The method of microlaryngoscopic surgery is associated with the method of direct, speculum-free examination of the larynx developed by A. Kirstein in 1895. This method of direct laryngeal examination significantly expanded the diagnostic capabilities of laryngeal pathology and formed the basis for later, minimally invasive endoscopic surgical techniques, opening up a wide range of new possibilities for surgical interventions within the larynx using microsurgical techniques and microsurgical instrumentation (O. Kleinsasser). This method is still commonly referred to as endolaryngeal microsurgery. Meanwhile, in 1861, K.A. Rauchfuss performed the world's first thyroidectomy to remove a laryngeal tumor. He effectively applied endolaryngeal surgery through an external approach. With the addition of a microscope, this method could also be called endolaryngeal microsurgery. Modern endoscopic microsurgery is used in virtually all surgical specialties and has a common name: endoscopic microsurgery. This term should also be applied to endoscopic microsurgery of the larynx, similar to "endoscopic microsurgery of the nose and paranasal sinuses," "endoscopic surgery of the gallbladder, stomach," and so on. Since the surgical microscope became universally used in conjunction with a laryngoscope, which was fixed with a self-retaining suspended or supporting apparatus, the use of microsurgery and laser surgery of the larynx has become possible. The development of endoscopic microsurgery is undoubtedly associated with the name of Professor Dr. Oskar Kleinsasser, currently Director of the Otorhinolaryngology Hospital of the Philipps University of Marburg. His achievement lies in the development of entirely new microsurgical instruments, combining them into kits for specific surgical procedures, and the detailed development of techniques for many microsurgical interventions on the larynx. These include, first and foremost, operations on the sensitive anatomical structures of the larynx for the purpose of correcting or restoring voice function, now collectively known as "phonosurgery." Extensive microsurgical interventions under endoscopic guidance for tumor resection, treatment of laryngeal paralysis, cicatricial stenosis, and congenital malformations of the larynx, including the use of laser microsurgery, have also become possible. Microlaryngoscopy and endoscopic microlaryngosurgery require a thorough understanding of the age-related anatomy and physiology of not only the larynx but also the anatomy and physiology of the pharynx, esophagus, and trachea. A clear understanding of the treatment methods employed is essential, and specific practical skills and experience are required for the successful and safe application of this method. We fully agree with the authors who believe that these examinations and surgeries are not as easy to perform as inexperienced physicians often assume. Therefore, the incidence of laryngeal injuries due to incorrect or unjustified interventions is unfortunately quite high. How to prepare for endoscopic microsurgical interventions on the larynx? Microsurgical interventions should not be undertaken without the assistance of an experienced mentor, even if all the necessary equipment and microinstruments are available. The use of modern diagnostic equipment is quite accessible and feasible for a sufficiently experienced specialist. Currently, three stages are distinguished for laryngeal examination: - Stage one - an initial examination using mirror indirect laryngoscopy; - Stage two - a more detailed assessment of the larynx with a rigid telescope for image magnification, which allows preparation for a detailed examination; - In the third stage, the examination is performed using a microsurgical microscope or laser surgery. A three-stage study of laryngeal pathology and its extent is mandatory before endoscopic microsurgery. This staged examination should be performed in all age groups of children and adults. Any endoscopic examination of the larynx should always begin with indirect laryngoscopy. In modern practical medicine, an otolaryngologist uses three methods of indirect laryngoscopy: 1. mirror laryngoscopy using a laryngeal mirror; 2. a rigid laryngo-pharyngo-telescope with a viewing angle of 70°, 90°; 3. a fiberoptic laryngoscope (soft fiberoptic laryngoscope). For a complete examination, it is desirable to use all three methods. However, in some cases, it is possible to use only one method. For example, in small children, it is often impossible to use mirror laryngoscopy or a rigid laryngo-telescope. In such cases, only fiberoptic laryngoscopy or direct laryngoscopy are used. Fiberoptic laryngoscopy is also used in adults who have a pronounced gag reflex or an insufficiently wide mouth opening that prevents the use of mirror or telelaryngoscopy. Indirect mirror laryngoscopy is considered a routine examination method. It requires a reflector, a light source (lamp), and a laryngeal mirror, which are available in diameters of 18 mm, 20 mm, and 25 mm. The reflector and lamp can be replaced with a single light source fixed to the examiner's head. The advantage