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Sections Transnasal Esophagoscopy
Overview
Indications
Contraindications
Anesthesia
Equipment
Positioning
Technique
Pearls
Complications
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Media Gallery
References

Overview

Transnasal flexible esophagoscopy is a helpful tool that reduces diagnostic delays and the need for endoscopy under general anesthesia.^[1]It is a safe and well-tolerated procedure that can be performed under local anesthesia and in the outpatient setting.^{[2, 3, 4]} The procedure can be performed for diagnostic and therapeutic purposes. Transnasal esophagoscopy requires no sedation.^{[2, 3]} It is a highly cost-effective tool that is easily learned.^{[3, 5]}

Indications

The indications for transnasal flexible esophagoscopy include the following:

Dysphagia (reported as the most common indication)^{[6, 7, 8]}
Screening tool for patient with reflux or globus sensation^{[9, 10, 7]}- A prospective multicenter cross-sectional study has even recommended it for use in the primary care population, with 38% of the participants reported with esophageal findings that altered their management.^[11]
Screening tool in patients with head and neck cancer^{[9, 12, 13]}- In addition, it can be used for the detection of metachronous esophageal squamous cell carcinoma (SCC) in the esophagus.^{[14, 15]}
Evaluation of a possible foreign body^[9]
Procedures such as dilation of a stricture or injection of botulinum toxin in the lower esophageal sphincter^[16]
Cough^[6]
Tracheoesophageal puncture replacement under direct vision,^[9]with excellent speech outcomes^[17]
Extrinsic esophageal compression^[6]
Candidiasis^[6]
Foreign body removal^[18]- This was once considered as a contraindication, but transnasal esophagoscopy is now being increasingly used as diagnostic and therapeutic tool for the extraction of foreign bodies with quick discharge of patients in less than an hour.^[19]

Contraindications

Transnasal esophagoscopy may be contraindicated in patients with bleeding diathesis or abnormal coagulation profile.^[20]

Anesthesia

See the list below:

After positioning the patient and obtaining informed consent, start examining the nasal cavities.
Spray the more patent nostril with a 1:1 ratio of oxymetazoline (Afrin) 0.05% and lidocaine (Xylocaine) 4%.
Then spray the oropharynx with lidocaine (Xylocaine) 10% and ask the patient to swallow immediately.
Lubricate the endoscope with viscous lidocaine 2%.^[9]

Equipment

See the list below:

Local anesthetic and oxymetazoline sprays
Viscous lidocaine
A distal video chip transnasal endoscope with a camera built into its tip (eg, Pentax 80K series digital video endoscope [5.1-mm diameter])^[2]
Suction, irrigation, and insufflation all attached to the endoscope (in the distal video chip endoscope) or linked to the EndoSheath (in an add-on camera transnasal endoscope)^[2]
Television monitor
Video cassette recorder
Light source
Pentax biopsy forceps

Positioning

See the list below:

Seat the patient upright on a treatment couch across from the endoscopist.^[2]
The endoscope stack is kept behind the patient, in view of the endoscopist.^[2]
If patient safety is in question, the patient should lie down on the couch for resuscitation, if needed.^[2]

Technique

See the list below:

Explain the procedure to the patient and obtain informed consent.
Check all equipment before beginning the procedure (see image below).

Checking all instruments is crucial before starting the endoscopy.
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Pass the endoscope parallel to the floor of the nose or between the middle and inferior turbinates (see image below).

Advancement of the scope intranasally parallel to the nasal floor.
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When the nasopharynx is reached, turn the flexible scope downward (see images below). Closely observe the nasopharynx, hypopharynx, and glottis for any abnormalities.^[21]

Advancement of the scope at the level of the nasopharynx.
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Advancement of the scope past the base of the tongue.
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As soon as the hypopharynx is reached, ask the patient to flex his head forward to reach his chest. At that time, ask the patient to swallow. This relaxes the cricopharyngeus.^[20]See images below.

Flexible endoscope passing into the hypopharynx.
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Scope passing through the cricopharyngeus as the patient is asked to swallow.
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Under direct visualization, advance the scope through the cervical esophagus toward the cardia. Asking the patient to phonate a vowel facilitates entry of the scope through the esophagogastric junction. This maneuver relaxes the lower esophageal sphincter and also allows movement of the diaphragm.^[21]
Rotate the scope 360º while angulating upward to look for the gastroesophageal junction and the gastric cardia. This is called the J maneuver.^[21]See images below.

