Transnasal esophagoscopy: state of the art

Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis

Introduction

Numerous indications require regular upper gastrointestinal endoscopy (oesophagogastroduodenoscopy; EGD) in outpatients. In most cases, peroral gastroscopy is performed. The aim of this study was to evaluate the need of transnasal gastroscopy (nEGD) in outpatients.

Methods

A questionnaire was used to assess patients’ preferred choice of method, previous experience with EGD, psychological aspects and sociodemographic data. Furthermore, patient satisfaction with and potentially perceived discomfort during the examination as well as preference for a method in regard to future examinations was evaluated.

Results

From September 2016 to March 2017, a total of 283 outpatients at endoscopy of the University Hospital of Leipzig were approached to participate in the study. 196 patients were eligible, of whom 116 (60%) chose nEGD. For 87 patients (87/283, 31%) nEGD had to be excluded for medical reasons. The average age in the total sample was 53 (±17) years. 147 (77%) have had previous experience with peroral EGD (oEGD). Of the nEGD examined patients 83% were fairly up to extremely satisfied with the procedure. Satisfaction significantly predicted the choice of future EGD examinations. Nasal pain experienced during nEGDs was associated with rejection of nEGD in further EGD examinations (p<0.01). Patients who did choose a specific procedure were more likely to select the same procedure as their future preference (χ²= 73.6, df=1, p<0.001); this preference was unaffected by the procedure that had been chosen previously (reselecting nEGD: 84%, oEGD: 89%, p=0.874).

Conclusion

nEGD without sedation is a viable alternative. Patient satisfaction with nEGD is high, and reselection rate for nEGD is similar to that for oEGD. As a result of this study nEGD is now offered as a routine procedure at the University of Leipzig.

Trial registration number

NCT03663491.

In-Office Evaluation and Management of Dysphagia

Dysphagia is a common complaint encountered in otolaryngology clinics. Approaching the patient with dysphagia starts with a comprehensive symptomatic analysis and thorough physical examination. The recent rapid revolution in office-based procedures has a great impact in the evaluation and management of dysphagia. Currently, diagnostic and therapeutic procedures can be performed safely and effectively in the office setting with the advantage of avoidance of sedation or general anesthesia.

The role of transnasal oesophagoscopy in the management of globus pharyngeus and non-progressive dysphagia

Introduction Transnasal oesophagoscopy is a relatively new method of examining the upper aerodigestive tract via the nasal passage as an outpatient procedure without the need for sedation. It has been shown to be a well tolerated, safe and accurate technique, that can therefore be used in the investigation of patients thought to have globus pharyngeus and other non sinister causes of dysphagia. Methods A total of 150 consecutive patients undergoing transnasal oesophagoscopy were analysed retrospectively. Results The main indications for this procedure were non-progressive dysphagia (n=68, 45%) and globus pharyngeus (n=60, 40%). Transnasal oesophagoscopy was normal in 65% of patients and 42% of patients were discharged from clinic at the same appointment with no further investigation. The most common positive findings were laryngeal erythema (13%) and oesophagitis (10%). Conclusions Transnasal oesophagoscopy is a useful adjunct to the management of patients with the symptoms of globus pharyngeus and non-progressive dysphagia.

Transoesophageal ultrasound and computer tomographic assessment of the equine cricoarytenoid dorsalis muscle: Relationship between muscle geometry and exercising laryngeal function

REASONS FOR PERFORMING STUDY

Early detection of recurrent laryngeal neuropathy (RLN) is of considerable interest to the equine industry.

OBJECTIVES

To describe two imaging modalities, transoesophageal ultrasound (TEU) and computed tomography (CT) with multiplanar reconstruction to assess laryngeal muscle geometry, and determine the relationship between cricoarytenoid dorsalis (CAD) geometry and function.

STUDY DESIGN

Two-phase study evaluating CAD geometry in experimental horses and horses with naturally occurring RLN.

METHODS

Equine CAD muscle volume was determined from CT scan sets using volumetric reconstruction with LiveWire. The midbody and caudal dorsal-ventral thickness of the CAD muscle was determined using a TEU in the same horses; and in horses with a range of severity of RLN (n = 112).

RESULTS

Transoesophageal ultrasound was able to readily image the CAD muscles and lower left:right CAD thickness ratios were observed with increasing disease severity. Computed tomography based muscle volume correlated very closely with ex vivo muscle volume (R² = 0.77).

