngoscopy and pharyngoscopy should be performed with the patient in the seated position with the back straight and flexed forward about 20 degrees

Transoral laryngopharyngoscopy may also be performed with a rigid angled telescope. The physician grasps the patient’s tongue and passes the telescope transorally to

from perpendicular. The chin should be inthe a “sniffing” position with the chin centered between shoulders and slightly elevated. This position may be used for all types of laryngoscopy (mirror, flexible fiberoptic, or rigid). The head flexion and extension may be adjusted to facilitate visualization of laryngeal and pharyngeal structures with different visualization techniques.

the vallecula. The tolarynx maywhile be visualized by telethen asking the patient phonate adjusting the scope to see the endolarynx (Figure 2-2). Rigid, telescopic laryngopharyngoscopy offers one of the best views of the posterior upper aerodigestive tract. The telescopes may be magnified (up to 10 ×) and provide unparalleled clarity. Most patients will tolerate this procedure without anesthesia, but topical application of local anesthetic (benzocaine/butyl aminobenzoate/tetracaine [Cetacaine]) may be performed to diminish gagging. Relaxation of the jaw and tongue with retraction by the examiner will prevent elevation of the base of tongue that prevents visualization. Asking the patient to smile widely facilitates elevation of the soft palate. Both 70- and 90-degree telescopes are available to achieve optimal visualization in the widest number of patients.

Successful endoscopy begins with correct positioning and verbal preparation of the patient. All the endoscopic skill and topical anesthesia in the world can’t overcome a poorly positioned or ill-prepared patient. This cannot be overemphasized.  ALMerati 

Mirror Examination Transoral laryngopharyngoscopy may be performed with a mirror. The physician gently grasps the tongue and, using a head mirror or headlight, directs focused light to the mirror placed onto or just beneath the soft palate. The soft palate is gently elevated and the mirror is angled inferiorly to perform the examination (Figure 2-1). In contrast to nasopharyngoscopy, mirror laryngoscopy can yield a magnificent view of the larynx and pharynx without topical anesthesia. Procedures such as vocal cord injection and laryngeal or pharyngeal biopsy may performed withtongue this technique if the patient graspsbehis or her own to free the physician’s second hand. Warming the mirror to body temperature or applying a detergent-based defogging solution facilitates visualization.

Flexible Examination Transnasal laryngopharyngoscopy may be performed with a flexible laryngoscope. The procedure is performed as in nasopharyngoscopy (see Chapter 1). Once in the nasopharynx, the scope is passed through the velopalatal closure while asking the patient to gently sniff (Figure 2-3). Flexible transnasal laryngopharyngoscopy may be performed in all patients and is generally well tolerated. It affordstrachea, the mostinaccess theallows subglottis and cervical some(including cases) and for both structural and functional examination of the larynx, oropharynx and upper portion of the hypopharynx. 7

 

8

UNIT I  I  Benign Upper Aerodigestive Disease

FIGURE 2-1.  2-1.  Indirect mirror laryngoscopy.

FIGURE 2-2. Indirect 2-2. Indirect rigid telescope laryngoscopy.

 

CHAPTER 2  2  Diagnostic Clinical Pharyngoscopy and Laryngoscopy

9

FIGURE 2-3.  2-3.  Flexible fiberoptic laryngoscopy.

Even in very experienced hands, there are patients in whom flexible fiberoptic laryngoscopy is difficult, nearly impossible, and even impossible. This is usually the result of a combination of the following: (1) patient physical sensitivities such as an extreme gag reflex; (2) poor preparation of the patient, that is, talking through the examination, informing the patient about the process, positioning, and anesthesia; (3) patient psychologic preparation. Although they may intrinsically be limited in their capacity to tolerate this simple examination, many patients have become “unexaminable” following a previous traumatic examination. This latter situation is best handled by addressing it directly, and doing so prior to any attempt to examine the patient.

 ALMerati 

Comprehensive flexible fiberoptic laryngoscopic examination should include examination of the base of tongue, vallecula, epiglottis, aryepiglottic folds, glossoepiglottic fold, superior hypopharynx, posterior pharyngeal wall, arytenoids, false vocal folds, true vocal folds, and immediate subglottis. Functional examination should include true vocal fold abduction and adduction (Figure 2-4). With the flexible endoscope in place, a number of techniques can be used to facilitate visualization. Protrusion of the patient’s tongue will often demonstrate the vallecula and may show the lingual surface of the epiglottis. Insufflation of patients the cheeks used to open the pharynx in some andmay allowbevisualization of the hypopharynx. Alternatively, left and right head turn usually allows inspection of the contralateral piriform sinus—sometimes to the apex.

Posterior pharyngeal wall

True vocal folds Piriform sinus

Epiglottis

Base of tongue

FIGURE 2-4.  2-4.  View of larynx through flexible fiberoptic laryngoscope.

Flexible scopes are available to the operator in several different sizes by diameter of tip cross section, allowing more patient comfort, pediatric examination, and suction or biopsy channel. The pediatric scope is 1.5 mm, the adult flexible scopes are 3.6 mm, and the channeled scope is 6.1 mm in diameter. The video scope with “chip in tip” is 3.9 mm, and other scopes have a tip diameter of 3.2 mm. Decision on which scopes fit the internal anatomy is achieved actively during the procedure. RHMaisel