Flexible esophagoscopy as part of routine panendoscopy in ENT resident and fellowship training.

Abstract

We conducted a retrospective study to evaluate the use of flexible esophagoscopy as part of routine panendoscopy in an academic setting. We reviewed the results of 378 procedures that were performed over a 4-year period in an academic otolaryngology--head and neck surgery program for residents and fellows. Medical records were reviewed for early and late complications as well as for adequacy of the examination. We found no immediate or long-term complications associated with flexible esophagoscopy. Adequate examination was achieved in all but two cases (99%), both of which involved patients who had significant strictures related to radiation therapy and who were not able to be evaluated by rigid esophagoscopy. We conclude that flexible esophagoscopy is a safe and accurate means of evaluating the esophagus during a panendoscopic evaluation of the upper aerodigestive tract, and that it should be included in the diagnostic armamentarium of every otolaryngology--head and neck surgery resident and fellow.

Introduction

Panendoscopy is an important diagnostic tool for evaluating patients for head and neck malignancies. A panendoscopic procedure includes nasopharyngoscopy, laryngoscopy, bronchoscopy, and esophagoscopy. For many years, esophagoscopy was performed with a rigid, end-illuminated, open-tube scope, which had been designed by Jackson in the early part of the 20th century. [1] In addition to the diagnosis of esophageal disease, its early uses included foreign body removal and stricture dilation. In 1957, Hirschowitz developed the first clinically functional flexible esophagoscope, which featured a fiberoptic light source, a circumferential magnified view, and channels for instrumentation and suction. [2] As the use of the flexible esophagoscope continues to be refined, an increasing number of otolaryngologists have incorporated it into their routine panendoscopy procedure. [3,4] Moreover, the flexible esophagoscope can play an important role in educating otolaryngology--head and neck surgery residents and fellows in the anatomy and pathophysiology of the esophagus. It provides a safe and effective means of visualizing the esophagus either directly or via a video monitor.

The purpose of the study described in this article was to evaluate the use of flexible esophagoscopy as part of routine panendoscopy in the academic otolaryngology setting.

Patients and methods

We performed a retrospective review of 378 flexible esophagoscopy procedures that had been performed between June 1995 and June 1999 at an academic tertiary care center. We determined the adequacy of each examination by reviewing the charts and operative reports of patients who had undergone flexible esophagoscopy as part of panendoscopy for the diagnostic evaluation of upper aerodigestive tract malignancies. We also evaluated the intraoperative, short-, and long-term postoperative complications associated with flexible esophagoscopy.

All of the flexible esophagoscopy procedures were performed after the completion of direct laryngoscopy while the patient was still under general anesthesia. The flexible esophagoscope was placed into the upper cervical esophagus under direct visualization. The sliding Jackson laryngoscope was not used to introduce the flexible esophagoscope because its light port can damage the cover portion of the esophagoscope. The esophagoscope was used to examine the area from the upper cervical esophagus to the gastroesophageal junction. The stomach was entered when necessary, and it was decompressed upon removal.

The cricopharyngeal portion of the upper esophagus was visualized by slowly removing the esophagoscope during insufflation. Biopsies of suspicious esophageal lesions were obtained as needed.

Results

Between 1995 and 1999, 378 flexible esophagoscopies were performed by residents and fellows under the supervision of attending staff. All of these procedures were part of the diagnostic evaluation of the upper aerodigestive tract for head and neck malignancies.

Adequate examination of the esophagus was achieved in all but two cases (99%). In both cases, neither a flexible nor rigid esophagoscope could be passed because these patients had significant strictures related to radiation therapy. Flexible esophagoscopy found evidence of esophageal carcinoma in one patient. There were no immediate or long-term complications associated with the flexible esophagoscopy component of the panendoscopy. Furthermore, no patient who had a negative examination developed secondary esophageal cancer following the diagnostic panendoscopy, which suggests that lesions were not being missed.

