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Fiberoptic esophagogastroscopy via nasal intubation
ACKNOWLEDGMENT
REFERENCE
The authors thank Joseph A. Caldrone, medical photographer of the Audio Visual Department of Youngstown Hospital Medical Center, for his help with the figures.
1. Shinya H. Colonoscopic polypectomy. In: Colonoscopy, diagnosis and treatment of colonic diseases. New York: Igaku-Shoin, 1982:191-4.
Fiberoptic esophagogastroscopy via nasal intubation
lymph nodes showed well differentiated squamous cell carcinoma. By use of a rigid cystoscope, a left tonsillar fossa mass was identified and on biopsy was confirmed as a squamous cell carcinoma. The patient's trismus rapidly progressed, and her mouth could only be opened to 7 mm under general anesthesia. Dental extraction to facilitate passage of the endoscope was considered, but in view of the extensive recent dental reconstruction, the patient was resistant to this as an option, unless it was unavoidable. The gastroenterology service was then consulted to provide flexible eso· phagoscopy. The patient was taken to the operating room, and nasotracheal intubation was accomplished under general anesthesia. Topical 4% cocaine was applied to the left nasal passage, and flexible nasotracheal dilators were passed up to 8.5 mm. A 9-mm pediatric flexible endosocope (Olympus P3, Olympus Corporation, New Hyde Park, N.Y.) was then introduced through the nares and advanced slowly into the esophagus. The upper esophageal sphincter was located at 18 em from the nares, and the squamocolumnar junction was located at 44 em. Panendoscopy of the stomach and esophagus was unremarkable. The left tonsillar fossa mass seen previously with the rigid cystoscope was not appreciated with the flexible endoscope. Examination of the nares and turbinates immediately following extubation revealed no significant trauma. Bronchoscopy, nasopharyngoscopy, and laryngoscopy with biopsies were subsequently performed by the primary physicians.
David A. Johnson, Edward L. Cattau, Jr., Anjum Khan, Donald E. Newell, Sarkis J. Chobanian,
MD MD MD MD MD
Multiple primary carcinomas may occur in the contiguous pathways of the upper aerodigestive tree, particularly in those patients who smoke tobacco or drink alcohol.1,2 As a result, panendoscopy is frequently carried out in staging patients with head and neck tumors. Although the percentage of simultaneous second primary cancers is low (2.5% to 8%),3-5 it is felt that a full assessment of the upper aerodigestive tract is necessary to accurately define the prognosis and to initiate early therapeutic measures in an attempt to maximize patient survival. In our institution, the head and neck surgeons routinely perform esophagoscopy as a staging procedure prior to head and neck cancer surgery. We were recently asked to provide the surgeons with preoperative esophagoscopy in a patient with squamous cell carcinoma of the left tonsillar fossa. Because severe trismus secondary to local extension of the tumor precluded a standard oropharyngeal intubation, a nasopharyngeal approach was used. CASE REPORT
A 60-year-old female was referred to the Otolaryngology Service, Naval Hospital, Bethesda, for evaluation of progressive trismus. For 8 months prior to the referral, the patient had been receiving extensive reconstructive treatment for dental injuries sustained in a fall. Two weeks prior to referral, the patient had noticed a swelling in her left submandibular area, prompting her attending dentist to seek an otolaryngology consultation. Needle aspiration of the mass was unremarkable, but a CT scan showed a submandibular mass. Excisional biopsies of the submandibular Received June 24, 1985. Accepted September 24, 1985. From the Gastroenterology and Otolaryngology Divisions, Naval Hos· pital, Bethesda, and Digestive Diseases Division, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Reprint requests: David A. Johnson, MD, Box 247, Naval Hospital, Bethesda, Maryland 20814-5011. The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Department of Defense, Department of the Navy, or the Uniformed Services University of the Health Sciences.
