Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 196 - файл
.pdf
ab
1 Clinical Diagnostic Nasopharyngolaryngoscopy
https://t.me/med1917
17
a
b
c
Fig. 1.13 (a) Severe retroexion of the epiglottis. (b) Same patient; view of the larynx with rotation manoeuvre (and NBI imaging). (c) Same
patient; view of same larynx on phonation showing glottic gap and severe muscle tension
Fig. 1.14 (a) Neutral. (b) The head tilted forward in a modied Killian’s position
1.7.4.6 Trachea
In a normal endoscopy, the view of the larynx is on a posterior/
anterior oblique angle. To get a view down the airway, the
scope must be moved forward to come into alignment with the
descending airway. To do this, the head must be moved forward slightly and the chin tucked down in a modied Killian’s
position (Fig.1.14). This will bring the tip of the scope above
the larynx and a view down to the carina will be obtained.
18
https://t.me/med1917
N. Gibbins and H. Galera-Ruiz
1.8 Imaging Modalities
Until quite recently, white light imaging (WLI) was the only
means of looking at the larynx. FNs are designed along the
principles of passing light along exible light source that
shines from the tip of the scope. The image is transported
back through the scope along a series of bres and when any
of these breaks, the light no longer passes up them giving the
image black spots and overall the image is pixelated.
These scopes are those that are very commonly used in
clinics globally requiring the user to either look through the
eyepiece or attach a camera to the scope to allow projection
onto a screen. The larger the screen, the more pixelated the
image became. More recently, chip-tip FNs have allowed a
much higher-denition image to be obtained. The image is
captured by the “chip” that is housed at the end of the scope
and then transported electronically to the screen. This means
the light has only to reach the tip of the scope rather than
passing along the length of the scope, and subsequently,
there is no pixilation of the image and the quality is much
higher. There are no eyepieces on chip-tip scopes as the
image is passed as an electrical signal rather than as light, so
one must have a linked processor or stack system to be able
to view the image.
With the progression of technology, different light modalities have been incorporated into these scopes to allow a
greater range of examination possibilities and, hopefully, to
allow the clinician to gain a greater diagnostic capability.
Two of the most commonly used are narrow band imaging
and stroboscopy.
1.8.1 Blue Light Imaging (BLI)
This is a technique that enhances the view of the supercial
mucosa vascularity. It is named differently by different endoscope manufacturers (see below), but the principle is the
same.
Some common endoscope manufacturers and their named
light sources include
green areas of the spectrum. This means that when WLI is
employed, the whole light spectrum is absorbed by the tissues differentially and reected with blood vessels shining
red, because the blue and green are absorbed and not
reected. Accentuating the blue and green light and reducing
the red spectrum means that red is not reected and the blue
and green is absorbed but not reected by the haemoglobin.
The blood vessels show up dark green or black.
In addition, the shorter wavelengths of the spectrum only
penetrate the most supercial tissues so that the epithelial
and immediate subepithelial vessels are highlighted with
precision and clarity. With WLI, the longer wavelengths
(red) penetrate deeper into the tissues and reect back, causing a slight defocussing of the image, even with highdenition equipment. This means that a benet of BLI is of
sharp-contrast images of the mucosa without the use of dyes.
BLI has been shown to be superior to WLI in the detection of mucosal squamous cell carcinoma (SCC) in a number
of studies [15–17]. It also appears to be a promising imaging
modality in the differentiation between benign and premalignant conditions [18]. A vascular pattern classication
has been proposed by Ni etal. that shows great promise and
may help the clinician decide whether to biopsy an indeterminate lesion or have the condence to monitor as an outpatient [19] (Fig.1.15).
As with any technique or novel piece of equipment, it
should be used regularly to get an appreciation of how it
works with normal tissue as well as with the abnormal.
