Esophagoscopy continues to be a reliable diagnostic and therapeutic tool with a wide variety of applications, including biopsy, dilatation of strictures, repair of Zenker's diverticulum, placement of stents, and retrieval of foreign bodies.

2. OUTLINE
 Introduction
 Statement Of Surgical Importance
 Historical Perspective
 Indications
 Contraindications
 Relevant Anatomy
 Preoperative Management
 History
 Examination
 Investigations
 Instruments
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3. OUTLINE
 Anaesthesia
 Position
 Procedure
 Postoperative Management
 Complications
 Alternatives
 Conclusion
 References
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4. INTRODUCTION
 Esophagoscopy is the technique of choice to evaluate
the mucosa of the esophagus and detect structural
abnormalities
 Allows a direct visual examination of the interior of the
esophagus
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5. STATEMENT OF SURGICAL IMPORTANCE
 Rigid esophagoscopy poses challenges and
complexities and therefore requires adequate training.
 This presentation will discuss the goals, indications,
contraindications, techniques for a successful
esophagoscopy.
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6. HISTORICAL PERSPECTIVE
 Bozzini, in 1806, was the first physician to report the
ability to visualize the proximal esophagus.
 Kussmaul performed the first rigid esophagoscopy in
1868.
 Advances in equipment continued to be made through
the work of physicians such as Von Mikulicz (1881),
Einhorn (1897), and Jackson (advances in endoscopic
instruments).
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7. HISTORICAL PERSPECTIVE
 While advances in equipment, lighting, and optics
were being made in rigid instrumentation, a major
advance toward flexible esophagoscopy was made
through the work of Hirschowitz and associates
 Three who presented the first fiberoptic gastroscope in
1957.
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8. HISTORICAL PERSPECTIVE
 Shaker, a gastroenterologist, published the first report
of unsedated transnasal esophagogastroduodenoscopy
(EGD) in 1994.
 The appeal of unsedated transnasal esophagoscopy
(TNE) grew among the otolaryngology community,
particularly after the reports of Herrmann and Recio
and the live demonstration by Aviv and colleagues in
2001.
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9. INDICATIONS
 DIAGNOSTIC
 THERAPEUTIC
 INTERVENTIONAL
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10. INDICATIONS
 DIAGNOSTIC
 Chronic upper abdominal pain
 Upper GI bleeding
 Dysphagia
 Stricture
 As a part of upper GI endoscopy
 Esophageal cancer
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11. INDICATIONS
 THERAPEUTIC
 Foreign body removal
 Stricture management
 Esophageal varices management
 Esophageal stenting
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12. INDICATIONS
 INTERVENTIONAL
 For insertion of percutaneous endoscopic gastrostomy
 Cauterization and endoscopic clip deployment
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13. CONTRAINDICATIONS
 ABSOLUTE
 Hemodynamic instability
 Possibility of perforation
 Failure to obtain consent
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14. CONTRAINDICATIONS
 RELATIVE
 Coagulopathy
 Pharyngeal diverticulum
 History of procedure intolerance
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15. RELEVANT ANATOMY
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16. RELEVANT ANATOMY
 The esophagus runs from the cricopharyngeal
sphincter to the oesophageal hiatus in the diaphragm
and cardia of the stomach.
 The oesophagus is a muscular rube which is 25cm in
length and 2.3-2.5cm in transverse diameter.
 The cricopharyngeal inlet lies, on average, 15cm from
the upper incisors.
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17. RELEVANT ANATOMY
 The indentation of the oesophagus by the aortic arch,
as it crosses from anterior to lateral on the left side, lies
at a distance of 25cm
 The gastro-oesophageal junction at approximately 40
cm from the anterior incisors.
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18. RELEVANT ANATOMY
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 During its course, the axis of
the oesophagus initially runs
in the midline, but once the
halfway point is reached it
tends to curve anteriorly and
slightly to the left.
 In order to pass a rigid
oesophagoscope, it is
therefore essential to align
the oral and oesophageal
inlet along the same axis.

19. INSTRUMENTS
 Rigid Esophagoscope
 Suction
 Bougie
 Light source / carrier
 Camera / monitor
 Forceps
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20. INSTRUMENTS
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21. PREOPERATIVE MANAGEMENT
 Full history should be obtained from the patient, and
all previous and current medical records should be
reviewed.
 A full physical examination should be performed, with
special attention given to the oral cavity and pharynx.
 The existence of poor dentition should be
documented.
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22. PREOPERATIVE MANAGEMENT
 Patients fast for 6 hours prior to the examination.
 Dentures and glasses are removed.
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23. PREOPERATIVE MANAGEMENT
 Barium study
 Chest X ray
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24. PREOPERATIVE MANAGEMENT
 FBC
 EUCr
 RBG
 Clotting profile
 Additional general anaesthesia investigations when
required
 Obtain an informed and written consent
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25. ANAESTHESIA
 General anaesthesia
 With ETT+ muscle relaxation
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26. POSITIONING
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 Patient lies supine with
extension of head and neck
 Surgeon stands at the head of
the table

