Stefanescu D 8 16 [631618]

http://www.revistadechimie.ro REV.CHIM.(Bucharest) ♦67♦No. 8 ♦2016 1558Methilene Blue Video Contact Endoscopy Enhancing Methods
DRAGOS CRISTIAN STEFANESCU1, OCTAVIAN CEACHIR2,3, VIOREL ZAINEA2,3, MURA HAINAROSIE2,
CATALINA PIETROSANU2*, IRINA GABRIELA IONITA2, RAZVAN HAINAROSIE2,3
1 Gen. Dr. Aviator Victor Anastasiu Institute of Aeronautical and Spatial Medicine, 88 Mircea Vulcanescu Str., Bucharest, Romania
2 Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., Bucharest, Romania
3 Prof. Dr. D. Hociota Institute of Phonoaudiology and Functional ENT Surgery, 21 Mihail Cioranu Str., Bucharest, Romania
Video contact endoscopy is not a new method. It was imagined by the gynecologist Hamou in the ‘70s, who
performed contact microcolposcopy. Because the development of medical optic was at it’s beginnings, the
methods was abandoned. In the year 1994 Professors Mario Andreea and Oscar Diaz started working with
Karl Storz company and applied the method at the level of the vocal folds. For nearly 20 years from the first
use of videocontact endoscopy no further developments of this technique were achieved in order to improve
the results. The aim of this article is to propose a new protocol meant to enhance videocontact endoscopy
value. In order to critically evaluate the proposed method, an analysis of the results will be performed.
Keywords: methylene blue, vocal fold carcinoma, contact endoscopy, narrow band imaging
* email: [anonimizat]; Tel:(+40)723627405Laryngeal cancer represents approximately 40% of the
head and neck cancers. Romania is on the 5th place in
Europe after Hungary, Serbia, Republic of Moldavia andMontenegro from the point of view of the incidence of the
disease (6.8:100.000 people) and on the 6th places for the
mortality (4.1:100.000), according to the 2012 data of TheInternational Agency for Research on Cancer funded by
The World Health Organization.
According to the same organization, the incidence of
laryngeal cancer for men is 14.1:100.000 people and in
women 0.5:100.000 people. The mortality for men is
8.6:100.000 people and 0.4:100.000 people in the womenpopulation.
The main symptom of the laryngeal cancer is
dysphonia. The gold standard for examining the larynx isflexible transnasal endoscopy. The larynx can be thoroughly
evaluated with white light. Starting two years ago, a new
evaluation technique of the larynx was introduced and theexamination is performed using narrow band light [1,2].
The development of HDTV (high definition TV) optical
chips provides the surgeon with crystal clear high resolutionimages that improved the diagnostic of the lesions located
on the vocal fold [3].
Methylene blue video contact endoscopy was imagined
in order to detect premalignant and malignant lesions
during suspended microlaryngoscopy [4]. The application
for the vocal fold of methylene blue video contactendoscopy was developed by Professors Mario Andreea
and Oscar Diaz [5,6] in colaboration with Karl Storz
company. The contact endoscopy rod has a 0 focal lengthendoscope and the magnification used was of 60X and
150X.
From the start the authors wanted to visualize and detect
the modifications of the cellular field from the superficial
layer of the vocal fold, aiming to obtain quickly important
information concerning the premalignant or malignantlesion of the vocal fold [7].
The parameters of the cellular field that were first
evaluated were the uniformity of the cellular field, the ratiobetween the nucleus and the cytoplasm, the size and the
shape of the cells.
New developments of this technique claim that the
evaluation of the vascular field of the superficial network
will provide the surgeon more information than the cellularfield, having in mind that a 1 mm tumor will start to produce
vascular growth factor and the vascular network
surrounding the tumor will develop abnormally.
We propose a new optical method to enhance the results
of the methylene blue video contact endoscopy of the vocal
fold. This method that we propose is the use of narrow
band imaging technology associated with video contactendoscopy in order to better define and to amplify the
obtained images [8].
Narrow band imaging is a technology developed by
Olympus company that uses an optical filter over the white
light. The NBI (narrow band imaging) light will allow only
two wave length to pass, 440 to 460 nm and 540 to 560nm. Due to the fact that these wave lengths are highly
absorbed by the hemoglobin from the capillaries and the
veins of the superficial vascular network, these will appearcolored in blue and dark brown. In this manner we will
amplify the contrast of the vascular network.