CONCLUSIONS

Computed tomography reconstruction can accurately determine intrinsic laryngeal muscle geometry. A relationship between TEU measurements of CAD geometry and laryngeal function was established. These imaging techniques could be used to track the response of the CAD muscle to restorative surgical treatments such as nerve muscle pedicle graft, nerve anastomosis and functional electrical stimulation.

Transnasal esophagoscopy in modern head and neck surgery

PURPOSE OF REVIEW

The role of transnasal esophagoscopy (TNE) in the evaluation and management of the head and neck cancer patient is evolving. This study reviews the most recent advances in the use of this technology in the head and neck patient population.

RECENT FINDINGS

It appears that in-office, unsedated TNE is a useful alternative to conventional endoscopy in the evaluation and management of the head and neck patient. The current literature defines the feasibility and limitations of this technology for screening for the development of synchronous and metachronous primaries, diagnosing esophageal and upper gastrointestinal disorders, as well as performing certain office-based procedures. Perhaps most importantly, TNE is better able to navigate the anatomical and functional limitations common to the head and neck patient, which can prevent use of conventional transoral endoscopy.

SUMMARY

TNE has a significant role in the evaluation and management of the head and neck cancer patient and it enables the otolaryngologist to provide improved quality of care.

A New Trend in the Management of Esophageal Foreign Body: Transnasal Esophagoscopy

OBJECTIVES

(1) To analyze the outcomes of patients with esophageal foreign body managed by transnasal esophagoscopy. (2) To review the value of lateral neck X-ray.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.

SUBJECTS AND METHODS

Lateral neck X-ray was used for initial screening in patients suspected of having an esophageal foreign body between 2007 and 2013. Rigid esophagoscopy was used as standard for further investigations before July 2010 and transnasal esophagoscopy after July 2010.

RESULTS

From January 2007 to June 2010, 43 patients who were suspected of having an esophageal foreign body under lateral neck X-ray received rigid esophagoscopy, 31 of whom were found to have an esophageal foreign body. From July 2010 to December 2013, 302 patients underwent transnasal esophagoscopy, and an esophageal foreign body was noted in only 52 of these patients. In the 302 patients who underwent transnasal esophagoscopy, the sensitivity and specificity of having an esophageal foreign body by lateral neck X-ray were 59% and 83%, respectively.

CONCLUSION

The introduction of transnasal esophagoscopy has changed the diagnosis and management for an esophageal foreign body. Transnasal esophagoscopy is a quick and safe procedure that can be performed under local anesthesia. Transnasal esophagoscopy could replace lateral neck X-ray to become the initial screening procedure and a useful treatment for patients with an esophageal foreign body.

Narrow-Band Imaging of Laryngeal Images and Endoscopically Proven Reflux Esophagitis

Objective

To compare the difference between white light (WL) and narrow-band imaging (NBI) endoscopy in evaluating patients who had reflux laryngitis and esophagitis.

Study Design

Retrospective review of medical records and endoscopic images.

Setting

Outpatient clinic.

Subjects and Methods

There were 102 consecutive patients with reflux esophagitis (mean age, 48 ± 11 years) who had office-based transnasal esophagoscopy (TNE) with WL and NBI views, including 60 men (59%) and 42 women (41%). We compared WL and NBI endoscopy in observing the laryngeal and esophageal epithelium. The nasopharynx, base of the tongue, epiglottis, hypopharynx, larynx, esophagus, gastroesophageal junction, and stomach were examined, and all procedures were digitally recorded. All patients were evaluated with WL and NBI views to determine the reflux finding score (RFS) in the larynx and Los Angeles (LA) classification grade in the esophagus.

Results

The NBI views were more sensitive than the WL views in the erythema/hyperemia, vocal cord edema, and global RFS scores. The NBI view facilitated the identification of the erythema/hyperemia change representing dilation or proliferation of microvessels caused by epithelial inflammation. The global RFS score was significantly associated with severity of LA grade only with the NBI view.

Conclusion

The endoscopic findings with the NBI view permit an easier identification of the RFS parameters of laryngeal erythema/vocal cord edema, which have a stronger correlation with the severity of reflux esophagitis, than the WL view. The importance of NBI in the evaluation of reflux laryngitis and gastroesophageal reflux disease deserves further study.

