Since the mid 1900s, esophagoscopy has been performed under sedation or general anesthesia. With transnasal esophagoscopy (TNE), there has been a return to awake, in-office esophagoscopy. Technologic advances have allowed the advent of a ultrathin, flexible esophagoscope that is introduced transnasally, allowing esophagoscopy to be performed in unsedated patients. TNE correlates with conventional esophagoscopy (sedated, flexible esophagoscopy) in diagnostic capacity. Over time, as the benefits of TNE have become elucidated, the procedure has gained wider acceptance and continues to have its role in patient care defined.
Key points
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Transnasal esophagoscopy (TNE) is performed in the office setting and obviates the need for sedation.
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TNE has been found to be both safe and efficacious. Its diagnostic accuracy is equal to sedated conventional endoscopy.
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The ability to perform TNE in awake patients decreases the cost and increases the safety of the procedure compared with conventional sedated esophagoscopy.
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TNE is valuable for both esophageal screening, as well as multiple in office procedures (ie, tracheoesophageal puncture, esophageal dilation, biopsy).
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As TNE becomes more common, the indications and role for the procedure will become more defined.
Video of transnasal esophagoscopy in-office procedure accompanies this article at http://www.oto.theclinics.com/
Otolaryngologists are frequently consulted to assist in management of patients requiring esophagoscopy for a thorough evaluation of their symptoms. The diagnostic applications of transnasal esophagoscopy (TNE) have now become widespread. Patients with history of dysphagia, globus, extraesophageal reflux and gastroesophageal reflux disease are often well managed by the otolaryngologist without requiring further referral to a gastroenterologist. With TNE, the otolaryngologist may examine from the nasal cavity to the level of the gastroesophageal junction (GEJ) and cardia of the stomach. Biopsies and additional procedures may be performed as needed. Furthermore, the ease and safety of TNE has made it invaluable, particularly in the care of patients with medical comorbidities and head and neck cancer.
TNE in Comparison to Conventional Endoscopy
As with most new technology, TNE was originally met with skepticism. Some early studies showed a lack of promise with concern generated in regard to the efficacy of the procedure. However, with increased user familiarity and further technological advancement, TNE has risen in popularity. Recent studies are uniformly in agreement that TNE has diagnostic capabilities that are equal to that of conventional endoscopy (CE). In a study by Jobe and colleagues, there was noted to be a good degree of agreement between TNE and CE on both endoscopic and histologic findings. Other studies have concluded that TNE biopsies are accurate, with a 97% congruence to those of CE. There is a high degree of correlation between TNE and CE, with TNE being 89% sensitive and 97% specific. Of interest, TNE has also been associated with higher patient satisfaction rates when compared with CE.
The great promise in TNE is that it may be performed without sedation. Sedation is responsible for the majority of adverse events (>50%) associated with CE, such as aspiration, oversedation, hypoventilation, vasovagal episodes, and airway obstruction. In a 2007 national survey of endoscopists, sedation was found accountable for 67% of complications and 72% of mortality associated with CE. These adverse events are all eliminated by the performance of unsedated esophagoscopy.
The ability to perform TNE awake also significantly decreases the cost of the procedure in comparison with CE. Direct costs, such as longer procedure time, recovery time, medications, and monitoring and nursing expenses are accrued with sedation. Indirect costs, such as loss of work, and need for a caretaker and driver are associated with sedation. Recent studies have estimated as much as a $2000 per-procedure cost savings with TNE versus CE.
Indications
Although the role of TNE continues to define itself with time and user experience, the current indications are broad and may be divided into 3 categories ( Table 1 ): (1)Esophageal, (2) extra-esophageal, and (3)Procedure related. By permitting direct visualization of the esophagus, TNE may be used to diagnose esophagitis, strictures, rings, hiatal hernias, webs, neoplasms, vascular anomalies, and diverticula. The tone of the lower esophageal sphincter may be assessed; high tone may be indicative of achalasia or pseudoachalasia. In addition, subjective peristaltic activity may be determined by assessing passage of liquids and solids during the examination. (Liquids should transit the esophagus within 13 seconds.)
| Esophageal | Extra-Esophageal | Procedure Related |
|---|---|---|
| Dysphagia | Significant globus | Pan-endoscopy for head and neck cancer |
| Refractory gastroesophageal reflux disease | Screening for head and neck cancer | Biopsy |
| Abnormal imaging | Moderate to severe EER | Botox injection |
| Screening for Barrett’s | Chronic cough | Balloon dilation |
| Percutaneous endoscopic gastrostomy | ||
| Tracheoesophageal puncture | ||
| Placement of wireless pH monitoring device |
Other applications for TNE are being evaluated
Helicobacter pylori infection
TNE may be used to document resolution of H pylori infection. In patients with cirrhosis or after liver transplantation at high risk for post-sedation encephalopathy, TNE serves as an ideal alternative to detect and grade esophageal varices. Patients who require frequent screening (history of head and neck cancer or caustic ingestion) also serve to benefit from the safety and ease of TNE. In morbidly obese patients at high risk with sedation, TNE is now commonly being performed before bariatric surgery and to evaluate the postoperative gastrointestinal tract as well.
Nasopharyngeal stenosis and neopharyngeal stricture
TNE has been proven successful for a number of in-office procedures. Hydrostatic balloons may be used to dilate narrow segments of the esophagus, as well as treat post-radiation nasopharyngeal stenosis and neopharyngeal stricture after total laryngectomy. Laser fibers may be advanced through the TNE working channel for treatment of recurrent respiratory papillomas and tumors. Secondary tracheoesophageal puncture can be performed on the awake patient. Percutaneous endoscopic gastrostomy may be performed; Botox can be injected into muscles of the esophagus ; feeding tubes can be inserted, and wireless pH monitoring devices may be placed as well.
