I. GENERAL CONSIDERATIONS

A. Definitions

1. “Panendoscopy” of the head and neck refers to combined rhinoscopy, nasopharyngoscopy, inspection of the oral cavity and oropharynx, direct laryngoscopy and hypopharyngoscopy, esophagoscopy, and bronchoscopy. Most cases of squamous cell carcinoma of the upper aerodigestive tract receive an endoscopic evaluation under general anesthesia, but most do not need a complete or “pan” endoscopy as defined.

2. Clinical evaluation of the nose (rhinoscopy) and nasopharynx (nasopharyngoscopy) is generally well executed in the clinical setting with topical anesthesia and generally does not require repeating for all cases in an operating room setting. Specific exceptions, such cases with metastatic spread of cancer to the neck with an unknown primary source, will mandate close inspection and directed biopsy of the nasopharynx. In general, however, most cases of “panendoscopy” do not require specific attention to the nose and nasopharynx in the operating room because these sites can be assessed well in the clinic.

3. Similarly, there is little benefit derived from routine bronchoscopy in the absence of symptoms directing attention to the lungs. In patients with a normal chest x-ray and without pulmonary signs or symptoms, bronchoscopy is not a necessary component to routine panendoscopy.

B. Indications for Panendoscopy Under General Anesthesia

1. To biopsy a tumor not accessible under local anesthesia in the clinic

2. Tumor mapping to identify extent of tumor through inspection, palpation, and sampling biopsies

a. See Toluidine blue protocol

b. See Suspension microlaryngoscopy protocol

3. Rule out associated malignancy: 3 to 12% of patients with a mucosal head and neck squamous cell cancer have another synchronous mucosal squamous cell carcinoma

a. In general, all patients with head and neck mucosal squamous cell carcinoma should undergo panendoscopy prior to treatment.

b. Panendoscopy is ideally done prior to definitive treatment planning (ie, presentation at tumor board), but, when done immediately prior to extirpative surgery, is more convenient, less expensive, and requires one less exposure to anesthesia.

c. A normal chest x-ray and normal barium swallow may constitute a sufficient survey for patients, without the need to further evaluate for synchronous second primaries if they are a high anesthetic risk. The hypopharynx is the region of the upper aerodigestive tract that is most difficult to assess through any approach other than rigid endoscopy.

II. PREOPERATIVE PREPARATION

A. Patient Preparation

1. A barium swallow (see Oropharyngeal Motility Study Report protocol) prior to esophagoscopy is not essential in all cases. It is of most benefit when

a. Dysphagia or odynophagia is identified

b. Difficulties exist in coordinating surgical teams for a complex extirpation and reconstruction. An abnormal barium swallow (or oropharyngeal motility study) will direct either panendoscopy or esophagoscopy to be done as a separate procedure before the time of the extirpative surgery. This practice diminishes the chance of finding an occult esophageal primary, requiring cancellation of a long procedure that may be difficult to reschedule due to involvement of multiple separate teams.

2. Flexion-extension lateral radiographic views of neck if history of neck arthritis, previous neck surgery, or previous neck injury

3. Consider referral to dental prosthodontics to make custom-made acrylic dental guards to protect teeth (see Dental Protection During Rigid Endoscopy, in recommended reading)

B. Consent

1. Describe procedure: “We will place flexible and rigid lighted tubes into your mouth, throat, voice box, swallowing tube, behind your nose, and into your lungs to inspect and possibly sample specimens.”

2. Describe potential complications

a. Bleeding, infection, reaction to anesthetic

b. Damage to adjacent structures: “We will be placing instruments past your lips, teeth, and tongue to gain access to the regions we are looking at. It is possible to bruise your lip, chip your tooth, make your tongue numb or alter your voice, swallowing, or breathing.”

