Rigid Upper Esophagoscopy

Richard Davis
Introduction:

As technology developed and flexible

fiberoptic upper endoscopy became more
widespread, rigid esophagoscopy became less
commonly used. The advantages of flexible over
rigid esophagoscopy include less anesthesia
requirement and less risk of perforation or other
iatrogenic injury. Another advantage of a flexible
fiberoptic approach is increased visualization, as
rigid esophagoscopy involves examination through a
long narrow metal tube. 47cm rigid esophagoscope with attachment for fiberoptic light
cable (Red Arrow,) suction cannula of suitable length (Top) and
One distinct location where rigid
brush for cleaning (Bottom.) The upper forceps is for biopsy
esophagoscopy is in the “back of the throat,” and the lower two are for foreign body removal. The entire
including the oropharynx, hypopharynx, upper esophagus to the gastroesophageal junction can be inspected
esophageal sphincter, and cervical esophagus. It is with this scope.
difficult to visualize this area well on flexible
endoscopy, even with adequate topical and If one is attempting to visualize only the
intravenous sedation anesthesia, due to the gag hypopharynx, upper sphincter, and the first 5cm of
reflex. Without general anesthesia, it is practically the cervical esophagus, it is quite acceptable to use a
impossible to perform any significant intervention, #4 or larger Miller (straight blade) laryngoscope.
such as foreign body removal or biopsy of lesions This allows one to use the Yankauer suction and the
above the upper sphincter. Magill forceps. We frequently use this strategy when
The indications for rigid esophagoscopy removing foreign bodies, when they are lodged in the
include: Foreign body removal from the oropharynx, hypopharynx or at the upper esophageal sphincter.
hypopharynx, or cervical esophagus, or other
intervention at the cervical esophagus such as biopsy
or dilation. It can also be performed as part of a direct
operative laryngoscopy and biopsy, as the surgeon
inspects all of the upper aerodigestive tract. Another
potential indication is need to examine any of the
esophagus, in the absence of a flexible
esophagoscope. While it is possible to perform rigid
endoscopy all the way to and through the lower
esophageal sphincter, this is progressively more
difficult the farther one goes. In a low-resource
setting without access to a flexible scope, this would
be an acceptable alternative, supplemented with
barium upper gastrointestinal studies to assess the
stomach and duodenum.
Rigid esophagoscopes generally come in
various lengths; it is advisable to use the shortest one The 4 Miller laryngoscope’s blade is a straight lighted tube. It
can be used to inspect, biopsy, or remove foreign objects from
possible, as visualization and instrumentation the hypopharynx, upper esophageal sphincter, and first 5cm of
becomes more difficult with longer tubes. the cervical esophagus.

The steps of rigid esophagoscopy consist of:

● Induction of general anesthesia and intubation
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Richard Davis
● Extending the neck using a head ring and
shoulder roll
● Insertion of the scope and advancement under
direct visualization
● Biopsy or intervention
● Repeat inspection to confirm hemostasis or
complete removal of the object without
perforation.

Steps:
1. Ask the patient to extend the neck to assess range
of motion. This helps to avoid injury by
hyperextension once the patient is anesthetized.
2. Induce general anesthesia and intubate.
Communicate the anticipated length of the
procedure to avoid inappropriate administration Insert the scope through the mouth with the bevel facing
of a long-acting anesthetic or paralytic. posteriorly. When the tip reaches the mucosa of the posterior
3. Extend the neck using a head ring and shoulder oropharynx (Red arrow) advance it in a caudal direction while
maintaining gentle pressure in a posterior direction. Keeping
roll. To avoid iatrogenic injury, make sure the the scope in the midline directs its tip into the upper esophageal
head is resting solidly on the head ring and sphincter (Blue Arrow.)
cannot be rotated or extended further. See
Pitfalls, below.

