Introduction
Disorders of the esophagus present a challenge to the otolaryngologist owing to the broad variety of pathology and oftentimes nonspecific nature of patient complaints. Using a mirror, Bozzini in 1809 was credited with the first attempts to evaluate the esophagus. Initially described in 1868 by Kussmaul, the straight esophagoscope underwent multiple refinements until the early 1900s when Chevalier Jackson introduced the technique and instrumentation of modern rigid esophagoscopy. After fiberoptic illumination was pioneered for this technique in the 1930s, flexible endoscopy was introduced in the 1960s and eventually led to the creation of the transnasal endoscope in the 1990s. The evolution of the technique and instrumentation reflects the challenges associated with evaluating the esophagus. The advent of flexible and rigid endoscopy has afforded the modern day practitioner several methods for conducting a thorough patient-specific assessment.
The diagnosis and management of esophageal disorders requires a thorough understanding of esophageal anatomy. The esophagus is a muscular conduit extending from the inferior portion of the pharynx to the superior portion of the stomach. At the approximate level of the sixth cervical vertebra, the esophagus begins at the pharyngoesophageal junction in the hypopharynx and descends to the level of the 11th thoracic vertebra, where it enters the cardia portion of the stomach. Shortly after its takeoff, the esophagus has a gentle leftward curvature until the level of the fifth thoracic vertebra, at which point it resumes its midline course. A second leftward curve of the esophagus can be appreciated as it crosses the descending aorta prior to entering the esophageal hiatus of the diaphragm; however, some sources have also noted the thoracic esophagus to have a right curvature due to the main stem bronchus.
The esophagus measures 22 to 25 cm in total length and can be divided into cervical, thoracic, and abdominal portions. The cervical esophagus begins at the cricopharyngeus and extends to the suprasternal notch, the thoracic portion from the suprasternal notch to the diaphragm, and the abdominal portion from the diaphragm to the stomach. Throughout its length, there are three constrictions of the conduit that the endoscopist should be familiar with. Approximately 16 cm from the upper incisors, the first and narrowest constriction occurs at the cricopharyngeal sphincter. At 23 to 27 cm from the upper incisors, the second constriction occurs at the level of the left main stem bronchus. The final constriction occurs at the gastroesophageal sphincter, 38 to 40 cm from the upper incisor teeth.
Histologically, the esophagus is composed of four circular layers: mucosa, submucosa, muscular layer, and adventitia. The esophagus lacks a serosa, a unique characteristic that differentiates it from the rest of the gastrointestinal tract.
Key Operative Learning Points
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Flexible and rigid esophagoscopy allow for visualization and instrumentation of the esophagus under specific situations. Understanding both techniques allows the practitioner to perform a safe and thorough evaluation depending on the patient’s general medical condition, ability to tolerate the procedure, and suspected diagnosis.
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Understanding esophageal anatomy allows the endoscopist to safely perform esophagoscopy while minimizing the potential for complications such as perforation.
Preoperative Period
History
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History of present illness
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Age of the patient
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Description of dysphagia or pain
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Onset, provocation, progression, duration of episodes
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Is this the first time or has this been repetitive/ongoing?
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What maneuvers or interventions has the patient tried to combat the problem?
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Is there dysphagia to solids, liquids, or both?
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Any accompanying symptoms—postnasal drip, heart burn, globus sensation, hoarseness, weight loss, weakness, lethargy, night sweats, hemoptysis, cough, neck masses?
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Past medical history
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History of cancer
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History of radiation to the head or neck
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Cardiac or pulmonary disease
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Rheumatologic conditions such as scleroderma
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Arthritis or vertebral problems that would limit motion of the neck
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Past surgical history
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What surgery has the patient had in the past?
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Any spinal fusion surgery?
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Any chest, abdominal, or mediastinal procedures?
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Family history
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Rheumatologic conditions in the family
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History of cancer of the head and neck
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Family history of dysphagia
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Social history
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Very important to collect detailed history of smoking and alcohol use because these are risk factors for cancer
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Medication
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Many medications can cause dryness and lead to a sensation of difficulty swallowing.