3. Mention potential for prolonged intubation or tracheotomy if it is more than a remote possibility.

III. NURSING CONSIDERATIONS

A. Room Setup

1. See Endoscopy Room Setup

B. Instrumentation and Equipment

1. Standard

a. Bronchoscopy tray, adult

b. Esophagoscopy tray, adult

c. Direct Laryngoscope Tray

2. Special

a. Tracheotomy tray

b. Tonsillectomy tray

c. Flexible bronchofiberscope

d. Jackson laryngeal dilator tray

e. Telescope, Storz, Hopkins straight forward, 0°, wide-angle, 5 x 20 cm

f. Telescope, Storz, Hopkins straight forward, 0°, 4 x 30 cm

g. Stortz fiber optic light cable

h. Stryker camera adapter

C. Medications (specific to nursing)

1. 4% lidocaine solution, topical: draw up in Luer Lock syringe to secure abbocath, used to spray vocal cords

2. Oxymetazoline HCL nasal spray, 0.05%

3. Silver nitrate sticks to control bleeding

4. Toluidine blue (see Toluidine blue protocol) and 1% acetic acid may be used to “stain” tumor for better visualization

5. FRED (Fog reduction elimination device)

D. Prep and Drape

1. Drape

a. Place a rolled sheet for shoulder roll

b. Two unfolded pillowcases with towel clamp for a head drape

c. Split sheet

E. Drains and Dressings

F. Special Considerations

1. Also see Suspension microlaryngoscopy protocol and Bronchoscopy protocol.

2. Keep a small amount of clean saline set aside to place biopsies in and to clean off biopsy forceps; will avoid cross-contamination between specimens.

3. May use silver nitrate sticks to control bleeding.

4. Open 18-gauge needle when taking biopsies to remove tissue from forceps.

5. Have oymetazoline and neurosurgical cottonoids (1/4 x 1/4 in) available to open if biopsies or other manipulation of vocal cords occurs.

6. Patients may have premade tooth guards.

7. Instruments should be set up prior to induction and remain assembled until patient is extubated and patent airway is established.

8. Tape eyes (employ moistened eye pads and cloth tape if use of laser is possible).

IV. ANESTHESIA CONSIDERATIONS

A. General Anesthesia

1. Communication with anesthesia staff is essential

a. Oral endotracheal intubation with small (5.5 to 6.0) endotracheal tube (MLT tube = micro-laryngeal-tracheal tube)

b. Short-term paralysis (duration dependent on procedure; communicate with anesthesiologist)

c. Consideration of alternative methods

(1) Jet anesthesia

(2) Apnea

(3) Local anesthesia with sedation (see Local anesthesia for rigid endoscopy protocol)

(4) The surgeon should be present in the operating room during induction if there is potential for airway compromise

B. Preoperative Systemic Medications

1. Glycopyrrolate 0.1 to 0.2 mg IM on call to the operating room

a. The drying effect improves exposure; consider avoiding in patients with xerostomia

b. The vagolytic effect diminishes the risk of laryngospasm

2. Consider Decadron 8 to 10 mg IV when IV started to diminish edema

3. Contraindications (eg, diabetes, ulcer disease.)

4. Antibiotics administered only if biopsies or incisions are made in an infected or contaminated region (not usually employed for vocal fold surgery) (see Antibiotic protocol)

C. Positioning

1. Head of table turned 90° from anesthesia

2. Arms tucked for placement of suspension laryngoscopy support

3. Neck extended with a shoulder roll

4. Head of bed elevated 15 to 30°

V. OPERATIVE PROCEDURE

A. Order of procedure is dictated by problem at hand, but in general:

1. Laryngoscopy

a. Place rubber tooth guard or moist 4 x 4 gauze (if edentulous), or custom-made dental guard

b. Jackson laryngoscope (first); alternatively employ Dedo laryngoscope instead. Evaluate oropharynx (tonsillar fossa, base of tongue, pharyngeal walls) with view of valleculae and supraglottic structures

c. Dedo laryngoscope provides the next-best illumination and exposure for endolarynx. If difficult to visualize because of neck immobility, retrognathism, or large teeth, consider Hollinger anterior commissure laryngoscope.

(1) Evaluate arytenoids, aryepiglottic folds, false vocal cords, true vocal cords, ventricles, pyriform sinuses, subglottis

(2) May palpate with spatula to test true vocal cord and arytenoid mobility

2. Bronchoscopy

a. Flexible fiber optic bronchoscopy most readily done when larynx is exposed with Dedo scope

(1) Pass flexible fiber optic bronchoscope through the laryngoscope past the vocal cords adjacent the endotracheal tube with cuff deflated.