Extension of the neck with a head ring and shoulder roll allows
the passage of a straight instrument through the mouth, down The beveled tip of the scope faces posterior, allowing the scope
the esophagus all the way to the gastroesophageal junction. to be gently advanced in the direction shown by the Red Arrow.
.
4. Rotate the table 90 degrees away from the 6. Taking care to avoid injury to the upper incisors,
anesthesia station to allow the surgeon room to direct the tip of the scope in a caudal direction
maneuver. Raise the table to a comfortable height while applying gentle pressure against the
or sit on a stool. posterior oropharynx and hyopoharynx. Keep the
5. Insert the scope with the bevel facing downward tip of the scope in the midline as you advance.
until the tip contacts the posterior oropharyngeal Use a folded gauze or an athletic mouthguard to
mucosa. protect the teeth.
7. You will encounter some slight resistance at the
upper esophageal sphincter. Stop at this point,
pull back slightly, and direct the scope to the left

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 Rigid Upper Esophagoscopy
Richard Davis
and right to inspect the pyriform sinuses, a further, it is supported by the cervical spine and not the head
frequent location for foreign bodies to become ring. The head ring should be raised to avoid this situation.
impacted. Be sure to remain posterior to the
● The scope can chip or fracture the upper incisors
endotracheal tube to avoid dislodging it.
or lacerate the upper lip, especially as the
8. Return to the midline and insert the scope into the
surgeon’s attention is directed deeper in the
esophagus as far as needed.
throat. The less the patient can open their mouth
9. Use retrieval forceps, suction, or biopsy forceps
or extend the neck, the more likely this is. A soft
to perform an intervention.
rubber mouthguard from a pharmacy or sporting
10. Inspect biopsy sites or sites of foreign body
goods store can protect this area. Patients with
impaction to confirm hemostasis or lack of deep
loose upper incisors should be advised that some
injury to mucosa.
injury may be unavoidable.
● Anesthesia may seem sufficient until a scope is
Pitfalls
inserted into the throat, triggering the gag reflex.
● If patient has trismus, a short wide neck, or
Stop and wait for the anesthetist to deepen the
decreased range of neck mobility, you may not
anesthesia.
be able to extend their neck sufficiently to allow
● The hypopharynx or cervical esophagus can be
a straight scope to pass into the esophagus.
lacerated by careless suctioning, deep biopsy, or
Assess the neck range of motion prior to
the presence of a foreign body for 24 hours or
induction of anesthesia.
more. Be very mindful of this complication and
● When a shoulder roll is in place, the neck will be
inspect carefully upon completing the
extended. The head ring should be at a level that
endoscopy. Use Barium esophagoscopy to rule
it supports the head. The head should not be
out perforation or to assess the depth of
supported by the vertebral column. Once the head
perforation and presence of extravasation.
ring is in place, assure that it supports the head
● In case of perforation, have a very low threshold
by pushing gently downwards on the forehead. If
for surgical exploration and repair. If a contrast
the head moves downwards, you are
study shows passage into the parapharyngeal
hyperextending the cervical spine. Place some
space or mediastinum, exploration is mandatory.
stacked blankets under the head ring to raise it up
Simply making the patient “NPO” is not
until it is supporting the head. Serious injury can
sufficient, as the average adult swallows 1.5L of
result from neglecting this step!
saliva per day. Neck exploration for esophageal
perforation is discussed in a separate chapter.

Pushing gently downward on the patient’s head after extension

of the neck with a head ring and shoulder roll. If the head moves

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 Rigid Upper Esophagoscopy
Richard Davis

Lateral view Barium swallow study shows extravasation of

contrast from the posterior hypopharynx area. The Red Arrow
shows the point of extravasation, and the Blue Arrow shows
passage of the contrast inferiorly into the mediastinum. This
patient will require surgical exploration, debridement, and
repair of the perforation. Case courtesy of RMH Core
Conditions, https://radiopaedia.org/?lang=us From the case
https://radiopaedia.org/cases/26313?lang=us

Richard Davis, MD FACS FCS(ECSA)

AIC Kijabe Hospital
Kenya

January 2022

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