This document describes contact endoscopy (CE), a non-invasive optical technique that uses a magnifying endoscope to provide real-time visualization and examination of the cellular architecture and vascular patterns of mucosal tissues. CE allows in vivo assessment of precancerous and cancerous lesions without biopsy. Several contact endoscope models from Karl Storz are described. The document outlines CE's applications in examining various head and neck tissues and its ability to detect abnormalities. The benefits of CE include its non-invasive nature, ability to examine large areas quickly, and provision of immediate results.
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Contact and Compact Endoscopy in ENT
1.
2.
3. Non Invasive Optical technique
Real time visualisation
In situ examination of
Pattern of vascularisation
Cellular architecture of the superficial
layers of the mucosa.
4. Hamou, 1979
Cervical & Uterine epithelial cells.
Andrea et al, 1990
Pathologies of larynx
5. Magnified images -Hopkins’ rod-lens
endoscope placed on the surface of the dye
stained mucosal tissue.
Allows assessment of precancerous and
cancerous lesions in vivo
Has significant potential in the
histopathologic diagnosis of many suspicious
head and neck mucosal lesions without tissue
biopsy.
11. magnifying endoscope 0° placed in contact
against the mucosal surface,
Documented magnified cytological images (at
60x or 150x) are recorded
Vascular patterns were studied without
staining as the stain prevents penetration of
light into submucosal plane where the blood
vessels lie.
12. Staining of the superficial cells of the mucosa
with a contrast dye, 1% methylene blue
13.
14. homogeneousness of distribution of cells
number of cells per field
uniformity of nucleus
staining, hyperchromatism, nuclear cytoplasmic
ratio,
Nuclear & cellular pleomorphism, prominent
nucleoli, presence of mitotic figures
pattern of distribution, branching & coiling of
blood vessels.
rate of flow of RBCs inside the blood vessels seen
on CE of unstained lesion.
16. For Oral Cavity & other accessible areas
can be used in outpatient dept
Laryngeal Mucosa
passage of CE through a suspension
laryngoscope under Anaesthesia.
17. Done under GA
Transition from ciliated to squamous
epithelium can be observed.
18. Abnormality
Metaplastic substitution of ciliated epithelium
by squamous in chronic smokers,GERD
patients.
Chronic laryngitis- epithelial cells have larger
nuclei than normal & an increased
nuclear:cytoplasmic ratio.
19. Keratosis detected easily- different stages of
keratinization can be seen.
Leukoplakia- heterogeneity of cell populations
with nuclei of different colour,size & shape.
20. Carcinoma- extreme heterogeneity of nuclear
size, shape & staining characteristics.
Enables assessment of transitional zone
between normal & abnormal mucosa
-a better evaluation of early stage disease.
Laryngeal papillomata assessment &
management- Typical vascular loops in the
core of pappillomata.also koilocytes.
21.
22.
23.
24. Normal-
Squamous epithelium-anterior tip & inferior
border of Inferior turbinate, septum & nasal
vestibule.
Ciliated epithelium- most of nasal cavity.
Duct orifices of the gland –most prominent at
the anterior end of turbinate.
Microvascular network
26. Chronic Rhinitis
Squamous epithelium covers most of inferior &
middle turbinate, anterior septum.
Area of keratosis predominate in the parts
exposed to turbulent air flow.
Overproduction of mucus.
27. Allergic Rhintis
Papillae of glands larger than normal.
ciliated epithelium preserved.
Nasal Polyps
Anterior surface covered by squamous
epithelium while rest ciliated cells.
Can detect metaplastic changes.
28. Normal
Oral mucosa morphology varies from site to site
Masticatory mucosa covering hard palate &
gingiva is keratinised epithelium
Transition from keratinised epithelium in lip to
non keratinised epithelium of vestibule.
29. Abnormality
Diagnosis of early cancer
Study of tumourmargins
Assessment of response to radiotherapy
& Chemotherapy
30.
