Stage 2

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

Passing the cricopharyngeus is the most difficult part of

esophagoscopy, especially if the patient is unanesthetized. Local

anesthesia helps little, if at all. The handle of the esophagoscope is

still pointing upward and consequently we are sure that the lip of the

esophagoscope is directed anteriorly. Force must not be used, but

steady firm pressure against the tonically contracted cricopharyngeus

is made, while at the same time the distal end of the esophagoscope is

lifted by the left thumb. At the first inspiration a lumen will

usually appear in the upper portion of the endoscopic field. The tip

of the esophagoscope enters this lumen and the slanted end slides over

the fold of the cricopharyngeus into the cervical esophagus. There is

usually from 1 to 3 cm. of this constricted lumen at the level of the

cricopharyngeus and the subjacent orbicular esophageal fibers.

[109] [FIG. 67.--Schematic illustration of the author's high-low

method of esophagoscopy. In the first and second stages the patient's

head fully extended is held high so as to bring it in line with the

thoracic esophagus, as shown above. The Rose position is shown by way

of accentuation.]

[FIG. 68.--Schematic illustration of the anatomic basis for difficulty

in introduction of the esophagoscope. The cricoid cartilage is pulled

backward against the cervical spine, by the cricopharyngeus, so

strongly that it is difficult to realize that the cricopharyngeus is

not inserted into the vertebral periosteum instead of into the median


[FIG. 69.--The upper illustration shows movements necessary for

passing the cricopharyngeus.

The lower illustration shows schematically the method of finding the

pyriform sinus in the author's method of esophagoscopy. The large

circle represents the cricoid cartilage. G, Glottic chink,

spasmodically closed; VB, ventricular band; A, right arytenoid

eminence; P, right pyriform sinus, through which the tube is passed in

the recumbent posture. The pyriform sinuses are the normal food