Author: Mr Michael Papesch FRACS, Head and Neck ENT Consultant at Whipps Cross University Hospital, London. This document was created from a PowerPoint presentation produced by Mr Papesch to teach junior doctors how to perform a panendoscopy. His website www.entcare.co.uk is also an excellent source of ENT information.
Reasons for Performing a Panendoscopy
- Assessment, staging, and biopsy of a known tumour
- Exclusion of a synchronous primary tumour (approximately 5–10% of head and neck cancers have a second primary)
- Search for an unknown primary in a patient presenting with metastatic cervical lymphadenopathy
- Biopsy of "at-risk sites": post-nasal space biopsy, tonsillectomy, tongue base biopsy, pyriform sinus, post-cricoid area
- Assessment and removal of oesophageal foreign bodies
Pre-Operative Assessment
- ASA grade — assess fitness for general anaesthesia
- Craniofacial abnormalities — may make rigid endoscopy technically difficult or impossible
- Retrognathia (receding jaw) — limits mouth opening and access for the pharyngoscope
- Local airway obstruction — particularly relevant if the tumour is causing supraglottic or glottic compromise; the anaesthetist must be warned in advance
The operating theatre should be set up as follows:
- Familiar team — scrub nurse who knows the instruments and sequence of the procedure
- Experienced anaesthetist who is comfortable with shared airway management
- Good equipment — all scopes checked and in working order before starting
- Patient on a proper operating table, not on a ward bed
- Mask, eye protection, and gloves for all staff — head and neck cancer patients have a significantly elevated prevalence of blood-borne virus infections
- Note: The cumulative career risk of HIV infection for surgeons from occupational exposure in a low-prevalence area is approximately 1% (Occupational Risk to Surgeons, World Journal of Surgery 1993; 17: 232–236). Universal precautions must always be applied.
Instruments
The standard panendoscopy set includes: a rigid pharyngoscope (Negus or Lindholm laryngoscope), a rigid oesophagoscope with light source, rigid biopsy forceps, suction tubing, a Negus bronchoscope, and a mouth guard. Flexible nasendoscopy equipment (for the nasal and post-nasal space component) should also be available.
Nasendoscopy
The nasal component should use Moffat's decongestion solution to shrink the nasal mucosa and provide topical vasoconstriction: 1 ml of 1:1000 adrenaline + 1 ml of 10% cocaine + 2 ml of 2% sodium bicarbonate, applied on neurosurgical patties to the nasal cavity. This both decongests the nasal mucosa and provides excellent topical anaesthesia for any flexible awake component.
Preparation — Patient Positioning
Sit comfortably on an adjustable stool or chair. Ensure the patient's eyes are taped shut to prevent corneal abrasion from contact with the surgeon, assistant, or drapes.
Protecting the Teeth
Always use a rigid mouth guard to protect the teeth from the metal scope. Some surgeons place their little finger between the scope and the teeth — the principle being that when the pressure becomes painful for the finger, it is excessive for the teeth. If the patient is edentulous, use folded gauze over the gums rather than relying on a hard guard.
Introducing the Scope
Using your non-dominant hand to keep the mouth open, hold the scope with your dominant hand. Enter the tip of the scope lateral to the midline — do not enter directly down the centre, as this risks impacting on the posterior tongue. Once past the teeth, straighten up to align with the pharynx.
Ergonomics — Protecting Your Back
Back pain is an occupational hazard of rigid endoscopy. Maintain a straight back throughout the procedure. Raise the operating table to bring the patient's head up to a comfortable working height — do not bend down to the patient. Adjust your chair or stool position accordingly.
Pharyngoscopy — Systematic Examination
Advance the scope and systematically examine the following structures in order:
- Hard palate and soft palate
- Base of tongue
- Vallecula (the recess between the tongue base and the epiglottis)
- Tonsils and tonsillar fossae
- Lateral pharyngeal walls
- Pyriform sinuses (the two recesses on either side of the larynx — a common site for hypopharyngeal carcinoma)
- Lift the larynx forward by placing the tip of the scope under the epiglottis to view the post-cricoid area
Direct Laryngoscopy
The laryngoscope can be advanced to view the vocal cords directly and may be suspended on a Draffin rod setup to allow bimanual operating (e.g., microlaryngeal biopsy). The scope is held in a fixed position by the suspension system, freeing both of the surgeon's hands.
Rigid Oesophagoscopy
The rigid oesophagoscope can be used to complete nearly all components of a panendoscopy, including assessment of the post-cricoid region and the oesophagus. The sequence of pictures below illustrates how the scope is passed smoothly into the oesophagus.
