Office procedures for the esophagus.
Since the days of Chevalier Jackson, esophagoscopy has undergone numerous changes. With the introduction of high-resolution optics and distal-chip camera technology, esophagoscopes can now be inserted through the nose with topical anesthesia alone. The entire upper aerodigestive tract--from the nasal vestibule to the gastric cardia and gastroesophageal junction--can be easily and safely visualized. (1-4)
Indications. The indications for TNE continue to evolve. The authors' indications for performing diagnostic TNE are somewhat broad. We use it primarily as a screening examination for patients with significant laryngopharyngeal or gastroesophageal reflux, dysphagia, strictures, or moderate to severe globus. We also use it extensively for screening and biopsy in patients with head and neck cancer. (2)
Equipment. Various vendors provide transnasal esophagoscopes (figure 1, A). The scope must be of adequate length to allow for a retroflexed view of the gastric cardia and gastroesophageal junction; therefore, the scope should extend at least 60 cm, and perhaps 65 cm. In addition, its diameter should be narrow enough to allow for comfortable transnasal passage in most patients (outer diameter: 4.9 to 5.2 mm). The scope must also be equipped with an air insufflation port and an irrigation port. A side or working channel for biopsy and suction is also necessary.
[FIGURE 1 OMITTED]
A recent advance in technology is the introduction of the distal-chip endoscope. This allows for greatly improved optics. A less expensive alternative is to use a fiberoptic transnasal esophagoscope attached to a standard endoscopic camera. Although such scopes do not have internal ports, protective sheaths with external working channels (Vision Sciences; Natick, Mass.) are available that can be placed over the scopes (figure 1, B). Another advantage of fiberoptic scopes, in addition to their lower cost, is that they require less time to clean. However, they are not as good as distal-chip scopes with respect to image quality and brightness. The effect that this difference in resolution has on the sensitivity and specificity of the examination is not clear.
Technique. With the patient seated upright in an examination chair, topical anesthesia is administered to the nasal cavity. (Administration of topical anesthesia is described in the first article in this supplement, "Topical anesthesia of the airway and esophagus," page 2.)
The endoscope is often held in a manner called the fishing pole method (figure 2, A). We prefer to insert the scope and hold it in place with the left hand while manipulating the controls with the right hand. Many pulmonologists and gastroenterologists prefer to reverse the position of the hands and hold the proximal end of the endoscope in a more upright fashion (figure 2, B). Each surgeon should determine which method is most comfortable for him or her.
[FIGURE 2 OMITTED]
The endoscope (VE-1530; Pentax Precision Instrument Corp.; Orangeburg, N.Y., and the Olympus PEF-V; Olympus America; Melville, N.Y.) is then lubricated (viscous lidocaine may be used) and passed through the nasal cavity, either along the floor of the nose or between the middle and inferior turbinates, and into the pharynx. As we do this, we observe nasopharyngeal closure, the tongue base, the hypopharynx, and the vocal fold motion, and we look for the possible pooling of oral secretions. We then have the patient flex the head toward the chest as the endoscope passes toward the esophageal inlet. Once there, we ask the patient to swallow, and as he or she does, we advance the instrument into the esophagus (figure 3, A). Our standard practice is to rapidly advance the instrument carefully through the esophagus and into the gastric cardia for a retroflexed view of the cardia and the gastroesophageal junction (figure 3, B). This is accomplished by rotating the entire scope 180[degrees] and maximally deflecting the endoscope's tip 120[degrees]. In many cases, extra air must be insufflated into the stomach to provide room for visualization. After the cardia and gastroesophageal junction are examined, the air should be suctioned from the stomach.
[FIGURE 3 OMITTED]
Using a combination of air insufflation, suction, and irrigation, we examine the mucosa of the entire esophagus as we withdraw the scope. We withdraw it deliberately to ensure that we see all mucosal surfaces. During peristalsis, the view of the esophagus will be briefly blocked by a white-out as the walls of the esophagus contract and saliva flows past the tip of the scope. The examiner must be patient and allow the peristaltic wave to pass before continuing the examination, so that the entire lumen of the esophagus can be seen. When we notice a mucosal lesion or other irregularity, we pass a biopsy forceps through the working channel and obtain multiple biopsies (figure 3, C).
