posterior to the arytenoids, requires a
degree of force dangerous to exert and almost certain to produce
damage to the cricoarytenoid joint or to the pharyngeal wall, or to
both.

The esophagoscope is steadied by the left hand like a billiard cue, the
terminal phalanges of the left middle and ring fingers hooked over the
upper teeth, while the left index finger and thumb encircle the tube
and retract the upper lip to prevent its being pinched between the
tube and upper teeth. The right hand holds the tube in pen fashion at
the collar of the handle, not by the handle. During introduction the
handle is to be pointed upward toward the zenith.

_Stage I. Entering the Right Pyriform Sinus_.--The operator standing
(as in Fig. 66), inserts the esophagoscope along the right side of the
tongue as far as and down the posterior pharyngeal wall. A lifting
motion imparted to the tip of the esophagoscope by the left thumb will
bring the rounded right arytenoid eminence into view (A, Fig. 69).
This is the landmark of the pyriform sinus, and care must be taken to
avoid injury by hooking the tube mouth over it or its fellow. The tip
of the tube should now be directed somewhat toward the midline,
remembering the funnel shape of the hypopharynx. It will then be found
to glide readily through the right pyriform sinus for 2 or 3 cm., when
it comes to a full stop, and the lumen disappears. This is the
spasmodically closed cricopharyngeal constriction.

[FIG. 66.--Esophagoscopy by the author's "high-low" method. First
stage. "High" position. Finding the right pyriform sinus. In this and
the second stage the patient's vertex is about 15 cm. above the level
of the table.]

_Stage 2. Passing the cricopharyngeus_ is the most difficult part of
esophagoscopy, especially if the patient is unanesthetized. Local
anesthesia helps little, if at all. The handle of the esophagoscope is
still pointing upward and consequently we are sure that the lip of the
esophagoscope is directed anteriorly. Force must not be used, but
steady firm pressure against the tonically contracted cricopharyngeus
is made, while at the same time the distal end of the esophagoscope is
lifted by the left thumb. At the first inspiration a lumen will
usually appear in the upper portion of the endoscopic field. The tip
of the esophagoscope enters this lumen and the slanted end slides over
the fold of the cricopharyngeus into the cervical esophagus. There is
usually from 1 to 3 cm.