32
DISCUSSION
If the nasal approach is to be attempted, the nasal cavity should first be anesthetized with 4 % cocaine on cotton pledgets. This effects good anesthesia of the nasal cavity and also serves to vasoconstrict the nasal mucosa. If possible, we would suggest cocaine application to both nasal cavities to allow for selection of the side with the greatest patency. Obstruction of nasal passages may be caused by deviation of the septum, septal spurs, and large turbinates. Sequential introduction of well lubricated nasotracheal dilators prior to endoscopy will further maximize the aperture of passage and define any obstruction that may cause difficulty in advancing the larger endoscope. The endoscope is next introduced gently through the nares, advanced under direct visualization, and carefully guided along the floor of the nasal cavity, identifying the septum medially and inferior turbinate laterally. Occasionally, it may not be possible to pass the instrument along the floor of the nose; one may need to GASTROINTESTINAL ENDOSCOPY
Superior Meatus Middle Meatus Inferior Meatus
Soft Palate Uvula Palatine Tonsil Tongue Epiglottis
Figure 1. Cross-sectional depiction of the endoscopic pathway showing anatomic landmarks of the nasopharynx and oropharynx.
approach the posterior part of the nose by maneuvering above the inferior turbinate. As the posterior nasal cavity is reached, the eustachian tube orifice is visualized. At this point, the endoscope is directed caudad to conform to the anatomy of the nasopharynx. Thereafter, the anatomic landmarks are identical to those observed when an oral approach is used. The anatomy of the nasopharynx and oropharynx is shown in crosssectional view in Figure 1. A flexible bronchoscope could serve as an alternative means for evaluation of the esophagus. The bron-
choscope is smaller in diameter and easier to pass by the turbinates. A potential disadvantage with the standard bronchoscope is the lack of the air/water channel, which may limit optimal visualization during the procedure. Additionally, in other patients who may have gastric or duodenal disease, the length of the bronchoscope would be unsatisfactory for providing an adequate examination. Oropharyngeal intubation is the standard route by which the flexible fiberoptic endoscope is advanced into the esophagus. Upon occasion, there may be patients who require esophagogastroduodenoscopy but who have anatomic abnormalities that preclude introduction of the endoscope via the oral cavity. When such an occasion arises, flexible EGD through an intranasal approach should be considered. ACKNOWLEDGMENT The authors thank Joy W. Barchers for her expert editorial assistance. REFERENCES 1. Warren S, Gates O. Multiple primary malignant tumors: a survey of the literature and a statistical study. Am J Cancer 1932;16:1358-414. 2. Mortel CG. Multiple primary malignant neoplasms. Cancer 1977;40:1786-92. 3. Atkins JP, Keane WM, Young KA, Rowe LD. Value of panendoscopy in determination of second primary cancer. Arch OtolaryngoI1984;110:533-4. 4. Shepshay SM, Hong WK, Fried WP, et al. Simultaneous carcinomas of the esophagus and upper aerodigestive tract. Otolaryngol Head Neck Surg 1980;88:373-7. 5. Maisel RH, Vermeersch H. Panendoscopy for second primaries in head and neck cancers. Ann Otol Rhinol Laryngol 1981;90:460-4.
Case Re po rts Acyclovir in endoscopically presumed viral esophagitis Shailesh C. Kadakia, MD German A. Oliver, MD David A. Peura, MD
Infectious esophagitis caused by opportunistic organisms is a common clinical problem in patients with malignancies and in those receiving immunosuppresFrom the Gastroenterology Service, Department of Medicine, Walter Reed Army Medical Center, Washington, DC; and the Digestive Diseases Division, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Reprint reqlU!sts: David A. Peura, MD, Director of Clinical Services, Gastroenterology Service, Walter Reed Army Medical Center, Washington, DC 203075001. The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official policy or reflecting the views of the Department of the Army or the Department of Defense. VOLUME 33, NO.1, 1987
sive agents. While most of these infections are due to Candida albicans,!,2 other organisms such as cytome-
galovirus (CMV)3,4 and herpes simplex virus (HSV)48 have also been implicated. We report a series of five immunocompromised patients presenting with acute odynophagia, all of whom had endoscopic findings suggestive of viral esophagitis. Based on their clinical presentation and endoscopic findings, we treated all five patients with intravenous acyclovir for a period of 7 to 10 days with marked improvement of symptoms. SUMMARY OF CASES
All five patients were immunocompromised by virtue of their underlying disease or as a result of treatment with immunosupressive agents. The clinical characteristics of the patients at the time of presentation are summarized in Table 1. 33
REFERENCE
The authors thank Joseph A. Caldrone, medical photographer of the Audio Visual Department of Youngstown Hospital Medical Center, for his help with the figures.