The Role of Transnasal Esophagoscopy in ENT Office: A Prospective, Multicenter Study in Korea

Objectives

The purpose of study was to report the current role of transnasal esophagoscopy (TNE) in Korea.

Methods

One hundred thirty-seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to February 2009 were prospectively analyzed. Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1.

Results

Fifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). Forty-two patients (41.1%) were found to have pathology (esophagitis, n=41; esophageal diverticulum, n=1) during the screening examination for LPRD. There were no significant complications in any of the patients.

Conclusion

TNE is a high-yield diagnostic and therapeutic modality available to otolaryngologists for use on awake patients in the office setting.

Use of Flexible Esophagoscopy by Otolaryngologists

Objectives:

We used questionnaires to determine current practice patterns for esophagoscopy by otolaryngologists in the United States, with attention to foreign body management.

Methods:

A 10-item questionnaire designed to determine the prevalence of flexible esophagoscopy use among otolaryngologists, with a particular focus on foreign body removal, was created and sent via e-mail to all members of the American Academy of Otolaryngology–Head and Neck Surgery. A second, 6-question survey to assess the level of resident training in flexible esophagoscopy was similarly created and sent to all directors of US otolaryngology residency programs.

Results:

There were a total of 160 respondents to the first survey from all geographic regions, most of whom were in group private practice. Overall, only 21.3% of the respondents were trained to perform flexible esophagoscopy during residency, whereas 43% of those who graduated after 1990 received this training. Most respondents performed flexible esophagoscopy without sedation in the office setting. The most common indications were evaluation of dysphagia, screening for complications of laryngopharyngeal reflux, and panendoscopy for head and neck cancer. Nearly 70% of the respondents were either primarily responsible for foreign body management at their institution or shared this responsibility with a gastroenterology department. Eighty-four percent used the rigid esophagoscope alone for this purpose. More than three quarters of otolaryngology residency programs currently include flexible esophagoscopy in their training, which is performed equally in the operating room and in the office; most favor rigid esophagoscopy for foreign body retrieval but use both techniques.

Conclusions:

There has been a rapid increase in the use of flexible esophagoscopy by otolaryngologists. The majority of residency programs currently include flexible esophagoscopy in their training. Otolaryngologists play a major role in esophageal foreign body management and primarily use the rigid esophagoscope for this purpose.

Changing trends in oesophageal endoscopy: a systematic review of transnasal oesophagoscopy

The safety, efficacy, and economic implications of using transnasal oesophagoscopy (TNE) are compared with conventional rigid or flexible oesophagoscopy for oesophageal disorders in otorhinolaryngology (ORL) clinics in this systematic review. Eleven electronic databases were searched for articles on transnasal oesophagoscopy. A total of 67 relevant titles were identified and 39 abstracts were screened of which 17 full- text articles were included in this report. There was fair level of evidence to suggest that TNE was effective for screening examination in patients with dysphagia, globus pharyngeus, and reflux symptoms and for detection of metachronous oesophageal carcinoma. TNE can also be used to biopsy suspicious lesions in the upper aerodigestive tract, placement of wireless pH capsule, transnasal balloon dilation of the oesophagus, secondary tracheoesophageal puncture, and management of foreign bodies. TNE was well tolerated and can be safely performed in an office setting with topical anaesthesia. Complications associated with TNE were mild and uncommon. There was evidence to suggest potential cost savings by performing TNE in the office setting compared with conventional investigation and examination for dysphagia. TNE may lead to a change in practice from investigation and treatment in the operating theatre or day care center to an office-based practice.

Role of flexible transnasal esophagoscopy and patient education in the management of globus pharyngeus

BACKGROUND/PURPOSE

Globus pharyngeus and dysphagia are common complaints of patients referred to ear, nose, and throat (ENT) clinics. We aimed to establish an efficient method to rule out the presence of malignancy in patients with globus pharyngeus and dysphagia.

METHODS

The use of flexible transnasal esophagoscopy (TNE) was evaluated in 30 patients with globus pharyngeus and 6 patients with dysphagia. The patients were immediately informed of the findings on TNE examination, and then treatments were planned. All patients were treated with lansoprazole for 2 weeks and provided education on lifestyle changes at the initial examination and at the 3-month follow-up.

