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Introduction Of The Esophagoscope

Source: 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).

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

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.

Next: Stage I Entering The Right Pyriform Sinus

Previous: Entering The Bronchi

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