Therefore, as the BLI is simply a button to press, the authors
would advocate using it on every patient the has an endoscope passed as part of their examination. This will ensure
the clinician becomes accustomed to what normal tissues
look like under BLI and then be able to ascertain how clearly
abnormal tissues differ under BLI.Once these ends of the
pathology spectrum are recognised, then and only then can
diagnostic decisions about intermediary stages (IPCL III, IV,
and possibly Va—see above) be attempted.
1.8.2 Others (OCT/Strobe)
Olympus Narrow Band Imaging (NBI)
Pentax iScan
Xion Piet
Storz Spectra
The light source is changed from WLI, that uses all of the
wavelengths of the visible spectrum, to more focussed wavelengths. They concentrate around the blue and green spectra,
at 415nm (blue and 540nm (green). The rest of the visible
spectrum is reduced to almost nothing.
Haemoglobin, like all matter, has an absorption spectrum
of light, but it has two main absorption peaks in the blue and
Stroboscopy is an instrument rather than a technique per se
and works by making cyclically moving objects appear slowmoving. This can be very helpful in examining the vocal
folds as when phonating the folds vibrate hundreds of times
per second. When viewed with the naked eye, this appears as
a blur; so, small lesions on the edges of the vocal folds that
only become apparent when the vocal folds are vibrating are
sometimes only seen when the stroboscopy is employed.
Stroboscopy is routinely employed in specialist voice
clinics, but when looking for malignant lesions in and around
the larynx, it is less useful. However, the post-radiotherapy
larynx patient often has hoarseness due to stiffening of the
1 Clinical Diagnostic Nasopharyngolaryngoscopy
https://t.me/med1917
19
a1
a2
a3
Fig. 1.15 IPCL classication (From [19]; with permission)
supercial lamina propria and reduced or asymmetrical
vibration of the vocal folds. This asymmetry will be picked
up on stroboscopy, as will acyclical waveforms.
As technology advances, newer experimental imaging
modalities may be added to either the endoscopy software or
hardware, allowing the clinician to examine the upper aerodigestive tract in a number of different ways to get a multifaceted assessment of a lesion.
One such modality is optical coherence tomography
(OCT). This currently involves placing a light source close to
the tissue in question. This “scans” the tissue up to a few millimeters in depth and registers the differential reection of
light. This is turn can be turned into an image showing different tissue characteristics. This has been termed an “optical
biopsy.” It has been shown both invivo and exvivo studies to
correlate well with histological sections and appears to be
able to distinguish between healthy and abnormal tissues in
a number of organs.
As the technology is miniaturised, it could be incorporated into the chip-tip software so that one can imagine an
endoscopic FN examination in clinic to involve WLI, BLI,
OCT, and stroboscopy. This could be followed by a biopsy
under local anaesthetic and a full diagnostic workup could be
done in one sitting.
b1
b2
b3
c1
c2
c3
d1
d2
d3
1.9 Extended Uses
Recent technological advancements in the types of transnasal endoscopes, instrument miniaturisation, and topical
anaesthetic techniques have led to a shift in management
from the operation room to ofce-based settings. This
enables clinicians to perform procedures under topical
anaesthesia, such as transnasal oesophagoscopy (TNE), ex-
e1
e2
e3
ible endoscopic biopsy (FEB), or certain exible endoscopic
procedures. A exible endoscopic laryngeal laser-assisted
surgical technique has been recently proposed for patients
with early glottic cancer and difcult laryngoscopy (trismus
secondary to previous maxillofacial trauma requiring complex surgery, signicant restriction of cervical spine mobility, or marked glossomegaly secondary to severe obstructive
sleep apnoea) [20].
f1
f2
f3
g1
g2
g3
1.9.1 Transnasal (O)Esophagoscopy (TNE)
Unsedated transnasal esophagogastroduodenoscopy
(T-EGD) was initially introduced by gastroenterologist
Shaker [21]. However, it was not widely adopted by his colleagues, presumably because of a lack of familiarity with
nasal anatomy or a reluctance to perform EGD without intravenous sedation. Because of a greater acceptance among
head and neck surgeons, TNE has evolved into an important
addition to the diagnosis and treatment of dysphagia, globus,
and other disorders of the oesophagus, such as squamous cell
carcinoma [22, 23]. Since then, TNE has been extensively
reported on, and has proved to accurately diagnose oesophageal pathology [23]. Several studies showed better patient
acceptability and less cardiopulmonary stress (i.e. rise in
blood pressure and heart rate) during TNE, compared to transoral esophagoscopy [23].
