Note: last updated before 2013

GENERAL CONSIDERATIONS

1. Indications
   1. To evaluate the upper airway and esophagus.
   2. To assess for structural or physiologic abnormality associated with dysphagia or GERD
   3. To obtain appropriate biopsy samples.
   4. To provide comprehensive staging information and evaluate the full extent of disease in patients with known or suspected upper airway or esophageal tumors.
   5. To provide objective assessment of tumor response to therapy by direct examination of the tumor site after therapy.
   6. To obtain cultures (bacterial/fungal).
   7. To observe the aerodigestive tract during procedures
   8. To administer topical anesthetic to the larynx prior to procedures (ie, patients with severe gag reflexes).
2. Relative Contraindications
   1. History of bleeding diathesis
   2. Inability to pass the endoscope through the nose.
   3. Airway compromise

PREOPERATIVE PREPARATION

1. Evaluation
   1. History and physician examination with written informed consent: The findings and explanations about the procedure given to the patient need to be documented in the chart prior to the procedure. The physical examination and history are needed to rule out other potentially serious diseases.

NURSING CONSIDERATIONS (see Preop Forms)

1. Room Setup
   1. Ascertain all equipment is available and in working order as follows
      1. Preparation of transnasal esophagoscope
         1. Attach air/water valve to correct location on scope.
         2. Attach seal to biopsy port.
         3. Attach scope to light source.
         4. Attach suction tubing to scope.
         5. Fill water bottle with sterile water and plug into air/water supplier.
   2. Equipment check
      1. Turn on air/water supplier to ensure the silver lever is directed upward to allow air and water delivery.
      2. Cover hole of grey valve for approximately 10 seconds and check for air delivery at the working end of the scope (residual isopropyl alcohol will be blown out end of channel).
      3. Depress grey valve to purge channel with sterile water.
      4. Place tip of scope in cup of sterile water and depress the red/black suction valve.
      5. If all is working, the scope is ready for use.
2. Instrumentation and Equipment
   1. Transnasal esophagoscope/biopsy forceps
   2. Air/water supplier
   3. Pentax light source
   4. Endopro computer system/monitors
   5. 2% Pontocaine
   6. Neosynephrine
   7. 2% viscous lidocaine
   8. Jar of enzymatic cleaner/gauze
   9. Cup filled with sterile water
   10. Exam gloves
   11. Suction equipment
   12. If biopsy performed, container with formalin and specimen label
   13. Defog solution or hot water bottle
3. Preparation and Procedure
   1. Explain the anticipated procedure to the patient and provide emotional support.
   2. Instruct the patient that he/she may feel the urge to burp, as the physician will be instilling air during the procedure.
   3. Place the patient in the chair in an erect sitting position.
   4. Support the patient from behind, if needed, while the physician performs the procedure.
4. Care of the Equipment
   1. Don exam gloves.
   2. Wipe the body and working end of the scope with gauze soaked in enzymatic cleaner.
   3. Place the tip of the scope in the jar of enzymatic detergent and depress the red valve to suction detergent/air up into the scope. Pull the tip in and out of detergent while depressing the valve to create agitation and break up/dislodge debris in the channel.
   4. Change the position of the silver lever on the air/water supplier so it is directed sideways. This allows only air to pass through the channel.
   5. Cover the hole on the grey valve to blow air through the air channel for five to 10 seconds.
   6. Depress the grey valve to blow air through the water channel.
   7. Detach the scope from the suction, water bottle and air/water supplier. Place it in the box with the biopsy forceps (if used) and water bottle. (Note: The water bottle needs to be sterilized at the completion of the exam day.)
5. Nursing Actions
   1. Assess respiratory/swallowing status.
   2. Elevate head.
   3. NPO until gag reflex returns. Advance diet as tolerated when awake and alert.
   4. Routine vital signs
   5. Post-esophagoscopy
      1. Assess for early signs of esophageal perforation and report to physician
         1. Chest pain
         2. Shortness of breath
         3. Crepitus about neck and chest
         4. Elevated temperature (greater than 37.6 degrees C oral)
   6. Hemoptysis may occur postoperatively. Report shortness of breath or signs of laryngeal edema, anxiety, stridor, or retractions.
   7. Review and send discharge instructions for "Transnasal Esophagoscopy".
   8. Return patient to clinic per physician.