Foreign bodies
There is limited application of TNE in management of foreign bodies (FB). Patients may be screened for esophageal FB, with definitive management in cases in which the FB may be pushed into the stomach. However, should retrieval be required TNE is not recommended as the airway may be placed at risk.
Barrett’s esophagus
The use of TNE for screening of Barrett’s esophagus has gained many advocates. In the past 30 years, esophageal adenocarcinoma has become the most rapidly increasing neoplasia in the United States. Barrett’s esophagus is recognized as a premalignant lesion, with 0.5% of patients developing malignant transformation each year. Symptoms of extraesophageal reflux, including chronic cough, are known to be more predictive of esophageal adenocarcinoma than symptoms of classic gastroesophageal reflux disease. Given the cost and morbidity associated with conventional esophagoscopy, current guidelines suggest empiric treatment of gastroesophageal reflux disease and extraesophageal reflux before esophagoscopy. As the use of TNE continues to evolve, guidelines may change to recommend earlier esophagoscopy. However, once diagnosed, surveillance of Barrett’s esophagus is performed with CE to allow for comfortable completion of a full, 4-quadrant set of biopsies spaced every 2 cm of Barrett’s esophagus with large biopsy instruments.
Head and neck cancer
TNE is emerging as an invaluable instrument for management of head and neck cancer patients. Initial panendoscopy may be performed in the office setting, and esophageal screening may be performed on a routine basis. In previous studies, TNE has been shown to provide 100% accuracy in biopsy results and staging of tumor when compared with standard panendoscopy. By obviating the need for sedation and operating room facilities, TNE decreases the time, costs, and risks involved with standard panendoscopy. TNE screening in head and neck cancer patients after treatment has also proved worthwhile. In a group of head and neck cancer patients undergoing TNE, only 13% were found to have normal examinations. Pathology ranged in severity, and included peptic esophagitis, stricture, candidiasis, Barrett’s metaplasia, gastritis, and carcinoma. Screening with TNE in head and neck cancer patients has revealed a 4% to 5% rate of metachronous esophageal cancer, with a significantly higher prevalence (15.9%) in patients with a history of hypopharyngeal cancer. The most appropriate protocol to use after head and neck cancer patients with TNE is not known at this time.
Contraindications
There are no absolute contraindications to TNE. The presence of diverticula may make TNE more difficult to perform. Although some have questioned TNE in anticoagulated patients, it is the experience of the senior author and others that both examination and biopsy may be performed without complication in patients on clopidogrel (Plavix) or Warfarin (Coumadin).
Preoperative planning
Before the procedure, one should become familiar with the equipment. There are a number of venders through which a transnasal esophagoscope may be obtained (EE-1580 K, Pentax Precision Instrument Corporation, Orangeburg, New York; Olympus PEF-V, Olympus America Inc, Melville, New York; and; Viscion Sciences TNE-2000 with Endosheath, Medtronic Xomed, Jacksonville, Florida). Transnasal esophagoscopes are generally 60 cm longer to allow adequate length for visualization of the stomach and retroflexion. They vary in width from 3.1 to 5.1 mm (compared with 10–12 mm for the conventional esophagoscope) and have capacity for suction, irrigation, and insufflation. A working channel is present though which instruments (biopsy forceps, laser fibers, and channels for topical anesthesia application) may be introduced.
Patients should be asked to remain NPO at least 3 hours before the procedure. This decreases the risk of regurgitation and aspiration. However, recent oral intake is not an absolute contraindication to TNE.
Preoperative planning
Before the procedure, one should become familiar with the equipment. There are a number of venders through which a transnasal esophagoscope may be obtained (EE-1580 K, Pentax Precision Instrument Corporation, Orangeburg, New York; Olympus PEF-V, Olympus America Inc, Melville, New York; and; Viscion Sciences TNE-2000 with Endosheath, Medtronic Xomed, Jacksonville, Florida). Transnasal esophagoscopes are generally 60 cm longer to allow adequate length for visualization of the stomach and retroflexion. They vary in width from 3.1 to 5.1 mm (compared with 10–12 mm for the conventional esophagoscope) and have capacity for suction, irrigation, and insufflation. A working channel is present though which instruments (biopsy forceps, laser fibers, and channels for topical anesthesia application) may be introduced.
Patients should be asked to remain NPO at least 3 hours before the procedure. This decreases the risk of regurgitation and aspiration. However, recent oral intake is not an absolute contraindication to TNE.
Patient preparation and positioning
The patient in placed in the otolaryngology office examination chair in the sitting position. As routine, vital signs are obtained. However, continuous monitoring of vital signs throughout the procedure is not necessary. Although this may be appropriate for elderly individuals with severe hypertension or coronary artery disease. Appropriate nasal anesthesia and decongestion is essential for tolerance of the procedure. A 1:1 solution of oxymetazalone 0.05% and lidocaine 4% is aerosolized and applied topically to the nasal cavity. The solution is then applied to a cotton pledget and the nasal cavity is packed for 10 minutes. A spray of 20% benzocaine (Hurricaine) may be administered to the oropharynx. Viscous lidocaine is used by some examiners. Although anesthesia is essential, excess anesthesia has potential to increase the difficulty of the procedure. Should the hypopharynx become overly anesthetized secretions will pool, leading to aspiration and subsequent coughing during the procedure.
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