Discussion

Gastroenterologists were the first to exploit the advantages of the flexible fiberoptic esophagoscope. Since then, many otolaryngologists have adopted it into their practices. Otolaryngologists use this tool to evaluate suspected upper aerodigestive tract malignancies, benign inflammatory conditions, esophageal strictures, and esophageal foreign bodies and to assist in the placement of percutaneous gastrostomy tubes. [3-5]

Several other studies have found that the flexible fiberoptic esophagoscope is safe, effective, and reliable. [3,4,6] Its flexibility has made esophageal endoscopy possible for patients who have diminished cervical spine mobility, trismus, or a history of irradiation. [7] The risk of esophageal perforation with flexible esophagoscopy has been reported to range from 0.018 to 0.119%, compared, with a range of 0.074 to 1.0% with rigid esophagoscopy? [3]

The instrument's ability to suction, irrigate, insufflate, and incorporate grasping instruments has broadened its area of otolaryngologic application. It can be used to evaluate the esophageal lumen, lower esophagus, and the stomach. Its usefulness is enhanced by its ability to magnify and project images onto video monitors and recorders. In teaching situations, the procedure allows residents and fellows to critically review their differential diagnoses and surgical technique with senior physicians.

It is important to recognize the limitations of flexible fiberoptic esophagoscopy. For example, its role in evaluating the upper esophagus, removing impacted or immobile esophageal foreign bodies, and dilating an esophageal stricture is still unclear. Several authors have reported that the upper esophageal sphincter is a difficult area to examine with a flexible esophagoscope. [6,7] This problem can be overcome by visualizing the upper esophagus while slowly withdrawing the esophagoscope and by using the direct laryngoscope. [4]

The incidence of a second esophageal primary tumor in patients diagnosed with squamous cell carcinoma of the head and neck varies from 0.3 to 7.4%. [8] In our study of 376 completed procedures, we found only one esophageal carcinoma (0.27%). The fact that none of the 375 patients who had negative findings on esophagoscopy later developed esophageal carcinoma indicates that lesions were not being missed.

Although the incidence of a second esophageal primary tumor in this study fell at the lower end of the spectrum, we feel that esophageal evaluation remains an important aspect of comprehensive management of upper aerodigestive tract malignancies. We conclude that flexible esophagoscopy is a safe and accurate means of evaluating the esophagus during a panendoscopic examination of the upper aerodigestive tract.

From the Department of Otolaryngology, University of Pennsylvania School of Medicine, Philadelphia (Dr. Kim), the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston (Dr. Deschler), and the Department of Otolaryngology--Head and Neck Surgery, MCP-Hahnemann University School of Medicine, Philadelphia (Dr. Hayden).

Reprint requests: Michael K. Kim, MD, Department of Otolaryngology, University of Pennsylvania School of Medicine, S. Silverstein/Ravdin, 3400 Spruce St., Philadelphia, PA 19104. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

References

(1.) Jackson C. Tracheobronchoscopy, esophagoscopy and gastroscopy. St. Louis: Laryngoscope Co., 1907:13.

(2.) Hirschowitz BI. A fibre optic flexible oesophagoscope. Lancet 1963;13:388.

(3.) Bacon CK, Hendrix RA. Open tube versus flexible esophagoscopy in adult head and neck endoscopy. Ann Otol Rhinol Laryngol 1992;l0l:147-55.

(4.) Glaws WR, Etzkorn KP, Wenig BL, et al. Comparison of rigid and flexible esophagoscopy in the diagnosis of esophageal disease: Diagnostic accuracy, complications, and cost. Ann Otol Rhinol Laryngol 1996;105:262-6.

(5.) Urban KG, Terris DJ. Percutaneous endoscopic gastrostomy by head and neck surgeons. Otolaryngol Head Neck Surg 1997;116:489-92.

(6.) Batch AJ. The role of fibreoptic oesophagogastroscopy in E.N.T. practice. J Laryngol Otol 1985;99:783-91.

(7.) Olsen AM. Chevalier Jackson lecture. Esophagology: An update. Ann Otol Rhinol Laryngol 1982;91:551-7.

(8.) Deleyiannis FW, Weymuller EA Jr., Garcia I, Potosky AL. Geographic variation in the utilization of esophagoscopy and bronchoscopy in head and neck cancer. Arch Otolaryngol Head Neck Surg 1997;123:1203-10.