The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2002 The American Laryngological,
Rhinological and Otological Society, Inc.
Digital Image Processing of Laryngeal
Lesions by Electronic Videoendoscopy
Masahiro Kawaida, MD; Hiroyuki Fukuda, MD; Naoyuki Kohno, MD
Objectives: To present electronic videoendoscopy of the
larynx with digital image processing and to discuss this
endoscopic technique from the stand-point of diagnostic
usefulness of laryngeal lesions. Study Design: Electronic
videoendoscopic evalua-tion of laryngeal lesions with digital
image pro-cessing. Methods: Seventy patients underwent
electronic videoendoscopy without digital image processing
and, subsequently, with the digital im-age processing function.
Of these, 15 patients with white lesion of the vocal fold and
laryngeal neo-plasms were assessed in the study. Clinical
assess-ments made before enhancement of digital image
processing function were compared with those af-ter
enhancement in 15 patients. Results: Of the 15 patients
observed, the clinical diagnoses of two pa-tients were changed
after enhancement. Both pa-tients underwent endolaryngeal
microsurgery with histopathological examination of the
removed le-sions, which confirmed the definitive diagnosis.
The clinical diagnoses of both patients after enhancement
were compatible with histopathological diagnoses.
Conclusions: The enhanced color images provided by this
system are superior in both quality and resolu-tion to those
obtained by conventional flexible fiber-optic endoscopy with a
video camera. This system should be a valuable tool for the
diagnosis of laryn-geal lesions. Key Words: Electronic
videoendoscopy, digital image processing, laryngeal lesions,
rhinolar-yngeal endoscope portion, single-plate red, green,
and blue sequencing method.
Laryngoscope, 112:559–564, 2002
INTRODUCTION
An electronic videoendoscope system has been devel-oped
with a small charge-coupled device (CCD) chip built into the tip
of the flexible endoscope.1–10 The system al-
Presented in part at the 13th Pacific Voice Conference, San Fran-cisco,
California, November 9 –11, 2000.
From the Department of Otolaryngology, Tokyo Metropolitan Oht-suka
Hospital (M.K.); the Department of Otolaryngology—Head and Neck Surgery, Keio
University School of Medicine (H.F.), Tokyo; and the Depart-ment of
Otolaryngology, National Defense Medical College (N.K.), To-korozawa, Japan.
Editor’s Note: This Manuscript was accepted for publication October 29,
2001.
Send Correspondence to Masahiro Kawaida, MD, Department of
Otolaryngology, Tokyo Metropolitan Ohtsuka Hospital, 2-8-1, Minamioht-suka,
Toshima-ku, Tokyo 170-0005, Japan.
Laryngoscope 112: March 2002
lows the visualization of laryngeal lesions with precision. The
images obtained from the CCD chip are converted into electronic
signals and transmitted as clear, dynamic color images to a color
video monitor. The Olympus Optical Co., Ltd. (Tokyo, Japan) has
produced the Endoscopic Video Information System 240 (EVIS-
240). A new model in this product line is the Olympus ENF-240
rhinolaryngeal elec-tronic videoendoscope, which contains a
distal tip and insertion tube measuring 3.9 mm outer diameter.
The CV-240 video system center of the EVIS-240 contains a
digital image processing function capable of producing enhanced
images in real time. We have observed and recorded the
nonenhanced and enhanced images of laryn-geal lesions obtained
by this electronic videoendoscope system and describe them from
the standpoint of their diagnostic usefulness.
PATIENTS AND METHODS
Patients
Seventy Japanese patients underwent electronic videoen-doscopy to
observe their laryngeal lesions at the Department of Otolaryngology,
Tokyo Metropolitan Ohtsuka Hospital, (Tokyo, Japan) during the 2-month
period from February 2000 to March 2000. The most common disease was
a vocal fold polyp (10 cases). The remaining 60 patients had Reinke
edema (nine cases), chronic laryngitis (eight cases), white lesion of the
vocal fold (six cases), glottic cancer (five cases), laryngeal paralysis (four
cases), vocal fold nodules (four cases), vocal fold cysts (four cases), laryn-
geal web (four cases), sulcus vocalis (four cases), supraglottic cancer (two
cases), vocal fold atrophy (two cases), intracordal hemorrhage (two cases),
papilloma of the larynx (one case), hem-angioma of the larynx (one case),
nonspecific granuloma of the larynx (one case), epiglottic cyst (one case),
cyst of the arytenoid (one case), and functional dysphonia (one case). Of
these, 15 patients with white lesion of the vocal fold, laryngeal cancer of
the glottis and supraglottis, papillomas, and hemangiomas, subse-quently
underwent endolaryngeal microsurgery. These were con-firmed
histopathologically. These 15 patients were assessed in the present study.
Principles of Electronic Videoendoscopy
There are two methods used to pick up and produce color dynamic
images in electronic videoendoscopy, the single-plate simultaneous color
CCD chip method and the single-plate red, green, and blue (RGB) surface
scanning method. The schematic representation of these methods is shown
in Figure 1.
Kawaida et al.: Electronic Videoendoscopy
559
 Digital Image Processing
The video system center of the EVIS-240 contains a digital image
processor equipped with a structure enhancement function that enables
detection of small structural or pathological changes represented by minor
color variations (Fig. 1B). It is possible to alternate an ordinary dynamic
image without enhancement to a dynamic image with enhancement in real
time using a switch on the scope. This function is divided into eight levels
for processing. In the present study, we used the middle (level 4) and the
highest (level 8) settings.

