Oesophagoscopy

Oesophagoscopy
Oesophagoscopy is of three types:
1. Rigid oesophagoscopy.
2. Flexible fibreoptic oesophagoscopy.
3. Transnasal oesophagoscopy.
 INDICATIONS

DIAGNOSTIC
1. To investigate cause for dysphagia, e.g. cancer
oesophagus, cardiac achalasia, strictures, oesophagitis,
diverticulae,etc.
2. To find cause for retrosternal burning, e.g. reflux
oesophagitis or hiatus hernia.
3. To find cause for haematemesis, e.g. oesophageal
varices.
4. Secondaries neck with unknown primary (as a part of
panendoscopy).
THERAPEUTIC
1. Removal of a foreign body.
2. Dilatation in case of oesophageal strictures or
cardiac achalasia.
3. Endoscopic removal of benign lesions, e.g.
fibroma,papilloma, cysts, etc.
4. Insertion of Souttar’s or Mousseau–Barbin tube
in palliative treatment of oesophageal carcinoma.
5. Injection of oesophageal varices.
CONTRAINDICATIONS
1. Trismus—makes the procedure technically difficult.
2. Disease of cervical spine, e.g. cervical trauma, spondylosis,
tuberculous spine, osteophytes and kyphosis.
They make rigid oesophagoscopy technically difficult.
Flexible fibreoptic oesophagoscopy is performed in these
cases.
3. Receding mandible.
4. Aneurysm of aorta for fear of rupture and fatal
haemorrhage.
5. Advanced heart, liver or kidney disease may be a relative
contraindication.
ANAESTHESIA
• General anaesthesia with orotracheal
intubation with tube in the left corner of the
mouth.
• It can be performed under local anaesthesia in
selected individuals
 POSITION
Same as for direct laryngoscopy. Patient lies
supine, head is elevated by 10–15 cm, neck
flexed on chest and head extended at atlanto-
occipital joint. The purpose of this position is
to attain the axes of mouth, pharynx and
oesophagus in a straight line to pass the rigid
tube easily. This position can be achieved with
the help of an assistant or a special head rest.
 TECHNIQUE
1. A piece of gauze is placed over the upper teeth to protect
them or a dental guard.

2. Oesophagoscope is lubricated with a swab of autoclaved

liquid paraffin or jelly.

3. The oesophagoscope is held by its proximal end in a penlike

fashion and introduced into the mouth by the right
side of the tongue and then towards the middle of its
dorsum.
Now there are four basic steps:
1. Identification of arytenoids.
2. Passing the cricopharyngeal sphincter.
3. Crossing the aortic arch and left bronchus.
4. Passing the cardia.
 APPLIED ANATOMY
It is a fibromuscular tube, about 25 cm
long in an adult. It extends from the
lower end of pharynx (C6) to the
cardiacend of stomach (T11). It runs
vertically but inclines to the left from
its origin to thoracic inlet and again
from T7 to oesophageal opening in
the diaphragm.
It shows three normal constrictions and.
They are:
1. At pharyngo-oesophageal junction
(C6)—15 cm from the upper incisors.
2. At crossing of arch of aorta and left
main bronchus (T4)—25 cm from
upper incisors.
3. Where it pierces the diaphragm
(T10)—40 cm from upper incisors.
1.Identification of arytenoids.
• Once oesophagoscope has been introduced
to the back of tongue, it is advanced gently by
the left thumb and index finger. Epiglottis is
first seen, then the endotracheal tube and a
little further down arytenoids can be
identified.
2. Passing the cricopharyngeal sphincter. Keeping the tip of
oesophagoscope strictly in the midline, behind the larynx, it is lifted
with movements of left thumb to open the hypopharynx.

With slow but sustained pressure, the sphincter will open and then the
tip of oesophagoscope can be guided easily into the oesophagus.

Never apply force to open the sphincter. Sometimes, a fine bougie

can be used to find the lumen.

An additional dose of muscle relaxant may be required if sphincter

does not open.
Once oesophagus has been entered, it is easier to advance the scope,
provided oesophageal lumen is kept constantly in view.
3.Crossing the aortic arch and left bronchus. In
an adult, this natural narrowing lies about 25
cm from the incisors.
• Aortic pulsation can be seen. When crossing
this area, head of the patient is slightly
lowered so that oesophageal lumen is in line
with that of the scope.
• 4. Passing the cardia. Head and shoulders
remain 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. Cardia is identified by its
redder and more velvety or rugose mucosa
 POSTOPERATIVE CARE
Patient is watched for
1. Pain in the interscapular region,
2. Surgical emphysema of neck and
3. Abrupt rise of temperature.
• They indicate oesophageal perforation
 COMPLICATIONS
1. Injury to lips and teeth.
2. Injury to arytenoids.
3. Injury to pharyngeal mucosa..
4. Perforation of oesophagus. Most often it occurs at the site of
Killian’s dehiscence (near cricopharyngeal sphincter) when undue
force has been used to pass the oesophagoscope. Surgical
emphysema develops within an hour or so and the patient
complains of pain in the interscapular region. This may be
complicated by abscess in retropharyngeal space or mediastinum.
5. Compression of trachea. Oesophagoscope may press
on posterior tracheal wall, especially in children, causing
obstruction to respiration and cyanosis. Treatment is
immediate withdrawal of oesophagoscope
 FLEXIBLE FIBREOPTIC
OESOPHAGOSCOPY
Its main advantage over the rigid oesophagoscopy
is that it is an outdoor procedure, does not
require general anaesthesia and can be used in
patients with abnormalities of spine or jaw where
rigid endoscopy is technically difficult.

The oesophagus, stomach and duodenum can all be

examined in one sitting.
It is performed through the oral route by
gastroenterologists.
TRANSNASAL OESOPHAGOSCOPY
In contrast to flexible fibreoptic oesophagoscopy,
which is performed through the oral route by
gastroenterologists, transnasal oesophagoscopy
is performed through nose.
This flexible fibrescope has a working channel of 2
mm and the air can also be inflated through it to
distend the walls of oesophagus to look for any
lesion in its mucosal folds.
Oesophagus can be examined up to gastric fundus