ANESTHESIA CONSIDERATIONS

1. Local Anesthesia
   1. Have the patient gargle with 5 cc of viscous lidocaine (optional). An alternative method that is usually reserved for cases requiring laryngeal manipulation is to have the patient sequentially dissolve two 100 mg capsules of benzonatate (tessalon perles) in the mouth before proceeding. This approach is generally not needed.
   2. Spray 2% nasal decongestant (0.25% phenylephrine) via atomizer at least two times in each nares (up to four times) and wait at least five minutes before spraying Pontocaine. Spray by pointing atomizer tip straight back, not up the nares. The patient is often uncomfortable until some anesthesia has been accomplished.
   3. Spray Pontocaine into each nares at least two times.
2. Alternate Anesthesia
   1. 2 sprays of oxymetazoline into each naris and allow time for effect.
   2. Then spray atomized 4% Lidocaine with 1% phenyephrine into each naris or concentrate into the most patent side for procedure.
   3. Place a 1/2"x3" pledget into floor of nose soaked in 4% Lidocaine with 1% phenyephrine and allow time for effect.
   4. To anesthetize the vocal cords spray 4% Lidocaine with 1% phenyephrine into the oropharynx while the patient inspires deeply to facilitate passage of anesthetic into larynx.
3. In rare cases, offer oral Valium 2.5 to 5.0 mg 45 minutes before the procedure. Ensure the patient has transportation home if sedation (he/she should not drive) is used. If no sedation is given and the procedure is uncomplicated, the patient may drive home.
   1. Four percent lidocaine solution can be dispensed through the TNE scope for local anesthetic of the larynx in patients with severe gag reflex

OPERATIVE PROCEDURE

1. Procedure
   1. Ensure that all of the esophagoscope ports have been flushed.
   2. Connect suction, irrigation, and light source ports to the esophagoscope.
   3. Have the biopsy forceps available on the counter adjacent to the esophagoscope. It is useful to perform a "trial run" with placement of the biopsy forceps through the scope prior to its insertion. The assistant, if not familiar with the equipment, will benefit from this exercise in manipulating the biopsy forceps before the endoscope is positioned.
   4. Insert the scope through the naris that appears most open on inspection with the endoscope. This is not always the same nostril that the patient reports the greatest ease in breathing through.
   5. Advance either along the floor of the nose (the 'low road') or between the inferior and middle turbinates (the 'high road') into the nasopharynx.
   6. Advance into the hypopharynx and through the postcricoid region. This, which may be the most difficult portion of the procedure, is done with timing similar to that of placing a nasogastric tube. Place the tip of the esophagoscope into the piriform sinus or postcricoid region and simultaneously ask the patient to swallow. Gently advance the scope as the patient swallows. Some find it easier to wait until the peristaltic wave has passed before advancing the scope.
   7. Do not advance the esophagoscope if the lumen of the esophagus is not seen. Visualization of the lumen may require small amounts of insufflated air. However, use of insufflation should be judicious due to the discomfort of gastric distension associated with a large air bolus.
   8. Advance through the esophagus and the gastroespohageal junction into the stomach.
   9. With the appropriately-sized scope, retroflex the esophagoscope and observe the esophageal hiatus from below. The shorter scopes will not permit this maneuver.
   10. Return the esophagoscope to normal position and evaluate the mucosa on exit.
   11. Biopsy any suspicious areas. The biopsy forceps should be advanced under direct visualization until they emerge from the tip of the endoscope. The jaws can be rotated to the desired axis by rotating the wire at the axis port entrance. Forceps opening is followed by a gentle push into the desired tissue. Close the forceps and remove quickly to obtain an adequate biopsy.
   12. Esophageal landmarks (distance from incisors; need to add 6 cm for transnasal route)
       1. 16 cm cricopharyngeus
       2. 23 cm aorta
       3. 27 cm left mainstem bronchus
       4. 40 cm gastroesophageal junction

POSTOPERATIVE CARE

1. In uncomplicated cases, the patient may be discharged immediately after the esophagoscopy.
2. Consider antibiotics for
   1. Biopsies through infected areas
   2. Biopsies done in contaminated areas, such as the oral cavity and oropharynx
   3. Postoperative orders
3. Postoperative Nursing Instructions (see Preop Forms)
4. Traditionally (many years ago), the patient was kept NPO for six to eight hours after esophagoscopy with no pain medication stronger than codeine and no Tylenol in order to observe for perforation with mediastinitis.
   1. The above should be observed if the esophaghoscopy was done with difficulty and with a chance for perforation.
   2. Postoperative neck, chest, or abdominal pain should raise concern for esophageal perforation until proven otherwise (see Esophageal Perforation Treatment protocol).