1. Shinya H. Colonoscopic polypectomy. In: Colonoscopy, diagnosis and treatment of colonic diseases. New York: Igaku-Shoin, 1982:191-4.
Fiberoptic esophagogastroscopy via nasal intubation
lymph nodes showed well differentiated squamous cell carcinoma. By use of a rigid cystoscope, a left tonsillar fossa mass was identified and on biopsy was confirmed as a squamous cell carcinoma. The patient's trismus rapidly progressed, and her mouth could only be opened to 7 mm under general anesthesia. Dental extraction to facilitate passage of the endoscope was considered, but in view of the extensive recent dental reconstruction, the patient was resistant to this as an option, unless it was unavoidable. The gastroenterology service was then consulted to provide flexible eso· phagoscopy. The patient was taken to the operating room, and nasotracheal intubation was accomplished under general anesthesia. Topical 4% cocaine was applied to the left nasal passage, and flexible nasotracheal dilators were passed up to 8.5 mm. A 9-mm pediatric flexible endosocope (Olympus P3, Olympus Corporation, New Hyde Park, N.Y.) was then introduced through the nares and advanced slowly into the esophagus. The upper esophageal sphincter was located at 18 em from the nares, and the squamocolumnar junction was located at 44 em. Panendoscopy of the stomach and esophagus was unremarkable. The left tonsillar fossa mass seen previously with the rigid cystoscope was not appreciated with the flexible endoscope. Examination of the nares and turbinates immediately following extubation revealed no significant trauma. Bronchoscopy, nasopharyngoscopy, and laryngoscopy with biopsies were subsequently performed by the primary physicians.
David A. Johnson, Edward L. Cattau, Jr., Anjum Khan, Donald E. Newell, Sarkis J. Chobanian,
MD MD MD MD MD
Multiple primary carcinomas may occur in the contiguous pathways of the upper aerodigestive tree, particularly in those patients who smoke tobacco or drink alcohol.1,2 As a result, panendoscopy is frequently carried out in staging patients with head and neck tumors. Although the percentage of simultaneous second primary cancers is low (2.5% to 8%),3-5 it is felt that a full assessment of the upper aerodigestive tract is necessary to accurately define the prognosis and to initiate early therapeutic measures in an attempt to maximize patient survival. In our institution, the head and neck surgeons routinely perform esophagoscopy as a staging procedure prior to head and neck cancer surgery. We were recently asked to provide the surgeons with preoperative esophagoscopy in a patient with squamous cell carcinoma of the left tonsillar fossa. Because severe trismus secondary to local extension of the tumor precluded a standard oropharyngeal intubation, a nasopharyngeal approach was used. CASE REPORT
A 60-year-old female was referred to the Otolaryngology Service, Naval Hospital, Bethesda, for evaluation of progressive trismus. For 8 months prior to the referral, the patient had been receiving extensive reconstructive treatment for dental injuries sustained in a fall. Two weeks prior to referral, the patient had noticed a swelling in her left submandibular area, prompting her attending dentist to seek an otolaryngology consultation. Needle aspiration of the mass was unremarkable, but a CT scan showed a submandibular mass. Excisional biopsies of the submandibular Received June 24, 1985. Accepted September 24, 1985. From the Gastroenterology and Otolaryngology Divisions, Naval Hos· pital, Bethesda, and Digestive Diseases Division, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Reprint requests: David A. Johnson, MD, Box 247, Naval Hospital, Bethesda, Maryland 20814-5011. The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Department of Defense, Department of the Navy, or the Uniformed Services University of the Health Sciences.