(2) See Bronchoscopy protocol.

b. Alternatively

(1) Pass bronchoscope through endotracheal tube or preexisting tracheotomy.

(2) Perform rigid bronchoscopy

(a) Value in providing improved view of the subglottis is no longer apparent due to availability of rigid telescopes that clearly define the anatomy of the subglottis around an appropriately small endotracheal tube.

(b) Placement of the rigid bronchoscopy generally requires removal of the endotracheal tube to permit ventilation through the bronchoscope; the potential to lose control of the airway exists with this maneuver.

(c) In general, the tracheobronchial tree is imaged much more completely with a flexible fiber optic bronchoscope.

c. In the absence of pulmonary symptoms and with a normal chest x-ray, yield from bronchoscopy in search for synchronous second primary is low.

3. Esophagoscopy

a. Procedure is most safely done with cervical (short) esophagoscope initially to be followed with thoracic (longer) esophagoscope.

b. May use Jackson dilators to follow lumen.

c. Do not advance the esophagoscope if the lumen of the esophagus is not seen.

d. Further extension of neck (rather than the “sniffing position” assumed for laryngoscopy) may be helpful.

e. If rigid esophagoscopy not possible due to anatomic constraints, either perform flexible esophagoscopy or obtain a barium esophagram without performing esophagoscopy.

f. Esophageal landmarks (distance from incisors):

(1) 16 cm cricopharyngeus

(2) 23 cm aorta

(3) 27 cm left main stem bronchus

(4) 40 cm gastroesophageal junction

4. Nasopharyngoscopy

a. Generally done best with surgeon wearing a headlight with an assistant retracting the tongue with a Weeder retractor or, better, place Crowe-Davis retractor (also a good time to reinspect oral cavity and oropharynx).

b. Visualize nasopharynx

(1) Love retractor can be used to elevate the soft palate to expose the nasopharynx to indirect mirror examination (prevent fogging of the mirror by application of ultrastop or soap solution).

(2) Alternatively, red rubber catheters placed through nose and out mouth permit elevation of palate (as is done for adenoidectomy).

(3) A Yankauer nasopharyngoscope may be used for direct view of nasopharynx without mirror but may induce injury to the palate, as it requires manipulation of the soft palate to permit inspection.

(4) Alternatively, when headlight is not available, Hollinger anterior commissure scope may be placed to elevate palate and permit inspection of illuminated nasopharynx.

(5) The nasopharynx may also be viewed transnasally with rigid nasal endoscopes.

c. Always palpate nasopharynx, tonsillar fossae, base of tongue, and neck

d. More important to do nasopharyngoscopy with unknown primary than as part of general work-up to evaluate for synchronous primaries.

e. Nasopharyngoscopy is also important in determining rostral extent of oropharyngeal lesions (involving the tonsil and soft palate).

B. Biopsies

1. General principles

a. Work from caudal to rostral so that bleeding will not obscure caudal lesions prior to biopsy.

b. For suspected tumor, take superficial biopsy, then deep biopsy through same site.

c. Biopsy those areas that will be important in defining surgical margins, those that will mean the difference between conservative and ablative operations. Also sample areas which, if positive, would indicate incurable disease.

d. Usually biopsy frank tumor last; exception: if frozen section is to be done to determine adequacy of sampling, frank tumor may be initially biopsied to permit processing of frozen section while other survey is conducted.

e. Between each biopsy, the scrub nurse should meticulously wipe biopsy forceps so as not to contaminate one biopsy with tissue from the previous biopsy.

f. In cases in which frank tumor is necrotic or otherwise may present difficulties in making histologic diagnosis, perform a frozen section while patient is asleep in order to

(1) Ensure that an adequate sample has been obtained

(2) Alert the pathologist to the need for special processing of specimen (ie, glutaraldehyde for EM, touch preps)

2. Specifics

a. Laryngeal biopsies

(1) Use Suspension microlaryngoscopy if tumor mapping is to be done; obtain immediate still pictures to place in chart.