Equipment
The electronic videoendoscope system used in the present study was
the Olympus EVIS-240 that uses the single-plate RGB surface scanning
method. The basic system consists of an ENF-240 rhinolaryngeal
endoscope portion, a CV-240 video system center, a CLV-U40 xenon light
source, and an OES 203 color video monitor (Fig. 2). An SVO-9500MD
Super-VHS video cassette tape recorder (VCR) and an OEP color video
printer were also used as ancillary components. The distal tip and insertion
tube of the endoscope have an outer diameter of 3.9 mm, which enables
easy insertion into the laryngeal cavity through the nasal passages

Fig. 1. Schematic representation of two methods used to pick up

and produce color dynamic images in electronic videoendoscopy.
(A) The single-plate, simultaneous color charge-coupled device
chip. (B) The single-plate red, green, and blue (RGB) surface scan-
ning method with the digital image processing function. The Olym-
pus EVIS-240 used in the present study used this method.

In the former method, the white light from the light source
illuminates the target while images are simultaneously received by
multiple pixels housed within the color CCD chip built into the distal tip
of the endoscope. This chip converts images to electronic signals that can
be transmitted to the video system center through the electric cable inside
the endoscope. These signals derived from the color CCD chip are
reconstructed within the video system center used to produce a composite
image that is viewed on a color video monitor.

In the single-plate RGB surface scanning method, a small

monochrome CCD chip is built into the distal tip of the endoscope, and the
rotating wheel filter is located between the light source and glass fiber
bundle of the light guide. The white light from the light source
sequentially passes through a high-speed, rotating wheel filter to produce
the three primary colors, red, green, and blue, and illuminates the target in
order. This wheel filter rotates at 30 revelations per second. The RGB light
components reflected from the target and perceived sequentially by a
single pixel housed within the monochrome CCD chip are converted into
electric signals and transmitted through the electric cable inside the
endoscope to three image memories in the video system cen-ter. When all
three color signals have been received by image memories, color dynamic Fig. 2. The four basic components of the Olympus EVIS-240
images are reconstructed and simulta-neously sent to the color video system are shown. (A) An ENF-240 rhinolaryngeal endoscope
portion. (B) An OES 203 color video monitor. (C) A CV-240 video
monitor. Then the dynamic color image is projected onto the screen of the
system center. (D) A CLV-U40 xenon light source. Equipment on
color video monitor. the lower part of the trolley is an ancillary product that is capable of
storing endo-scopic images.

