Bronchoscopy and Esophagoscopy Part 6

_The right upper-lobe bronchus_ is recognized by its vertical spur; the orifice is exposed by displacing the right lateral wall of the right main bronchus at the level of the carina. Usually this orifice will be thus brought into view. If not the bronchoscope may be advanced downward 1 or 2 cm., carefully to avoid overriding. This branch is sometimes found coming off the trachea itself, and even if it does not, the overriding of the orifice is certain if the right bronchus is entered before search is made for the upper-lobe-bronchial orifice. The head must be moved strongly to the left in order to view the orifice. A lumen image of the right upper-lobe bronchus is not obtainable because of the sharp angles at which it is given off. _The left upper-lobe bronchus_ is entered by keeping the handle of the bronchoscope (and consequently the lip) to the left, and, by keeping the head of the patient strongly to the right as the bronchoscopist goes down the left main bronchus. This causes the lip of the bronchoscope to bear strongly on the left wall of the left main bronchus, consequently the left upper-lobe-bronchial orifice will not be overridden. The spur separating the upper-lobe-bronchial orifice from the stem bronchus is at an angle approximately from two to eight o'clock, as usually seen in the rec.u.mbent patient. A lumen image of a descending branch of the upper-lobe bronchus is often obtained, if the patient's head be borne strongly enough to the right.

[FIG. 65.--Schema ill.u.s.trating the entering of the anteriorly branching middle lobe bronchus. T, Trachea; B, orifice of left main bronchus at bifurcation of trachea. The bronchoscope, S, is in the right main bronchus, pointing in the direction of the right inferior lobe bronchus, I. In order to cause the lip to enter the middle lobe bronchus, M, it is necessary to drop the head so that the bronchoscope in the trachea TT, will point properly to enable the lip of the tube mouth to enter the middle lobe bronchus, as it is seen to have done at ML.]

Branches of the stem bronchus in either lung are exposed, or their respective lumina presented, by manipulation of the lip of the bronchoscope, with movement of the head in the required direction.

Posterior branches require the head quite high. A large one in the left stem just below the left upper-lobe bronchus is often invaded by foreign bodies. Anterior branches require lowering the head. The _middle-lobe bronchus_ is the largest of all anterior branches. Its almost horizontal spur is brought into view by directing the lip of the bronchoscope upward, and dropping the head of the patient until the lip bears strongly on the anterior wall of the right bronchus (see Fig. 65).

[106] CHAPTER X--INTRODUCTION OF THE ESOPHAGOSCOPE

The esophagoscope is to be pa.s.sed only with ocular guidance, never blindly with a mandrin or obturator, as was done before the bevel-ended esophagoscope was developed. Blind introduction of the esophagoscope is equally as dangerous as blind bouginage. It is almost certain to cause over-riding of foreign bodies and disease. In either condition perforation of the esophagus is possible by pus.h.i.+ng a sharp foreign body through the normal wall or by penetrating a wall weakened by disease. Landmarks must be identified as reached, in order to know the locality reached. The secretions present form sufficient lubrication for the instrument. A clear conception of the endoscopic anatomy, the narrowings, direction, and changes of direction of the axis of the esophagus, are necessary. The services of a trained a.s.sistant to place the head in the proper sequential "high-low"

positions are indispensible (Figs. 52 and 70). Introduction may be divided into four stages.

1. Entering the right pyriform sinus.

2. Pa.s.sing the cricopharyngeus.

3. Pa.s.sing through the thoracic esophagus.

4. Pa.s.sing through the hiatus.

The patient is placed in the Boyce position as described in Chapter VI. As previously stated, the esophagus in its upper portion follows the curves of the cervical and dorsal spine. It is necessary, therefore, to bring the cervical spine into a straight line with the upper portion of the dorsal spine and this is accomplished by elevation of the head--the "high" position (Figs. 66-71).

[PLATE III--ESOPHAGOSCOPIC VIEWS FROM OIL-COLOR DRAWINGS FROM LIFE, BY THE AUTHOR: 1, Direct view of the larynx and laryngopharynx in the dorsally rec.u.mbent patient, the epiglottis and hyoid bone being lifted with the direct laryngoscope or the esophageal speculum. The spasmodically adducted vocal cords are partially hidden by the over-hang of the spasmodically prominent ventricular hands. Posterior to this the aryepiglottic folds ending posteriorly in the arytenoid eminences are seen in apposition. The esophagoscope should be pa.s.sed to the right of the median line into the right pyriform sinus, represented here by the right arm of the dark crescent. 2, The right pyriform sinus in the dorsally rec.u.mbent patient, the eminence at the upper left border, corresponds to the edge of the cricoid cartilage. 3, The cricopharyngeal constriction of the esophagus in the dorsally rec.u.mbent patient, the cricoid cartilage being lifted forward with the esophageal speculum. The lower (posterior) half of the lumen is closed by the fold corresponding to the orbicular fibers of the cricopharyngeus which advances spasmodically from the posterior wall.

