 Rigid Upper Esophagoscopy 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
Introduction:  
 
As technology developed and flexible 
fiberoptic 
upper 
endoscopy 
became 
more 
widespread, rigid esophagoscopy became less 
commonly used. The advantages of flexible over 
rigid 
esophagoscopy 
include 
less 
anesthesia 
requirement and less risk of perforation or other 
iatrogenic injury. Another advantage of a flexible 
fiberoptic approach is increased visualization, as 
rigid esophagoscopy involves examination through a 
long narrow metal tube.  
One 
distinct 
location 
where 
rigid 
esophagoscopy is in the “back of the throat,” 
including the oropharynx, hypopharynx, upper 
esophageal sphincter, and cervical esophagus. It is 
difficult to visualize this area well on flexible 
endoscopy, even with adequate topical and 
intravenous sedation anesthesia, due to the gag 
reflex. Without general anesthesia, it is practically 
impossible to perform any significant intervention, 
such as foreign body removal or biopsy of lesions 
above the upper sphincter.  
The indications for rigid esophagoscopy 
include: Foreign body removal from the oropharynx, 
hypopharynx, or cervical esophagus, or other 
intervention at the cervical esophagus such as biopsy 
or dilation. It can also be performed as part of a direct 
operative laryngoscopy and biopsy, as the surgeon 
inspects all of the upper aerodigestive tract. Another 
potential indication is need to examine any of the 
esophagus, 
in 
the 
absence 
of 
a 
flexible 
esophagoscope. While it is possible to perform rigid 
endoscopy all the way to and through the lower 
esophageal sphincter, this is progressively more 
difficult the farther one goes. In a low-resource 
setting without access to a flexible scope, this would 
be an acceptable alternative, supplemented with 
barium upper gastrointestinal studies to assess the 
stomach and duodenum.  
Rigid esophagoscopes generally come in 
various lengths; it is advisable to use the shortest one 
possible, as visualization and instrumentation 
becomes more difficult with longer tubes.  
 
47cm rigid esophagoscope with attachment for fiberoptic light 
cable (Red Arrow,) suction cannula of suitable length (Top) and 
brush for cleaning (Bottom.) The upper forceps is for biopsy 
and the lower two are for foreign body removal. The entire 
esophagus to the gastroesophageal junction can be inspected 
with this scope. 
 
If one is attempting to visualize only the 
hypopharynx, upper sphincter, and the first 5cm of 
the cervical esophagus, it is quite acceptable to use a 
#4 or larger Miller (straight blade) laryngoscope. 
This allows one to use the Yankauer suction and the 
Magill forceps. We frequently use this strategy when 
removing foreign bodies, when they are lodged in the 
hypopharynx or at the upper esophageal sphincter. 
 
The 4 Miller laryngoscope’s blade is a straight lighted tube. It 
can be used to inspect, biopsy, or remove foreign objects from 
the hypopharynx, upper esophageal sphincter, and first 5cm of 
the cervical esophagus. 
 
The steps of rigid esophagoscopy consist of:  
● Induction of general anesthesia and intubation 
 Rigid Upper Esophagoscopy 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
● Extending the neck using a head ring and 
shoulder roll 
● Insertion of the scope and advancement under 
direct visualization 
● Biopsy or intervention 
● Repeat inspection to confirm hemostasis or 
complete removal of the object without 
perforation. 
 
Steps: 
1. Ask the patient to extend the neck to assess range 
of motion. This helps to avoid injury by 
hyperextension once the patient is anesthetized. 
2. Induce 
general 
anesthesia 
and 
intubate. 
Communicate the anticipated length of the 
procedure to avoid inappropriate administration 
of a long-acting anesthetic or paralytic.  
3. Extend the neck using a head ring and shoulder 
roll. To avoid iatrogenic injury, make sure the 
head is resting solidly on the head ring and 
cannot be rotated or extended further. See 
Pitfalls, below.  
 
Extension of the neck with a head ring and shoulder roll allows 
the passage of a straight instrument through the mouth, down 
the esophagus all the way to the gastroesophageal junction. 
 
4. Rotate the table 90 degrees away from the 
anesthesia station to allow the surgeon room to 
maneuver. Raise the table to a comfortable height 
or sit on a stool. 
5. Insert the scope with the bevel facing downward 
until the tip contacts the posterior oropharyngeal 
mucosa.  
 