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560
(Fig. 3). The specifications of the endoscope portion are shown in Table I.
Technique
When performing endoscopic examinations with the system, surface
anesthesia of the nasal cavity is achieved with 4% lido-caine
hydrochloride spray. With the patient in the seated posi-tion, the insertion
tube of the endoscope is introduced through the nasal passages. The
examiner conducts the endoscopic examina-tion while observing the
dynamic image on the color video mon-itor. Dynamic images of the
laryngeal lesions observed by this system are recorded on a VCR. Still
color images are also printed using the video printer. The date and patient
information, such as name, age, sex, and identity number, can be also be
displayed on the screen of the color video monitor by operating a
keyboard.
Clinical Assessment
All patients underwent electronic videoendoscopy without digital
image processing and, subsequently, with the digital im-age processing
function. Clinical assessments made before en-hancement were compared
with those after enhancement in 15 patients.
RESULTS
Table II summarizes the age, sex, and clinical diag-nosis
made before and after enhancement during elec-tronic
videoendoscopy, any changes in diagnosis with en-hancement,
and the histopathological diagnosis made after endolaryngeal
microsurgery. Of the 15 patients ob-served, the clinical diagnoses
of two patients were changed after enhancement of digital image
processing. Figures 4 and 5 exemplify still images of the larynx of
these two patients obtained with the freeze-frame facility of the
electronic videoendoscope system and printed by a color video
printer.
Figure 4 represents still images of the larynx in a 68-year-
old man (patient 6) who had smoked 30 cigarettes a day for 48
years and complained of continuous hoarse-ness for 3 months.
Figure 4A shows an image without enhancement. Each of the
observers had the clinical im-pression of a nonmalignant white
lesion of the left-side vocal fold with inflammation. Figure 4B
shows the en-hanced image of the same patient’s larynx using the
max-imum setting (level 8). The surface irregularities of the lesion
were enhanced clearly. The clinical diagnosis of this patient was
changed to that of a T1a, left-side glottic cancer.
Videostroboscopy with a rigid endoscope was sub-sequently
performed and demonstrated absence of a mu-cosal wave on the
lesion of the left-side vocal fold. A biopsy performed during
subsequent surgery confirmed the his-topathological diagnosis of
squamous cell carcinoma at the site of the surface irregularities on
the left-side vocal fold.
TABLE I.
Specifications of the Olympus ENF-240 Rhinolaryngeal
Endoscope Capable of Connecting to the Olympus EVIS 240
Electronic Videoendoscope System.
Optical system Field of view 100°
Direction of view 0° (Forward viewing)
Illumination Light guide system
Bending section Range of tip bending Up 130°/down 130°
Distal tip Outer diameter 3.9 mm
Insertion tube Outer diameter 3.9 mm
Working length 365 mm
enhancement setting of level 4 (Fig. 5B). The clinical di-agnosis
of this patient was changed to that of a papilloma arising from the
left-side vocal process, which was con-firmed histopathologically
after endolaryngeal microsur-gery and resection of the lesion.
DISCUSSION
An electronic videoendoscope system has been devel-oped
in which a small CCD chip is located at the distal tip of the
endoscope for image capturing. The CCD chip was first used in an
endoscope manufactured by Welch-Allyn, Inc. (New York) Tips
and insertion tubes of early models were thick because of the
large size of the CCD chip, limiting their use to imaging of the
gastrointestinal tract.1– 4 Because the rhinolaryngeal endoscope
required a thinner outer diameter to the distal tip and insertion
tube to facilitate advancement through the nasal passages,
electronic videoendoscopy could not be applied easily in the field
of otolaryngology. When a smaller CCD chip became available,
the system was able to be used in bron-choendoscopy. 5 The
Pentax VNL-1530 rhinolaryngeal en-doscope with an outer
diameter of approximately 5 mm to the distal tip and insertion
tube was developed by Asahi Optical Co., Ltd. (Tokyo, Japan), in
1993.6 In 1996, a similar model was released by Olympus Optical
Co., Ltd. The authors of the present study have performed elec-
tronic videoendoscopy for laryngeal lesions using these

Figure 5 shows still images of the larynx of a 60-year-old

man (patient 14) who complained of a foreign body sensation in
the larynx for 6 months. This patient had no history of smoking.
Electronic videoendoscopy without en-hancement revealed a
spherical, tumorous lesion with a pale red, smooth surface arising
from the right-side vocal process. This lesion was clinically
diagnosed as an idio-pathic nonspecific granuloma of the larynx
before en-hancement (Fig. 5A). The processed image clearly de-
picted the papillary surface of the lesion using an Fig. 3. The Olympus ENF-240 rhinolaryngeal endoscope portion.
The outer diameter of distal tip of the endoscope is 3.9 mm.