31.
32. Used in
Long term followup of patients treated for
Nasopharyngeal Carcinoma.
33. Normally
Squamous epithelium in central & inferior part
of posterior wall.
Orifices of glandular duct throughout nose.
35. Non invasive, simple, quick, repeatable, in
vivo examination of cellular architecture and
vascular pattern of mucosa.
36. Large and multiple areas examined quickly & in the
same sitting.
Avoids tissue damage and changes in cells which
can occur due to biopsy and processing of tissue for
histopathological examination. Suspicious lesions
thus can be followed up serially.
Can help in deciding precise site for taking biopsy
by identifying areas of cellular atypia which may
improve the yield of biopsy.
37. Can help in deciding margins of resection
during tumour removal by differentiating
tumour.
Results are known immediately.
Can be employed both in out patient
department and operation theatre.
38. Can be combined with other techniques like
autofluorescence (Compact Endoscopy).
Video and still images can be stored and
reviewed as many time as necessary
39. Inability to detect very early dysplasia
differentiation of 'carcinoma in situ' from
'invasive carcinoma'.
40. Accuracy & clinical applicability of contact
endoscopes will continue to improve by
- improvements in optical system, new cell
dyes, markers,fluorescent products,light
sources,image processing & better recording
techniques.
Enable CE findings to be instrumental in
deciding the treatment modality both pre
operatively as well as during surgery.
42. In autofluorescence endoscopy, an emission
spectrum fixed wavelength(375 to 440 nm), &
autofluorescence is measured in green spectrum
between 470 and 800 nm.
Appearance & degree of autofluorescence depend
on structure of the examined tissue, mainly
content of fluorophores.
43. Normal mucosa -bright green autofluorescence
*translucent elastic fibers in the lamina propria.
Significant decrease in fluorescence intensity - in
areas with dysplastic & cancerous changes
After visualization of the dysplastic or cancerous
hot spots by autofluorescence, contact endoscopy
was performed.
44.
45. Compact endoscopy
- useful method in the detection and
delineation of Precancerous
& Cancerous lesions.
-complementary tool supplementing
Microlaryngoscopy.
Editor's Notes
Contact Endoscopy is essentially a noninvasive,
optical technique of visualisation which helps real time and in situ examination of the pattern of vascularisation as well as cellular
architecture of the superficial layers of the mucosa
1865 by desormeaux who obtained a direct view of bladder mucosa.
CE was originally described and used by Hamou in 1979 as a technique for visualization of cervical and uterine epithelial cells for screening and diagnosis of cervical and uterine pathology
The first reported use of CE in otolaryngology head and neck surgery was by Andrea et al. as a diagnostic tool in the evaluation of various pathologies in the larynx in the 1990s
Magnified images are obtained using Hopkins’ rod-lens endoscope placed on the surface of the dye stained mucosal tissue. This technique allows assessment of precancerous and cancerous lesions in vivo and has significant potential in the histopathologic diagnosis of many suspicious head and neck mucosal lesions without tissue biopsy.
Current contact microlaryngoscopes come in a variety of lengths, diameters and viewing angles.
Straight forward (O°) and Forward-Oblique telescopes (30°) are also available,
& all are capable of 1x, 60x, and 150x magnification.
These endoscopes require a high intensity xenon light source,& images can be digitally captured for real-time photographic and video documentation
After sucking out the secretions
and wiping off saliva, a zero degree contact endoscope
O degree & 30 degree endoscope
Close up view.
Top- Zero Degree scope Bottom 30 degree scope
documented magnified cytological images (at 60x or 150x) are recorded
Thereafter, the lesion was stained by placing cottonoids soaked in 1% Methylene blue against it for five minutes
Stained area was then studied by repeating the procedure mentioned above.