(Compare Fig. 10.) This view is not obtained with an esophagoscope. 4, Pa.s.sing through the right pyriform sinus with the esophagoscope; dorsally rec.u.mbent patient. The walls seem in tight apposition, and, at the edges of the slit-like lumen, bulge toward the observer. The direction of the axis of the slit varies, and in some instances it is like a rosette, depending on the degree of spasm. 5, Cervical esophagus. The lumen is not so patulent during inspiration as lower down; and it closes completely during expiration. 6, Thoracic esophagus; dorsally rec.u.mbent patient. The ridge crossing above the lumen corresponds to the left bronchus. It is seldom so prominent as in this patient, but can always be found if searched for. 7, The normal esophagus at the hiatus. This is often mistaken for the cardia by esophagoscopists. It is more truly a sphincter than the cardia itself. In the author's opinion there is no truly sphincteric action at the cardia. It is the failure of this hiatal sphincter to open as in the normal deglut.i.tory cycle that produces the syndrome called "cardiospasm." 8, View in the stomach with the open-tube gastroscope.

The form of the folds varies continually. 9, Sarcoma of the posterior wall of the upper third of the esophagus in a woman of thirty-one years. Seen through the esophageal speculum, patient sitting. The lumen of the mouth of the esophagus, much encroached upon by the sarcomatous infiltration, is seen at the lower part of the circle. 10, Coin (half-dollar) wedged in the upper third of the esophagus of a boy aged fourteen years. Seen through the esophageal speculum, rec.u.mbent patient. Forceps are retracting the posterior lip of the esophageal "mouth" preparatory to removal. 11, Fungating squamous-celled epithelioma in a man of seventy-four years. Fungations are not always present, and are often pale and edematous. 12, Cicatricial stenosis of the esophagus due to the swallowing of lye in a boy of four years.

Below tile upper stricture is seen a second stricture. An ulcer surrounded by an inflammatory areola and the granulation tissue together ill.u.s.trates the etiology of cicatricial tissue. The fan-shaped scar is really almost linear, but it is viewed in perspective. Patient was cured by esophagoscopic dilatation. 13, Angioma of the esophagus in a man of forty years. The patient had hemorrhoids and varicose veins of the legs. 14, Luetic ulcer of the esophagus 26 cm. from the upper teeth in a woman of thirty-eight years. Two scars from healed ulcerations are seen in perspective on the anterior wall. Branching vessels are seen in the livid areola of the ulcers. 15, Tuberculosis of the esophagus in a man of thirty-four years. 16, Leukoplakia of the esophagus near the hiatus in a man aged fifty-six years.]

The hypopharynx tapers down to the gullet like a funnel, and the larynx is suspended in its lumen from the anterior wall. The larynx is attached only to the anterior wall, but is held closely against the posterior pharyngeal wall by the action of the inferior constrictor of the pharynx, and particularly by its specialized portion--the cricopharyngeus muscle. A bolus of food is split by the epiglottis and the two portions drifted laterally into the pyriform sinuses, the recesses seen on either side of the larynx. But little of the food bolus pa.s.ses posterior to the larynx during the act of swallowing. It is through the pyriform sinus that the esophagoscope is to be inserted, thereby following the natural food pa.s.sage. To insert the esophagoscope in the midline, posterior to the arytenoids, requires a degree of force dangerous to exert and almost certain to produce damage to the cricoarytenoid joint or to the pharyngeal wall, or to both.

The esophagoscope is steadied by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooked over the upper teeth, while the left index finger and thumb encircle the tube and retract the upper lip to prevent its being pinched between the tube and upper teeth. The right hand holds the tube in pen fas.h.i.+on at the collar of the handle, not by the handle. During introduction the handle is to be pointed upward toward the zenith.

_Stage I. Entering the Right Pyriform Sinus_.--The operator standing (as in Fig. 66), inserts the esophagoscope along the right side of the tongue as far as and down the posterior pharyngeal wall. A lifting motion imparted to the tip of the esophagoscope by the left thumb will bring the rounded right arytenoid eminence into view (A, Fig. 69).

