Keywords
Endoscopy - esophagoscopy - deglutition disorders
Introduction with Objectives
Introduction with Objectives
The use of transnasal esophagoscopy (TNE) is increasing across the world in the field of otolaryngology as an investigative and interventional tool in patients with reflux, globus and dysphagia.[1] The procedure has been widely validated since the first switch from oral to nasal esophageal intubation using a flexible fiber-optic scope in the 1990's. Jonathan Aviv, an American head and neck surgeon, developed the technique and demonstrated that it could be performed in an outpatient setting, without sedation, in consecutive clinical patients.[2] Since then, TNE has been used to carry out biopsies, balloon dilation of the esophagus, medialisation of the vocal cords, and secondary tracheoesophageal puncture.[3]
[4]
The primary advantage of TNE over the more traditional esophagoscopy, with oral intubation, or rigid esophagoscopy, under general anesthesia, is that the patients do not require sedation or a general anesthetic. This, in turn, results in a reduced hospital stay and in a shorter procedure time.[5] An economic analysis has shown TNE to be more cost-effective as a result.[3]
We have recently incorporated a TNE service into our ear-nose-throat (ENT) department within a district general hospital (DGH) in Lancaster, United Kingdom. We had noticed that many of the patients referred to us had already undergone other investigations, mainly in the form of esophagogastroduodenoscopy (EGD), for the same complaint. The main aim of the present study was to assess if, in the future, we could prevent the duplication of endoscopic examinations within the gastroenterology and ENT departments.
This study presents a case series detailing the results obtained from our first 25 patients undergoing TNE. Due to the limited space in our outpatient clinic, our TNE procedures are currently performed in the operation theater. Currently, we only possess one TNE endoscope, and do not have the sterilization equipment set up to run back-to-back procedures. Therefore, we run a half-day operation theater list where we perform two TNE procedures interspersed with a general anesthesia procedure, in order to allow time for the scope to be sterilized. However, our long-term aim is to develop the infrastructure required to integrate this procedure into the clinic.
Methods
There were no ethical considerations needed for the collection of data or its analysis. All data was fully anonymous.
We have searched our theater database using Microsoft Excel (Microsoft Corp, Redmond, WA, US) for procedures that used TNE from the initial trial period in March 2016 up to June 2017. The details of the patients were extracted, and their electronic patient record (Lorenzo) was analyzed for the following information: preceding investigations, indication for TNE, whether a biopsy was taken, the endoscope view, and the type of anesthetic used.
During that period, 25 TNE procedures were listed. One of these procedures was cancelled due to a patient having uncontrolled hypertension, and another patient was unable to be analyzed due to a missing operation note. This left us with 23 procedures for analysis.
All the statistical analysis was performed using the simple tools available in Microsoft Excel and free online statistical tools on Calculator.net.
Results
The average age of the patients undergoing TNE was 61 years old (standard deviation [SD] = 17). All of these patients underwent TNE after a combined administration of a topical anesthetic and a decongestant nasal spray (lidocaine and phenylephrine). [Table 1] shows each patient numbered with their previous investigations and information detailing their individual TNE.
Table 1
Demographics of patients undergoing transnasal esophagoscopy, their indication and the procedural details
|
Age
|
Procedure
|
Preceding investigation
|
Indication
|
Biopsy taken and result
|
TNE view
|
Findings
|
Anesthesia type
|
Length of stay
|
|
48
|
TNE
|
MRI - right vallecular cyst, chronic sialadenitis. EGD 2012 = gastritis
|
Fluctuating right submandibular mass
|
Yes = normal squamous epithelium
|
No issue
|
Vallecular cyst
|
LA
|
Day-case
|
|
70
|
TNE
|
EGD 2015 = gastric polyp
|
CP contraction and ? Pouch
|
No
|
Blurry (x2 passes); balloon dilation abandoned
|
Normal
|
LA
|
Day-case
|
|
60
|
TNE
|
Barium swallow. Removal of vallecular cyst. Subsequently able to eat and drink normally
|
Globus
|
No
|
No issue
|
Normal
|
LA
|
Day-case
|
|
46
|
TNE
|
TNE
|
