Introduction
Multiple variations of the nasal speculum have been described in the literature for use in elective, emergency and operative settings. These include but are not limited to Thudichum, Cottle, Cardiff and Killian specula.Reference Pirsig1 Nasal specula serve to retract the nasal alar to widen the external nasal valve and subsequent view of the anterior nasal cavity during anterior rhinoscopy. They allow better visualisation of the anterior nasal septum and turbinates for procedures such as cautery, septoplasty and turbinectomy, to name a few.
During anterior rhinoscopy, the orthodox use of the nasal speculum relies on one-handed operating: the surgeon retracts the nasal alar with one hand and uses the dominant hand to perform the intervention. Evidence has shown the advantages of bimanual nasal operating; however, this requires an additional operator or a self-retaining instrument.Reference Briner, Simmen and Jones2 Another limitation with current nasal specula is that a typical rigid endoscope of 4 mm may completely obliterate the external nasal valve. In turn, this can lead to inadvertent injury to the nasal mucosa, vestibule and alar during instrumentation.Reference Gao, Han, Gu and Wang3, Reference Selvarajah, Saim, Bt Hj Idrus and Lokanathan4 There is also evidence that nasal examination and intervention using specula can be a challenging skill to acquire for junior doctors, particularly given the one-handed technique.Reference Morris, Burton and Owens5
The Lieberman speculum is used traditionally in ophthalmological procedures for eyelid retraction. However, we demonstrate its use for nasal alar retraction (Figures 1 and 2). The speculum has an adjustable locking mechanism allowing it to self-retract. As a result, the user is free to utilise both hands for rhinological procedures.
Image of Liebermann speculum (MMSU1290S, Malosa® Medical, Beaver Visitec International).
Figure 1 Long description
The Lieberman speculum is made of metal and has three main connected components: 1) two blunt open-wire blades which are inserted into the edges of the tissue to be retracted 2) arms which angle the speculum out of the surgeons way, and 3) a thumb screw which locks the blades of the device at the desired aperture.
Use of Liebermann speculum for biopsy and plasma wand ablation of an anterior septal inverted papilloma.
Figure 2 Long description
A comparison of intraoperative photographs. The left-hand image shows a left nostril without any speculum. The right-hand image shows the same patient but with a Lieberman speculum in their left nostril. The blades of the Lieberman speculum have been inserted into the left nostril and are retracting the nasal alar rim. As a result, a view of the patients left anterior nasal septum is achieved where an inverted papilloma can be visualised.
Methods and materials
The Open Blade Mechanical Speculum (MMSU1290S, Malosa® Medical, Beaver Visitec International, Waltham, Massachusetts, USA) is an adjustable-body wire speculum designed for eyelid retraction in ophthalmic surgery; see Figure 1.6 It is traditionally referred to as a Lieberman speculum.
During anterior rhinoscopy, delicate and careful positioning of the Lieberman speculum will avoid minor trauma to the intra-nasal alar skin and minimise discomfort for the patient. The speculum has been successfully utilised in our centre for both elective procedures such as turbinectomy, septoplasty, cryotherapy, FESS and in the emergency setting for nasal cautery. It has been trialled successfully in the out-patient department for procedures under local anaesthesia (see Figure 2) and in operating theatres under general anaesthesia.
Results
On maximal retraction, the self-retainer can provide a maximum diameter of 14 mm and has been successfully utilised in over 50 rhinological procedures at this site, which, in some cases, can widen the resting nares by more than 50 per cent, facilitating improved access and visualisation to the anterior nasal septum. This has the added benefits of preventing crowding of instruments at the external nasal valve during endoscopic sinus surgery and inadvertent injury to the vestibule/alar/septum.
Adverse events
In over 50 rhinological operations performed at this site, no cases of alar injury, alar necrosis, notching or other side effects were noted, including cases exceeding 2 hours’ duration.
Discussion
Interestingly, self-retaining nasal specula were initially invented in the late 1870s, with Frankel designing a screw-operated self-retaining speculum.Reference Pirsig1, Reference Briner, Simmen and Jones2, 7 However, Frankel’s speculum appears to have been lost in current practice, and we suggest the Liebermann speculum as a similar replacement.
The benefits of the Liebermann speculum include adequate retraction, in addition to facilitating a bimanual approach to rhinological procedures. The self-adjustable mechanism allows retraction specific to the individual patient’s anatomy without causing trauma. One concern with existing nasal instrumentation and trauma is the risk of alar necrosis;Reference Rachel and Mathog8 however, no cases of this have been demonstrated with our use of the Liebermann speculum to date.
Currently, rhinological procedures performing headlight surgery rely on one operating hand, using a Killian or Thudichum speculum for visualisation of the operating field. In contrast, the Liebermann speculum allows bimanual operating when performing headlight surgery, which the authors have found to improve efficiency. Furthermore, there are benefits of this speculum as an adjunct to endoscopic nasal surgery; the retraction of nasal alar enhances positioning of the endoscope and also prevents lens clouding with secretions or blood. Endoscopically, a bimanual approach has been demonstrated previously to reduce operative time, increasing surgical efficiency and reducing time under anaesthesia for the patient.Reference Briner, Simmen and Jones2 However, in contrast to the bimanual endoscopic approach described by Briner et al., use of this speculum only requires one skilled endoscopist, as opposed to two.Reference Briner, Simmen and Jones2
As these specula are commonly utilised in ophthalmological procedures, they are packaged as single items. This may prove useful for procedures performed in the out-patient clinic to avoid opening entire sets of instruments. We also argue the Liebermann speculum is intuitive to set up and poses a good choice of speculum for trainees or junior doctors, whereas Thudichum can be challenging to operate for those in training.Reference Morris, Burton and Owens5
One limitation observed is that the speculum does not block nasal hairs, which can obscure the view further into the nasal passage or necessitate nasal hair trimming. Additionally, the cost of the Liebermann speculum is £9 per speculum at our site, which is more expensive than traditional Thudichum specula (approximately £1.50), although with increased use, cost may decrease.9
Conclusion
While the Liebermann retractor’s conventional application is in ophthalmology, this study demonstrates its adaptation for nasal surgeries, offering a relatively cheap, safe alternative to traditional nasal specula, with the added benefits of improved visualisation of the caudal nasal septum and allowing bimanual intervention.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Ethical statement and informed consent
All patients provided informed written consent to treatment and photography for medical publication of images. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation (MHRA) and with the Helsinki Declaration of 1975, as revised in 2008.
Competing interests
The authors declare none.