of this method is that additional anesthesia is rarely required, visibility is generally good, and the technology is inexpensive. During examination, the laryngeal mirror should be positioned at a 45° angle relative to the axis of the larynx; only then will the larynx be reflected in the mirror. The anterior portions of the larynx (epiglottis, anterior commissure, anterior laryngeal wall) are visible in the upper portion of the mirror, while the posterior portions (posterior laryngeal wall, arytenoid cartilages, interarytenoid space) are visible in the lower portion. During indirect laryngoscopy, the true vocal folds are primarily visible, clearly visible as whitish structures against the pink mucous membrane of the larynx. Below the vocal folds, the subglottic region and the tracheal mucosa are examined, along with the transversely located yellowish tracheal rings. Slightly superior and lateral to the true vocal folds, pinkish folds are visible—the vestibular folds. Between the true and vestibular folds are the laryngeal ventricles, which are usually not visible during indirect laryngoscopy. At the base of the epiglottis, a tubercular thickening—the petiolus epiglottis—is noticeable. During quiet breathing, the glottis is wide open, and the aryepiglottic folds are displaced laterally toward the lateral walls of the hypopharynx, partially obscuring the pyriform sinuses and making them invisible. When producing the "e" sound, the soft palate and uvula rise posteriorly, and the epiglottis approaches the root of the tongue, improving visibility of the larynx. During phonation, the vocal folds move toward each other due to the medial displacement of the arytenoid cartilages and aryepiglottic folds. The rima glottidis closes, and the pyriform sinuses, conversely, open and become visible. During respiration, the vocal folds separate, forming a triangular slit, the apex of which points toward the epiglottis. By asking the patient to alternately breathe and phonate, the vocal folds are examined at rest and during movement, determining their mobility. For a more detailed examination of one or the other wall of the larynx, certain modifications of indirect laryngoscopy are used. For a more thorough examination of the posterior laryngeal wall, indirect laryngoscopy using the Killian method is used. The patient stands with their head tilted slightly forward, and the physician performs the laryngoscopy from below, sitting or kneeling. If a more thorough examination of the anterior commissure and the inner surface of the epiglottis is required, the patient remains seated with their head tilted back slightly, while the physician performs the laryngoscopy standing. Mirror laryngoscopy is the classic method and is performed at the beginning of each laryngeal examination. It can be supplemented by examination of the mirror image through an outpatient or surgical microscope (indirect microlaryngoscopy). Laryngoscopy with a rigid telescope is an expensive, routine method for examining the larynx. In foreign literature, it is known as "loupe laryngoscopy" because it utilizes endoscopes with Hopkins cylindrical lenses, which not only provide excellent illumination of the larynx and laryngopharynx but also produce a magnified image. This method is considered ideal for photographic documentation, and the image can be displayed on a monitor. This type of telescope is also used for stroboscopy. It is ideal for a thorough examination of the root of the tongue, valleculae, laryngeal inlet, and lower pharynx, as well as for examining the vocal folds and their mobility. Fiberoptic laryngoscopy. The fiberoptic laryngoscope is inserted through the nasal cavity, requiring preliminary nasal anesthesia. This method is recommended for use in young children, including infants, for diagnosing dysfunctions. The fiberoptic laryngoscope is constantly being improved; devices with additional channels for biopsy and foreign body removal are available. This method allows for easy visualization of the larynx, determination of vocal fold mobility, and diagnosis of congenital pathologies, including laryngomalacia. However, the image obtained with a fiberoptic scope is not as sharp and clear as with mirror laryngoscopy and telescopy and therefore cannot always be considered reliable for diagnosing minor injuries or early changes. Direct laryngoscopy (laringoscopia directa). B. Benyamin identified three stages of direct laryngoscopy under anesthesia, which are used worldwide. 1. Direct laryngoscopy with manual fixation of the laryngoscope. At this stage, an endoscopic examination of the larynx is usually performed without the use of technical devices for fixing the laryngoscope. At this stage of the examination, it is possible to additionally use a telescopic endoscope for a more detailed examination. 2. Suspension or support laryngoscopy. A detailed assessment of the larynx and lower pharynx is possible using various types of optical telescopes. 