Most oesophageal pathologies are found in patients suffering from both globus pharyngeus and dysphagia; thus,
this combination might be a strong indication to perform
TNE (). An ongoing point of discussion is the screening for
second primary tumours in the oesophagus in patients with
hypopharyngeal carcinoma, given the relatively higher incidence of oesophageal carcinoma in these patients [23].
20
https://t.me/med1917
N. Gibbins and H. Galera-Ruiz
Traditional diagnostics consisted of exible pharyngolaryngoscopy, video uoroscopy, rigid oesophagoscopy under
general anaesthesia, and referral to a gastroenterologist in
cases requiring exible oesophageal inspection. Furthermore,
in the diagnostic workup of hypopharyngeal carcinoma,
inspection of the proximal oesophagus has been usually performed under general anaesthesia to determine the distal border of the tumour. With the introduction of TNE, patients
with suspected hypopharyngeal carcinoma can have it performed in ofce the same day to identify the distal border of
the tumour and biopsies taken if necessary. Ofce-based
TNE is a signicant cost savings procedure, for patients with
globus pharyngeus and/or dysphagia, and suspicion of hypopharyngeal carcinoma. Furthermore, this procedure has good
patient acceptance and few complications [22].
The goal of TNE is to evaluate the oesophageal inlet and
the upper third of the oesophagus in order to stage adequately
hypopharyngeal pathology or detect upper third oesophageal
cancer.
1.9.1.1 Technique
TNE can be performed as a continuation or not of exible
hypopharyngeal evaluation. The procedure is performed
with the patient sitting upright in an examination chair
across from the endoscopist. Two sprays of 20% benzocaine are then administered to the oropharynx. The endoscope is lubricated with 2% viscous lidocaine. The examiner
waits at least 5min to allow the topical anaesthesia to take
effect. The patient’s head is then exed forward towards
their chest (Killian’s manoeuvre) as the bre-optic scope is
passed towards the cricopharyngeus muscle (Fig. 1.16).
The patient is asked to swallow or belch, and the instrument
is gently advanced. Our standard practice is to advance the
instrument as far as it gets. Using a combination of air
insufation and irrigation, the mucosa of the oesophagus
can be examined whilst the scope is slowly withdrawn. If
mucosal lesions or irregularities are noted, biopsy forceps
are passed through the biopsy port and multiple biopsies
are obtained.
1.9.2 Flexible Endoscopic Biopsies (FEB)
Advanced stage laryngopharyngeal cancer has poor prognosis and early diagnosis is crucial for improving treatment
results and survival [22]. The initial work-up starts in the
ofce with history, physical examination, and imaging
request, despite a biopsy being essential for the histological
diagnosis. Traditionally, the biopsy of laryngopharyngeal
lesions has been performed under general anaesthesia; nevertheless, Ofce-based FEB is reported to be safe, feasible,
cost-effective, and easy to perform [23]. The advantages are
an awake patient who is sitting in an upright position and able
to control laryngeal function during the procedure, which can
result in adequate visualisation. Furthermore, there is avoidance of general anaesthesia with possible health benets and
its costs are relatively low. By arranging a fast diagnostic
track, patients are evaluated sooner by the pathologist
(<1week) and the diagnostic process can be shortened.
The disadvantages of FEB are the need for a cooperative
patient (e.g. able to sit still, minimal gag reex) and the
inability to perform deep biopsies of submucosal tumours.
