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2 Transnasal Oesophagoscopy andAdvanced Applications
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Fig. 2.3 TNO removal of a shbone foreign body in the left tongue base area
27
priately selected patients can also be treated expediently with
transoral laser surgery using the TNO channelled scope. For
instance patients with laryngeal dysplasia who following
laser intervention can then undergo serial endoscopic surveillance with photo-documentation and narrow band imaging in the outpatient setting.
An appropriately well-established TNO clinic allows the
patient pathway to potentially be expedited, minimising
unnecessary delay in denitive treatment as it can be performed as an ofce procedure [9].
TNO permits standard screening of the oesophagus,
which could also be applied to specic subsites of head
and neck cancer, such as hypopharyngeal carcinoma, in
which patients show a higher incidence of oesophageal
carcinoma [6].
2.5.2.1 TNO-Guided Biopsy
A biopsy may be obtained in the ofce setting following
topical administration of LA via the TNO using a exible
biopsy forceps (Fig.2.4a, b).
2.5.2.2 TNO-Guided Laser Therapy
Laser bre laryngopharyngeal procedures can also be performed in the ofce under LA via the channel endoscope
TNO.The laser type may be blue laser, KTP, or CO2 bre. The
nasal cavity, pharynx, and larynx are anaesthetised with 2.5mL
lidocaine HCl 5% w/v and phenylephrine HCl 0.5% w/v topical nasal spray and 2 mL of 10% Xylocaine throat spray.
Examples of lesions that can be removed with laser include
recurrent laryngeal papilloma (Fig.2.5a, b), vocal cord polyps,
granuloma (Fig.2.5c), leukoplakia, and Reinke’s oedema.
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a
b
Fig. 2.4 (a) Flexible biopsy forceps; (b) Biopsy right vocal cord polyp in the ofce via TNO
a
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b
Fig. 2.5 (a) TNO laser recurrent laryngeal papilloma. (b) TNO laser of recurrent laryngeal papilloma (1) pre-procedure, (2) peri-procedure, (3)
post-procedure; (c) TNO laser of left vocal process granuloma (1) pre-procedure, (2) peri-procedure, (3) post-procedure
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c
Fig. 2.5 (continued)
2.6 TNO Tracheo-oesophageal Puncture
A secondary tracheo-oesophageal puncture (TOP) can be
performed using rigid oesophagoscopy under general anaesthesia or by TNO under general or local anaesthesia. In
patients who have undergone salvage surgery following previous radiotherapy, neck mobility is often signicantly
impaired and this can be compounded by unfavourable biometrics, such as limited mouth opening. These factors can
make adequate exposure challenging and increase the risk of
inadvertent endoluminal mucosal trauma. TNO is therefore a
valuable adjunct in challenging cases to optimise views of
the oesophagus/neo-pharyngo-oesophagus due to its inherent endoscopic exibility. For appropriately selected, compliant patients, there is also the additional potential benet of
avoiding the need for a general anaesthesia all together.
2.6.1 Materials
The equipment required to perform secondary tracheooesophageal puncture in the ofce under LA via the TNO:
– Speech valve (Fig.2.6a)
– 1% lidocaine injection with adrenaline 1:200,000 (to be
injected at the posterior tracheal wall)
– 2.5 mL lidocaine HCl 5% w/v and phenylephrine HCl
0.5% w/v topical nasal (in the nasal nostrils)
– Transnasal oesophagoscope.
2.6.2 Procedure
The endoscope is advanced towards the most patent nasal
nostril and is directed into the oesophagus. Air insuation
allows us to maintain the operative view. The light at the tip
of the endoscope will need to transilluminate the area where
the valve should be inserted. The puncture needle should be
inserted on the aforementioned area (Fig.2.6b) and checking
the intraesophageal area where the needle is inserted by
direct vision with the endoscope (Fig.2.6c). Care must be
taken not to puncture and damage the TNO.The guide wire
needs to be inserted into the puncture needle until it exits
through the oral cavity. The next step would be to attach the
a
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valve to the tip of the wire and to retract it towards the
oesophagus (Fig.2.6d) until it exits at the level of the posterior tracheal wall where it needs to be placed (Fig.2.6e).
