_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. of this constricted lumen at the level of the cricopharyngeus and the subjacent orbicular esophageal fibers. [109] [FIG. 67.--Schematic illustration of the author's "high-low" method of esophagoscopy. In the first and second stages the patient's head fully extended is held high so as to bring it in line with the thoracic esophagus, as shown above. The Rose position is shown by way of accentuation.] [FIG. 68.--Schematic illustration of the anatomic basis for difficulty in introduction of the esophagoscope. The cricoid cartilage is pulled backward against the cervical spine, by the cricopharyngeus, so strongly that it is difficult to realize that the cricopharyngeus is not inserted into the vertebral periosteum instead of into the median raphe.] [FIG. 69.--The upper illustration shows movements necessary for passing the cricopharyngeus.