ENDOSCOPES IN OMFS

Presenter :- Guide :-
Dr Anant Kahare Dr Ramakrishna Shenoi
Junior Resident (Guide, Professor and HOD)
OMFS Department of OMFS
CONTENTS
 Introduction
 History
 General endoscopic principals
 Endoscopic Armamentarium
 Types of Endoscopes
 General concepts
 Advantages
 Disadvantages
 Applications in OMFS
 Conclusion
 INTRODUCTION

Endoscopy can be broadly defined as the ability to

visualize internal structures within the body using an
illuminated, navigable instrument called an endoscope
which can be introduced via a natural orifice or surgical
incision.

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
 HISTORY OF ENDOSCOPE

In 1806, Phillipp Bozzini first developed internally lit endoscope;

termed as “Lichtleiter”(light conductor).

The term Endoscope was coined by Antonin Jean Desormeaux in

1853; he used it in urological surgery.

First Arthroscopy was of knee and done by Dr. Eugen Bircher in

1921.

The first application of endoscopic surgery in OMFS was done by

a Japanese surgeon Masatoshi Onishi who was first to conduct Lichtleite
temporomandibular joint (TMJ) arthroscopy using an r
arthroscope developed by Masaki Watanabe who was a
Japanese orthopedic surgeon.
Mohamed A. Hakim, Joseph P. McCain, David Y. Ahn, Maria J. Troulis, Minimally Invasive Endoscopic Oral and Maxillofacial Surgery, OCNA, Volume 31, Issue 4,
2019, Pages 561-567
 GENERAL ENDOSCOPIC PRINCIPALS
Surgical education and documentation: As an instrument for
teaching, endoscopically assisted surgery allows trainee surgeons
to easily and directly visualize the operation on the monitor. The
teaching surgeons are enabled to clearly describe the procedure in
real time, while also are able to easily capture images that can be
later used for subsequent education and research.

Patient recovery and surgical safety outcomes: Patient

outcome studies evaluating endoscopic surgical procedures have
demonstrated reduced patient morbidity, shorter hospital
admission times, and expedited healing and recovery with return to
normal function when compared with standard open surgical
techniques.

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
 ENDOSCOPIC ARMAMENTARIUM

The components of the endoscopic

equipment setup include
• Endoscopy tower
• Camera
• Light source
• Video processor
• Monitor
• Endoscopic coupler
• Endoscope itself

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral
and maxillofacial surgery. Front Oral Maxillofac Med 2023;5:17.
 TYPES OF ENDOSCOPES

According to functions of the endoscope

• Single-function endoscope: A single-function endoscope

refers to an observation mirror that only has an optical system
with it.
• Multi-function endoscope: For a multi-functional endoscope,
in addition to the function of observation, it also has at least
one working channel like lighting, surgery, flushing and other
functions.

Source: Wikipedia
 According to rigidity of the endoscope

• Flexible endoscopes: are utilized for

procedures such as laryngoscopy and
gastrointestinal endoscopy.
• Rigid endoscopes: are the most commonly
used scope in maxillofacial endoscopic surgery,
and are used in arthroscopy, sinuscopy and
rhinoscopy.
• Semirigid endoscopes: are commonly used in
sialoendoscopy.

Hakim MA, McCain JP, Ahn DY, et al. Minimally Invasive Endoscopic Oral and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am
2019;31:561-7.
 GENERAL CONCEPTS OF ENDOSCOPES

The optical characteristics of the

endoscope include :

• The field of view: the angle

measured at the tip of the endoscope
to two points at the extreme diameter
of the viewed field.
• The direction of view: the angle
between the mechanical axis and the
center of the field of view.
Endoscopes most commonly utilized
in head and neck endoscopy are 0°,
10°, 30°, 45°, and 70°.

Hakim MA, McCain JP, Ahn DY, et al. Minimally Invasive Endoscopic Oral and
Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2019;31:561-7.
 ADVANTAGES OF ENDOSCOPES
Minimally invasive approach: requires only small incisions or natural opening
which results in reduced tissue trauma as compared to open surgeries leading
to better cosmetic outcomes.

Enhanced visualization and precision: High-definition cameras provide superior

magnified views of deep anatomical structures thus improves accuracy in
complex surgical procedures.

Reduced postoperative complications: Less risk of infections due to smaller

surgical wounds, Lower chances of excessive bleeding and nerve damage,
Minimizes postoperative swelling and pain.

Faster recovery and shorter hospital stay.

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
 DISADVANTAGES OF ENDOSCOPES
High Initial Cost and Equipment Requirements

Steep Learning Curve and Technical Expertise

Limited Field of View and Depth Perception: Although endoscopes provide

magnified views, depth perception is reduced compared to direct vision.