The key principle is to identify the pyriform fossa, follow one side of it posteriorly into the midline, and enter the upper oesophagus (at the cricopharyngeus / Killian's dehiscence level). As you advance the scope it should glide forward smoothly with minimal force. Never push against resistance — resistance indicates the scope is not in the correct lumen.
At each step of the oesophagoscopy, you should always be able to see the lumen clearly ahead of you. Never push through mucosa without knowing exactly where you are going. Use suction to clear secretions or blood and restore a clear view before advancing further.
Bronchoscopy
If bronchoscopy is indicated (e.g., to assess the tracheobronchial tree for synchronous lung primary or assess subglottic extension of a tumour), the following steps are followed:
- On reaching the glottis, rotate the bronchoscope 90 degrees to align it with the transversely oriented vocal cords
- Instruct the anaesthetist to pause ventilation momentarily at the time of cord passage to avoid conflict between the scope and the tube/jet
- Once the scope is past the cords, instruct the anaesthetist to resume ventilation
- Turn the patient's head to the left to straighten the right main bronchus for better access — view the right main bronchus, right upper lobe bronchus, and right middle and lower lobe bronchi
- Turn the patient's head to the right to access the left main bronchus and its divisions
Bimanual Palpation
Every panendoscopy should be completed with bimanual palpation of the base of the tongue, tonsils, and lateral pharyngeal walls. A submucosal lesion that is not visible endoscopically can often be felt as an area of firmness or asymmetry. If a submucosal lesion is detected, take a biopsy.
Palpation is conventionally left until the end of the procedure because friable tumours bleed on contact, and a field of blood will obscure endoscopic vision and make the rest of the examination impossible to complete systematically.
Complications of Panendoscopy
- Loss of airway control: The most immediately life-threatening complication. Requires rapid conversion to surgical airway (cricothyroidotomy or tracheotomy) if the airway cannot be secured by other means.
- Damage to teeth or gums: The most common complication — preventable with a properly fitted mouth guard.
- Dislocation of the jaw / jaw pain: The temporomandibular joint is stressed by prolonged or forceful mouth opening. Frank dislocation can occur.
- Damage to the pharynx, larynx, or oesophagus: Mucosal tears and lacerations from instrument passage.
- Bleeding: From biopsy sites or mucosal injury.
- Perforation: The most serious non-airway complication. Oesophageal perforation is most likely at the cricopharyngeus or at Killian's dehiscence (the natural anatomical weak point in the posterior pharyngeal constrictors). Perforation into the mediastinum causes mediastinitis.
- Infection / mediastinitis: Secondary to perforation. Mediastinitis carries a very high mortality rate and requires urgent surgical drainage.
Post-Operative Care
- After laryngoscopy with biopsy: Voice rest for 24–48 hours; softened diet; return if stridor or significant haemoptysis develops.
- After pharyngoscopy with biopsy: Analgesia (typically paracetamol ± ibuprofen); observe for haemorrhage; soft diet initially.
- After oesophagoscopy: Monitor carefully. If biopsy was taken — overnight stay; nil by mouth until the morning (NBM till mane).
- Monitoring: Temperature, heart rate, blood pressure, and respiratory rate should be recorded regularly in the post-operative period.
- Warning symptoms: Chest pain and back pain after oesophagoscopy should raise immediate concern for oesophageal perforation. Consider chest X-ray and water-soluble contrast swallow (Gastrografin swallow) if perforation is suspected.
Frequently Asked Questions
What is panendoscopy and why is it performed?
Panendoscopy is the systematic rigid endoscopic examination of the entire upper aerodigestive tract under general anaesthesia. It includes assessment of the nasal cavity, post-nasal space, oropharynx, hypopharynx, larynx, oesophagus, and tracheobronchial tree. It is most commonly performed in the staging of head and neck squamous cell carcinoma, to search for a second primary tumour, to identify an unknown primary in a patient with metastatic cervical lymphadenopathy, and to assess and treat oesophageal foreign bodies.
What is Moffat's solution and why is it used?
Moffat's solution is a topical nasal decongestion and anaesthetic preparation consisting of 1 ml of 1:1000 adrenaline, 1 ml of 10% cocaine, and 2 ml of 2% sodium bicarbonate. The cocaine provides topical anaesthesia and potent vasoconstriction (shrinking the nasal mucosa); the adrenaline provides additional vasoconstriction; and the sodium bicarbonate buffers the solution to improve its mucosal penetration and reduce irritation. It is applied on neurosurgical patties soaked in the solution and placed in the nasal cavity prior to nasal endoscopy.
What is Killian's dehiscence and why is it relevant to oesophagoscopy?