2.6.3 Training
Otolaryngologists with appropriate skills and competency
performing bre-optic nasolaryngoscopy are well placed to
acquire the fundamental competencies required for the TNO
technique. Nonetheless, there is still a learning curve with
regards to the clinical skills of diagnosing functional oesoph-
ageal and organic pathology as well as the different invasive
techniques under LA.It is also of paramount importance to
have a well-trained support team comprising of an assistant
(medical, speech and language therapist, nurse, or healthcare
assistant). A TNO training workshop is recommended, and it
is advisable also to visit an expert to watch a live procedure.
As an otolaryngologist, it is essential to visit your local
endoscopy suite and to liaise closely with the radiologist,
gastroenterologist, and upper gastrointestinal surgeons.
Otolaryngologists, gastroenterologists, and upper gastrointestinal surgeons with appropriate training may perform this
procedure.
b
Fig. 2.6 (a) Speech valve; (b) Tracheo-oesophageal puncture (TOP) ; (c) Trocar being introduced into the oesophagus via tracheal puncture site;
(d) Speech valve 10 being retracted transorally; (e) Speech valve in situ
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c
d
e
Fig. 2.6 (continued)
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2.7 Discussion
Flexible endoscopic techniques and its applications have
notably improved during the last few decades enabling a
revolution of ofce-based procedures under LA for procedures that were conventionally performed in the operating
room under general anaesthesia. Transnasal oesophagoscopy
and its advanced applications is now an established practice
in the UK.The use of this technique will continue to increase
in the foreseeable future as the associated technology with
the evolution and improvements of the endoscopic image
capability and interventional tools inherent with TNO.This
process is evidently ongoing and driven by commercial competition in the market by manufacturers.
Compared to the more traditional exible transoral
oesophagoscopy, TNO provides similar diagnostic accuracy,
but it is better tolerated by the patient [6]. TNO allows accelerated diagnostic and therapeutic phases for patients with
head and neck cancer, and it is crucial when it comes to
patients unt for a general anaesthetic. Patient selection is
important as they need to be able to understand the instructions and to cooperate during the procedure. Availability of
materials and facilities should also be considered before
establishing this procedure.
In specic cancers, such as post-cricoid tumours, TNO is an
invaluable tool not only for the diagnosis but also for surveillance and photo-documentation following oncological treatment, potentially reducing the need for costly scans and thereby
minimising the associated radiation that the patient receives.
TNO also provides potentially signicant cost savings in
patients presenting with globus pharyngeus and/or dysphagia
in order to exclude an oesophageal tumour, as this can also
avoid the need for additional imaging investigations such as a
barium swallow examination, again avoiding radiation risk
exposure. It also allows patients go home on the same day and
even return to work, which also decreases the costs of absence
on a larger socio-economic scale. It leads to favourable patient
acceptance and minimal rates of complications [6, 8, 10].
2.8 Conclusions
Ofce-based TNO is an invaluable tool for any ENT department. It is particularly useful for the initial workup of patients
with swallow dysfunction including globus pharyngeus, in
selected patients with suspected head and neck lesions to
perform a tissue biopsy and for endoscopic video-recorded
surveillance and photo-documentation following head and
neck cancer treatment. Additional benets include the possibility of interventional treatment, such as laser and oesophageal dilatation for patients with benign or malignant head
and neck conditions and as a guide for performing secondary
tracheo-oesophageal puncture. A pre-requisite for the establishment of a successful TNO service includes appropriate
training for all the members involved as well as careful consideration of necessary adjunct equipment and infrastructural space.
References
1. Howell RJ, Pate MB, Ishman SL, Isseroff TF, Rubin AD, Soliman
AM, et al. Prospective multi-institutional transnasal esophagoscopy: predictors of a change in management. Laryngoscope.
2016;126(12):2667–71.
2. Sanyaolu LN, Jemah A, Stew B, Ingrams DR.The role of transnasal oesophagoscopy in the management of globus pharyngeus and non-progressive dysphagia. Ann R Coll Surg Engl.
2016;98:49–52.
