The Practicability of Transnasal Esophagoscopy and the Evaluation of Patient's Perception: A Prospective Study

Prospective Assessment of Safety, Tolerance, and Perceptions of Awake Airway and Esophageal Dilation

OBJECTIVE

An increasing number of laryngeal and esophageal procedures are being performed as "awake" procedures (non-general anesthesia), with some under local anesthesia, including in clinic. While high tolerance and safety profiles have been reported for various laryngeal procedures, few studies directly assess tolerability of awake dilation procedures of the upper esophagus (UE) and laryngotracheal airway (LTA).

STUDY DESIGN

Prospective, open-label.

METHODS

Prospectively collected patient and physician surveys from a tertiary laryngology center recorded patient tolerance, safety, and perceptions of awake UE and LTA balloon dilation.

RESULTS

Fifty-six awake procedures were performed on 41 patients, including 46 UE and 20 LTA dilations. All procedures were successfully completed. Overall pain was mild (3.5 ± 2.4/10, ranging 0 = no pain to10 = worst pain) and the dilation itself was reportedly the most painful portion (4.1 ± 2.9/10). Patient satisfaction with the procedure was high (7.0 ± 2.2/10, ranging 0 = worst to 10 = best experience). Most patients would undergo the procedure again (73.6%) and would recommend the procedure to others (89.3%). Patient-reported tolerance was similar immediately postoperatively and at follow-up. LTA and UE dilation patients reported similar levels of tolerance.

CONCLUSIONS

Awake upper esophageal balloon dilation is a safe, well-tolerated procedure with high completion and patient satisfaction rates. Similarly, early experience with awake laryngotracheal airway balloon dilation suggests comparable favorability, although careful consideration of patient selection and procedural implementation is strongly recommended to optimize and protect patient safety.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1343-1351, 2025.

[Use of flexible transnasal esophagogastroscopy in patients with unclear globus sensation]

BACKGROUND

Globus pharyngeus is a common symptom with considerable suffering. Globus sensation can be caused by reflux. In many places, endoscopy of the esophagus is recommended for clarification, especially when there is a question about the presence of a hiatal hernia as the cause of reflux. Transnasal esophagogastroscopy (TNE) represents an alternative to conventional gastroesophagoscopy. It enables a quick low-complication examination of the upper aerodigestive tract in the sitting, non-sedated patient.

OBJECTIVE

The aim of this work was to assess the feasibility of outpatient TNE in patients with globus sensation. Furthermore, the results of dual-probe pH monitoring were compared with the results of TNE in order to assess the value of TNE in the clarification of globus sensation and reflux.

MATERIALS AND METHODS

In 30 patients with globus symptoms, 24-hour dual-probe pH monitoring and TNE were performed. In pH monitoring, reflux number, fraction time, reflux surface area index, and DeMeester score were evaluated as indicators of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GERD). Abnormalities of the esophageal mucosa and the gastroesophageal junction were recorded in TNE. The results were compared.

RESULTS

The TNE could be performed without any complications. Mean examination time was 5.34 ± 0.12 min. Reflux was measured in 80% of the patients (24/30) with pH monitoring. In almost half of these patients (46%), abnormalities were detected in TNE as indirect evidence of reflux. In addition to an axial hiatal hernia, these included mucosal changes such as erosive esophagitis and Barrett's metaplasia. Patients with a hiatal hernia also suffered significantly more often from LPR than patients without a hernia (9:1).

CONCLUSION

TNE is a quick and safe examination method for diagnosing patients with an unclear globus sensation. Detection of a hiatal hernia can be seen as an indication of reflux disease. Lack of evidence of a hernia does not rule out reflux. Thus, TNE is a useful addition to pH monitoring in patients with globus sensation, because reflux-related changes in the mucosa can be recognized early and adequately treated.

Prevalence of Synchronous ESCN in Head and Neck Cancer: A Single-Institution Perspective

OBJECTIVES

The primary objective was to determine the prevalence of synchronous esophageal squamous cell carcinoma in head and neck squamous cell carcinoma (HNSCC) patients. The secondary objective was to determine risk factors for the development of synchronous esophageal squamous cell carcinoma (ESCN).

STUDY DESIGN

Cross sectional observation study.