RESULTS

The patients reported an improvement in symptoms of globus pharyngeus after treatment (p<0.001). Follow-up TNE confirmed improvement with less dysphagia, erythema, and vocal cord edema evident (all p<0.001).

CONCLUSION

The use of TNE and patient education are efficient management strategies for patients with symptoms of globus pharyngeus and dysphagia.

Different patterns of second primary malignancy in patients with squamous cell carcinoma of larynx and hypopharynx

PURPOSE

The aim of the present study was to compare the incidence, patterns, and survival of second primary malignancy (SPM) in patients with squamous cell carcinoma of the larynx (LSCC) and hypopharynx (HPSCC).

METHODS

We retrospectively review the medical record of 581 previously untreated patients with LSCC (392 cases) and HPSCC (189 cases) who received primary surgery with or without postoperative radiotherapy from 1990 to 2000. Data including age, sex, risk factors, subsites and TNM stage of primary tumor, treatment, site and incidence of SPM, and prognosis were collected from medical charts.

RESULTS

Groups with HPSCC had a higher incidence (4.2% vs 2.9% annual rate) and shorter median time (30 vs 59 months) developing SPM rather than LSCC. Fifty-five percent of the SPM occurred in the respiratory axis in LSCC, and 66% developed in the digestive axis in HPSCC. The factors influencing the appearance of SPM included early T stage, tobacco use, and less tumor recurrence. Long-term survival was poorer in those with than without SPM (38% vs 49% at 10 years).

CONCLUSIONS

There is a tendency for SPM to occur in the respiratory axis (lung and larynx) in LSCC and in the digestive axis (oral cavity, pharynx, and esophagus) in HPSCC. This information is important for posttreatment follow-up.

Transnasal esophagoscopy findings: interspecialty comparison

INTRODUCTION

Otolaryngologists implement transnasal esophagoscopy (TNE) to assess esophageal pathology. Previous studies using TNE are largely retrospective and deal with select patient populations. The prevalence of esophageal pathology in patients presenting with throat symptoms to an otolaryngology voice center is presently unknown.

OBJECTIVE

To assess the prevalence of esophageal pathology in this population and determine the interobserver variability of the findings reviewed by an otolaryngologist and a gastroenterologist.

STUDY DESIGN

A prospective study.

SETTING

This study was conducted in a laryngology/voice subspecialty clinic.

SUBJECTS AND METHODS

Fifty patients with throat symptoms presenting to the voice center were asked prospectively to undergo TNE. The findings were videotaped and reviewed by an otolaryngologist and a gastroenterologist blinded to the patients' presenting complaint.

RESULTS

Hoarseness was the most common presenting symptom (68%). According to the gastroenterologist, the prevalence of esophageal findings was: z-line irregularity suspicious for Barrett esophagus (12%), esophagitis (10%), hiatal hernia (32%), and esophageal stricture (10%). The percent agreement for a normal study was 72 percent. The percent agreement for various pathological findings were as follows: Barrett esophagus 86 percent, esophagitis 88 percent, hiatal hernia 76 percent, and esophageal stricture 96 percent. For an abnormal study, the percent agreement was 80 percent.

CONCLUSION

Esophageal abnormalities are common in patients presenting to a voice subspecialty clinic.

In-office transnasal esophagoscope-guided botulinum toxin injection of the lower esophageal sphincter

PURPOSE OF REVIEW

Thin caliber transnasal esophagoscopes allow for a rapidly expanding array of office-based esophageal procedures, including botulinum toxin injections, in unsedated patients.

RECENT FINDINGS

While botulinum toxin has been used in the esophagus and lower esophageal sphincter for many years, there is no current description of performing this procedure in an unsedated patient using transnasal esophagoscopy. Indications include achalasia, hypertensive lower esophageal sphincter, distal esophageal spasm, nutcracker esophagus and obstructing muscular rings. There is a paucity of data in the literature pertaining to spastic esophageal motility disorders and muscular rings. Randomized controlled trials of achalasia treatments suggest that botulinum toxin injections should be reserved for patients who are poor surgical candidates and/or have failed pneumatic dilation.

SUMMARY

In-office transnasal esophagoscopy-guided lower esophageal sphincter botulinum toxin injection has not been described in the literature. Indications include esophageal spasm, muscular rings and achalasia, with recent data suggesting that botulinum toxin should not be an initial therapy for most patients with achalasia.