Experimental part
We conducted this study in two medical centers, The
Institute of Phonoaudiology and Functional ENT SurgeryProf. Dr. Dorin Hociota and The Institute of Aeronautical
and Spatial Medicine Gen. Dr. Aviator Victor Anastasiu.
We enrolled in our study 15 patients with suspicion of
premalignant or malignant lesions of the vocal fold . The
age of the patients was between 36 and 62 year old. The
patients group consisted of 12 males and 3 females.
The patients were enrolled in the study after performing
transnasal flexible endoscopy using white light and narrow
band imaging light.
The surgery was performed under general anesthesia
with oral intubation. The laryngoscopy metallic tube with
triangular section was inserted trans orally and the glottisplan was exposed.
Methylene blue video contact endoscopy was performed
using normal light and narrow band imaging light,respecting the following protocol.
The focal fold was cleaned with a sponge with saline
solution and then 1% acetic acid. The vocal fold was stainedwith methylene blue 1% with the sponge and a time of 5
min was used in order for the methylene blue to adhere to
the vocal fold mucosa. A rigid laryngeal 0 degree

REV.CHIM.(Bucharest) ♦67♦No. 8 ♦2016 http://www.revistadechimie.ro 1559
Table 1
RESULTS AFTER COMPARING
VIDEOCONTACT ENDOSCOPY USING
WHITE LIGHT AND NBI LIGHT WITH
THE HISTOPATHOLOGICAL RESULTS.
Fig. 3. Video contact endoscopy image of
the vocal fold 60X magnification using
narrow band imaging light.
Fig.1. Chemical formula of methilene
blue.
Fig. 2. Video contact endoscopy image of the
vocal fold 60X magnification using white light.
endoscope was used to explore the vocal fold using white
and NBI light.
The video contact 0 degree laryngeal endoscope 60X
magnification was applied on the vocal fold surface and
the white light was used to expose the cellular field. Both
cellular field and vascular network were analyzed, usingalso the narrow band imaging light, and the results were
interpreted.
We observed an important amplification of the contrast
of the cellular field and of the vascular network. The images
were analyzed and then interpreted. Targeted biopsies were
performed and the specimens were send to thehistopahological department.
We centralized the data and we compared the results
obtained during video contact endoscopy with white light,NBI light and the biopsy paraffin results.
Results and discussions
The results obtained after comparison of the contact
endoscopy technique using white light, NBI light and the
histopathological result are as shown in the table (table 1).
The results concluded that the methylene blue video
contact endoscopy method will provide the surgeon with
more information when used in conjunction with NBI(narrow band imaging) light. Specificity, sensitivity and
accuracy of the methylene blue method are improved when
NBI light is used.
The paraffin histological result still remains the gold
standard for the histopathological diagnosis of the vocal
fold lesions.
The subjet concerning metilene blue was walso studied
in [9,10].
Conclusions
The methylene blue video contact endoscopy remains
an easy to use, minimal invasive and cheap test to analyzethe premalignant and malignant lesions of the vocal fold.
Still, during more than 10 years since we have started
using this method, we have observed an important learningcurve of about 5 years for visualizing and interpreting the
obtained images. The ENT surgeon must acquire the
necessary experience in order to properly evaluate theresults offered by this method.Narrow Band Imaging tends to become the new
standard for visualizing the vocal fold during flexibleendoscopic exam and also during rigid endoscopic exam
in suspended laryngoscopy. If the surgical centers have
the NBI technology to investigate the patients, it can beeasily used in the operation room as well.
The enhanced NBI methylene blue contact endoscopy
will offer better results than conventional contactendoscopy, but the paraffin histopathological exam still
remains the absolute exam in assessing the nature of the
vocal fold lesions.
The costs of instruments involved in the enhanced NBI
methylene blue contact endoscopy are quite high, but the
necessary technology is available in more and morecenters in our days, so the surgeon will just have to combine
the two available technologies.
Acknowledgement. All authors have contributed equally to this paper.
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Manuscript received: 28.05.2016