Rigid Oesophagoscopy

Rigid oesophagoscopy is the direct examination of the oesophagus using a straight, hollow metal tube passed through the mouth under general anaesthesia. Even with the wide use of flexible endoscopes, the rigid oesophagoscope remains important for foreign-body removal, accurate biopsy, and dilation of complex strictures, because it provides better control and a steady working channel.

Principle of Rigid Oesophagoscopy

The procedure works by aligning the oral, pharyngeal, and oesophageal axes to create a straight pathway for the scope. This alignment allows safe entry and clear visualisation of the mucosa. The scope must never be advanced blindly. Controlled advancement is essential to avoid injury. Forceful entry can cause oesophageal perforation, especially at natural narrowing’s such as the cricopharynx.

Indications

Diagnostic      

1. Dysphagia (difficulty swallowing) of unknown cause, e.g., oesophageal cancer, benign strictures (e.g., corrosive or peptic), achalasia cardia, oesophagitis, or diverticula (Zenker’s pouch). To see the lesion clearly and take a biopsy.
2. Retrosternal Burning/Pain, e.g., severe reflux oesophagitis or hiatus hernia. To assess mucosal damage.
3. Haematemesis (vomiting blood), e.g., suspected oesophageal varices. To confirm bleeding site.
4. Secondaries Neck with Unknown Primary (as part of Panendoscopy). To search for a primary malignancy in the upper aerodigestive tract.

Therapeutic    

1. Foreign Body Removal from the oesophagus. Most common therapeutic indication.
2. Dilatation of oesophageal strictures (benign) or cardiac achalasia. To restore patency of the oesophageal lumen.
3. Endoscopic Removal of benign lesions, e.g., fibroma, papilloma, cysts. Minimally invasive excision.
4. Palliative management of oesophageal carcinoma. Insertion of a stent (e.g., Souttar’s or Mousseau–Barbin tube) and maintain patency.
5. Injection sclerotherapy or banding of oesophageal varices. To control active or prevent recurrent bleeding.

Contraindications:

Absolute Contraindications:

1. Severe Trismus: The mouth cannot open enough to allow scope entry; therefore, flexible endoscopy is required.
2. Cervical Spine Disease: Conditions that prevent safe neck extension, such as cervical trauma, severe cervical osteoarthritis, ankylosing spondylitis, tuberculosis of the spine, or severe kyphosis. Flexible oesophagoscopy is mandatory in these cases.
3. Aortic Aneurysm: Passing a rigid scope across the aortic arch carries a high risk of aortic rupture.
4. Receding Mandible/Micrognathia: The scope cannot be guided easily into the oropharynx due to the altered jaw–pharynx angle.

Relative Contraindications

1. Acute Oesophageal Perforation: Rigid oesophagoscopy may dangerously worsen the defect.
2. Severe Cardiopulmonary, Hepatic, or Renal Disease: General anaesthesia significantly increases the risk in these unstable patients.

Pre-Procedure Evaluation (Must-Know for Practical Exams)

1. Detailed History: Foreign body ingestion time, corrosive history, and dysphagia duration.
2. Physical Examination: Complete airway assessment, check for cervical spine mobility, and examination of teeth (specifically checking for loose incisors to prevent avulsion).
3. Investigations: Haemoglobin and coagulation profile are essential, particularly when a biopsy is planned.
4. NPO (Nil Per Oral): Mandatory for at least 6 hours before the procedure to prevent aspiration.
5. Informed Consent: Explain the procedure and complications, and take informed consent.

Anaesthesia and Patient Position

1. Anaesthesia: Rigid oesophagoscopy is almost always performed under General Anaesthesia (GA) with endotracheal intubation; therefore, complete muscle relaxation is necessary to smoothly pass the cricopharynx. The endotracheal tube is placed in the left corner of the mouth to keep the midline clear for scope insertion.
2. Position (The Key Step): The standard position is called the Boyce–Jackson Position (also known as the Barking Dog Position or Sword-Swallowing Position). The patient lies supine, the neck is extended at the cervical spine, and the head is flexed at the atlanto-occipital joint. A pillow is placed under the head to elevate it 10-15 cm. This specific positioning achieves the “alignment of the 3 axes” (oral cavity, pharynx, and oesophagus), which aligns the oral cavity, pharynx, and oesophagus in a straight line to allow easy and safe entry of the scope.