3. Abou-Nader L, Wilson JA, Paleri V. Transnasal oesophagoscopy:
diagnostic and management outcomes in a prospective cohort of
257 consecutive cases and practice implications. Clin Otolaryngol.
2014;39(2):108–13.
4. Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal
esophagoscopy: a position statement from the American
Bronchoesophagological Association (ABEA). Otolaryngol Head
Neck Surg. 2008;138(4):411–4.
5. Hassan NH, Usman R, Yousuf M, Ahmad AN, Hirani I. Transoral
exible laryngoscope biopsy: safety and accuracy. World J
Otorhinolaryngol Head Neck Surg. 2019;5(1):30–3.
6. Wellenstein DJ, Schutte HW, Marres HAM, Honings J, Belafsky
PC, Postma GN, etal. Ofce-based procedures for diagnosis and
treatment of esophageal pathology. Head Neck. 2017;39(9):1910–9.
7. Wellenstein DJ, Schutte HW, Takes RP, Honings J, Marres HAM,
Burns JA, etal. Ofce-based procedures for the diagnosis and treatment of laryngeal pathology. J Voice. 2018;32(4):502–13.
8. Schimberg AS, Wellenstein DJ, Van Den Broek EM, Honings J, van
den Hoogen FJA, Marres HAM, etal. Ofce-based vs operating
room-performed laryngopharyngeal surgery: a review of cost differences. Eur Arch Otorhinolaryngol. 2019;276(1):2963–73.
9. Lee F, Smith KA, Chandarana S, Matthews TW, Bosch JD, etal.
An evaluation of in-ofce exible ber-optic biopsies for laryngopharyngeal lesions. J Otolaryngol Head Neck Surg. 2018;47(1):31.
10. Wellenstein DJ, Honings J, Schutte HW, Herruer JM, van
den Hoogen FJA, Marres HAM, et al. Cost analysis of ofcebased transnasal esophagoscopy. Eur Arch Otorhinolaryngol.
2019;276(5):1457–63.
Operative Pharyngoscopy
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andLaryngoscopy (Microlaryngoscopy)
NatalieA.Watson, AnthonyAymat, ElfyChevretton,
andYakubuKaragama
3
3.1 Introduction
Examination of the larynx and pharynx may be performed by
using different techniques, whether under local or general
anaesthetic. The traditional method of indirect laryngopharyngoscopy using a bulls-eye head mirror to reect light off
a laryngeal mirror placed under the soft palate, to visualise a
mirror image of the laryngopharynx, has been superseded by
exible bre-optic transnasal endoscopy. This technique not
only avoids the gag reex often encountered during an indirect mirror examination but also allows videos and images to
be recorded for review at a later stage, or to be shared, as
needed, with patients and healthcare professionals.
Although the newer exible bre-optic endoscopes have
working channels facilitating biopsies and minor procedures,
more substantial pathologies of the larynx or pharynx
requires direct rigid larygopharyngoscopy with examination
of these structures under general anaesthetic. Appropriately
sized and shaped short metallic illuminated tubes (depending
on the patient’s neck and oral anatomy) are introduced
through the oral cavity and oropharynx to allow good visualisation of these structures and safe instrumentation. A suspension platform is used to allow stability during procedures
N. A. Watson (*)
Department of Ear, Nose and Throat Surgery, Guy’s
and St Thomas’s NHS Foundation Trust, London, UK
Department of Ear, Nose, and Throat Surgery, Guy’s and St.
Thomas NHS Foundation Hospital, London, UK
e-mail: nataliewatson@nhs.net
A. Aymat
Department of Ear, Nose and Throat Surgery, University Hospital
Lewisham, London, UK
e-mail: tony@aymat.com; anthony.aymat@nhs.net
E. Chevretton · Y. Karagama
Department of Ear, Nose and Throat Surgery, Guy’s
and St Thomas’s NHS Foundation Trust, London, UK
e-mail: e.chevretton@doctors.org.uk;
Yakubu.Karagama@gstt.nhs.uk
and for the surgeon to have both hands free for
interventions.