This is the landmark of the pyriform sinus, and care must be taken to avoid injury by hooking the tube mouth over it or its fellow. The tip of the tube should now be directed somewhat toward the midline, remembering the funnel shape of the hypopharynx. It will then be found to glide readily through the right pyriform sinus for 2 or 3 cm., when it comes to a full stop, and the lumen disappears. This is the spasmodically closed cricopharyngeal constriction.

[FIG. 66.--Esophagoscopy by the author's "high-low" method. First stage. "High" position. Finding the right pyriform sinus. In this and the second stage the patient's vertex is about 15 cm. above the level of the table.]

_Stage 2. Pa.s.sing the cricopharyngeus_ is the most difficult part of esophagoscopy, especially if the patient is unanesthetized. Local anesthesia helps little, if at all. The handle of the esophagoscope is still pointing upward and consequently we are sure that the lip of the esophagoscope is directed anteriorly. Force must not be used, but steady firm pressure against the tonically contracted cricopharyngeus is made, while at the same time the distal end of the esophagoscope is lifted by the left thumb. At the first inspiration a lumen will usually appear in the upper portion of the endoscopic field. The tip of the esophagoscope enters this lumen and the slanted end slides over the fold of the cricopharyngeus into the cervical esophagus. There is usually from 1 to 3 cm. of this constricted lumen at the level of the cricopharyngeus and the subjacent orbicular esophageal fibers.

[109] [FIG. 67.--Schematic ill.u.s.tration of the author's "high-low"

method of esophagoscopy. In the first and second stages the patient's head fully extended is held high so as to bring it in line with the thoracic esophagus, as shown above. The Rose position is shown by way of accentuation.]

[FIG. 68.--Schematic ill.u.s.tration of the anatomic basis for difficulty in introduction of the esophagoscope. The cricoid cartilage is pulled backward against the cervical spine, by the cricopharyngeus, so strongly that it is difficult to realize that the cricopharyngeus is not inserted into the vertebral periosteum instead of into the median raphe.]

[FIG. 69.--The upper ill.u.s.tration shows movements necessary for pa.s.sing the cricopharyngeus.

The lower ill.u.s.tration shows schematically the method of finding the pyriform sinus in the author's method of esophagoscopy. The large circle represents the cricoid cartilage. G, Glottic c.h.i.n.k, spasmodically closed; VB, ventricular band; A, right arytenoid eminence; P, right pyriform sinus, through which the tube is pa.s.sed in the rec.u.mbent posture. The pyriform sinuses are the normal food pa.s.sages.]

_Stage 3. Pa.s.sing Through the Thoracic Esophagus_.--The thoracic esophagus will be seen to expand during inspiration and contract during expiration, due to the change in thoracic pressure. The esophagoscope usually glides easily through the thoracic esophagus if the patient's position is correct. After the levels of the aorta and left bronchus are pa.s.sed the lumen of the esophagus seems to have a tendency to disappear anteriorly. The lumen must be kept in axial view and the head lowered as required for this purpose.

_Stage 4. Pa.s.sing Through the Hiatus Esophageus_.--When the head is dropped, it must at the same time be moved horizontally to the right in order that the axis of the tube shall correspond to the axis of the lower third of the esophagus, which deviates to the left and turns anteriorly. The head and shoulders at this time will be found to be considerably below the plane of the table top (Fig. 71). The hiatal constriction may a.s.sume the form of a slit or rosette. If the rosette or slit cannot be promptly found, as may be the case in various degrees of diffuse dilatation, the tube mouth must be s.h.i.+fted farther to the left and anteriorly. When the tube mouth is centered over the hiatal constriction moderately firm pressure continued for a short time will cause it to yield. Then the tube, maintaining this same direction will, without further trouble glide into and through the abdominal esophagus. The cardia will not be noticed as a constriction, but its appearance will be announced by the rolling in of reddish gastric mucosal folds, and by a gush of fluid from the stomach.

[FIG. 70.--Schematic ill.u.s.tration of the author's "high-low" method of esophagoscopy, fourth stage. Pa.s.sing the hiatus. The head is dropped from the position of the 1st and 2nd stages, CL, to the position T, and at the same time the head and shoulders are moved to the right (without rotation) which gives the necessary direction for pa.s.sing the hiatus.]

[FIG. 71.--Esophagoscopy by the author's "high-low" method. Stage 4.