3. Microlaryngoscopy. Microsurgical operations on the larynx and laser surgery are possible. The first stage allows for an assessment of the general condition of the larynx and lower pharynx, an evaluation of the laryngeal lumen and the possibility of unimpeded intubation if necessary, as well as the location of possible pathology. The second stage involves a more detailed assessment of the larynx using a rigid telescope for magnification, which prepares for a detailed examination in the third stage using a microsurgical or laser microscope. Rigid rod optical telescopes used for the diagnostic examination in the second stage are very convenient for examining the pharynx, larynx, and trachea under general anesthesia. Angled telescopes help examine anatomical structures of the larynx and pharynx that are not visible with a straight telescope. These telescopes offer high resolution, contrast, and a wide field of view of 30°, 70°, 90°, and 120°. The diameters of these telescopes range from 1.9 to 10 mm, allowing for the examination of anatomical details both in narrow spaces and in hidden areas of the larynx and pharynx. The laryngoscope can be held manually at this stage of the examination, but a support system is more practical, as it frees both hands, allows for endoscopic photography, and transmits images of the identified pathological details to a monitor. In children, the second stage of laryngoscopy allows for its combination with bronchoscopy and esophagoscopy. During the third stage, an operating microscope is used. It allows for microlaryngoscopy, microlaryngovideoscopy, and, most importantly, microlaryngeal surgeries, including laser surgery. The surgical procedure can be videotaped, analyzed, and archived. Video recording is performed using a video camera. However, not all areas of the larynx are easily accessible for examination with microlaryngoscopy. Difficulties may arise when examining the valleculas, pyriform sinuses, anterior commissure, interarytenoid region, and subglottic region of the larynx. A rigid, straight, or angled endoscope is used to examine these anatomical structures. However, during surgical procedures, they obstruct and impede visibility. This task is significantly facilitated by a laryngoscope correctly selected for a specific purpose. The choice of a laryngoscope should be clearly justified. Some recommendations for choosing a laryngoscope model. Today, the medical equipment market offers a wide selection of laryngoscopes for various purposes: 1. For a general image of the larynx and pharynx, it is most suitable to use the LINDHOLM surgical laryngoscope, 15 cm long, 18 mm distal width. Positioned in the vallecula, it provides a panoramic view of the entire laryngopharyngeal surface, ensuring a good view of the epiglottis, arytenoid cartilage area, pyriform sinuses, and subglottic region. The laryngoscope has a wide (24 x 40 mm) proximal end, allowing free manipulation of instruments in the larynx. Pediatric laryngoscopes are 9.5 cm long, with proximal dimensions of 16 x 26 mm. 2. The KLEINSASSER surgical laryngoscope, 18 cm long, is more convenient for working in the vocal fold area. A complete set is available in seven different sizes and lengths of 13, 15, and 18 cm for children and adults. 3. The HOLINGER laryngoscope, 17 cm long, is more convenient for working in the anterior commissure area. 4. The BENYAMIN surgical laryngoscope is most suitable for patients with a hard-to-see larynx and is convenient when working in the subglottic region of the larynx. 5. The WEERDA expanding surgical laryngoscope, 18 cm long, is designed for special operations (cysts, tumors, extended cicatricial stents, etc.). 6. The universal pharyngolaryngoscope with a dental fixation device developed by us allows manipulations from the oral cavity to the lower pharynx and larynx. The most important thing is the correct selection of the laryngoscope model and its size in pediatric practice. In pediatric practice, endoscopic examination of the upper respiratory tract requires close collaboration between the surgeon and anesthesiologist, with the ability to switch between anesthetic modes during surgery, sometimes necessitating intubation. To reduce the risk of anesthesia, trauma to the child's larynx, and ensure optimal visibility of the anatomical parts of the larynx, specially designed instruments and laryngoscopes for pediatric use are essential. Dr. Bruce Benjamin, of Sydney, Australia, has established clear requirements for pediatric laryngoscopes. They must: be manufactured in appropriate sizes for children of all ages, from premature infants (weighing, for example, 1000 g) to older children and adolescents; provide optimal illumination of the object, allowing for both diagnostic examinations and microsurgical procedures in the larynx, pharynx, and tracheobronchial tree; allow for continuous anesthesia and adequate ventilation; and be suitable for both microsurgical procedures and laser surgery. Previously manufactured domestic laryngoscopes and fixation systems from VNIIMT did not meet these requirements. The technical imperfections of laryngoscopic blades of various sizes, the weakness and fragility of the screw-type fixation devices, and poor illumination prevented their widespread adoption by otolaryngologists. For a long