360-degree rotation of the scope to view the gastroesophageal junction (J maneuver).
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Air insufflation to view the stomach.
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Scope at the level of the gastroesophageal junction and stomach.
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Remove the endoscope gently, using intermittent insufflation and suction, while taking close look at the esophageal lumen (see images below).^[21]

Slow withdrawal of the scope with careful attention to the monitor.
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Air insufflation in the stomach.
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Slow withdrawal of the scope allows careful visualization of the esophageal mucosa.
View Media Gallery

Pearls

Compared to the transoral esophagogastroduodenoscopy (EGD), the transnasal route has the advantage of not stimulating the uvula and the posterior part of the tongue, thus not stimulating the gag reflex.^[22]

Most complications encountered in regular sedated oral endoscopy are usually due to sedation. Cardiopulmonary complications account for over 50% of complications.^[5]

Complications

Complications may include the following:

Transient anterior epistaxis^[2](reported to be the most frequent complication^[3])
Vomiting or gagging^[20]
Vasovagal syncope^[9]
Bleeding and infection (if a biopsy is performed)
Esophageal perforation (This is a very rare complication, reported once in the literature so far.^[23])
Laryngospasm^[24]

Bush CM, Postma GN. Transnasal esophagoscopy. Otolaryngol Clin North Am. 2013 Feb. 46 (1):41-52. [QxMD MEDLINE Link].
Price T, Sharma A, Snelling J, Bennett AM, Qayyum A, Bradnam T, et al. How we do it: The role of trans-nasal flexible laryngo-oesophagoscopy (TNFLO) in ENT: one year's experience in a head and neck orientated practice in the UK. Clin Otolaryngol. 2005 Dec. 30(6):551-6. [QxMD MEDLINE Link].
Sabirin J, Abd Rahman M, Rajan P. Changing trends in oesophageal endoscopy: a systematic review of transnasal oesophagoscopy. ISRN Otolaryngol. 2013 Aug 1. 2013:586973. [QxMD MEDLINE Link]. [Full Text].
Abou-Nader L, Wilson JA, Paleri V. Transnasal oesophagoscopy: diagnostic and management outcomes in a prospective cohort of 257 consecutive cases and practice implications. Clin Otolaryngol. 2014 Apr. 39 (2):108-13. [QxMD MEDLINE Link].
Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal esophagoscopy: a position statement from the American Bronchoesophagological Association (ABEA). Otolaryngol Head Neck Surg. 2009. 140(2):280.
Andrus JG, Dolan RW, Anderson TD. Transnasal esophagoscopy: a high-yield diagnostic tool. Laryngoscope. 2005 Jun. 115(6):993-6. [QxMD MEDLINE Link].
Sanyaolu LN, Jemah A, Stew B, Ingrams DR. The role of transnasal oesophagoscopy in the management of globus pharyngeus and non-progressive dysphagia. Ann R Coll Surg Engl. 2016 Jan. 98 (1):49-52. [QxMD MEDLINE Link].
Sanyaolu LN, Jemah A, Stew B, Ingrams DR. The role of transnasal oesophagoscopy in the management of globus pharyngeus and non-progressive dysphagia. Ann R Coll Surg Engl. 2016 Jan. 98 (1):49-52. [QxMD MEDLINE Link]. [Full Text].
Belafsky PC, Postma GN, Daniel E, Koufman JA. Transnasal esophagoscopy. Otolaryngol Head Neck Surg. 2001 Dec. 125(6):588-9. [QxMD MEDLINE Link].
Cheng CC, Fang TJ, Lee TJ, et al. Role of flexible transnasal esophagoscopy and patient education in the management of globus pharyngeus. J Formos Med Assoc. 2012 Mar. 111(3):171-5. [QxMD MEDLINE Link].
Peery AF, Hoppo T, Garman KS, et al. Feasibility, safety, acceptability, and yield of office-based, screening transnasal esophagoscopy (with video). Gastrointest Endosc. 2012 Mar 15. [QxMD MEDLINE Link].
Parker C, Alexandridis E, Plevris J, O'Hara J, Panter S. Transnasal endoscopy: no gagging no panic!. Frontline Gastroenterol. 2016 Oct. 7 (4):246-256. [QxMD MEDLINE Link]. [Full Text].
