What Is the Best Technique for Diagnosing Esophageal Diverticulum?

The FEES/TNE Diagnostic Process

Dr. Chhetri maintained that his methods for diagnosing diverticula offer a way to overcome what he calls the shortcomings of traditional radiologic evaluation-that is, diagnosis and treatment planning do not have to be delayed. Because many otolaryngologists now routinely perform FEES and TNE, they can more readily diagnose and plan treatment in one patient visit. (This may be more of an issue in private practice than at an academic center, where radiology is generally housed in the same building or on the same campus.)

When performing FEES, Dr. Chhetri first uses a 4% neosynephrine solution, without topical anesthetic, to decongest the nasal passages. After the scope has been passed along the floor of the nose and into the oropharynx, food mixed with green coloring is fed to the patient, beginning with puree, followed by nectar-thick, thin liquids, and a cookie. If patients are suspected to have a diverticulum, the endoscopist performs additional maneuvers to provoke EPR. These include asking the patient to phonate a sustained vowel (eeeee) after swallowing the food bolus and/or pressing on or massaging the patient’s anterior neck during sustained phonation. In his experience, said Dr. Chhetri, these maneuvers can cause the contents of a cervical esophageal diverticulum to be refluxed back to the hypopharynx. Observance of EPR would then lead Dr. Chhetri to perform TNE. After anesthetizing the nasal cavity with 4% lidocaine-soaked pledgets for several minutes, the transnasal esophagoscope is passed through the nasal cavity, advanced to the hypopharynx, and directed into a pyriform sinus, then allowed to pass into the cervical esophagus during a swallow.

If a ZD is present, the tip falls naturally into the diverticular pouch. Dr. Chhetri contended that he can generally estimate the pouch size by noting the distance the endoscope travels from the tip of the esophageal pouch to the level of the cricopharyngeal bar. After assessing the diverticulum, the scope is withdrawn to the cricopharyngeal bar and redirected toward the esophagus. The entire esophagus is then assessed all the way to the stomach.

Hindrance to Surgical Planning?

Dr. Hillel said that he recommends the standard barium swallow for definitive diagnosis and ease of surgical planning. So does Dr. Postma. The barium swallow gives you the ability to tell the size of the pouch-and size is pretty important, noted Dr. Postma. If the pouch is tiny, he explains, it may be impossible to insert the staple device used to perform the diverticulostomy. In the latter case, a laser myotomy is then performed.