Transnasal Esophagoscopy
Updated: Dec 11, 2018
Author: Mohamad R Chaaban, MD, MBA, MSCR, FACS, FAAOA; Chief Editor: Arlen D Meyers, MD, MBA
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:
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Dysphagia (reported as the most common indication)[6, 7, 8]
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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]
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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]
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Evaluation of a possible foreign body[9]
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Procedures such as dilation of a stricture or injection of botulinum toxin in the lower esophageal sphincter[16]
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Cough[6]
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Tracheoesophageal puncture replacement under direct vision,[9] with excellent speech outcomes[17]
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Extrinsic esophageal compression[6]
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Candidiasis[6]
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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:
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After positioning the patient and obtaining informed consent, start examining the nasal cavities.
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Spray the more patent nostril with a 1:1 ratio of oxymetazoline (Afrin) 0.05% and lidocaine (Xylocaine) 4%.
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Then spray the oropharynx with lidocaine (Xylocaine) 10% and ask the patient to swallow immediately.
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Lubricate the endoscope with viscous lidocaine 2%.[9]
Equipment
See the list below:
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Local anesthetic and oxymetazoline sprays
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Viscous lidocaine
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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]
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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]
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Television monitor
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Video cassette recorder
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Light source
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Pentax biopsy forceps
Positioning
See the list below:
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Seat the patient upright on a treatment couch across from the endoscopist.[2]
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The endoscope stack is kept behind the patient, in view of the endoscopist.[2]
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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.
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.
Scope passing through the cricopharyngeus as the patient is asked to swallow. -
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]
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Rotate the scope 360ยบ 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).
Air insufflation to view the stomach.
Scope at the level of the gastroesophageal junction and stomach. -
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.
Air insufflation in the stomach.Slow withdrawal of the scope allows careful visualization of the esophageal mucosa.
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:
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Transient anterior epistaxis[2] (reported to be the most frequent complication[3] )
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Vomiting or gagging[20]
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Vasovagal syncope[9]
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Bleeding and infection (if a biopsy is performed)
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Esophageal perforation (This is a very rare complication, reported once in the literature so far.[23] )
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Laryngospasm[24]