Mohammed H, Coates M, Masterson L, Chan WY, Hassan Y, Nassif R. Role of transnasal flexible laryngo-oesophagoscopy (TNFLO) in investigating patients with globus symptoms. Clin Otolaryngol. 2017 Dec. 42 (6):1311-1318. [QxMD MEDLINE Link].
Su YY, Fang FM, Chuang HC, Luo SD, Chien CY. Detection of metachronous esophageal squamous carcinoma in patients with head and neck cancer with use of transnasal esophagoscopy. Head Neck. 2010 Jun. 32(6):780-5. [QxMD MEDLINE Link].
Wellenstein DJ, Schutte HW, Marres HAM, Honings J, Belafsky PC, Postma GN, et al. Office-based procedures for diagnosis and treatment of esophageal pathology. Head Neck. 2017 Sep. 39 (9):1910-1919. [QxMD MEDLINE Link].
Rees CJ. In-office transnasal esophagoscope-guided botulinum toxin injection of the lower esophageal sphincter. Curr Opin Otolaryngol Head Neck Surg. 2007 Dec. 15(6):409-11. [QxMD MEDLINE Link].
LeBert B, McWhorter AJ, Kunduk M, et al. Secondary tracheoesophageal puncture with in-office transnasal esophagoscopy. Arch Otolaryngol Head Neck Surg. 2009 Dec. 135(12):1190-4. [QxMD MEDLINE Link].
Shih CW, Hao CY, Wang YJ, Hao SP. A New Trend in the Management of Esophageal Foreign Body: Transnasal Esophagoscopy. Otolaryngol Head Neck Surg. 2015 Aug. 153 (2):189-92. [QxMD MEDLINE Link].
Bennett AM, Sharma A, Price T, Montgomery PQ. The management of foreign bodies in the pharynx and oesophagus using transnasal flexible laryngo-oesophagoscopy (TNFLO). Ann R Coll Surg Engl. 2008 Jan. 90(1):13-6. [QxMD MEDLINE Link].
Aviv JE, Takoudes TG, Ma G, Close LG. Office-based esophagoscopy: a preliminary report. Otolaryngol Head Neck Surg. 2001 Sep. 125(3):170-5. [QxMD MEDLINE Link].
McPartlin DW, Nouraei SA, Tatla T, Howard DJ, Sandhu GS. How we do it: transnasal fibreoptic oesophagoscopy. Clin Otolaryngol. 2005 Dec. 30(6):547-50. [QxMD MEDLINE Link].
Yagi J, Adachi K, Arima N, Tanaka S, Ose T, Azumi T, et al. A prospective randomized comparative study on the safety and tolerability of transnasal esophagogastroduodenoscopy. Endoscopy. 2005 Dec. 37(12):1226-31. [QxMD MEDLINE Link].
Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal esophagoscopy: a position statement from the American Bronchoesophagological Association (ABEA). Otolaryngol Head Neck Surg. 2008 Apr. 138(4):411-4. [QxMD MEDLINE Link].
Postma GN. Transnasal esophagoscopy. Curr Opin Otolaryngol Head Neck Surg. 2006 Jun. 14(3):156-8. [QxMD MEDLINE Link].

Media Gallery

Advancement of the scope past the base of the tongue.
Advancement of the scope intranasally parallel to the nasal floor.
360-degree rotation of the scope to view the gastroesophageal junction (J maneuver).
Checking all instruments is crucial before starting the endoscopy.
Advancement of the scope at the level of the nasopharynx.
Air insufflation to view the stomach.
Slow withdrawal of the scope with careful attention to the monitor.
Flexible endoscope passing into the hypopharynx.
Air insufflation in the stomach.
Scope passing through the cricopharyngeus as the patient is asked to swallow.
Slow withdrawal of the scope allows careful visualization of the esophageal mucosa.
Scope at the level of the gastroesophageal junction and stomach.

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Author

Mohamad R Chaaban, MD, MBA, MSCR, FACS, FAAOA Head and Neck Institute, Cleveland Clinic

Mohamad R Chaaban, MD, MBA, MSCR, FACS, FAAOA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society, European Rhinologic Society, North American Skull Base Society

Disclosure: Nothing to disclose.

Coauthor(s)

Louis de Guzman Portugal, MD Associate Professor, Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medical Center

Louis de Guzman Portugal, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Chicago Medical Society, Illinois State Medical Society, Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

Additional Contributors