Magnication through a microscope or a rigid telescope
may be required to precisely perform and document a
detailed examination of the larynx and pharynx and enable
interventions to be performed. Further, examination of the
oesophagus, trachea, and rigid nasendoscopy through the
nasal cavity to the post nasal space might be performed at the
same time, completing what is called an upper panendoscopy, an examination of the entire upper aerodigestive tract.
Relative contraindications for a rigid laryngopharyngoscopy
might be poor neck extension or trismus where visualisation
may be suboptimal.
3.2 History ofPharyngoscopy
andLaryngoscopy
Direct rigid pharyngoscopy and laryngoscopy are most commonly performed to remove a suspected foreign body, stage
and biopsy neoplasms, excise lesions, and treat a pharyngeal
diverticulum. Traditionally, this was performed with an
oesophageal speculum or laryngoscope [1].
Eminent laryngologists in the past developed laryngoscopes, some named after them, to examine the larynx. The
Chevalier Jackson (Fig.3.1) laryngoscope had illumination
provided at the distal end of the scope. Negus’ laryngoscope
had two lamps set obliquely in the walls of the scope,
whereas Bruning, Kahler, and Haslinger all developed scopes
with illumination at the proximal end. Light was powered by
dry cells or accumulators or from the mains using a
transformer.
In the past, direct laryngoscopy with these instruments
was performed under local anaesthesia only. In children, particularly those under 3years of age, laryngoscopy was often
used with no anaesthesia at all [2]. For others, a cocktail of
medications was used and included pre-medications of
Omnopon (Papaveretum) and Scopolamine injections, loz-
© 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_3
35
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enges of Amethocaine, and cocaine/amethocaine or
Nupercaine±adrenaline applications with sprays and swabs.
General anaesthesia was reserved for patients who could not
tolerate local anaesthesia, namely, “nervous” adults, children,
or in situations where prolonged manipulation of the larynx
was required.
Fig. 3.1 A Chevalier Jackson laryngoscope
Laryngoscopes of varying size were used depending on
the age of the patient including an anterior commissure
laryngoscope. Also a suction tube±gum-elastic ends, swab
holders, and laryngeal forceps/instruments of different
design depending on the indication were needed.
There were two main positions when performing the procedure: the rst was to use a Boyce-Jackson position with the
head, neck, and shoulders being off the head end of the table
with the head resting on a Haslinger/Negus rest (Fig.3.2) or
being held by an assistant. The aim was for the head to be
held 10cm above the level of the table. If the head rest or
assistant were not available, the second was a supine position
with the head rested on a small pillow or sandbag. The surgeon would approach from the left side of the patient with
the laryngoscope in their left hand (Fig.3.3) and their ring
and middle ngers retracting the upper and lower lips,
respectively. Once the laryngoscope was in position, it was
held in place by the surgeon’s non-dominant hand and the
dominant “working” hand used for instruments (Fig.3.4) to
examine and perform any necessary interventions (Fig.3.5).
Interestingly, from photographs depicted in Scott-Brown’s
original text, a mask and glass shield were worn by the surgeon to protect the face from droplet exposure [2]. This eye
protection measure was subsequently abandoned until more
recently in the COVID-19 era, where mask and eye/face protection are advised (Fig.3.3).
Fig. 3.2 A traditional set-up demonstrating the Boyce-Jackson position with the head, neck, and shoulders being off the head end of the table with
the head resting on a Haslinger/Negus rest
a
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Fig. 3.3 A traditional set-up, approaching the patient from the left side
and inserting a laryngoscope using the left hand, note use of traditional
face shield, mask, gloves, and gown
Fig. 3.5 Traditional position of a one-handed instrument approach
standing on the left side
Suspension laryngoscopy devised by Killian and rst
demonstrated over 100years ago, in 1911, allowed the surgeon to have both hands free for interventions. The suspension laryngoscopy and gallows used (Fig.3.6) had variable
acceptance worldwide. Of note, if a view of the anterior
commissure was required, an anterior commissure laryngoscope was still sometimes needed (Fig.3.7).
b
c
e
d
f
Fig. 3.4 Traditional instruments used in direct laryngoscopy; (a) suc-
tion, (b) swab holder, (c) nodule forceps, (d) grasping forceps, (e)
biopsy forceps, (f) cutting forceps
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