Pa.s.sing the hiatus The patient's vertex is about 5 cm. below the top of the table.]

_Normal esophageal mucosa_ under proper illumination is glistening and of a yellowish or bluish pink. The folds are soft and velvety, rendering infiltration quickly noticeable. The cricoid cartilage shows white through the mucosa. The gastric mucosa is a darker pink than that of the esophagus and when actively secreting, its color in some cases tends toward crimson.

_Secretions_ in the esophagus are readily aspirated through the drainage ca.n.a.l by a negative pressure pump. Food particles are best removed by "sponge pumping," or with forceps. Should the drainage ca.n.a.l become obstructed positive pressure from the pump will clear the ca.n.a.l.

_Difficulties of Esophagoscopy_.--The beginner may find the esophagoscope seemingly rigidly fixed, so that it can be neither introduced nor withdrawn. This usually results from a wedging of the tube in the dental angle, and is overcome by a wider opening of the jaws, or perhaps by easing up of the bite block, but most often by correcting the position of the patient's head. If the beginner cannot start the tube into the pyriform sinus in an adult, it is a good plan to expose the arytenoid eminence with the laryngoscope and then to insert the 7 mm. esophagoscope into the right pyriform sinus by direct vision. Pa.s.sing the cricopharyngeal and hiatal spasmodically contracted narrowings will prove the most trying part of esophagoscopy; but with the head properly held, and the tube properly placed and directed, patient waiting for relaxation of the spasm with gentle continuous pressure will usually expose the lumen ahead. In his first few esophagoscopies the novice had best use general anesthesia to avoid these difficulties and to accustom himself to the esophageal image. In the first favorable subject--an emaciated individual with no teeth--esophagoscopy without anesthesia should be tried.

In cases of kyphosis it is a mistake to try to straighten the spine.

The head should be held correspondingly higher at the beginning, and should be very slowly and cautiously lowered.

Once inserted, the esophagoscope should not be removed until the completion of the procedure, unless respiratory arrest demands it.

Occasionally in stenotic conditions the light may become covered by the upwelling of a flood of fluid, and it will be thought the light has gone out. As soon as the fluid has been aspirated the light will be found burning as brightly as before. If a lamp should fail it is unnecessary to remove the tube, as the light carrier and light can be withdrawn and quickly adjusted. A complete instrument equipment with proper selection of instruments for the particular case are necessary for smooth working.

_Ballooning Esophagoscopy_.--By inserting the window plug shown in Fig. 6 the esophagus may be inflated and studied in the distended state. The folds are thus smoothed out and constrictions rendered more marked. Ether anesthesia is advocated by Mosher. The danger of respiratory arrest from pressure, should the patient be dyspneic, is always present unless the anesthetic be given by the intratracheal method. If necessary to use forceps the window cap is removed. If the perforated rubber diaphragm cap be subst.i.tuted the esophagus can be reballooned, but work is no longer ocularly guided. The fluoroscope may be used but is so misleading as to render perforation and false pa.s.sage likely.

_Specular Esophagoscopy_.--Inspection of the hypopharynx and upper esophagus is readily made with the esophageal speculum shown in Fig.

4. High lesions and foreign bodies lodged behind the larynx are thus discovered with ease, and such a condition as a retropharyngeal abscess which has burrowed downward is much less apt to be overlooked than with the esophagoscope. High strictures of the esophagus may be exposed and treated by direct visual bouginage until the lumen is sufficiently dilated to allow the pa.s.sage of the esophagoscope for bouginage of the deeper strictures.

_Technic of Specular Esophagoscopy_.--Rec.u.mbent patient. Boyce position. The larynx is to be exposed as in direct laryngoscopy, the right pyriform sinus identified, the tip of the speculum inserted therein, and gently insinuated to the cricopharyngeal constriction.

Too great extension of the head is to be avoided--even slight flexion at the occipito-atloid joint may be found useful at times. Moderate anterior or upward traction pulls the cricoid away from the posterior pharyngeal wall and the lumen of the esophagus opens above a crescentic fold (the cricopharyngeus). The speculum readily slides over this fold and enters the cervical esophagus. In searching for foreign bodies in the esophagus the speculum has the disadvantage of limited length, so that should the foreign body move downward it could not be followed.

_Complications Following Esophagoscopy_.--These are to be avoided in large measure by the exercise of gentleness, care, and skill that are acquired by practice. If the instructions herein given are followed, esophagoscopy is absolutely without mortality apart from the conditions for which it is done.

Injury to the crico-arytenoid joint may simulate recurrent paralysis.