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561
 TABLE II.
The Comparison of Clinical Diagnoses Before and After Enhancement of Digital Image Processing for 15 Patients Who Underwent
Electronic Videoendoscopy.
Clinical Diagnosis
Patient Age Alteration of Clinical Diagnosis
No. (y) Sex Before Enhancement After Enhancement After Enhancement Histopathologic Diagnosis
1 73 Female Supraglottic cancer, T2 Supraglottic cancer, T2 No Squamous cell carcinoma
2 57 Male Supraglottic cancer, T2 Supraglottic cancer, T2 No Squamous cell carcinoma
3 67 Male Right glottic cancer, T2 Right glottic cancer, T2 No Squamous cell carcinoma
4 58 Male Right glottic cancer, T2 Right glottic cancer, T2 No Squamous cell carcinoma
5 61 Male Right glottic cancer, T1b Right glottic cancer, T1b No Squamous cell carcinoma
6 68 Male White lesion of left vocal Left glottic cancer, T1a Yes Squamous cell carcinoma
fold
7 64 Male Right glottic cancer, T2 Right glottic cancer, T2 No Squamous cell carcinoma
8 66 Male White lesion of right White lesion of right No Epithelial hyperplasia with
vocal fold vocal fold parakeratosis
9 78 Male White lesion of both White lesion of both No Epithelial hyperplasia with
vocal folds vocal folds parakeratosis
10 69 Male White lesion of right White lesion of right No Epithelial hyperplasia with
vocal fold vocal fold parakeratosis
11 70 Male White lesion of right White lesion of right No Epithelial hyperplasia with
vocal fold vocal fold parakeratosis
12 51 Male White lesion of right White lesion of right No Epithelial hyperplasia with
vocal fold vocal fold parakeratosis
13 69 Female White lesion of right White lesion of right No Epithelial hyperplasia with
vocal fold vocal fold parakeratosis
14 60 Male Nonspecific granuloma of Papilloma of right vocal Yes Squamous papilloma
right vocal fold fold
15 56 Male Hemangioma of left Hemangioma of left No Cavernous hemangioma
arytenoid arytenoid

models.7,8 Videoendoscopic laryngeal surgery using a sys-tem
with this endoscope has also been reported. 9 The Pentax VNL-
1330 rhinolaryngeal endoscope with a 4.1-mm-outer-diameter tip
and insertion tube was developed in 1997. 10 Recently, Olympus
Optical Co., Ltd., developed the EVIS-240 series with a
rhinolaryngeal endoscope with a thinner outer diameter to the tip
and insertion tube (3.9 mm). We used this system in the present
study to observe and record these laryngeal lesions.
The four basic components of an electronic videoen-doscope
system are an endoscope portion, a video system center, a light
source, and a color video monitor. There are two methods used to
pick up and produce color dynamic images in electronic
videoendoscopy, the single-plate si-multaneous color CCD chip
method and the single-plate RGB surface scanning method. In the
former method, a color CCD chip built into the tip of the
endoscope contains multiple color pixels and can simultaneously
capture dif-ferent wavelengths of light. In the latter method, the
tip of the endoscope incorporates a monochrome CCD chip that
can only provide black and white signals. The color CCD chip
simplifies color acquisition but is considerably larger than the
monochrome CCD chip, requiring a wider diam-eter to the distal
tip of the endoscope.1 For this reason, the single-plate RGB
surface scanning method is preferred in a rhinolaryngeal
endoscope that can be connected to an electronic videoendoscope
system. This method facilitates easy access to the larynx through
the nasal passages with the use of a narrower scope.
The main difference between the images obtained with the
electronic videoendoscope system and those ob-tained with the
flexible fiberoptic endoscope attached to a color video camera is
the quality of the dynamic color images. With the flexible
fiberoptic endoscope attached to a color video camera, a
honeycomb pattern exists and optical interference known as the
“moire effect” is occa-sionally seen on the color video monitor.
The electronic videoendoscope system provides clear, high-
quality color images that are transmitted in the form of electric
signals and reproduced on the color video monitor.
Color information perceived from the target by the CCD
chip is transmitted in the form of electric signals to the video
system center. As an alternative, it is possible to put the electric
signals directly into the personal computer and perform digital
image processing of the color images captured by the electronic
videoendoscope system.11 We have reported our clinical
experience with digital image processing using the special
processor making it possible to connect it to the conventional
electronic videoendoscope system. 8 The CV-240 video system
center of the EVIS-240 contains a digital image processing
function capable of processing dynamic images in real time.
The laryngeal lesions were observed with the EVIS-240
system using the ENF-240 rhinolaryngeal endoscope coupled with
real-time digital image processing. An adap-tive band
enhancement system containing bandpass fil-tering has been
adopted for structure enhancement in this system. With repeated
transformation of the coordinates