32
DISCUSSION
If the nasal approach is to be attempted, the nasal cavity should first be anesthetized with 4 % cocaine on cotton pledgets. This effects good anesthesia of the nasal cavity and also serves to vasoconstrict the nasal mucosa. If possible, we would suggest cocaine application to both nasal cavities to allow for selection of the side with the greatest patency. Obstruction of nasal passages may be caused by deviation of the septum, septal spurs, and large turbinates. Sequential introduction of well lubricated nasotracheal dilators prior to endoscopy will further maximize the aperture of passage and define any obstruction that may cause difficulty in advancing the larger endoscope. The endoscope is next introduced gently through the nares, advanced under direct visualization, and carefully guided along the floor of the nasal cavity, identifying the septum medially and inferior turbinate laterally. Occasionally, it may not be possible to pass the instrument along the floor of the nose; one may need to GASTROINTESTINAL ENDOSCOPY
Superior Meatus Middle Meatus Inferior Meatus
Soft Palate Uvula Palatine Tonsil Tongue Epiglottis
Figure 1. Cross-sectional depiction of the endoscopic pathway showing anatomic landmarks of the nasopharynx and oropharynx.
approach the posterior part of the nose by maneuvering above the inferior turbinate. As the posterior nasal cavity is reached, the eustachian tube orifice is visualized. At this point, the endoscope is directed caudad to conform to the anatomy of the nasopharynx. Thereafter, the anatomic landmarks are identical to those observed when an oral approach is used. The anatomy of the nasopharynx and oropharynx is shown in crosssectional view in Figure 1. A flexible bronchoscope could serve as an alternative means for evaluation of the esophagus. The bron-
choscope is smaller in diameter and easier to pass by the turbinates. A potential disadvantage with the standard bronchoscope is the lack of the air/water channel, which may limit optimal visualization during the procedure. Additionally, in other patients who may have gastric or duodenal disease, the length of the bronchoscope would be unsatisfactory for providing an adequate examination. Oropharyngeal intubation is the standard route by which the flexible fiberoptic endoscope is advanced into the esophagus. Upon occasion, there may be patients who require esophagogastroduodenoscopy but who have anatomic abnormalities that preclude introduction of the endoscope via the oral cavity. When such an occasion arises, flexible EGD through an intranasal approach should be considered. ACKNOWLEDGMENT The authors thank Joy W. Barchers for her expert editorial assistance. REFERENCES 1. Warren S, Gates O. Multiple primary malignant tumors: a survey of the literature and a statistical study. Am J Cancer 1932;16:1358-414. 2. Mortel CG. Multiple primary malignant neoplasms. Cancer 1977;40:1786-92. 3. Atkins JP, Keane WM, Young KA, Rowe LD. Value of panendoscopy in determination of second primary cancer. Arch OtolaryngoI1984;110:533-4. 4. Shepshay SM, Hong WK, Fried WP, et al. Simultaneous carcinomas of the esophagus and upper aerodigestive tract. Otolaryngol Head Neck Surg 1980;88:373-7. 5. Maisel RH, Vermeersch H. Panendoscopy for second primaries in head and neck cancers. Ann Otol Rhinol Laryngol 1981;90:460-4.
Case Re po rts Acyclovir in endoscopically presumed viral esophagitis Shailesh C. Kadakia, MD German A. Oliver, MD David A. Peura, MD
Infectious esophagitis caused by opportunistic organisms is a common clinical problem in patients with malignancies and in those receiving immunosuppresFrom the Gastroenterology Service, Department of Medicine, Walter Reed Army Medical Center, Washington, DC; and the Digestive Diseases Division, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Reprint reqlU!sts: David A. Peura, MD, Director of Clinical Services, Gastroenterology Service, Walter Reed Army Medical Center, Washington, DC 203075001. The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official policy or reflecting the views of the Department of the Army or the Department of Defense. VOLUME 33, NO.1, 1987
sive agents. While most of these infections are due to Candida albicans,!,2 other organisms such as cytome-
galovirus (CMV)3,4 and herpes simplex virus (HSV)48 have also been implicated. We report a series of five immunocompromised patients presenting with acute odynophagia, all of whom had endoscopic findings suggestive of viral esophagitis. Based on their clinical presentation and endoscopic findings, we treated all five patients with intravenous acyclovir for a period of 7 to 10 days with marked improvement of symptoms. SUMMARY OF CASES
All five patients were immunocompromised by virtue of their underlying disease or as a result of treatment with immunosupressive agents. The clinical characteristics of the patients at the time of presentation are summarized in Table 1. 33