Can Endoscopy cause chronic laryngitis?

[Herb1932]

Within the past year, my 72-year-old wife has undergone two gastroscopy procedures. After the first, she had no ill effects, but following the second in November 2007, she almost immediately developed respiratory problems -- a hoarse voice, a deep and persistent cough, shortness of breath, and some bloody discharges through the nose. I informed her personal physician that I felt the endoscopy, itself, was responsible for my wife's condition, but she at first treated her with Pednisone, which did not help. She was then given Doxycycline, which also did not help. Chest x-rays showed no evidence of pneumonia and a C-scan gave no indication of a problem. She was then sent to an ear, nose and throat specialist, who diagnosed her problem as chronic laryngitis. Additional tests (barium swallow) are upcoming. I still feel the endoscopy caused my wife's problems. Is that possible?


This discussion is related to Laryngitis, chronic dry cough, upper chest.

[Herb1932]

Risks of Gastroscopy with the Flexible Gastroscope
SIR,-It is with great interest that I read the article by
Drs. C. M. Fletcher and F. Avery Jones on the risks of gastroscopy
with the flexible gastroscope (Sept. 29, p. 421). I, personally,
experienced a similar fatal case about two years ago.

Although this article should be of considerable value, especially
to those whose enthusiasm for this kind of examination rather
overshadows their experience, I would nevertheless like to add
that in my opinion there are definite causes that contribute to
these mishaps, and there are certain features about these patients
and methods of procedure which, if considered, should go a
long way to minimize this small but most disconcerting risk.

The three cases quoted by Drs. Fletcher and Avery Jones
were in elderly women; my own case was in a woman of 63
years, and the perforation also occurred within the upper 11
inches of the oesophagus. If one considers the normal anatomy
of the oesophagus it will be recalled that the musculature
posteriorly is deficient in the upper 1- inches, there being a
dehiscence of the inner longitudinal fibres, and the gap thus
left is covered only by the circular fibres. The mucosa, like
that of the stomach, tends to atrophy with age, especially in
women; if this atrophic change occurs in the upper end of
the organ an area exists which may be particularly vulnerable
and liable to injury or perforation.

The tendency for many gastroscopists is to extend the head
too much during introduction of the instrument. The upper
end of the oesophagus becomes stretched over the bodies of
the 6th and 7th cervical vertebrae and its posterior wall lies
in direct contact with them, and, in the presence of an atrophic
mucosa, the impact of the metal tip of the gastroscope may be
sufficient to start a small tear; subsequent pressure on the
delicate area by the rigid portion of the instrument against the
bony background with the head fully extended would increase
the damage already inflicted.

Another important point is that it is impossible to obtain a circular field of vision or to visualize fully certain areas in the kyphotic subjects, and it is a great temptation to the operator to keep on extending the head in order to increase the field of vision. In these circumstances undue pressure of the rigid portion of the instrument may cause a small burst rather than a tear in the atrophied mucosa ; in this type of patient the instrument is frequently passed with ease, no injury being produced during introduction.

Following upon my own mishap, I always introduce the instrument with
the head slightly flexed, gradually extending the head as the
rigid portion passes; in addition I find that the rubber fingertip
fitted to my Hermon Taylor gastroscope is a great help in
negotiating the crico-pharyngeal sphincter and the hypopharynx.

I feel convinced that if the operator is acquainted with the
above anatomical and pathological points, and exercises care in
introduction, even in the types of cases mentioned, the risks
associated with the use of the gastroscope are really no greater
than those during bronchoscopy or other endoscopic examinations.
-
I am, etc.,
London, W.I. HARRY FREEMAN.

SIR,-The article written by Dr. C. M. Fletcher and Dr. F.
Avery Jones on the dangers of gastroscopy brings a timely
warning. There is a danger that the practice of gastroscopy
may be brought into undeserved disrepute if it becomes
a weapon of " the occasional gastroscopist." It is still thought
that gastroscopy is as easy as cystoscopy or oesophagoscopy and that the gastroscope can be passed after reading about it
or watching an expert on a few occasions.

Fletcher and Avery Jones with their vast experience show
clearly how dangerous the instrument can be, even in expert
hands. In my opinion they have, however, failed to emphasize
sufficiently the fact that under no circumstance is force to be
applied in the passage of the instrument.

If the instrument
sticks in the hypopharynx or in the region of the cardiac orifice
it should be withdrawn slightly and another attempt made to
pass it on. If it persists in sticking, force will then cause it to
pass but at the expense of severe damage to the oesophagus. If
the obstruction is due to spasm, waiting for half a minute and
then attempting gently to pass the instrument will often succeed.
If a second attempt fails, then, in my opinion, it is unsafe to
continue and the manceuvre should be abandoned.

It should be borne in mind that cases occur where it is impossible
to pass the instrument owing to spinal curvature or
other physical abnormalities, and, while I would not go so far
as to say that gastroscopy should not be attempted in these
cases, I certainly would emphasize that if it is attempted not the
slightest force should be employed, and that one should be
prepared for complete failure. Both the Wolf-Schindler and the
Hermon Taylor gastroscopes are composed of a flexible tube
attached to a rigid one. Nobody would dream of passing an
oesophagoscope except under direct vision, but in gastroscopy
a semi-rigid tube is passed blindly. Surely in such a case no
force dare be applied.

Again I deprecate the large out-patient gastroscopy clinics
where patients undergo gastroscopy and are allowed to go
home very soon after. Perhaps the only excuse for the outpatient
gastroscopic clinic is the shortage of beds. I have made
a practice of keeping every gastroscopy case in hospital for 24
hours before discharge, and though, after nearly 500 cases, I
have not had a single mishap, Fletcher and Avery Jones have
clearly shown that gastroscopy, like cystoscopy, is not without
its dangers. Schindler has emphasized how necessary it is for
the complete general examination to be made of the gastroscopy
patient. This should include the spine, chest, abdomen, and
throat. All my cases receive this examination, and a careful
anamnesis has saved me twice from passing this instrument on
epileptics. There is also the nervous, unstable, and uncooperative
individual who may easily convert his examination
into a catastrophe.

Gastroscopy in the edentulous, big-mouthed individual is
very easy, and is apt to mislead the novice. When the opposite
type of case is attempted the experienced gastroscopist knows
when to desist. It is said that the good surgeon knows when not
to operate, so the good gastroscopist should know when not to
persevere in his attempts to pass a semi-rigid tube blindly.-I
am, etc.,

St. Mary Islington Hospital, I. I. PRICE.