time, pediatric laryngeal surgeons used homemade surgical laryngoscopes with straight blades. Сегодня фирмы предлагают широкий выбор специализированных детских хирургических ларингоскопов, которые отвечают всем вышеперечисленным требованиям. Применение некоторых видов подобных ларингоскопов подтверждает высокое качество их изготовления и целесообразность использования их в диагностике и хирургическом лечении детей различных возрастных групп. С нашей точки зрения для универсального применения в детской практике наиболее целесообразно применение комплекта ларингоскопов по Беньямину с щелеобразным боковым отверстием. Комплект состоит из: — ларингоскопа длиной 8,0 см для недоношенных и новорожденных детей, — ларингоскопа длиной 9,5 см для грудных детей, — ларингоскопа длиной 11,0 см для детей более старшего возраста, — ларингоскопа длиной 13,5 см для подростков. Освещение производится с помощью призматического прожектора с возможностью подключения стекловолоконного световода в комплекте с осветителем. Применение уникальной короткодуговой лампы дает резкое уменьшение инфракрасной “тепловой” составляющей, белый свет и равномерное распределение световой энергии по освещенному полю, благодаря чему улучшается цветопередача, исключается перегрев тканей и разрушение световодных жгутов. Ларингоскопы позволяют достаточно хорошо осмотреть валлекулы, переднюю комиссуру, межчерпаловидное пространство, т.е. те анатомические образования, которые трудно обозримы с помощью обычных ларингоскопов. Широкое щелеобразное отверстие в правой боковой стенке ларингоскопов позволяет вводить интубационную трубку, трахеоскоп, бронхоскоп, эзофагоскоп под прямым визуальным контролем. В сочетании с нагрудной опорой они удобны для микрохирургических и лазерно-хирургических вмешательств. Как чисто специально операционный ларингоскоп очень удобным оказался детский ларингоскоп по Беньямину и Парсонсу длиной 15 см, с щелеобразным боковым отверстием. Широкий проксимальный конец ларингоскопа размером 20 х 40 мм позволяет осуществлять стереоскопический осмотр, легко применять микроскоп, упрощает введение инструментов. Два наружных боковых канала предназначены для инсуффляции анестезирующего газа, присоединения стекловолоконного световода или отсасывания паров во время лазерной операции. Другие детские ларингоскопы (ларингоскопы по Парсонсу, по Беньямину и Линдхольму, по Линдхольму, по Холингеру и др.) весьма специализированного прназначения и их применение целесообразно в специализированных центрах. При микроларингоскопических операциях необходимо освободить обе руки от удерживания ларингоскопа. Все перечисленные ларингоскопы снабжены в области рукоятки ларингоскопа специальным устройством для фиксации держателя ларингоскопа (опорная система). Для этой цели применяются два типа опорной системы: 1. Опорная система Riecker-Kleinsasser 2. Опорная система Benyamin-Parsons c металлической платой Опорная система Riecker-Kleinsasser - круговая опора диаметром 7,5 и 9,5 см и длиной удерживателя соответственно 24 и 34 см. Опора фиксируется на груди больного или на специальной стойке, которая крепится к операционному столу (Chest Support Lubeck model). Применение данной опоры не всегда дает устойчивую фиксацию. Так при фиксации опоры на груди больного она затрудняет дыхание, а при фиксации на круговой опорной стойке может соскальзывать с последней. Более устойчива опорная стойка Benyamin-Parsons c металлической платой и латеральными регулирующими фиксаторами. Регулируемый держатель ларингоскопа плотно крепится к операционному столу как единое целое. Его можно поднимать, опускать или наклонять, при этом она не лежит на груди больного и не затрудняет дыхание. Инструменты для микроларингохирургических операций. Существует множество типов и модификаций инструментов различной длины и формы, использующихся для эндоскопической микрохирургии. Длина инструментов может быть от 18 до 23 см. Более короткие инструменты удобны при операциях с большим увеличением и снижают тремор дистального конца во время операции. Однако при операциях с малым увеличением, они могут затруднять обзор операционного поля в связи с некоторым увеличением фокусного расстояния. В этих случаях удобны более длинные инструменты. В последнее время выпускаются инструменты с более усиленной конусообразной рукояткой, поэтому дистальная часть инструментов тонкая и не закрывает обзор операционного поля. Необходимый набор стандартных инструментов для микроопераций на гортани: — ножницы прямые; — ножницы прямые с изгибом вверх на 45° — ножницы изогнутые влево и вправо; — округлые или овальные щипцы с рабочей частью в виде “ложечки” с режущим краем, изогнутые влево, вправо, кверху, диаметр “ложечки” - 1,0; 3,0; 5,0 мм. — специальные щипцы /Bouchayer and Yako/ для захвата и фиксации части или всего края истинной голосовой складки; — захватывающие щипцы прямые; — захватывющие щипцы типа “Аллигатор”; — ларингоскопический нож прямой заостренный; — ларингоскопический нож под углом 45° — ларингоскопический нож изогнутый; — отсосы различной длины и диаметра с простым или шарообразным наконечником. Другие дополнительные инструменты необходимы при специальных более редких операциях.