Posticus paralysis may occur from recurrent or vagal pressure by a misdirected esophagoscope. These conditions usually recover but may persist. Perforation of the esophageal wall may cause death from septic mediastinitis. The pleura may be entered,--pyopneumothorax will result and demand immediate thoracotomy and gastrostomy. Aneurysm of the aorta may be ruptured. Patients with tuberculosis, decompensating cardiovascular lesions, or other advanced organic disease, may have serious complications precipitated by esophagoscopy.

_Retrograde Esophagoscopy_.--The first step is to get rid of the gastric secretions. There is always fluid in the stomach, and this keeps pouring out of the tube in a steady stream. Fold after fold is emptied of fluid. Once the stomach is empty, the search begins for the cardial opening. The best landmark is a mark with a dermal pencil on the skin at a point corresponding to the level of the hiatus esophageus. When it is desired to do a retrograde esophagoscopy and the gastrostomy is done for this special purpose, it is wise to have it very high. Once the cardia is located and the esophagus entered, the remainder of the work is very easy. Bouginage can be carried out from below the same as from above and may be of advantage in some cases. Strictural lumina are much more apt to be concentric as approached from below because there has been no distortion by pressure dilatation due to stagnation of the food operating through a long period of time. At retrograde esophagoscopy there seems to be no abdominal esophagus and no cardia. The esophagoscope encounters only the diaphragmatic pinchc.o.c.k which seems to be at the top of the stomach like the puckering string at the top of a bag.

Retrograde esophagoscopy is sometimes useful for "stringing" the esophagus in cases in which the patient is unable to swallow a string because he is too young or because of an epithelial scaling over of the upper entrance of the stricture. In such cases the smallest size of the author's filiform bougies (Fig. 40) is inserted through the retrograde esophagoscope (Fig. 43) and insinuated upward through the stricture. When the tip reaches the pharynx coughing, choking and gagging are noticed. The filiform end is brought out the mouth sufficiently far to attach a silk braided cord which is then pulled down and out of the gastrostomic opening. The braided silk "string"

must be long enough so that the oral and the abdominal ends can be tied together to make it "endless;" but before doing so the oral end should be drawn through nose where it will be less annoying than in the mouth. The purpose of the "string" is to pull up the retrograde bougies (Fig. 35)

[117] CHAPTER XI--ACQUIRING SKILL

Endoscopic ability cannot be bought with the instruments. As with all mechanical procedures, facility can be obtained only by educating the eye and the fingers in repeated exercise of a particular series of maneuvers. As with learning to play a musical instrument, a fundamental knowledge of technic, positions, and landmarks is necessary, after which only continued manual practice makes for proficiency. For instance, efficient use of forceps requires that they be so familiar to the grasp that their use is automatic. Endoscopy is a purely manual procedure, hence to know how is not enough: manual practice is necessary. Even in the handling of the electrical equipment, practice in quickly locating trouble is as essential as theoretic knowledge. There is no mystery about electric lighting. No source of illumination other than electricity is possible for endoscopy. Therefore a small amount of electrical knowledge, rendered practical by practice, is essential to maintain the simple lighting system in working order. It is an insult to the intelligence of the physician to say that he cannot master a simple problem of electric testing involving the locating of one or more of five possibilities.

It is simply a matter of memorizing five tests. It is repeated for emphasis that a commercial current reduced by means of a rheostat should never be used as a source of current for endoscopy with any kind of instrument, because of the danger to the patient of a possible "grounding" of the circuit during the extensive moist contact of a metallic endoscopic tube in the mediastinum. The battery shown in Fig.

8 should be used. The most frequent cause of trouble is the mistake of over-illuminating the lamps. _The lamp should not be over-illuminated to the dazzling whiteness usually used in flash lights_. Excessive illumination alters the proper perception of the coloring of the mucosa, besides shortening the life of the lamps. The proper degree of brightness is obtained when, as the current is increased, the first change from yellow to white light is obtained. Never turn up the rheostat without watching the lamp.

_Testing for Electric Defects_.--These tests should be made beforehand; not when about to commence introduction.

If the first lamp lights up properly, use it with its light-carrier to test out the other cords.

If the lamp lights up, but flickers, locate the trouble before attempting to do an endoscopy. If shaking the carrier cord-terminal produces flickering there may be a film of corrosion on the central contact of the light carrier that goes into the carrier cord-terminal.

If the lamp fails to show a light, the trouble may be in one of five places which should be tested for in the following order and manner.