Method of Intubation (Styletubation)
Alan H. Shikani, MD, FACS
The history of the Shikani Optical stylet started in 1996. I was approached at the time by Tom Barthel, the CEO of Clarus Medical, who wanted to know whether I could use a neuro-endoscopy fiberoptic cable which Clarus promoted for neurosurgical procedures, in endoscopic pituitary surgery. Tom had learned about me through a paper that I had recently published in the Journal of Otolaryngology, describing an utterly novel pituitary surgery technique [1]. Until that time all pituitary surgery in the US had been done following the traditional transeptal transsphenoidal hypophysectomy technique introduced by Harvey Cushings at Johns Hopkins at the turn of the century, and that involves removing pituitary tumors through an incision made under the upper lip and nasal cavity, to expose the piriform aperture and the rostrum of the maxilla, allowing access to the sella turcica for tumor resection (for review, see [2]). During my training in Otolaryngology-Head and Neck surgery at Johns Hopkins, between 1985 and 1991, I had become proficient in functional endoscopic sinus surgery for chronic sinusitis, a technique invented by Prof Walter Messerklinger in Austria [3] and introduced to the United States by Dr David Kennedy at Johns Hopkins. Sinus surgery was however a totally different procedure than pituitary surgery. In 1991, I ventured to perform a case of endoscopic surgery for a pituitary tumor, a minimally invasive surgical procedure done through the nose and sphenoid sinus, offering a less invasive approach compared to the traditional Cushings technique and I published the paper in the Journal of Otolaryngology [1]. At the time, it was the first pituitary case ever done endoscopically. Since then, endoscopic transsphenoidal surgery has become the norm and replaced the Cushings technique as the preferred surgical approach for removing pituitary tumors.
After evaluating the Clarus fiberoptic cables, I informed Tom Barthel that I could foresee a more interesting use for their technology, by incorporating a fiberoptic cable into an optical stylet for the purpose of endotracheal intubation and airway management. The concept of airway management using intubating fiberoptic scopes had been previously described, however transforming the blind bougie used in endotracheal intubation into a “seeing” stylet would be unique and novel. I designed the Shikani Optical stylet (SOS), a new intubating stylet which has a lens at the distal end, a fiberoptic cable inside and is connected to a camera and a video monitor, hence allowing continuous visualization of the airway during introduction of the tube into the glottis (Figure 1). I used the SOS in 120 patients and published the first paper in 1999 in the Journal Otolaryngology-Head and Neck Surgery [4]. This new “seeing” stylet would prove to combine the advantages of a fiberoptic scope and the semi-rigidity of a classic metal stylet. Its advantage over the flexible fiberoptic scope would be that it can keep its semi-rigid shape, allowing better maneuvering around a large epiglottis that is flopping against the posterior pharyngeal wall, which in the supine position, may constitute an insurmount¬able problem using a flexible scope. In addition, it would offer the advantages of the light wand but would be superior to it in that it acts not only as a source of illumination but also allows visualization and helps direct the course of the endotracheal tube.
Alan H. Shikani, MD, FACS
The history of the Shikani Optical stylet started in 1996. I was approached at the time by Tom Barthel, the CEO of Clarus Medical, who wanted to know whether I could use a neuro-endoscopy fiberoptic cable which Clarus promoted for neurosurgical procedures, in endoscopic pituitary surgery. Tom had learned about me through a paper that I had recently published in the Journal of Otolaryngology, describing an utterly novel pituitary surgery technique [1]. Until that time all pituitary surgery in the US had been done following the traditional transeptal transsphenoidal hypophysectomy technique introduced by Harvey Cushings at Johns Hopkins at the turn of the century, and that involves removing pituitary tumors through an incision made under the upper lip and nasal cavity, to expose the piriform aperture and the rostrum of the maxilla, allowing access to the sella turcica for tumor resection (for review, see [2]). During my training in Otolaryngology-Head and Neck surgery at Johns Hopkins, between 1985 and 1991, I had become proficient in functional endoscopic sinus surgery for chronic sinusitis, a technique invented by Prof Walter Messerklinger in Austria [3] and introduced to the United States by Dr David Kennedy at Johns Hopkins. Sinus surgery was however a totally different procedure than pituitary surgery. In 1991, I ventured to perform a case of endoscopic surgery for a pituitary tumor, a minimally invasive surgical procedure done through the nose and sphenoid sinus, offering a less invasive approach compared to the traditional Cushings technique and I published the paper in the Journal of Otolaryngology [1]. At the time, it was the first pituitary case ever done endoscopically. Since then, endoscopic transsphenoidal surgery has become the norm and replaced the Cushings technique as the preferred surgical approach for removing pituitary tumors.
After evaluating the Clarus fiberoptic cables, I informed Tom Barthel that I could foresee a more interesting use for their technology, by incorporating a fiberoptic cable into an optical stylet for the purpose of endotracheal intubation and airway management. The concept of airway management using intubating fiberoptic scopes had been previously described, however transforming the blind bougie used in endotracheal intubation into a “seeing” stylet would be unique and novel. I designed the Shikani Optical stylet (SOS), a new intubating stylet which has a lens at the distal end, a fiberoptic cable inside and is connected to a camera and a video monitor, hence allowing continuous visualization of the airway during introduction of the tube into the glottis (Figure 1). I used the SOS in 120 patients and published the first paper in 1999 in the Journal Otolaryngology-Head and Neck Surgery [4]. This new “seeing” stylet would prove to combine the advantages of a fiberoptic scope and the semi-rigidity of a classic metal stylet. Its advantage over the flexible fiberoptic scope would be that it can keep its semi-rigid shape, allowing better maneuvering around a large epiglottis that is flopping against the posterior pharyngeal wall, which in the supine position, may constitute an insurmount¬able problem using a flexible scope. In addition, it would offer the advantages of the light wand but would be superior to it in that it acts not only as a source of illumination but also allows visualization and helps direct the course of the endotracheal tube.
