Introduction Of The Esophagoscope


Categories: INTRODUCTION OF THE ESOPHAGOSCOPE
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The esophagoscope is to be passed only with ocular guidance, never

blindly with a mandrin or obturator, as was done before the

bevel-ended esophagoscope was developed. Blind introduction of the

esophagoscope is equally as dangerous as blind bouginage. It is almost

certain to cause over-riding of foreign bodies and disease. In either

condition perforation of the esophagus is possible by pushing a sharp

foreign body through the normal wall or by penetrating a wall weakened

by disease. Landmarks must be identified as reached, in order to know

the locality reached. The secretions present form sufficient

lubrication for the instrument. A clear conception of the endoscopic

anatomy, the narrowings, direction, and changes of direction of the

axis of the esophagus, are necessary. The services of a trained

assistant to place the head in the proper sequential high-low

positions are indispensible (Figs. 52 and 70). Introduction may be

divided into four stages.

1. Entering the right pyriform sinus.

2. Passing the cricopharyngeus.

3. Passing through the thoracic esophagus.

4. Passing through the hiatus.



The patient is placed in the Boyce position as described in Chapter

VI. As previously stated, the esophagus in its upper portion follows

the curves of the cervical and dorsal spine. It is necessary,

therefore, to bring the cervical spine into a straight line with the

upper portion of the dorsal spine and this is accomplished by

elevation of the head--the high position (Figs. 66-71).



[PLATE III--ESOPHAGOSCOPIC VIEWS FROM OIL-COLOR DRAWINGS FROM LIFE, BY

THE AUTHOR:

1, Direct view of the larynx and laryngopharynx in the dorsally

recumbent patient, the epiglottis and hyoid bone being lifted with the

direct laryngoscope or the esophageal speculum. The spasmodically

adducted vocal cords are partially hidden by the over-hang of the

spasmodically prominent ventricular hands. Posterior to this the

aryepiglottic folds ending posteriorly in the arytenoid eminences are

seen in apposition. The esophagoscope should be passed to the right of

the median line into the right pyriform sinus, represented here by the

right arm of the dark crescent. 2, The right pyriform sinus in the

dorsally recumbent patient, the eminence at the upper left border,

corresponds to the edge of the cricoid cartilage. 3, The

cricopharyngeal constriction of the esophagus in the dorsally

recumbent patient, the cricoid cartilage being lifted forward with the

esophageal speculum. The lower (posterior) half of the lumen is closed

by the fold corresponding to the orbicular fibers of the

cricopharyngeus which advances spasmodically from the posterior wall.

(Compare Fig. 10.) This view is not obtained with an esophagoscope. 4,

Passing through the right pyriform sinus with the esophagoscope;

dorsally recumbent patient. The walls seem in tight apposition, and,

at the edges of the slit-like lumen, bulge toward the observer. The

direction of the axis of the slit varies, and in some instances it is

like a rosette, depending on the degree of spasm. 5, Cervical

esophagus. The lumen is not so patulent during inspiration as lower

down; and it closes completely during expiration. 6, Thoracic

esophagus; dorsally recumbent patient. The ridge crossing above the

lumen corresponds to the left bronchus. It is seldom so prominent as

in this patient, but can always be found if searched for. 7, The

normal esophagus at the hiatus. This is often mistaken for the cardia

by esophagoscopists. It is more truly a sphincter than the cardia

itself. In the author's opinion there is no truly sphincteric action

at the cardia. It is the failure of this hiatal sphincter to open as

in the normal deglutitory cycle that produces the syndrome called

cardiospasm. 8, View in the stomach with the open-tube gastroscope.

The form of the folds varies continually. 9, Sarcoma of the posterior

wall of the upper third of the esophagus in a woman of thirty-one

years. Seen through the esophageal speculum, patient sitting. The

lumen of the mouth of the esophagus, much encroached upon by the

sarcomatous infiltration, is seen at the lower part of the circle. 10,

Coin (half-dollar) wedged in the upper third of the esophagus of a boy

aged fourteen years. Seen through the esophageal speculum, recumbent

patient. Forceps are retracting the posterior lip of the esophageal

mouth preparatory to removal. 11, Fungating squamous-celled

epithelioma in a man of seventy-four years. Fungations are not always

present, and are often pale and edematous. 12, Cicatricial stenosis of

the esophagus due to the swallowing of lye in a boy of four years.

Below tile upper stricture is seen a second stricture. An ulcer

surrounded by an inflammatory areola and the granulation tissue

together illustrates the etiology of cicatricial tissue. The

fan-shaped scar is really almost linear, but it is viewed in

perspective. Patient was cured by esophagoscopic dilatation. 13,

Angioma of the esophagus in a man of forty years. The patient had

hemorrhoids and varicose veins of the legs. 14, Luetic ulcer of the

esophagus 26 cm. from the upper teeth in a woman of thirty-eight

years. Two scars from healed ulcerations are seen in perspective on

the anterior wall. Branching vessels are seen in the livid areola of

the ulcers. 15, Tuberculosis of the esophagus in a man of thirty-four

years. 16, Leukoplakia of the esophagus near the hiatus in a man aged

fifty-six years.]



The hypopharynx tapers down to the gullet like a funnel, and the

larynx is suspended in its lumen from the anterior wall. The larynx is

attached only to the anterior wall, but is held closely against the

posterior pharyngeal wall by the action of the inferior constrictor of

the pharynx, and particularly by its specialized portion--the

cricopharyngeus muscle. A bolus of food is split by the epiglottis and

the two portions drifted laterally into the pyriform sinuses, the

recesses seen on either side of the larynx. But little of the food

bolus passes posterior to the larynx during the act of swallowing. It

is through the pyriform sinus that the esophagoscope is to be

inserted, thereby following the natural food passage. To insert the

esophagoscope in the midline, posterior to the arytenoids, requires a

degree of force dangerous to exert and almost certain to produce

damage to the cricoarytenoid joint or to the pharyngeal wall, or to

both.



The esophagoscope is steadied by the left hand like a billiard cue, the

terminal phalanges of the left middle and ring fingers hooked over the

upper teeth, while the left index finger and thumb encircle the tube

and retract the upper lip to prevent its being pinched between the

tube and upper teeth. The right hand holds the tube in pen fashion at

the collar of the handle, not by the handle. During introduction the

handle is to be pointed upward toward the zenith.





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