Restricted Instrument Mobility: Endoscopic instruments are long and narrow,

which limits movement in small surgical spaces. Reduced maneuverability can make
procedures like fracture fixation or tumor resection more challenging.

Limited Use in Complex Cases: Severe facial fractures, large tumors, or deep
infections may still require open surgery.

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
 APPLICATIONS OF ENDOSCOPES IN OMFS
Orbital floor reconstruction Sialoendoscopy

Sub-condylar fractures
TMJ arthroscopy

Angle and body fractures of mandible

Eminectomy
Frontal sinus fractures

TMJ total joint replacement

Removal of foreign bodies/sinuscopy

Orthognathic surgical applications Coronoidectomy

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
 ORBITAL FLOOR FRACTURES

Reconstruction of an orbital fracture via a combination of trans-antral and subtarsal approaches. (A)
Illustration of the orbital floor fracture with herniation of orbital contents into the maxillary sinus. (B)
Removal of bony fragments with endoscopic instrumentation. (C) Confirmation of position of the orbital
implant with an endoscope

Approach - Trans-antral only approach or in combination with the open approach.

The benefits of the endoscopic approach - improved visualization, reduction in the

surgical insult and inflammatory response to the tissues of the surrounding area.
Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
ORBITAL FLOOR FRACTURES
Intraoral maxillary vestibular incision.
Creation of bony window in anterolateral wall of
sinus.
Insertion of endoscope.
Visualization of defect and prolapsed contents.
Roof of sinus is de-mucosalized.
Reduction of orbital contents.
Insertion of implant.

For trans-oral approach – bony window, if

preserved, secured back in position.
Closure.
 SUB-CONDYLAR FRACTURE

Approaches - intraoral incision

or a trans-cervical incision

Benefits- reduced risk of injury

to marginal mandibular branch
of facial nerve. Endoscopic-assisted ORIF of left subcondylar fracture. (A)
Visualization and reduction of left subcondylar fracture via a
trans-cervical approach. (B) Placement and confirmation of left
subcondylar hardware.

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
SUB-CONDYLAR FRACTURE FIXATION
Lateral vestibular
incision or trans-
cervical incision
given.

Sub-periosteal
dissection over
lateral mandibular
ramus.

Insertion of
endoscope in
subperiosteal optical
cavity.

Reduction and
fixation of fracture.

Closure.
 ANGLE AND BODY FRACTURES OF MANDIBLE
Lateral vestibular
incision or trans-
cervical incision
given.

Sub-periosteal
dissection over
lateral mandibular
ramus.

Insertion of
endoscope in
subperiosteal optical
cavity.
Endoscopic-assisted ORIF of right mandibular angle
fracture. (C) Visualization and reduction of right
mandibular angle fracture. (D) The use of an endoscope Reduction and
fixation of fracture.
facilitates placement of right mandibular angle hardware.
ORIF, open reduction and internal fixation.

Closure.

Fanelli CA, Vera LC, Ahn DY, McCain JP. A review of endoscopic surgical applications in oral and maxillofacial surgery. Front Oral
Maxillofac Med 2023;5:17.
REMOVAL OF FOREIGN BODIES/SINUSCOPY
The endoscope can provide a very useful
diagnostic and operative aid in locating and
removing foreign bodies that are dislodged
into the maxillary sinus.

The sinus, given it is hollow bony

architecture, is a natural optical cavity.

The endoscope is also used commonly to

assist in conducting a Caldwell Luc approach
and/or sinuscopy when the anterior wall of
the antrum is fractured due to trauma to
remove intruded teeth or a foreign
body/debris.
 SIALOENDOSCOPY
Sialoendoscopy is a nuanced technique of transluminal management of
obstructive and nonneoplastic pathology of the major salivary glands.

Indications:
• Sialolithiasis: Sialoliths between 4 and 5 mm
diameter are amenable to sialoendoscopy.
• Stenosis.
• Mucous plugs.
• Foreign bodies and polyps.

Chandra SR. Sialoendoscopy: Review and Nuances of Technique. J Maxillofac Oral Surg. 2019
 ALGORITHMS IN DECISION MAKING

Chandra SR. Sialoendoscopy: Review and Nuances of Technique. J Maxillofac Oral Surg. 2019
 SIALOENDOSCOPY EQUIPMENT
 Diagnostic scopes (0.8 mm, 1.0 mm, 1.3 mm diameter).
 Operative scopes.
 Cold lighting source.
 Video camera.
 Monitor—wheel-mounted or wall-mounted system.
 Irrigation system—most simple is a 20-mL syringe filled with saline
attached by intravenous catheter.
 Wire basket—for extirpation of stones and foreign bodies.
 Grasping forceps.
 Balloons—intraluminal dilators.
 Laser—fragmentation and incisions.
 Microdrills—fragmentation of sialoliths.
Chandra SR. Sialoendoscopy: Review and Nuances of Technique. J Maxillofac Oral Surg. 2019
 LITHOTRIPSY, LASERS AND
COMBINED APPROACHES

Stones more than 4 mm diameter and spiculated calcified

stones are difficult to remove with sialoendoscopy alone.

