Indications
In-office procedures can be offered for various esophageal disorders for a diverse patient population. Transnasal esophagoscopy (TNE) is the most common procedure performed in the clinic setting for patients with esophageal complaints and will be the focus of this chapter. Although TNE can be offered to nearly any patient with suspected esophageal disorders, choosing the appropriate patient for a successful in-office procedure is more nuanced. For example, patients with a history of head and neck cancer (HNCA) are good candidates because of the decreased sensitivity of the pharynx and esophagus, making TNE and balloon dilation more tolerable. Additionally, HNCA patients often require serial procedures to deal with life-long sequelae and treatment complications from surgery and radiation, and avoidance of frequent procedures under general anesthesia limits the risks associated with those procedures. Patients can be screened for anxiety related to awake procedures and candidacy for TNE during an initial otolaryngology visit as part of a routine examination. Nasal patency is likely the most important factor in predicting success. Patients who do not tolerate flexible laryngoscopy will not tolerate a larger diameter TNE scope (4.1 vs. 5 mm) required for esophageal procedures.
The American Broncho-Esophogological Association (ABEA) published indications for the procedure in 2007, and members of the ABEA were recently surveyed on the most common indications for performing TNE. For diagnostic purposes, TNE is most commonly utilized in patients with dysphagia, persistent gastroesophageal and extraesophageal reflux, chronic cough, and persistent globus sensation ( Box 46.1 ). Additionally, patients with HNCA can be screened in the office for esophageal disease.
Box 46.1
Indications for In-Office Esophageal Procedures
Diagnostic transnasal esophagoscopy
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Dysphagia
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Reflux
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Cough
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Globus
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Screening for malignancy
Balloon dilation
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Esophageal web
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Esophageal stricture
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Cricopharyngeal muscle dysfunction
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Narrowing after total laryngectomy
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Narrowing and fibrosis after head and neck radiation
Other procedures (less common)
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Foreign body removal
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Botox
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Tracheoesophageal prosthesis placement
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Nasogastric tube placement
Indications for balloon dilation include esophageal strictures, esophageal webs, cricopharyngeal muscle dysfunction (CMD), narrowing and fibrosis after HNCA treatment, and Schatzki rings. The upper esophageal sphincter (UES) is the most common site for in-office balloon dilation. Patients with a history of HNCA will frequently present with dysphagia that responds to targeted balloon dilation. Biopsies of suspicious lesions can also be performed during a TNE. Other less common procedures include foreign body removal, tracheoesophageal prosthesis placement, nasogastric tube placement, and Botox injection into the lower esophageal sphincter. The side channel of the TNE scope can also be utilized for extraesophageal procedures, including airway and pharynx procedures, such as fiber-based laser ablation of papilloma. In addition to the side channel, the TNE scope provides suction, irrigation, and air insufflation.
Although no absolute contraindications exist for awake TNE, caution should be taken when evaluating unhealthy patients in-office. For example, patients with a significant cardiopulmonary history should have the procedure completed in a monitored setting with anesthesiology expertise, even if performing the procedure awake. Depending on the specific clinical situation, blood thinner use is not a contraindication for TNE, but it may preclude in-office biopsies or balloon dilation based on the surgeon’s discretion.
Technique
Patient
A 75-year-old male is referred to the clinic for persistent dysphagia following chemoradiation for a T3N1M0 squamous cell carcinoma of the hypopharynx. After radiation treatment, the patient had significant dysphagia and became dependent on enteral feeding. A barium swallow showed the possibility of a UES stricture. The patient is offered an in-office diagnostic TNE and balloon dilation of the stricture. The patient receives significant improvement for one year and is offered a repeat dilation annually.
Local Anesthesia and Patient Preparation
Patients should be instructed to avoid eating for three hours before the procedure. After the TNE is completed, patients should wait one hour before resuming oral intake to allow the effects of the local anesthetic to wear off. Patients should be scheduled for thirty minutes and can drive to and from the clinic, assuming no sedation is utilized. Routine perioperative pain medications are not required. TNE examinations are easily conducted unassisted; however, interventions, such as biopsy or balloon dilation, require a trained assistant.
Before introducing the TNE, adequate topical anesthesia is essential for a tolerable and successful procedure. A 1:1 mixture of a topical decongestant (e.g., oxymetazoline) and topical anesthetic (e.g., 2% lidocaine) is atomized and sprayed into the nose. The nasal cavity is then packed bilaterally using size-appropriate neuro-patties or cotton soaked in the same mixture. The packing should be left for at least 5 minutes for adequate nasal topicalization.
