Specialist ENT oesophagus

RIGID OESOPHAGOSCOPY, INDICATIONS AND COMPLICATIONS

Indications:

  1. Rigid oesophagoscopy is indicated to inspect and obtain biopsies from lesions within the oesophagus. Dysphagia is the cardinal symptom investigated by rigid endoscopy. 
  2. Foreign bodies lodged in the oesophagus can be removed by rigid oesophagoscopy.
  3. Oesophagoscopy is a part of pan-endoscopic investigation of undiagnosed cervical lymphadenopathy in suspected malignancy.
  4. Oesophagoscopy may be therapeutic when combined with dilatation by bougies for strictures or for placement of indwelling tubes.
  5. A preliminary oesophagoscopy is done to insert acriflavine gauze in treatment of pharyngeal pouch.
Specialist ENT Screenshot 2020 11 29 book oesophagus almost final3

Procedure:

Position:

Patient is supine, with head elevation and extension at the atlanto-occipital joint (Boyce position). The main aim of this position is to have the mouth, pharynx and oesophagus in a straight line.

Technique:

Protection of the lips and teeth is done by a gauze piece or a silicon teeth guard.

Lubrication of the oesophagoscope is done by jelly.

Introduction of the oesophagoscope is done into three stages:

    1. Passage through the cricopharyngeal sphincter, called the ‘pinch cock’.
    2. Passage through the thoracic oesophagus.
    3. Passage through the hiatal sphincter.
    4. The proximal part of the oesophagoscope is held like a pencil in the right hand.
    5. The oesophagoscope is passed up-to the base of the tongue, the epiglottis, arytenoids and endotracheal tube is identified. The tip of the oesophagoscope is passed behind the right posterolateral pharyngeal wall and into the right pyriform sinus.
    6. The cricopharyngeus muscle at the sphincter remains in a state of contraction. The distal position of the oesophagoscope is lifted anteriorly by the left thumb with slow sustained pressure, the oesophagus opened. The danger of oesophageal perforation at this point is very high. No force should be used.
    7. After the sphincter is opened, the oesophagoscope is passed easily into the thoracic oesophagus.
    8. Head of the patient slightly lowered. The narrowing of the oesophagus at the crossing of the aortic arch and left bronchus lies about 25 cms from the incisors. The aortic pulsations are seen.
    9. The head and shoulders are lowered below the level of the table, head being slightly higher than the shoulders and moved slightly to the right. At this stage, the oesophagoscope points to the left anterior-superior iliac spine. The hiatal opening presents as a small slit from 10 o’clock to 4 o’clock position.
    10. The cardiac end is identified by its reddish mucosa.
    11. The oesophagoscope is always removed under direct vision.
Specialist ENT Screenshot 2020 11 29 book oesophagus almost final4

Complications:

a) Damage to the lips and teeth.

b) Perforation of oesophagus or pharynx: It is the most serious complication. Patient needs to be monitored regularly for development of surgical emphysema within the neck, severe pain, breathlessness and intra-abdominal pain.

c) Perforation of the lower end may result in a clinical picture of an acute abdominal emergency.

d) Hematoma of posterior pharyngeal wall.

e) Failure to obtain appropriate biopsy.

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