1.9.2.1 Technique
After acquiring informed consent from the patient, the pharynx and larynx are sprayed with 10% lidocaine spray transorally, just prior to the procedure. In case of a laryngeal
biopsy, additional anaesthesia is injected intratracheally
(1.0mL of 10% lidocaine) through the cricothyroid membrane and topically on the vocal cords.
Biopsies are obtained using a 2.0mm diameter working
channel and a single-use 1.8 mm diameter exible biopsy
forceps. During biopsy, the exible videoendoscope is
inserted transnasally in a sitting position. After visualisation
of the laryngopharyngeal lesion, a biopsy fórceps is passed
through the working channel. The lesion is approached with
an open jaw biopsy forceps, pushed deep into the lesion, and
closed. The biopsy forceps is then pulled back swiftly, whilst
feeling for resistance when removing the tissue from the suspected lesion, which indicates a deeply taken biopsy.
ab
cd
1 Clinical Diagnostic Nasopharyngolaryngoscopy
https://t.me/med1917
21
Fig. 1.16 (a–d) The patient’s head is then exed forward towards their chest (Killian’s manoeuvre) as the bre-optic scope is passed towards the
cricopharyngeus muscle
1.10 Summary
tioned in this Chapter will be possible. However, the caveat
is that none of these will be possible without good knowl-
FN has revolutionised the examination of the upper aerodigestive tract and the scope of use has now extended beyond
the connes of pure examination into the treatment of pathology. In-ofce procedures are becoming more commonplace
edge of the equipment and sound FN examination technique
by the clinician. Whenever a clinician thinks that a technique
has been mastered, it is always worth going back to the
basics to check.
and as technology advances, more adjuncts to those men-
22
https://t.me/med1917
N. Gibbins and H. Galera-Ruiz
More technology will surely be incorporated into the software available on the FN equipment so that a patient will be
able to undergo an array of diagnostic investigations in the
out-patient setting followed by a biopsy. In one visit, it may
be possible for the patient to get a complete diagnosis and a
treatment plan. The future of out-patient endoscopy is very
bright.
References
1. Garritano FG, Goldenberg D.Telemedicine in otolaryngology head
and neck surgery. Ear Nose Throat J. 2012;91:226–7.
2. Quimby AE, Kohlert S, Caulley L, etal. Smartphone adapters for
exible nasolaryngoscopy: a systematic review. J Otolaryngol Head
Neck Surg. 2018;47:30.
3. Hiss S, Postma G.Fiberoptic endoscopic evaluation of swallowing.
Laryngoscope. 2003;113:1386–93.
4. Shah JP, Shaha AR, Spiro RH, etal. Carcinoma of the hypopharynx. Am J Surg. 1976;132:439–43.
5. Lee KD, Lu CH, Chen PT, etal. The incidence and risk of developing a second primary esophageal cancer in patients with oral and
pharyngeal carcinoma: a population-based study in Taiwan over a
25year period. BMC Cancer. 2009;9:373.
6. Watanabe A, Hosokawa M, Taniguchi M, etal. Impact of endoscopic screening on early detection of hypopharyngeal cáncer.
Head Neck. 2006;28:350–4.
7. Ni XG, Zhang QQ, Zhu JQ, etal. Hypopharyngeal cancer associated with synchronous oesophageal cancer: risk factors and benets of image-enhanced endoscopic screening. J Laryngol Otol.
2018;132:154–61.
8. Tsunoda A, Ishihara A, Kishimoto S, etal. Head torsion technique
for detailed observation of larynx and hypopharynx. J Laryngol
Otol. 2007;121:489–90.
9. Spraggs PD, Harries ML. The modied Valsalva manoeuvre to
improve visualization of the hypopharynx during exible nasopharyngoscopy. J Laryngol Otol. 1995;109:863–4.
