Post written by Marc Julius H. Navarro, MD, from the Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan, the Institute of Digestive and Liver Diseases, St. Luke’s Medical Center, Quezon City, and the Section of Gastroenterology, Department of Medicine, Makati Medical Center, Makati City, Philippines.

In this video, we present a case of en bloc resection of right piriform sinus squamous cell carcinoma via hypopharyngeal endoscopic submucosal dissection (ESD). We highlight the usefulness of percutaneous cricothyrotomy and super-soft hood in maximizing limited space of the pharynx.

Recent advances in GI endoscopy enable us to minimally invasively resect superficial hypopharyngeal carcinomas by ESD and endoscopic laryngopharyngeal surgery with patients under general anesthesia.

Lesions for ESD and endoscopic laryngopharyngeal surgery situated in the oropharynx and hypopharynx are usually technically challenging to resect because of the limited space for the endoscope and other devices to maneuver. The endotracheal (ET) tube inserted to protect and secure the airway sometimes impairs endoscopic manipulation.

To solve this problem, at our institution, if there is no determined contraindication, we conduct pharyngeal ESD with patients under general anesthesia with controlled ventilation through a percutaneous uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway performed by the anesthetist. This prevents the ET tube from affecting endoscopic maneuverability and is beneficial for postoperative airway management in the event of potentially life-threatening laryngeal edema.

We also use a super-soft hood, a newly developed transparent distal attachment with a tip that can be adjusted to the shape of narrow spaces because of its flexibility.

This case suggests that in more challenging oropharyngeal or hypopharyngeal ESD, to maximize the restricted space, using a super-soft hood and requesting the anesthetist to perform percutaneous cricothyrotomy (instead of ET intubation) for airway management will significantly augment endoscopic maneuverability in a limited space.

Percutaneous cricothyrotomy.

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