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It is preferable and safer to teach insertion of the endoscope using the direct visual technique rather than under finger guidance. The latter technique may be needed rarely, however, if the patient is unable to swallow the endoscope upon command. Under direct visualization, the trainee should first align the scope so that the tongue will be at the top of the screen as the scope is inserted into the mouth. The tip of the endoscope should be gently advanced over the midline of the tongue, past the uvula and the epiglottis as the up/down knob is rotated counterclockwise with moving the left thumb down. If the teeth are visualized, the endoscope should be withdrawn and reintroduced. Once the base of the vocal cords is visualized, the tip of the endoscope should be placed under the cricoarytenoid cartilage on either side with temporary nonvisualization of the mucosa (Figure 5.10). The trainee should ask the patient to swallow and maintain gentle pressure so that the instrument will be directed into the proximal esophagus. Trainees should be alerted to the relatively rare possibility of entering a Zenker's diverticulum. If this occurs, the endoscope should be slowly withdrawn while searching for the entrance to the esophagus. If esophageal intubation is not easily achieved, more sedation may be required for patients who still have a strong gag reflex or a more experienced endoscopist should attempt intubation.

Figure 5.8 Recommended grip technique for the endoscope with left index and middle fingers free to activate suction and air/water buttons and thumb to control up/down and left/right dials.

Figure 5.9 (a) Upward tip deflection demonstrated with the thumb pushing the up/down dial counterclockwise. (b) Leftward tip deflection shown with the left/right dial rotated counterclockwise.

Figure 5.10 White light HRE view showing erythema of the aryepiglottic folds in this patient with endoscopically confirmed active GERD and throat clearing (NYU School of Medicine, New York City, USA).