10. Hillel AD, Schwartz AN. Trumpet maneuver for visual and CT
examination of the pyriform sinus and retrocricoid area. Head
Neck. 1989;11:231–6.
11. Purser S, Antippa P.Maneuver to assist examination of the hypopharynx. Head Neck. 1995;17:389–93.
12. Sakai A, Okami K, Ebisumoto K, et al. New techniques to
detect unknown primaries in cervical lymph node metastasis.
Laryngoscope. 2010;120:1779–83.
13. Murono S, Tsuji A, Endo K, etal. Evaluation of modied Killian’s
method: a technique to expose the hypopharyngeal space.
Laryngoscope. 2014;124:2526–30.
14. Ni XG, Cheng RR, Lai SQ, etal. Novel laryngoscopic strategies to
improve evaluation of the site and extent of primary hypopharyngeal tumours. J Laryngol Otol. 2013;127:882–9.
15. Chu PY, Tsai TL, Tai SK, Chang SY.Effectiveness of narrow band
imaging in patient with oral squamous cell carcinoma after treatment. Head Neck. 2012;34(2):155–61.
16. Lin YC, Wang WH, Lee KF, Tsai WC, Weng HH.Value of narrow
band imaging endoscopy in early mucosal head and neck cancer.
Head Neck. 2012;34(11):1574–9.
17. Piazza C, Dessouky O, Peretti G, Cocco D, De Benedetto L,
Nicolai P.Narrow-band imaging: a new tool for evaluation of head
and neck squamous cell carcinomas. Review of the literature. Acta
Otorhinolaryngol Ital. 2008;28(2):49–54.
18. Bertino G, Caciola S, Fernandes WB Jr, etal. Effectiveness of narrow band imaging in the detection of premalignant and malignant
lesions of the larynx: validation of a new endoscopic clinical classication. Head Neck. 2015;37(2):215–22.
19. Ni XG, He S, Xu ZG, etal. Endoscopic diagnosis of laryngeal cancer and precancerous lesions by narrow band imaging. J Laryngol
Otol. 2011;125(3):288–96.
20. Karkos PD, Stavrakas M, Markou K. Early glottic cancer and
difcult laryngoscopy: exible endoscopic diode laryngeal laserassisted surgery—a pilot study of an oncologically safe tool. Clin
Otolaryngol. 2016;41:830.
21. Shaker R. Unsedated trans-nasal pharyngoesophagogastroduodenoscopy (T-EGD): technique. Gastrointest Endosc. 1994;40:346–8.
22. Mohammed H, Del Pero M, Coates M, etal. Ofce-based transnasal esophagoscopy biopsies for histological diagnosis of head and
neck patients. Laryngoscope. 2019;129:2721–6.
23. Wellenstein DJ, Honings J, Schutte HW, et al. Cost analysis of
ofce-based transnasal esophagoscopy. Eur Arch Otorhinolaryngol.
2019;276:1457–63.
Transnasal Oesophagoscopy
https://t.me/med1917
andAdvanced Applications
YakubuKaragama, AinaBrunet-Garcia, NatalieA.Watson,
andAsitArora
2
2.1 Introduction
Transnasal oesophagoscopy (TNO) is a specialised channelled bre-optic endoscope that allows the practitioner to
perform a full endoscopic examination of the upper aerodigestive tract in an ofce set-up under local anaesthetic.
Although not entirely new, TNO is still not widely practiced
worldwide [1–3]. It is not known why TNO has not been so
widely adopted, but there are suggestions that initially there
were doubts on the ability to examine the post-cricoid area
fully, the cost of setting up such a service, and the relevant
experience required. Most recently, however, there has been
a gradual increased interest in this practice possibly owing to
the added features on the TNO endoscope, such as the working channel, suction and insufation, and the length of the
TNO, which has made it possible to perform both diagnostic
and therapeutic examination of the entire aerodigestic tract
in the ofce under local anaesthetic.