(2) Consider laser “vestibulectomy,” resection (not vaporization) of the false vocal cords to improve exposure for surgery on the true vocal cords and improved imaging on follow-up exams.

b. Nasopharyngeal biopsies

(1) The most direct approach to eustachian tube orifices is through the nose (decongest first with Neosynephrine). Biopsies may be done using biopsy forceps through the nose and either mirror visualization of nasopharynx or finger palpation of the eustachian tubes.

(2) More conventional biopsies are done directly through the mouth with palate elevated by Love retractor or with Yankauer nasopharyngoscope (can occasionally cause significant trauma to palate).

c. Directed biopsies for unknown primary squamous cell carcinoma with metastases to the neck

(1) Bilateral nasopharynx (fossa of Rosenmuller)

(2) Ipsilateral tonsil (do tonsillectomy): It is most reasonable to perform a bilateral tonsillectomy to prevent confusion during examination years later when the remaining single large contralateral tonsil is identified.

(3) Ipsilateral base of tongue

(4) Ipsilateral pyriform sinus

d. May use silver nitrate to cauterize biopsy sites; alternatively, Freche monopolar needle tip laryngeal electrocautery unit may be used.

e. Make a carefully labeled drawing in the chart indicating each biopsy site.

f. Understand the difficulty in communicating numerous complicated names of biopsy sites to the nurses.

VI. POSTOPERATIVE CARE

A. Medications

1. Consider additional IV Decadron if edema and airway compromise is a concern

2. Consider antibiotics for

a. Biopsies through infected areas

b. Large biopsies requiring suture closure

c. Biopsies done in contaminated areas such as the oral cavity and oropharynx

B. Postoperative Orders

1. Traditionally (many years ago) the patient was kept NPO for 6 to 8 hours after esophagoscopy with no pain medicine stronger than codeine and no Tylenol in order to observe for perforation with mediastinitis.

a. The above should be observed if the esophagoscopy was done with difficulty and with a chance for perforation.

b. If esophagoscopy was done by experienced endoscopist without complication, patient may be fed and discharged once recovered from anesthetic.

c. Postoperative neck, chest, or abdominal pain should raise concern for esophageal perforation until proven otherwise (see Esophageal perforation protocol).

VII. CPT CODING

A. 31525, 31526, 31535, 31536, 31540, 31541, Direct laryngoscopy

B. 43200, 43202, Esophagoscopy

C. 31615, 31622, 31623, 31624, 31625, Bronchoscopy

D. 92511, 42804, 42806, Nasopharyngoscopy

VIII. SUGGESTED READING

A. Benninger MS, Enrique RR, Nichols RD. Symptom-directed selective endoscopy and cost containment for evaluation of head and neck cancer. Head Neck. 1993;15:532-536.

B. Elleson DA, Rowley SD. Esophageal perforation: its early diagnosis and treatment. Laryngoscope. 1992;92:678-680.

C. Elner A, Dahlbach O. Instrumental perforation of the esophagus. Acta Otolaryngol. 1962;51:279.

D. Kraus, EM. Endoscopy: A Scion of Sword Swallowing. Manuscript for Iowa Basic Science Course. 1981.

E. Lefor AT, Bredenberg CE, Kellman RM, Aust JC. Multiple malignancies of the lung and head and neck. Arch Surg. 1986;121:265-270.

F. Levine B, Neilsen EW. The justifications and controversies of panendoscopy--a review. Ear Nose Throat. 1992;71:335-343.

G. McGuirt WF. Panendoscopy as a screening examination for simultaneous primary tumors in head and neck cancer: a prospective sequential study and review of the literature. Laryngoscope. 1982;92:569-576. Follow-up letter to editor. Laryngoscope. 1982;92:688.

H. Ibid discussion by McQuarrie p 270.

I. Olsen GT, Moreano EH, Arcuri MR, Hoffman HT. Dental protection during rigid endoscopy. Laryngoscope. 1995;105:662-663.

J. Parker JT, Hill JH. Panendoscopy in screening for synchronous primary malignancies. Laryngoscope. 1998:98:147-149.

K. Shaha AR, Hoover EL, Mitrani M, Marti JR, Krespi YP. Synchronicity, multicentricity, and metachronicity of head and neck cancer. Head Neck Surg. 1988;4:225-228.