27. PROCEDURE
 The position is maintained by placing the forefinger of
the left hand on the hard palate and palatal surface of
the incisor teeth, while the lower lip is retracted using
the third finger.
 The oesophagoscope is inserted into the mouth and
advanced until the uvula is visualised.
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28. PROCEDURE
 The Esophagoscope is then lowered such that it rests
on the thumb of the left hand, thus protecting the
upper dentition.
 The thumb is used to advance the scope.
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29. PROCEDURE
 The aim of observation via the lumen of the scope is to
maintain the centre of the lumen through which it is
intended to pass the scope.
 The scope is then advanced into the hypopharynx off-
centre, such that it is possible to visualise the right
aryepiglottic fold and the right pyriform sinus.
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30. PROCEDURE
 The scope is then advanced into the pyriform sinus
and swept into the midline as it is advanced, so that it
comes to lie behind the posterior lamina of the cricoid.
 At this point, the puckered inlet at the
cricopharyngeus should become visible.
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31. PROCEDURE
 Gentle dilatatory pressure with the beak of the
oesophagoscope at this point should be maintained
until cricopharyngeal relaxation is achieved and the
tip of the oesophagus passes with ease into the upper
oesophagus
 Once the endoscope is in the upper oesophageal
lumen, its tip is advanced, using similar rotatory
movements and left thumb pressure, until the
pulsating indentation of the aortic arch is identified
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32. PROCEDURE
 At this point, the esophagus will tend to curve
anterolaterally to the left and this may cause some
difficulty with the advancement of the scope.
 In kyphotic patients it may be necessary to extend the
back and thus align the axes of the upper and lower
oesophageal segments.
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33. PROCEDURE
 The distal segment of the oesophagus should then be
examined in the same manner, but with great care
 Given that the directional stability of the tip of the
oesophagoscope is somewhat reduced by the
reduction in the lever arm between the proximal end
of the oesophagoscope and the fulcrum on the left
thumb.
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34. PROCEDURE
 Care should be taken to assess not only the mucosal
integrity of the oesophageal lumen, but also the
presence of any reflux or indenting mass lesion.
 Examination should be continued during the removal
of the endoscope.
 Particular attention should be paid to the
cricopharyngeal inlet and postcricoid regions
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35. PROCEDURE
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36. POST OPERATIVE MANAGEMENT
 Following IV sedation most patients require between
15 and 30min on a trolley before being able to be
transferred to a chair to recover.
 By 1h postprocedure, patients are able to be discharged
home with supervision.
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37. POST OPERATIVE MANAGEMENT
 Where the examination has been uneventful and there
has been no recognisable laceration or breach of the
oesophageal mucosa, the patient should be kept on
clear fluids for 6h postoperatively.
 Thereafter a normal diet may be reintroduced.
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38. POST OPERATIVE MANAGEMENT
 Given the risk of silent perforation, close attention
should be paid to the acute onset of pain.
 Where oesophageal perforation is recognised, initial
treatment may be conservative.
 Continuous close observation is essential during this
period as further deterioration indicates that open
surgical closure of the perforation may be necessary.
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39. POST OPERATIVE MANAGEMENT
 Healing may be assessed with contrast studies, and
where recovery is protracted it may be necessary to
institute parenteral feeding.
 Where there is gross thoracic contamination open
closure is indicated.
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40. COMPLICATIONS
 Perforation
 Haemorrhage
 Infection
 Cardiopulmonary problems
 Adverse reaction to medications
 Aspiration, over sedation, hypoventilation, and airway
obstruction account for more than 50% of major
complications related to upper esophagoscopy
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41. ALTERNATIVES
 Flexible Esophagoscopy
 Transnasal esophagoscopy
 Esophageal capsule endoscopy
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42. CONCLUSION
 Rigid esophagoscopy allows endoscopic inspection and
management of the esophagus.
 Rapid technical advances in endoscopy have led to
changes in indications for different procedures.
 The recommendations for esophagoscopy are designed
to provide ENT and affiliated specialties guidance for
choosing and processing instruments and sedation
methods.
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43. THANK YOU
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44. REFERENCES
 Thomson HG & Batch AJ (1989) Flexible oesophagogastroscopy in otolaryngology. J.
Laryngo. Otol. 103, 399-1103
 Sabirin J, Abd Rahman M, Rajan P. Changing trends in oesophageal endoscopy: a
systematic review of transnasal oesophagoscopy. ISRN Otolaryngol 2013; 2013: 586973.
 Hall CHT, Nguyen N, Furuta GT, Prager J, Deboer E, Deterding R, et al. Unsedated In-
office Transgastrostomy Esophagoscopy to Monitor Therapy in Pediatric Esophageal
Disease. J Pediatr Gastroenterol Nutr. 2018 Jan. 66 (1):33-36.
 American Gastroenterologic Association medical position statement: guidelines on the
use of esophageal pH recording. Gastroenterology. 1996;110:19811996.
 American Society for Gastrointestinal Endoscopy. The role of endoscopy in the
surveillance of premalignant lesions of the upper gastrointestinal tract. Gastrointest
Endosc. 1998;48:663-668.
 Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al.
Complications of upper GI endoscopy. Gastrointest Endosc. 2002 Jun. 55 (7):784-
93. [Medline].
 Andrus JG, Dolan RW, Anderson TD. Transnasal esophagoscopy: a high-yield diagnostic
tool. Laryngoscope. 2005;115:993-996.
 Aviv JE, Takoudes TG, Ma G, et al. Office-based esophagoscopy: a preliminary report.
Otolaryngol Head Neck Surg. 2001;125:170-175.
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45. REFERENCES
 Som, M. L.: Endoscopy in Diagnosis and Treatment of Diseases of Esophagus. J. Mt. Sinai
Hosp. 23: 56-74, 1956.
 Lerche, W.: The Esophagus and Pharynx in Action: A Study of Structure in Relation to
Function. Springfield, Ill., Charles C Thomas, 1953, pp. 48-50.
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