A difficult passage through the upper esophageal sphincter should alert the examiner to the possibility of a hypertonic sphincter or a Zenker's diverticulum. If this is the case, the examiner should perform a particularly gentle investigation or abort the procedure altogether. (5)
One common error is overinsufflation, which can cause the patient significant discomfort. Air should be insufflated gently until all mucosal surfaces can be completely visualized, and then it may be suctioned out as needed to avoid distention. This is particularly important if the patient has previously undergone fundoplication.
Study results. Several of the authors of this supplement conducted a study of 700 consecutive patients who had undergone TNE between Oct. 1, 2000, and June 1, 2003. (6) All of these procedures were performed at either the Center for Voice and Swallowing Disorders at Wake Forest University in Winston-Salem, N.C., or the Scripps Center for Voice and Swallowing in La Jolla, Calif. TNEs were successfully completed in 677 patients (96.7%). All but 2 of the 23 failures were attributable to an inability to pass the scope through the nasal vault.
Just over half of our patients had significant findings (figure 4; table). The number of patients who had long-segment Barrett's esophagus or esophageal candidiasis--33 (4.7%) and 28 (4.0%), respectively--was somewhat surprising. None of the candidiasis patients exhibited any oropharyngeal manifestations, and only 1 was immunocompromised. Only 8 patients (1.1%) experienced a complication--6 had self-limited epistaxis, and 2 had a minor vasovagal reaction.
[FIGURE 4 OMITTED]
The moderately high prevalence of esophageal pathologies in otolaryngology patients makes TNE a valuable addition to our diagnostic armamentarium. (1) It is also useful for obtaining biopsies of lesions in the laryngopharynx (see "Office-based procedures for the voice," page 6) and the esophagus. Finally, it can be used to detect second primaries in patients with carcinoma of the head and neck or dysphagia following cancer therapy. (2) We have experienced no complications related to biopsies.
Patients who have undergone total laryngectomy benefit from vocal rehabilitation via the placement of a prosthesis in a tracheoesophageal fistula. This procedure has been well accepted and widely practiced since it was first described by Singer and Blom in 1980. (7)
Tracheoesophageal puncture (TEP) can be performed as either a primary procedure (i.e., at the time of laryngectomy) or a secondary procedure (i.e., following maturation of the traeheostoma). Many surgeons perform secondary TEP in order to optimize placement of the puncture and to avoid the complications that have been associated with primary placement. (8) Secondary TEP is usually performed in the operating room with a rigid esophagoscope while the patient is under general anesthesia. (4-6) Some flexible techniques have also been reported. (9-11)
Since the introduction of TNE, we have gained experience in performing TEP in the clinic setting. (12) Office TEP is associated with significant cost savings, and it requires neither sedation nor general anesthesia. TEP allows for direct visualization of the surgical site in the neopharynx throughout the duration of the procedure, thereby ensuring maximum safety and appropriate and immediate placement of the voice prosthesis. TEP has also proven to be very useful for the replacement of extruded voice prostheses in cases where the tracheocutaneous fistula has partially closed. (13)
Equipment. The equipment typically required to perform TEP includes a transnasal esophagoscope, a local anesthetic (1 to 2% lidocaine with epinephrine), a #15 scalpel blade, a hemostat, a TEP dilator, and a TEP sizer. A variety of differently sized prostheses should be available.
Technique. Patients who undergo secondary TEP must have a large-enough stoma; it is also preferable that they not have a neopharyngeal stricture. The procedure requires two surgeons, and it is performed while the patient is seated upright. After standard TNE anesthesia has been administered, the patient is asked to swallow approximately 5 ml of a viscous 2% lidocaine solution. Next, a solution of 1 to 2 ml of 1% lidocaine and 1:100,000 epinephrine is injected into the posterior tracheal wall at the area of the planned TEP site.