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Physical Examination
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Always undertake a thorough examination of the head and neck.
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Examination/observation of the head and neck
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Look for obvious deformities, masses, ulcerations, and gross abnormalities.
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Palpation of the head and neck
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Carefully inspect the neck for masses and adenopathy; also palpate to see if any pain can be elicited.
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Assess range of motion of the neck to assess for fibrosis and ability to extend or flex neck.
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Nasal endoscopy
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Should routinely be performed on patients with dysphagia related to the laryngopharyngeal complex or the cervical esophagus ( Fig. 45.1 )
Fig. 45.1
Transnasal endoscopy showing a cervical osteophyte (O) displacing the epiglottis anteriorly (E).
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The nasal mucosa should be sprayed with a topical anesthetic/decongestant, such as lidocaine with phenylephrine.
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Nasal endoscopy will help assess for dynamic movement of the laryngopharyngeal complex.
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Evaluate the patency of the airway and the mobility of the vocal folds.
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Evaluate for the presence of masses or mucosal abnormalities.
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Imaging
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Not required but may be helpful to determine elements of disease pathology. Oftentimes, patients may be referred for a swallow evaluation with a speech-language pathologist to identify salient features of the dysphagia not reported by the patient. This evaluation can also be helpful to identify the potential location of pathology, as well as to begin swallowing therapy for the patient if needed. A modified barium swallow can also shed light on the dynamic process of swallowing and point to areas of concern.
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A preoperative contrast-enhanced esophagram may be helpful in diagnosing certain conditions, especially when dysmotility, mass effect, stricture, or diverticulum is suspected ( Fig. 45.2 ). An esophagram can also identify foreign bodies not visualized on plain film.
Fig. 45.2
A , Barium esophagram demonstrating a Zenker diverticulum. B , Barium esophagram of a patient with dysphagia and a large anterior cervical osteophyte (black arrow) . C , Barium esophagram demonstrating an esophageal web (white arrow) .
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Barium is generally recommended as the contrast agent except when esophageal injury is suspected. In cases of suspected esophageal perforation, a water-soluble agent, such as gastrograffin, is recommended because it does not induce an inflammatory reaction with extravasation, which can be seen with barium. Barium is typically used if a perforation is not suspected because it does not induce the same inflammatory reaction as gastrograffin if aspirated into the lower respiratory tract.
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Important to note that masses identified on esophagram may require computed tomography (CT) imaging for further characterization
Indications for Rigid and Flexible Esophagoscopy
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Rigid or flexible esophagoscopy can be a diagnostic tool for the evaluation of suspected masses, trauma, strictures, or inflammatory conditions. It allows for visualization and the ability to take biopsies if needed.
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In the case of esophageal foreign body, rigid esophagoscopy can be used to visualize and extract the foreign body.
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Rigid esophagoscopy can be used as a surgical approach for dilation of strictures, placement of a stent, cricopharyngeal myotomy for diverticula, and laser procedures.
Contraindications
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Hemodynamic instability
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Poor general health
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Lack of patient and family understanding inhibiting informed consent
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Esophageal perforation
Preoperative Preparation
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The preoperative evaluation is minimal in these patients and typically requires only medical clearance to ensure safety for tolerating anesthesia. In some cases a cardiology clearance may be needed for patients with significant cardiopulmonary history.