Killian's dehiscence (also called Killian's triangle or the pharyngo-oesophageal triangle) is a natural anatomical weak point in the posterior wall of the pharynx between the oblique fibres of the inferior pharyngeal constrictor and the transverse fibres of the cricopharyngeus muscle. It is the area through which a pharyngeal pouch (Zenker's diverticulum) herniates. During rigid oesophagoscopy, this is the most vulnerable area for iatrogenic perforation, especially if the scope is advanced without a clear view of the lumen or if the patient has an undiagnosed pharyngeal pouch. The surgeon should be particularly cautious at this level.
How do you recognise and manage an oesophageal perforation after panendoscopy?
Post-operative oesophageal perforation presents with chest pain, back pain (from mediastinal involvement), subcutaneous emphysema in the neck, fever, and tachycardia. The diagnosis is confirmed with a chest X-ray (showing surgical emphysema, widened mediastinum, or pleural effusion) followed by a water-soluble contrast (Gastrografin) swallow — not barium, which is highly inflammatory in the mediastinum. Management is a surgical emergency: the patient should be kept nil by mouth, intravenous broad-spectrum antibiotics started immediately, and urgent surgical or cardiothoracic input obtained. Small contained perforations may be managed conservatively with antibiotics and parenteral nutrition; large or mediastinal perforations require surgical drainage.
What are "at-risk sites" biopsied during panendoscopy and why?
At-risk sites are anatomical areas with a propensity for harbouring occult primary squamous cell carcinoma in patients presenting with metastatic cervical lymphadenopathy without a clinically apparent primary. They include: the post-nasal space (nasopharyngeal carcinoma is common in South-East Asian populations), the tongue base, the tonsils (often unilateral tonsillectomy is performed), the pyriform sinus, and the post-cricoid area. Biopsies from these sites may identify the primary tumour and direct radiotherapy fields appropriately, converting what was an unknown primary into a known primary — which has significant prognostic and management implications.
How does bronchoscope orientation differ when examining the left versus right main bronchus?
The right main bronchus is wider and departs from the trachea at a less acute angle than the left — hence inhaled foreign bodies most commonly lodge on the right. To view the right main bronchus, the patient's head is turned to the left, which straightens the right main bronchus relative to the axis of the bronchoscope. To view the left main bronchus (which curves more acutely to the left and passes under the aortic arch), the head is turned to the right. This counterintuitive head-turning technique is worth memorising for exam questions.
Why is palpation of the tongue base and tonsils left until the end of panendoscopy?
Bimanual palpation of the tongue base, tonsils, and lateral pharyngeal walls is left until the end of the endoscopic examination because palpating a friable or vascular tumour will often provoke haemorrhage. Blood pooling in the pharynx will obscure the endoscopic view and prevent the systematic completion of the rest of the examination. By leaving palpation until after all endoscopy is complete, the surgeon ensures a clear field for every part of the visual examination before accepting the inevitable risk of bleeding from the palpation itself.
ST3 interview: A patient with a 3 cm neck node and no identifiable primary has been listed for panendoscopy. Walk me through your approach.
I would first confirm the CT and PET-CT findings, note which nodal level is involved (level II/III suggests oropharyngeal or nasopharyngeal primary; level IV suggests hypopharyngeal, oesophageal, or thyroid origin), and review any flexible endoscopy findings from clinic. Under general anaesthesia I would perform a systematic panendoscopy starting with flexible nasendoscopy under Moffat's decongestion, examining the post-nasal space and nasal cavity. I would then proceed to rigid pharyngoscopy, systematically examining the oropharynx, tongue base, vallecula, pyriform sinuses, post-cricoid area, and larynx. I would then perform rigid oesophagoscopy to the gastro-oesophageal junction. I would take biopsies from any suspicious areas and perform bilateral tonsillectomy (or unilateral ipsilateral tonsillectomy) and tongue base biopsies as standard. Finally, I would complete the examination with bimanual palpation of the tongue base and pharynx. Specimens would be sent fresh to pathology for imprint cytology and formalin-fixed for histology.
References
- Gleeson M, ed. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 7th ed. London: Hodder Arnold; 2008. Chapter on head and neck cancer staging.
- Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology. 4th ed. Philadelphia: Elsevier Mosby; 2012.
- Watkinson JC, Gilbert RW, eds. Stell and Maran's Textbook of Head and Neck Surgery and Oncology. 5th ed. London: Hodder Arnold; 2012.
- Papesch M. ENT Care. Available at: http://www.entcare.co.uk [accessed 2025].
- Occupational Risk to Surgeons of Unrecognised HIV Infection in a Low-Prevalence Area. World Journal of Surgery. 1993; 17(2): 232–236.
- National Institute for Health and Care Excellence. Head and Neck Cancers: Overview. NICE pathway. Available at: https://www.nice.org.uk/guidance/ng36
- British Association of Head and Neck Oncologists (BAHNO). Standards and datasets for head and neck cancer. London: BAHNO; 2023.