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562

Fig. 4. Laryngeal findings in patient 6 with electronic videoendos-
copy. Still image without enhancement obtained by freeze-frame
appeared to be nonmalignant white lesion of the left-side vocal fold
with inflammation (A). The enhanced still image of the same pa-
tient’s larynx with the maximum value of level 8 clearly revealed the
surface rough structure of the lesion (B). The clinical diagnosis of
patient 6 was changed to left-side glottic cancer, T1a.
of the electric signals, enhancement of the contours and surface
irregularities of the lesions is noted. Use of a switch on the scope
makes it possible to alternate between ordinary and enhanced
images in real time.
In two patients, the marked surface irregularities of the
laryngeal lesions were depicted clearly using structure
enhancement. The initial clinical impressions were of be-nign
laryngeal lesions while observing color images with-out
enhancement. In patient 6, the clinical diagnosis of a benign white
lesion of the vocal fold was changed to that of a glottic cancer
after enhancement. In patient 14, the spherical tumor arising from
the left-side vocal process that appeared to be a nonspecific
granuloma without the use of enhancement demonstrated a
papillary surface with enhancement, prompting a different clinical
diagno-sis of a papilloma. Both patients underwent endolaryngeal
microsurgery with histopathological examination of the removed
lesions that confirmed the diagnosis in both of
Laryngoscope 112: March 2002
Fig. 5. Laryngeal findings in patient 14 with electronic videoendos-
copy. Still image without enhancement obtained by freeze-frame
showed a pale red, spherical tumor arising from the right-side vocal
process (A). The tumorous lesion was suspected to be an idio-
pathic, nonspecific granuloma of the larynx before enhancement.
The enhanced still image of the same patient’s larynx with the
medium value of level 4 clearly revealed the papillary surface struc-
ture of the lesion (B). The clinical diagnosis of patient 14 was
changed to papilloma arising from the right-side vocal process.
them. Accordingly, it appears to be possible to detect with
precision irregular laryngeal lesions at the point of outpa-tient
endoscopic examination. However, there is one lim-itation to the
clinical use of electronic videoendoscopy with the single-plate
RGB surface scanning method. Videostro-boscopy is the most
practical method of determining the vibratory pattern of the vocal
folds during phonation.12,13 The laryngostroboscope is not
compatible with the elec-tronic videoendoscope system that uses a
single-plate RGB surface sequencing method because of the
location of the rotating wheel filter between the light source and
glass fiber bundle of the light guide. To observe and record
stroboscopic images with an electronic videoendoscope system, a
single-plate simultaneous color CCD chip method must be used.
As noted previously, the color CCD chip requires a wider distal
tip of the endoscope, which limits its advancement through the
nasal passages.
Kawaida et al.: Electronic Videoendoscopy
563
CONCLUSION
It is possible to detect laryngeal neoplasms such as
papillomas and cancer with a fair degree of accuracy using the
digital image processing function of an electronic videoendoscope
system. Although this system does not yet allow the performance
of videostroboscopy, it appears to provide valuable information
that may guide in the selec-tion of optimal treatment. In the
future, we plan to con-tinue our clinical assessments with this
system.
Acknowledgments
The authors thank Ken-ichiro Hara and Koichi Tatsumi
(Olympus Promarketing Inc., Tokyo, Japan) for their cooperation.
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