Preface.

When I started my otolaryngology residency some 30 years ago, laryngology was just coming out of the Stone Age. Suspension microlaryngoscopy, the C[O.sub.2] surgical laser, Venturi jet ventilation, and videostroboscopy were all still in their nascent forms. As the laryngology-and-voice specialty evolved, precision became the focus and battle cry of the laryngologist; we desired greater precision in both diagnosis and treatment.

Fortunately, as laryngologists began to expand the use of endoscopic technology, medical insurance programs generally kept pace and paid the bills for technologic growth. In those days, the idea of doing in-office surgery was antithetical to the healthcare delivery model that was in vogue. Today, however, issues of quality of care, patient preference, and cost are all intermingled with measures of results. Consequently, there now are external financial pressures on healthcare providers to demonstrate cost-effective outcomes, which many types of in-office diagnostic and therapeutic procedures provide.

In 2000, groups at Columbia University and Wake Forest University began to perform transnasal esophagoscopy (TNE). From the beginning, it was apparent that the new technology is extraordinary. The distal-chip camera provides superb optics, and since there is no optical bundle, the external diameter of the scope is only 5.1 mm. Thus, it can be passed through the nose. In addition, its 2.0-mm working channel allows for irrigation, air insufflation, biopsy, and therapeutic manipulations and procedures. As you will see in the pages that follow, in only 4 short years the TNE instrument has become a universal panendoscope for many diverse applications.

At the same time as the introduction of the TNE instrument, two other important developments occurred. First, topical anesthesia methods were refined so that virtually all in-office procedures can be performed without the need for an intravenous line or sedation. Second, the pulsed-dye laser (PDL) was popularized by Zeitels et al.

By combining the TNE scope, PDL, and stroboscopy and with effective topical anesthesia, otolaryngologists (as well as speech-language pathologists) began to re-explore the aerodigestive tract. Now, unsedated in-office diagnostic laryngoscopy, esophagoscopy, bronchoscopy, and swallowing evaluations can be performed with high rates of patient acceptance. Use of the PDL allows a variety of laryngotracheal and esophageal lesions to be accessed and treated.

If one adds fiberoptic evaluation of swallowing (for dysphagia and aspiration) and injection augmentation (for glottal closure problems) to the list of in-office diagnostic and treatment options, the proportion of in-office procedures of the speech-language pathologist and the otolaryngologist is already significant.

Independent of economic considerations, in-office procedures benefit patients in many ways, and we are now expanding the indications for and uses of office-based technology--although unquestionably some new technologic components and instruments remain to be developed. This supplement presents and discusses some of the most important contemporary applications. Personally, I have no doubt that within a decade, more than half of all aerodigestive endoscopic procedures will be performed in the office. It is an important part of the future of our specialty.

Jamie A. Koufman, MD, FACS 

Director

Center for Voice and Swallowing Disorders of Wake Forest University

Winston-Salem, N.C.