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Toluidine Blue Vital Staining

last modified on: Thu, 02/29/2024 - 18:31

Note: last updated before 2013


  1. The yield from panendoscopy to identify cancer of the upper aerodigestive tract varies substantially between institutions. Identification of second primaries associated with an index squamous cell carcinoma of the head and neck has been reported as low as 2.5% and as high as 25%. Savary et al (a) have reported that the majority (89%) of the synchronous second primary lesions in their studies were T1 or Tis and, as such, are difficult to identify. These investigators reported an increased detection rate of synchronous second primary tumors from 6.4% to 25% with the advent of "oncologically oriented upper aerodigestive panendoscopy." Enhanced tumor detection through this approach was credited to use of 3% Lugol solution and 1% Toluidine blue applied to the mucosa of the upper aerodigestive tract in the course of performing panendoscopy.
  2. We have implemented a similar approach for selected cases to help direct biopsies and determine initial mucosal margins before resection. Our experience has not been as positive as that described by Savary et al and therefore has not been universally adopted for all panendoscopies. We have found that Toluidine blue tends to stain areas of irritated epithelium without specificity for dysplasia or carcinoma. There remain, however, selected cases wherein we employ this supravital staining to help direct biopsies and margin assessment.


  1. Notify nursing in operating room prior to procedure
    1. 1% acetic acid solution as mucolytic agent
    2. 1% to 2% Toluidine blue
  2. Consent
    1. Not necessary other than to explain to patient that the mouth may be blue after endoscopy
    2. Obtain consent as normally would for planned excision/biopsy
  3. Glycopyrrolate (Robinal) 0.1 to 0.2 mg IM on call to operating room helpful for drying effect


  1. Wipe mucosal area suspicious for carcinoma with 4 x 4 soaked in acetic acid solution.
  2. Apply Toluidine blue solution.
  3. Blot dry.


  1. Toluidine blue is an acidophilus metachromatic nuclear stain that colors sites of squamous cell carcinoma, but not adjacent normal mucosal surfaces. Whether or not Toluidine blue actually stains tumor nuclei is still not proven, but dye may diffuse into larger intercellular canaliculi present in the tumor cells.


Savary M, Pasche R, Monnier P. Endoscopic screening for multiple squamous cell carcinoma of the upper digestive and respiratory tracts (oncologically oriented upper aerodigestive pan-endoscopy). In: Wigand ME, Steiner W, Stell PM, eds. Functional Partial Laryngectomy: Conservation Surgery for Carcinoma of the Larynx. New York, NY: Springer-Verlag; 1984;51-58.

Snow GB. Evaluation and staging of the patient with head and neck cancer. In: Myers EN, Suen JY, eds. Cancer of the Head and Neck. 2nd ed. New York, NY: Churchill Livingston; 1989;17-38.