Y. Karagama
Guy’s and St Thomas’s NHS Foundation Trust, London, UK
ENT Department, Guy’s Hospital, London, UK
e-mail: Yacubu.Karagama@gstt.nhs.uk
A. Brunet-Garcia
Department of Otorhinolaryngology and Head and Neck Surgery,
Guy’s and St Thomas NHS Foundation Trust, London, UK
e-mail: aina.brunet@nhs.net
N. A. Watson
ST8 Otolaryngology, Guy’s and St Thomas’s NHS Foundation
Trust, London, UK
e-mail: nataliewatson@nhs.net
A. Arora (*)
Department of Head and Neck Surgery, Guy’s and St Thomas’s
NHS Foundation Trust, London, UK
e-mail: asitarora@doctors.org.uk
2.2 Indications forTNO
• Examination of the pharynx, oesophagus, stomach, and
duodenum, also known as Video Panendoscopy (VIP)
examination of the aerodigestive tract.
• Balloon dilatation in the management of dysphagia
caused by cricopharyngeal spasm or hypertonicity, web
or stricture (particularly after surgery or after radiotherapy treatment), or oesophageal ring.
• Placement of Bravo™capsule for pH monitoring.
• Insertion of nasogastric tube.
• Removal of foreign body in the aerodigestive tract.
• Biopsy of lesions in the upper aerodigestive tract.
• Laser therapy for ablation of lesions with bre KTP, blue
laser, or bre CO2 laser.
• Secondary tracheo-oesophageal puncture and placement
of speech valve.
• Cancer surveillance, especially in post-cricoid
tumours.
2.3 Equipment Set-up
• Video stack system.
• Transnasal oesophagoscope.
• Local anaesthetic (LA).
• Extra equipment depends on transnasal intervention, for
example biopsy (biopsy forceps), injection (injectable
substance and injectable applicator), laser (exible KTP,
blue light or CO2 laser), balloon dilatation (balloons of
different sizes and pump), oesophageal speech valve, or
Bravo™capsule for pH monitor etc.
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_2
23
24
https://t.me/med1917
Y. Karagama et al.
2.4 TNO Procedures
2.4.1 Technique forTNO
This procedure is performed in the outpatient set-up with the
patient sitting up comfortably. The nasal passage is anaesthetised with 2.5mL of lidocaine 5% HCL w/v with phenylephrine 0.5% w/v. The throat is further sprayed with 5–10 puffs
of 10% lidocaine oral spray. The TNO (Fig. 2.1) is introduced transnasally and the nasal cavity, pharynx, and larynx
are inspected before passing the TNO into the oesophageal
inlet. It is important to ask the patient to swallow immediately when the TNO is placed in the piriform fossa and gentle pressure is applied until the upper oesophagus is
visualised. Sometimes the oesophagus may need to be insufated to enhance visualisation. This is mostly helpful during
examination of the gastro-oesophageal junction. It is important not to over-inate the stomach. This can be avoided by
aspirating the air every so often.
2.4.2 TNO-Guided Balloon Dilatation
2.4.2.1 Preoperative Preparation
Full clinical history and examination and patient selection
based on symptoms, examination ndings, and diagnosis
from Barium swallow and TNO ndings.
2.4.2.2 Materials
– There are different sizes of balloon, but most patients will
require a 20mm size. There are different manufacturers,
for example Cook® Medical and Boston Scientic balloons that are suitable.
– Pressure pump syringe (size 60mL for Cook® Medical)
– Transnasal oesophagoscope and a Videostack system (e.g.
from PENTAX Medical, Olympus, Storz, and DP medicals are available)
– 2.5mL lidocaine HCL 5% w/v and phenylephrine HCL
0.5% w/v topical nasal spray
– 2mL of 10% Xylocaine throat spray
2.4.3 Procedure
This procedure is performed with the patient sitting up at
approximately 60°. Good topical anaesthesia of the nasal
passages and pharynx is essential in order to complete the
whole procedure successfully. This can be achieved with at
least 2 mL local anaesthetic spray in both nasal cavities
±2mL of 4% lidocaine nebuliser. A mild sedation may be
required in anxious and nervous patients.