Steps of surgery:

1. Surgeon Positioning: The surgeon sits on a stool at the head end of the patient.
2. Protection of teeth: Apply the dental guard to protect the teeth of the patient.
3. Selection of the scope: Choose the largest appropriate-sized oesophagoscope, suitable for the patient’s age because it allows easier foreign-body removal and better visualization.
4. Lubrication: Lubricate the scope tip with lignocaine gel to reduce friction.
5. Entry into the oral cavity: Insert the scope gently through the midline of the mouth, using the right hand to hold the scope and the left hand to protect the lips/guide the scope, until the posterior pharyngeal wall is visible.
6. Hypopharynx: Now the scope is slightly tilted and introduced into the hypopharynx and one of the pyriform sinuses is entered.
7. Identification of Arytenoids and Larynx: Advance gently to see the epiglottis, then the endotracheal tube, and finally the arytenoids (the most important landmark). Maintain a midline orientation; however, avoid pressing on the arytenoids, as this risks injury and oedema.
8. Passing the Cricopharyngeal Sphincter (First Constriction). The surgeon must gently elevate the larynx slightly with the left hand (traction) while waiting for the cricopharynx (Upper Oesophageal Sphincter) to relax. Insert the bevel pointing upwards. Never use force. If difficulty persists, ask the anaesthetist to administer additional muscle relaxant. This is the most dangerous step because perforation is common here at Killian’s dehiscence (a potential gap in the muscle posteriorly).
9. Crossing the Aortic Arch and Left Main Bronchus (Second Constriction): Slightly lower the patient’s head to straighten the thoracic spine and align the oesophageal lumen with the scope. This narrowing is approximately 25 cm from the upper incisors; therefore, care is required. You may observe visible aortic pulsations or a transiently narrow lumen.
10. Passing the Cardia (Third Constriction): This is the gastro-oesophageal junction (Lower Oesophageal Sphincter). The surgeon lowers the patient’s head and shoulders below table level, tilting the head to the right, and directs the scope towards the left anterior-superior iliac spine (NEET PG fact) to smoothly enter the stomach. The mucosa appears redder, velvety, and rugose.
11. Assessment and Intervention: The oesophagus is systematically evaluated for pathology, and any necessary biopsies or therapeutic procedures are performed.
12. Inspection and Withdrawal: Students often forget this step, but you must always inspect thoroughly during withdrawal for any iatrogenic trauma, foreign body remnants, varices, or inflammation.

Postoperative Care and Warning Signs (Viva Focus)

Immediate post-operative care involves vigilant observation for complications.

1. Uneventful Recovery: Start with small sips of water once the patient fully recovers from anaesthesia, then progress to a normal diet.
2. Monitor for Perforation: Watch for the red flags:
   • Interscapular Pain (severe, radiating between shoulder blades).
   • Surgical Emphysema (crepitus felt in the neck).
   • Fever (indicating inflammation/infection).
3. Management of Suspected Perforation: If the signs appear, immediately make the patient NPO, start IV fluids, administer broad-spectrum IV antibiotics, and obtain an urgent surgical consult. Confirm with a water-soluble contrast swallow or CT scan.

Complications of Rigid Oesophagoscopy

1. Trauma to the lips, teeth (especially upper incisors), floor of the mouth, soft palate, hard palate, or posterior pharyngeal wall may occur during insertion.
2. Arytenoid injury may develop if the scope presses against these structures.
3. Pharyngeal mucosal injury is possible when the scope is inserted without proper control or alignment.
4. Oesophageal perforation may occur, most often at Killian’s dehiscence near the cricopharyngeal sphincter, especially if force is used; patients may develop surgical emphysema and interscapular pain, and severe cases may lead to retropharyngeal or mediastinal abscess.
5. Tracheal compression may happen when the scope presses on the posterior tracheal wall, particularly in children, leading to respiratory obstruction and cyanosis; immediate withdrawal of the scope relieves the obstruction.
6. Minor oesophageal mucosal tears or lacerations can occur and are usually managed with antibiotics and nasogastric tube feeding.
7. Full-thickness oesophageal perforation is the most serious complication and may be fatal if not detected and managed promptly.