Cellular architecture was now seen clearly- nuclei appearing as dark blue structures while cytoplasm was light blue
Both a cytopathologist and an otolaryngologist can then assess these images, comparable to histology
Evaluuation of laryngeal mucosa
Smokers Gerd- interferes with normal mucus clearance.
1) CE image of blood vessels on normal vocal cords: Blood vessels are parallel to long axis of vocal cord; bifurcations and anastomoses are few
2) blood vessels in early laryngeal cancer: Increased number of blood vessels with increase in bifurcations and anastomoses. Decreased parallelity with long axis of vocal cord is also seen
CE image of blood vessels in advanced laryngeal cancer: Complete loss of parallelity, extensive anastomoses leading to formation of vascular loops
normal vocal cord: Homogenous cells with uniform size and shape,
N:C ratio uniform & less than 1, nuclei of uniform size & shape, no hyperchromatism or mitotic figures
SQ CA: Increased number of cells per field, non homogenous distribution,
size & shape of cells, nucleus shape & size varying in the same field, nuclei more darkly stained & larger in size,
N:C ratio of more than one (arrow), mitotic figures present
Vascular patterns seen on CE of unstained lesions.
A: Normal blood vessels in cheek. Minimal branching. No coiling or micro haemorrhages.Brisk Flow of RBCs inside the vessels.
B: Numerous tufts of vessels seen in lichen planus.
C: Numerous dilated blood vessels in erythroplakia
D: Blood vessels in malignant lesion showed coiling, micro haemorrhages & increased tortuosity of vessels. Flow of RBCs inside the vessels was sluggish.
A: CE image of normal cheek.Note the uniform pattern of cells and nuclei. Uniform Nuclear cytoplasmic ratio & less than one. No mitotic figure.
B: Corresponding HPE image.Reactive changes with mild keratinisation is seen.
C: CE image of leukoplakia of cheek. Cells uniform with normal N:C ratio. Acellular areas of keratin deposition present.
D: Corresponding HPE image Reactive changes with acanthosis, keratinisation and inflammation in submucosa seen.
Acanthosis –thickening of skin
Anisokaryosis-size of nucleus varies
Large and multiple areas examined quickly & in the same sitting as compared to limited areas assessed by biopsy
Can help in deciding precise site for taking biopsy by identifying areas of cellular atypia which may improve the yield of biopsy.
Can help in deciding margins of resection during tumour removal by differentiating tumour areas from normal mucosa.
Early dysplasia first appears in the cells near basement
membrane which are not seen on CE as the light as well as dye are unable to penetrate deeper than few superficial layers
of the mucosa.
invasive carcinoma is differentiated from carcinoma in situ by angioinvasion/neoangiogenesis at the
level of basement membrane which may not be picked up by CE
Inautofluorescence endoscopy, an emission spectrum is produced with a fixed excitation wavelength(375 to 440 nm), the autofluorescence is measured
in the green spectrum between 470 and 800 nm.
appearance & degree of autofluorescence depend on the structure of the examined tissue, especially the content of fluorophores,
Fluorophores are predominantly proteins, eg, elastin and keratin, as well as NADH.
Normal mucosa shows a bright green
autofluorescence because of the translucent elastic
fibers in the lamina propria. A significant decrease
in fluorescence intensity is observed in areas with dysplastic
and cancerous changes as a result of changes
in tissue structure and metabolism.
After visualization of the dysplastic or cancerous
hot spots by autofluorescence, contact endoscopy was
performed.
Microinvasive carcinoma. A)Microlaryngoscopic view-tumorous bulging of right vocal fold with hyperkeratosis at medial aspect. Histologic examination found microinvasive carcinoma.
B) Autofluorescence endoscopy presents reddish violet signal of entire right vocal fold. Left vocal fold & both ventricular folds show normal green fluorescence.
C) Contact endoscopy demonstrates irregular cell distribution with extreme heterogeneity. Increased nuclear density & dyschromia. dyskaryosis,
& changes in nuclei-to-cytoplasm ratio are visible.