Insert the scope through the mouth with the bevel facing 
posteriorly. When the tip reaches the mucosa of the posterior 
oropharynx (Red arrow) advance it in a caudal direction while 
maintaining gentle pressure in a posterior direction. Keeping 
the scope in the midline directs its tip into the upper esophageal 
sphincter (Blue Arrow.)  
 
 
The beveled tip of the scope faces posterior, allowing the scope 
to be gently advanced in the direction shown by the Red Arrow. 
.  
6. Taking care to avoid injury to the upper incisors, 
direct the tip of the scope in a caudal direction 
while applying gentle pressure against the 
posterior oropharynx and hyopoharynx. Keep the 
tip of the scope in the midline as you advance. 
Use a folded gauze or an athletic mouthguard to 
protect the teeth.  
7. You will encounter some slight resistance at the 
upper esophageal sphincter. Stop at this point, 
pull back slightly, and direct the scope to the left 
 Rigid Upper Esophagoscopy 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
and right to inspect the pyriform sinuses, a 
frequent location for foreign bodies to become 
impacted. Be sure to remain posterior to the 
endotracheal tube to avoid dislodging it.  
8. Return to the midline and insert the scope into the 
esophagus as far as needed.  
9. Use retrieval forceps, suction, or biopsy forceps 
to perform an intervention.  
10. Inspect biopsy sites or sites of foreign body 
impaction to confirm hemostasis or lack of deep 
injury to mucosa. 
 
Pitfalls 
● If patient has trismus, a short wide neck, or 
decreased range of neck mobility, you may not 
be able to extend their neck sufficiently to allow 
a straight scope to pass into the esophagus. 
Assess the neck range of motion prior to 
induction of anesthesia.  
● When a shoulder roll is in place, the neck will be 
extended. The head ring should be at a level that 
it supports the head. The head should not be 
supported by the vertebral column. Once the head 
ring is in place, assure that it supports the head 
by pushing gently downwards on the forehead. If 
the 
head 
moves 
downwards, 
you 
are 
hyperextending the cervical spine. Place some 
stacked blankets under the head ring to raise it up 
until it is supporting the head. Serious injury can 
result from neglecting this step! 
 
Pushing gently downward on the patient’s head after extension 
of the neck with a head ring and shoulder roll. If the head moves 
further, it is supported by the cervical spine and not the head 
ring. The head ring should be raised to avoid this situation.  
 
● The scope can chip or fracture the upper incisors 
or lacerate the upper lip, especially as the 
surgeon’s attention is directed deeper in the 
throat. The less the patient can open their mouth 
or extend the neck, the more likely this is. A soft 
rubber mouthguard from a pharmacy or sporting 
goods store can protect this area. Patients with 
loose upper incisors should be advised that some 
injury may be unavoidable.  
● Anesthesia may seem sufficient until a scope is 
inserted into the throat, triggering the gag reflex. 
Stop and wait for the anesthetist to deepen the 
anesthesia.  
● The hypopharynx or cervical esophagus can be 
lacerated by careless suctioning, deep biopsy, or 
the presence of a foreign body for 24 hours or 
more. Be very mindful of this complication and 
inspect 
carefully 
upon 
completing 
the 
endoscopy. Use Barium esophagoscopy to rule 
out perforation or to assess the depth of 
perforation and presence of extravasation. 
● In case of perforation, have a very low threshold 
for surgical exploration and repair. If a contrast 
study shows passage into the parapharyngeal 
space or mediastinum, exploration is mandatory. 
Simply making the patient “NPO” is not 
sufficient, as the average adult swallows 1.5L of 
saliva per day. Neck exploration for esophageal 
perforation is discussed in a separate chapter.  
 Rigid Upper Esophagoscopy 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
Lateral view Barium swallow study shows extravasation of 
contrast from the posterior hypopharynx area. The Red Arrow 
shows the point of extravasation, and the Blue Arrow shows 
passage of the contrast inferiorly into the mediastinum. This 
patient will require surgical exploration, debridement, and 
repair of the perforation. Case courtesy of RMH Core 
Conditions, https://radiopaedia.org/?lang=us   From the case 
https://radiopaedia.org/cases/26313?lang=us 
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
January 2022 
 