Approximately 10 minutes is required for the infiltrative anesthesia and vasoconstriction to occur. When they do, the transnasal esophagoscope is lubricated and passed into the neopharynx. If significant neopharyngeal stenosis is seen, the esophagoscope is gently advanced through the affected segment, and a guide wire is passed under direct vision. The scope is then withdrawn over the wire, and the proximal end of the wire is withdrawn via the oral cavity for dilation (as described later in this article).
Identification of the TEP site is made from within the lumen by visualizing the tip of a hemostat placed against the prospective site. Both surgeons are able to see the video monitor throughout the entire procedure. Once the site is determined, an 18- to 20-gauge needle is passed in the midline through the posterior tracheal wall and anterior wall of the esophagus (figure 5,A). Appropriate positioning is verified on the monitor prior to the penetration of the esophageal mucosa. The needle is withdrawn, and the incision is made with the scalpel blade. A hemostat may be spread within the incision to ease the subsequent passage of the dilator (figure 5, B). Again, careful observation ensures that there is no contact with the posterior esophageal wall during the creation and manipulation of the puncture. Insufflation via the esophagoscope provides maximal anteroposterior distention of the esophageal lumen during the procedure and protects the posterior esophageal wall. TEP dilators are then passed under direct vision through the puncture and into the esophagus (figure 5, C).
[FIGURE 5 OMITTED]
A speech-language pathologist sizes the puncture, and an appropriate prosthesis is selected and placed via the gelcap technique. The gelcap holds the inner flanges of the prosthesis together to aid in its insertion, and then it rapidly dissolves, allowing the "opening" of the flange in the neopharyngeal lumen. Under direct vision, the dissolving of the gelcap is confirmed and appropriate positioning is verified (figure 5, D). The duration of the procedure, not including time for anesthesia and vasoconstriction, is less than 10 minutes. The patient is then able to immediately begin working with the speech-language pathologist.
Esophageal dilation requires a transnasal esophagoscope, Savary dilators, a vascular guide wire, and a large hemostat or Kelly clamp. In our experience--as well as that of some gastrocnterologists, according to Larry Johnson, MD (oral communication, July 2003)--this technique is particularly useful for treating high esophageal strictures. Savary dilators (Wilson-Cook Medical; Winston-Salem, N.C.) are over-the-wire dilators that are used primarily by gastroenterologists (figure 6, A).
[FIGURE 6 OMITTED]
The technique involves inserting the esophagoscope into the area of the stricture (figure 6, B). The guide wire is placed through the scope's working channel and advanced through the stricture under direct vision. As the guide wire is maintained in place, the scope is removed. At this point, the guide wire is protruding from the patient's nose. The wire is extracted with a hemostat so that it now protrudes from the patient's mouth. At this point, well-lubricated Savary dilators are placed over the wire, and the stricture is gently opened with sequentially larger Savary dilators. (14)
Esophageal foreign bodies
In general, we do not advocate using TNE to remove esophageal foreign bodies, although we have used it to push some foreign bodies distally into the stomach. (15-17) Prior to pushing the foreign body, debris around it must be suctioned. Air is then insufflated to facilitate examination of the area and identify the cause of the impaction. Often-times, significant esophagitis, a stricture, a diverticulum, or a tumor is seen. (18)
When it appears that gently pushing the foreign body into the stomach will not be difficult, this can be accomplished with air insufflation, with biopsy forceps through a working channel, or with the endoscope itself. If difficulty is encountered, the patient can be taken to the operating room for rigid esophagoscopy or referred for upper endoscopy under intravenous sedation. After the foreign body is removed, it is critical to determine the cause of the foreign body impaction and to reevaluate the area for signs of trauma.