Operative Period
The general condition of the patient, purpose of intervention, and patient compliance are three factors that determine whether patients should undergo rigid esophagoscopy or flexible esophagoscopy. Flexible esophagoscopy can be performed either transorally or transnasally. Flexible esophagoscopy allows for visualization of the gastroesophageal junction and improved instrumentation in patients with limited range of motion at the neck or obstructing osteophytes. Transoral esophagoscopy is typically performed under sedation and topical anesthesia, whereas transnasal esophagoscopy is performed with topical anesthesia only. Transnasal esophagoscopy is well suited for the office setting, is of minimal risk, and allows for patients to return home without need for observation. This procedure can be performed with relatively little patient discomfort and is associated with mostly minor complications, such as epistaxis. It is imperative that prior to any procedure, a full discussion of the risks and benefits be discussed with patients in a manner suited to their level of understanding. Overall, flexible esophagoscopy is a viable option for patients that cannot tolerate general anesthesia; however, it is important to note that it has limitations and should be reserved for specific situations. According to recent studies, transnasal esophagoscopy can be helpful in changing the course of management in male patients, obese patients, and especially those patients with a history of dysphagia associated with head and neck cancer.
Rigid esophagoscopy is more advantageous in evaluating the hypopharynx, cricopharyngeal sphincter, and cervical esophagus. Oftentimes, redundant mucosal folds can hide pathology which can be readily missed with flexible esophagoscopy. Rigid instrumentation also confers the advantage of allowing larger suction cannulas and larger caliber instruments to be used for retrieval of foreign bodies.
Flexible Transnasal Esophagoscopy
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Anesthesia : topically sprayed 4% lidocaine and 0.05% oxymetazoline, followed by cotton pledgets with 0.5% tetracaine, followed by oral 2% lidocaine gel
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Positioning : patient kept sitting in the upright position or reclined
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Antibiotics : not needed on a routine basis
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Monitoring : no cardiac monitoring necessary if patient is not sedated
Instruments and Equipment to Have Available
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Transnasal esophagoscope (TNE)
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Video monitor
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Flexible suction
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Flexible biopsy instrument
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Flexible grasping instrument
Key Anatomic Landmarks
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Nasal passage, nasopharyngeal inlet, laryngeal inlet, piriform sinus, postcricoid area, endolarynx, superior esophageal constrictor, and gastric inlet
Prerequisite Skills
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Transnasal endoscopy
Operative Risks
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Esophageal perforation, mucosal injury (less likely than with rigid)
Surgical Technique
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The patient is placed into the sitting position either upright or slightly reclined.
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Nasal cavity is sprayed with lidocaine and oxymetazoline spray. After decongestion, cotton pledgets with tetracaine are placed for further anesthesia. Patient is then given 2% lidocaine gel to gargle and swallow. At this time, the nasal cavity and pharynx should be well anesthetized.
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Under direct visualization, the TNE should be introduced into the larger nasal passage and advanced to the pharynx, taking the largest pathways with care not to injure the mucosa of the septum or turbinate.
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Prior to advancing into the hypopharynx, an overall view of the laryngopharyngeal complex can be appreciated.
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The scope is then used to examine each piriform sinus.
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The scope is then placed into the left piriform sinus and, while the patient swallows, is advanced into the esophagus through the cricopharyngeal inlet.
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As the scope is advanced, insufflation can be performed to evaluate the esophageal mucosa. The lower esophageal sphincter and gastroesophageal junction should be assessed before entering the stomach.
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After entering the stomach, the scope is used to evaluate the lining of the stomach. The scope is retroflexed to evaluated the gastric cardia.
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While the scope is being withdrawn, the walls of the esophagus are again examined.
Common Errors in Technique
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Inadequate anesthesia leading to patient discomfort and poor cooperation
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Passing the scope through narrow portions of the nasal cavity, causing the patient significant pain
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Failure to evaluate the esophageal mucosa while withdrawing the scope
Rigid Esophagoscopy
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Anesthesia : General anesthesia with endotracheal intubation
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Positioning : Neutral position without head extension. Extension with techniques such as a shoulder roll can make passage of the esophagoscope more difficult
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Antibiotics : Not needed on routine basis
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Monitoring : standard cardiacpulmonary monitoring with pulse oximetry
Instruments and Equipment to Have Available
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Rigid esophagoscope
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Grasping forceps
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Biopsy forceps
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Cannula suction
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Camera head
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0-degree long endoscope
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Optical forceps ( Fig. 45.3 )