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High-Yield Points for Quick Revision (NEET PG & Viva)

1. Position: Boyce–Jackson Position (Neck extended, head flexed). Aligns 3 axes.
2. Perforation Site: Cricopharynx (Killian’s Dehiscence). Most dangerous area.
3. Perforation Triad: Interscapular Pain, Surgical Emphysema, Fever.
4. Contraindication: Aortic Aneurysm (Absolute).
5. Coin in Oesophagus: Appears in the coronal plane on X-ray.
6. Scope Direction at Cardia: Towards the Left Anterior-Superior Iliac Spine.
7. Corrosive Injury: Avoid Rigid Oesophagoscopy in the acute phase (after 48-72 hours).

NEET PG–Style MCQs (10 Questions)

1. The most common site of iatrogenic oesophageal perforation during rigid oesophagoscopy is: A. Aortic arch B. Gastroesophageal junction C. Killian’s dehiscence D. Left main bronchus
2. All of the following are absolute contraindications for rigid oesophagoscopy EXCEPT: A. Severe cervical spondylosis B. Aneurysm of the aorta C. Severe trismus D. Chronic corrosive stricture
3. The specific patient position used to align the pharyngo-oesophageal axis for rigid oesophagoscopy is known as: A. Rose position B. Sniffing position C. Trendelenburg position D. Boyce–Jackson position
4. A coin lodged in the oesophagus of a child typically presents with which orientation on a posteroanterior chest X-ray? A. Sagittal B. Oblique C. Coronal D. Lateral
5. Which of the following is considered the most common therapeutic indication for rigid oesophagoscopy in ENT practice? A. Dilatation of peptic stricture B. Biopsy of a proximal growth C. Removal of a large, sharp foreign body D. Sclerotherapy for varices
6. The scope is directed toward which anatomical landmark when attempting to pass the cardia (Lower Oesophageal Sphincter)? A. Right anterior-superior iliac spine B. Left anterior-superior iliac spine C. Umbilicus D. Right iliac crest
7. The three cardinal symptoms suggestive of oesophageal perforation post-oesophagoscopy include fever, severe interscapular pain, and: A. Haematemesis B. Surgical emphysema C. Hypotension D. Bradycardia
8. Why is an additional dose of muscle relaxant administered when there is difficulty passing the cricopharynx? A. To numb the area B. To relax the Upper Oesophageal Sphincter (UES) C. To reduce blood pressure D. To prevent gag reflex
9. Rigid oesophagoscopy is strongly avoided and flexible endoscopy is preferred in the acute phase of: A. Zenker’s diverticulum B. Oesophageal varices C. Corrosive injury D. Achalasia cardia
10. The endotracheal tube is intentionally placed in the left corner of the mouth during rigid oesophagoscopy primarily to: A. Reduce the risk of a mucosal tear B. Facilitate better suctioning C. Keep the midline clear for the scope D. Avoid pressure on the arytenoids

Answers and Explanations

1. C. Killian’s dehiscence: This is the weakest anatomical point (a triangle between the oblique fibres of the inferior constrictor muscle and the cricopharyngeus muscle) and is located near the cricopharynx.
2. D. Chronic corrosive stricture: This is an indication for rigid oesophagoscopy (for dilatation), not a contraindication. The other three are conditions where neck extension is hazardous or the risk of rupture is too high.
3. D. Boyce–Jackson position: This specific positioning (neck extended, head flexed) is crucial for aligning the three axes for safe scope passage.
4. C. Coronal: Coins lie flat against the naturally flattened (coronal) walls of the oesophagus. Tracheal foreign bodies appear sagittal (edge-on) due to the C-shaped cartilages.
5. C. Removal of a large, sharp foreign body: Rigid oesophagoscopy provides the best control and protection for removing these high-risk objects, making it the most common ENT therapeutic use.
6. B. Left anterior-superior iliac spine: This direction aligns the scope with the final turn of the oesophagus as it enters the stomach, facilitating smooth passage of the cardia.
7. B. Surgical emphysema: The triad is Interscapular Pain, Surgical Emphysema (air leaking into the neck tissues), and Fever.
8. B. To relax the Upper Oesophageal Sphincter (UES): The cricopharyngeus muscle is the UES, and its relaxation is key to non-traumatic scope passage; therefore, muscle relaxation is essential.
9. C. Corrosive injury: In the acute phase (24-72 hours), the oesophageal wall is oedematous and fragile, making rigid oesophagoscopy highly risky for perforation.
10. C. Keep the midline clear for the scope: Placing the tube laterally ensures the rigid scope has a clear, central path into the hypopharynx and oesophagus.

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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