METHODS

A prospective cross sectional, observational study on consecutive 300 newly diagnosed oral cavity, oropharynx, hypopharynx, and laryngeal squamous cell carcinoma patients who underwent trans-nasal esophageal endoscopy with white light imaging and narrow band imaging.

RESULTS

Among 300 patients, index HNSCCs were located in the oral cavity (n = 154, 51.3%), oropharynx (n = 63, 21%), larynx (n = 53, 17.7%), and hypopharynx (n = 30, 10%). The prevalence of synchronous ESCN was 2.7% (n = 8), including four low-grade, two high-grade dysplasia, and two squamous cell carcinomas. On logistic regression analysis, moderate to heavy alcohol consumption (OR 8.7, P = .01) and primary HNSCC involving supraglottis [(OR 12.5, P = .02) were risk factors for synchronous ESCN. The association of pyriform sinus carcinoma and synchronous ESCN was of borderline significance (P = .054, OR 10.92).

CONCLUSION

The prevalence of synchronous ESCN in HNSCC was 2.7%. Routine trans-nasal esophagoscopy should be performed in all newly diagnosed patients with carcinoma of the supraglottis and pyriform sinus, and those with consumption of moderate to heavy alcohol for the screening of synchronous ESCN.

LEVEL OF EVIDENCE

2b Laryngoscope, 131:E807-E814, 2021.

Safety of in-office laryngology procedures

PURPOSE OF REVIEW

A wide range of diagnostic and therapeutic laryngology procedures are currently performed in an office setting. In-office laryngology procedures (IOLP) are increasingly seen as standard-of-care, and while generally considered safe, high-quality evidence supporting the latter statement is lacking. This review aims to summarize recent literature regarding the safety of IOLP.

RECENT FINDINGS

There is a paucity of guidelines and standardized protocols for IOLP. To date, there is one available safety protocol specific to in-office laser procedures. Haemodynamic changes during IOLP have been documented and the significance of these changes continues to be unclear. Therefore, monitoring of vital signs is recommended. Continuing antithrombotic therapy during IOLP also appears safe, and this decision may be left to surgeon discretion. A protocol for management of antithrombotic therapy prior to in-office laser procedures is available. Actual serum lidocaine levels following topical application of mixed lidocaine preparations falls well below reported toxic levels but persists for longer than previously reported.

SUMMARY

IOLP are safer that suspension laryngoscopy under general anaesthetic. Although complication rates of IOLP are low, patient characteristics and potential complications of both the procedure and of topical anaesthetic use must be considered. One must be prepared and equipped to deal with these potential complications.

Endoscopic meatus scoring scale versus sniff test to predict insertability before transnasal endoscopy: A prospective, randomized study

BACKGROUND AND AIM

Sniff test is a common method before unsedated transnasal esophago-gastro-duodenoscopy (UT-EGD) to select a nostril insertion site. Yet there is no objective method to select a more specific meatus insertion tract for anesthesia and insertion. We devised an endoscopic meatus scoring scale by anterior meatuscopy to select the most optimal meatus insertion tract. We hypothesized that meatuscopy instead of sniff test might improve tolerance and reduce adverse events during nasal anesthesia and UT-EGD.

METHODS

A prospective randomized controlled trial to compare patient tolerance and adverse events.

RESULTS

A total of 359 patients were assessed and finally 310 patients were analyzed. There were no statistical differences in patient characteristics and insertion failure rates. Pain scores during nasal anesthesia, nasal insertion/exsertion, UT-EGD, and overall tolerance were significantly lower in the meatuscopy group than sniff test group. Compared with the sniff tested patients, the meatuscopied patients had significantly lower epistaxis rates during insertion/exsertion, better visual capacity after decongestive anesthesia, and shorter total procedure time. A significantly higher proportion of the meatuscopied than sniff tested patients would like to receive the same procedure next time. Nasal discharge, nasal pain, epistaxis, and blowing out blood clots occurred significantly less frequent in the meatuscopy group than sniff test group. More sniff tested than meatuscopied patients had headache, delayed epistaxis, and sinusitis although they were not statistically significant.

CONCLUSION

Selection of an optimal meatus insertion tract by an anterior meatuscopy causes lesser nasal pain, epistaxis, and post-procedural side effects in nasal anesthesia and UT-EGD than the conventional sniff test.