A transnasal oesophagoscopy is performed to examine
the larynx and pharynx. The TNO is advanced into the upper
oesophagus transnasally via the most patent of the two nasal
cavities. A full oesophagoscopy down to the gastrooesophageal junction and into stomach may be performed at
this stage if necessary.
Once the TNO is placed past the cricopharyngeus muscle,
a guide wire (Fig.2.2a) is introduced through the TNO channel until the guide wire tip emerges at the distal end of the
TNO.The TNO is then withdrawn out of the patient completely, whilst the guide wire remains in the oesophagus. It is
not always possible to pass the TNO through the cricopharyngeus muscle especially in a very tight stricture. In such
cases, the TNO is placed over the piriform fossa and the
guide wire introduced into the cricopharyngeal inlet under
direct view. The guide wire is only about 1.5mm in diameter,
so it can usually be introduced through the smallest stricture
unless there is a complete blockage of the stricture. In such
Fig. 2.1 A transnasal oesophagoscope (TNO) with labels to the nger controls, channel, suction, insufation buttons, and dials to control the
movement of the tip
Finger
control
5 mm
Suction &
insufflation
2mm channel
2 Transnasal Oesophagoscopy andAdvanced Applications
https://t.me/med1917
a
25
Fig. 2.2 (a) Cook® Medical balloon; (b) TNO balloon dilatation
26
https://t.me/med1917
b
Fig. 2.2 (continued)
Y. Karagama et al.
cases, a retrograde dilatation might be necessary via a percutaneous endoscopic gastrostomy (PEG) tube route.
Once the guide wire tip is placed beyond the stricture, the
TNO is re-introduced nasally via the most patent nasal cavity. The un-inated balloon is then passed over the guide
wire nasally until it passes through the area to be dilated.
Both TNO and the balloon cables may be passed via the
same nostril if the opposite nasally is too narrow. The balloon
is positioned with the proximal metallic silver marker visible
approximately 1cm above the level to be dilated. The balloon is then inated (Fig.2.2b) using the pressure pump
syringe until 20 mm (6 atm, 60 Fr) full dilatation (for a
18-19-20 balloon). This is then deated after 1min and the
balloon is removed with the guide wire. In some cases of
webbing, two 20mm balloons (40mm) maximum may be
used simultaneously. However, this carries a higher risk of
perforation and may be more painful requiring more
sedation.
2.4.4 Postoperative Instruction
The authors recommend the patient to be nil by mouth for
40–60min post-procedure. Most patients will be day cases
unless there are any complications: oesophageal tear. If such
unfortunate complications occur, the patient will be managed nil by mouth until a water-soluble contrast swallow test
is performed to check for a perforation.
2.5 Complications
The main signicant complication is oesophageal perforation, but this is rare with this technique with only one
reported perforation reported [4]. Other minor complications are bleeding, nose or throat pain, need for further
procedures, and failure of the procedure to improve
symptoms.
2.5.1 TNO-Guided Removal Foreign Body
A foreign body in the throat such as a sh bone may be
removed with the use of TNO and exible forceps in the
ofce under LA (Fig.2.3).
2.5.2 TNO andSuspected Head andNeck
Malignancy
TNO is a safe and reliable adjunct to panendoscopy under
general anaesthesia for the assessment of patients with suspected head and neck lesions [5–8]. In particular, patients
with potentially suspicious head and neck lesions who are
not t for general anaesthesia are good candidates for TNO
to provide a tissue diagnosis. This can help to expedite management and initiate treatment by allowing radiotherapy, for
example, to commence in a timely fashion. Moreover, appro-
Соседние файлы в папке @xirurgi_2025