Other than mechanical microdrills extracorporeal shock wave

lithotripsy (ESWL) and intracorporeal lasers are utilized to
fragment the mineralized sialoliths. Ho/YAG laser at pulsed
setting with a 2080 nm wavelength carried in a fiber diameter
as small as 200 micrometers is well documented.

Picture of retrieved stones with

Intracorporeal lithotripsy by shockwave is known to cause sialoendoscopy and fragmentation.
ductal damage.

Chandra SR. Sialoendoscopy: Review and Nuances of Technique. J Maxillofac Oral Surg. 2019
 SIALOENDOSCOPY
The procedure starts with cannulation of the duct using
dilating probes.

The endoscope is introduced in the duct along with

irrigation to flush out debris.

If visualized, an obstruction may be retrieved or

instrumented using a basket, clasp, Fogarty catheter,
or holmium laser (HL) for laser lithotripsy.

A 2-mm polyethylene stent is placed into the duct and

sutured into place for 4 weeks postoperatively to help Stone retrieval basket with stone
prevent ductal stenosis.

Chandra SR. Sialoendoscopy: Review and Nuances of Technique. J Maxillofac Oral Surg. 2019
SIALOENDOSCOPY
 CONTRAINDICATIONS

The only definitive contraindication of sialoendoscopy is active

inflammatory or suppurative salivary gland disease.

Skill level and access to specialized instrumentation is a relative

consideration too.

Patients with severe trismus and poor access to endoscopic

technique are certainly limitations for these procedures.

Chandra SR. Sialoendoscopy: Review and Nuances of Technique. J Maxillofac Oral Surg. 2019
 TMJ ARTHROSCOPY

Arthroscopy of the TMJ allows for minimally invasive diagnosis and

surgical management of intra-articular disorders.

The arthroscope most commonly employed for this procedure is small—

ranging from 1.2–2.4 mm in size; rigid; and, is commonly angled with a
30° field of view.
Levels of operative sophistication and complexity exist in TMJ
arthroscopy which denotes the type of intra-articular procedures that
can be conducted. These levels of TMJ arthroscopic surgery can be
classified utilizing the McCain Classification.

Mohamed A. Hakim, Joseph P. McCain, David Y. Ahn, Maria J. Troulis, Minimally Invasive Endoscopic Oral and Maxillofacial Surgery,
OCNA, Volume 31, Issue 4, 2019, Pages 561-567
 Level I: single-puncture Level II: a second puncture Level III: arthroscopic
arthroscopic portal into the is conducted, consisting of articular disc reduction and
posterior recess of the an operative cannula (OC). fixation (discopexy). This
superior joint space of the The importance of portal includes conducting a
TMJ, in conjunction with an placement is paramount to myotomy of the superior
outflow needle. This the success of intra articular belly of the lateral pterygoid
facilitates arthroscopic arthroscopic surgery. The OC (SBLP) muscle attachment
arthrocentesis, which allows is introduced into the joint onto an anteriorly displaced
for lysis and lavage along within the anterior recess. articular disc, disc reduction,
with diagnostic visualization Image: Level II arthroscopic contracture of RDTs, and
and examination of intra- TMJ surgery demonstrating fixation of the articular disc.
articular anatomical obtaining a synovial biopsy
structures utilizing the utilizing the Ergo forceps.
arthroscope.

Mohamed A. Hakim, Joseph P. McCain, David Y. Ahn, Maria J. Troulis, Minimally Invasive Endoscopic Oral and Maxillofacial Surgery,
OCNA, Volume 31, Issue 4, 2019, Pages 561-567
LEVEL III ARTHROSCOPIC DISCOPEXY
 CONCLUSION
The incorporation of endoscopy into oral and maxillofacial surgical
procedures has enhanced our diagnostic and surgical capabilities
and skillset in the care of patients.

Oral and maxillofacial surgeons continue to implement and

discover novel applications for endoscopically assisted and
facilitated maxillofacial surgical procedures.
Decreased complication rates, comparable success rates, diverse
functionality, and efficiency render the endoscope an
indispensable instrument in the modern surgeon’s
armamentarium.
THANKYOU