Table. TNE findings in 700 consecutive patients (6) Finding n (%) * Normal 340 (48.6) Esophagitis 117 (16.7) Hiatal hernia 51 (7.3) Barrett's esophagus 33 (4.7) Candidiasis 28 (4.0) Stricture 28 (4.0) Carcinoma 27 (3.9) Abnormal motility 20 (2.9) Polyp 14 (2.0) Patulous gastroesophageal 11 (1.6) junction Foreign body 7 (1.0) Diverticulum 5 (0.7) Web 5 (0.7) Tracheoesophageal fistula 2 (0.3) Procedure unsuccessful 23 (3.3) * Some patients had more than one finding.
(1.) Belafsky PC, Postma GN, Daniel E, Konfman JA. Transnasal esophagoscopy. Otolaryngol Head Neck Surg 2001;125:588-9.
(2.) Postma GN, Bach KK, Belafsky PC, Koufman JA. The role of transnasal esophagoscopy in head and neck ontology. Laryngoscope 2002;112:2242-3.
(3.) Aviv JE, Takoudes TG, Ma G, Close LG. Office-based esophagoscopy: A preliminary report. Otolaryngol Head Neck Surg 2001;125: 170-5.
(4.) Bampton PA, Reid DP, Johnson RD, et al. A comparison of transnasal and transoral oesophagogastroduodenoscopy. J Gastroenterol Hepatol 1998;13:579-84.
(5.) Postma GN, Belafsky PC, Koufman JA. The evaluation of esophageal function with transnasal esophagoscopy. Presented at the annual meeting of the American Academy of Otolaryngology--Head and Neck Surgery; Sept. 21, 2003; Orlando, Fla.
(6.) Postma GN, Belafsky PC, Koafman JA. Transnasal esophagoscopy revisited: 700 consecutive cases. Presented at the annual meeting of the Southern Section of the Triological Society; Jan. 9, 2004; Marco Island, Fla.
(7.) Singer MI, Blom ED. An endoscopic technique for restoration of voice alter laryngectomy. Ann Otol Rhinol Laryngol 1980;89: 529-33.
(8.) Maniglia AJ, Lundy DS, Casiano RC, Swim SC. Speech restoration and complications of primary versus secondary tracheocsophagcal puncture following total laryngectomy. Laryngoscope 1989;99:48991.
(9.) Hong GS, John AB, Theobald D, Soo KC. Flexible endoscopic tracheo-oesophageal puncture under local anaesthetic. J Laryngol Otol 1995;109:1077-9.
(10.) Eerenstein SE, Schouwenburg PF. Secondary tracheoesophageal puncture with local anesthesia. Laryngoscope 2002;112:634-7.
(11.) Desyatnikova S, Caro JJ, Andersen PE, et al. Tracheoesophageal puncture in the office setting with local anesthesia. Ann Otol Rhinol Laryngol 2001;110:613-6.
(12.) Bach KK, Postma GN, Koufman JA. In-office tracheoesophageal puncture using transnasal esophagoscopy. Laryngoscope 2003; 113: 173-6.
(13.) Belafsky PC, Postma GN, Koufman JA. Replacement of a failed tracheoesophageal puncture prosthesis under direct vision. Ear Nose Throat J 2001;80:862.
(14.) Postma GN, Belafsky PC, Koufman, JA. Dilation of an esophageal stricture caused by epidermolysis bullosa. Ear Nose Throat J 2002;81:86.
(15.) Clyne S, Bach KK, Postma GN, Koufman, JA. Foreign body in the esophagus. Ear Nose Throat J 2002;81:440.
(16.) Belafsky PC, Halsey WS, Postma GN, Koufman JA. Distal esophageal meat impaction. Ear Nose Throat J 2002;81:702.
(17.) Belafsky PC, Halsey WS, Postma GN, Koufman JA. Cervical esophageal foreign body. Ear Nose Throat J 2003;82:24.
(18.) Bach KK, Postma GN, Koufman JA. Esophageal carcinoma discovered during evaluation of food impaction. Ear Nose Throat J 2002;81:620.
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|Author:||Belafsky, Peter C.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Jul 1, 2004|
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