With the nasal packing in situ, an additional topical anesthetic such as Cetacaine (benzocaine 14%, butamben 2%, and tetracaine HCL 2%) can be sprayed into the patient’s oropharynx and swallowed after gargling. The procedure should begin immediately after application of a topical anesthetic. If the patient is sensitive or other procedures are planned, adjunct methods can achieve further topicalization. The side channel of the TNE scope can be used to drip topical anesthetic directly on the postcricoid area. Although more effective for airway procedures, topical lidocaine can also be aerosolized using a jet nebulizer while asking the patient to take deep respirations. However, some restraint is necessary regarding topical anesthetics. The surgeon should be mindful of the toxic dose of lidocaine, especially if using a 4% concentration. Additionally, if a patient’s hypopharynx is too anesthetized, they are at a higher risk of aspiration during the procedure.
Procedure: Transnasal Esophagoscopy and Biopsy
The ideal patient and physician positioning is shown in Fig. 46.1 . The distal end of the scope should be lightly lubricated for smooth passage. Always examine each nasal passage first to determine the more patent side. With the patient sitting upright with a forward bend at the waist and head slightly extended, gently advance the scope along the floor of the more patent nasal passage and instruct the patient to breathe through their nose. After advancing the scope to the pharynx, the scope should be positioned just above the postcricoid region. Instruct the patient to flex their neck and swallow. While the patient swallows, advance the scope with small puffs of air. The esophagus and UES are best examined in a distal-to-proximal direction; therefore, the clinician should quickly advance the scope toward the stomach but carefully acknowledge increased resistance. Once in the stomach, additional air is insufflated to provide a complete examination, and the LES is examined by turning the handpiece 180 degrees and retroflexing the scope. For patient comfort, some air should be suctioned before retracting the endoscope into the esophagus. Once in the esophagus, carefully retract the scope while keeping the lumen in the center of view; maintaining the lumen in the center of the monitor is crucial for an accurate, thorough examination of the upper aerodigestive tract. One area of particular interest is the squamocolumnar junction or Z-line. For example, Barrett’s esophagus, reflux esophagitis, or small lesions are commonly identified there. Small puffs of air are used to evaluate the UES as the scope is carefully retracted in this area. Recording the examination is critical for slow motion and individual frame capture postprocedure.
The optimal patient positioning for transnasal esophagoscopy is shown with forward flexion at the hip and slight neck extension.
Concerning esophageal lesions can be biopsied as part of routine examination without needing more local anesthesia. Flexible biopsy forceps are inserted through the TNE side channel. With the lesion centered on the monitor, the forceps can be opened and advanced simultaneously, gently advancing the scope to get an adequately deep biopsy. Typically, 3 to 4 specimens are taken of the concerning area to increase the diagnostic yield.
Balloon Dilation
For performing a balloon dilation, it is helpful to have trained assistants. Ideally, one person handles the TNE while another positions the balloon, and a third person operates the inflation device ( Fig. 46.2 ). If the esophagus has recently been examined, the surgeon can proceed immediately with the dilation procedure. Once the TNE is in the proximal esophagus with the lumen in clear view, the balloon guidewire can be passed through the side channel and into the esophagus. It is crucial to advance the guidewire to the distal esophagus or stomach to avoid accidental misplacement back into the oropharynx. The endoscope is removed from the nose, and the guidewire is held at the nasal tip to avoid accidental removal. Next, the balloon is fed over the guidewire via the Seldinger technique. The TNE is reintroduced to follow the balloon in the ipsilateral nasal passage. If there is limited space in the nasal cavity, the TNE can also be inserted on the side contralateral to the balloon dilator. Once positioned appropriately, the balloon is carefully and slowly inflated with isotonic saline, with the proximal end visualized in the postcricoid area ( Fig. 46.3 ). Inflation can be completed with various inflation devices measuring balloon pressure in atmospheric units. It is critical to pay close attention to the patient’s level of discomfort. If the patient is not tolerating the procedure well, more liquid topical anesthesia can be applied via the side channel of the TNE scope. Inflate until the balloon feels taut, and it becomes difficult to manipulate the balloon. It is important to avoid sudden balloon movements, which can cause mucosal tears and bleeding. Once inflated to the desired width and pressure, hold for at least 30 seconds. This procedure is often repeated until the desired dilation pressure is reached or any bleeding is encountered. After the dilation procedure, the area should be carefully reexamined with the TNE to evaluate for possible complications.