Odynophagia
|
No
|
No issue
|
Normal
|
LA
|
Day-case
|
|
85
|
TNE
|
EGD 2010 = Barret1's esophagus (dysphagia)
|
Globus
|
No
|
Poor view, passed to 35 cm
|
Normal
|
LA
|
Day-case
|
|
76
|
TNE
|
EGD 2013 = gastritis and small HH
|
Globus
|
No
|
No issue
|
Small HH
|
LA
|
Day-case
|
|
73
|
TNE
|
Barium swallow
|
Dysphagia
|
No
|
No issue
|
Esophagial candidiasis, HH
|
LA
|
Day-case
|
|
68
|
TNE
|
Previous Head and Neck Ca and Radiotherapy
|
Dysphagia
|
No
|
Unable to pass past pyriform fossa
|
Stricture at level of pyriform fossa
|
LA
|
Day-case
|
|
90
|
TNE
|
Failed EGD. Barium swallow. Previous direct esophagoscopy and balloon dilation (December 2016)
|
Dysphagia
|
No
|
No issues
|
Normal
|
LA
|
Day-case
|
|
57
|
TNE
|
Previous total laryngectomy with neck dissection
|
Dysphagia
|
No
|
Poor view - secretions
|
Unclear
|
LA
|
Day-case
|
|
32
|
TNE
|
None
|
Tightness in chest
|
No
|
No issues
|
Normal
|
LA
|
Day-case
|
|
72
|
TNE
|
Barium swallow, EGD 2013 = candidiasis, gastritis
|
High dysphagia
|
No
|
No issues
|
Normal
|
LA
|
Day-case
|
|
58
|
TNE
|
Underwent EGD after the procedure (gastritis, CLO test taken)
|
Globus and Dyspepsia
|
No
|
Nasal spur (difficult to pass scope), stomach not visualized
|
Normal
|
LA
|
Day-case
|
|
43
|
TNE
|
None
|
Dysphagia, hoarse voice
|
No
|
No issues
|
Normal
|
LA
|
Day-case
|
|
52
|
TNE
|
USS neck = cystic nodule in thyroid
|
Globus
|
No
|
No issues
|
Normal
|
LA
|
Day-case
|
|
70
|
TNE + balloon dilation
|
None
|
Dysphagia
|
No
|
No issues
|
Mild GERD, SCJ 3 cm above GEJ, stenotic upper esophagus
|
LA
|
Inpatient
|
|
48
|
TNE + balloon dilation
|
USS neck - midline cysts, MRI neck - midline cysts, gastroscopy 2014 = normal
|
Choking episodes
|
No
|
No issues
|
Spasm of cricopharyngeus, balloon dilation
|
LA
|
Day-case
|
|
23
|
TNE
|
None
|
Dysphagia
|
No
|
No issues
|
Food bolus - unable to retrieve, referred for EGD
|
LA
|
Day-case
|
|
77
|
TNE
|
EGD abandoned in 2016
|
Dysphagia
|
No
|
No issues
|
Normal
|
LA
|
Day-case
|
|
49
|
TNE + balloon dilation
|
None
|
Dysphagia
|
No
|
No issues
|
Prominent cricopharyngeus, Schatzki ring. Good result at follow-up.
|
LA
|
Day-case
|
|
49
|
TNE + balloon dilation
|
Barium swallow, EGD 2014 = normal
|
Dysphagia
|
No
|
No issues
|
Spasm of cricopharyngeus
|
LA
|
Day-case
|
|
68
|
TNE
|
None
|
Dysphagia
|
No
|
Difficult procedure*
|
Normal
|
LA
|
Day-case
|
|
79
|
TNE + balloon dilation
|
Barium swallow
|
Dysphagia
|
No
|
No issues
|
Narrow cricopharyngeus
|
LA
|
Day-case
|
Abbreviations: Ca, Cancer; CLO test, Rapid Urease Tedt; CP, Cricopharyngeus; EGD, esophagogastroduodenoscopy; GEJ, gastroesophageal junction; GERD, gastroesophageal reflux disease; HH, Hiatus Hernia; LA, local anesthesia; MRI, magnetic resonance imaging; SCJ, squamocolumnar junction; TNE, transnasal esophagoscopy; USS, ultrasound scan.
Notes: *No indication was made as to why this was a difficult procedure in the medical notes; all data has been anonymized.
TNE View and Technical Issues
In three cases, there were problems with the endoscope view. Two of these were due to the scope itself, and one was due to large amounts of secretions. In another case, we were unable to pass the scope through the cricopharyngeus, and in another patient the scope did not fit through the nasal airway due to a septal spur. In the remaining 78% of the cases, there were no anatomical or technical issues.
TNE Findings
From the total of 23 patients, 13 (57%) had normal findings during the TNE. All 10 (43%) patients with positive findings presented with benign pathologies, which included the following: vallecular cyst, hiatus hernia, esophageal candidiasis, cricopharyngeal stricture and spasm, Schatzki ring, and foreign body.
Previous Investigations
From the total of 23 patients, 5 (21%) had previously undergone a successful EGD with normal findings. Four of these patients had exactly the same findings during the TNE. The remaining patient had some cricopharyngeal narrowing, which was dilated using a balloon with good postoperative outcomes.
Balloon Dilation
From the total of 23 patients, 5 (21%) required balloon dilation, which was tolerated well in 4 of these patients. One patient found the procedure painful after one minute of dilation, so further attempts were abandoned.
Biopsy
Only one patient required biopsy of a vallecular cyst, which returned results of normal squamous epithelium.
Findings from the Larynx to the Cricopharyngeus
One patient had a stricture at the level of the pyriform fossa. In other cases in which a pathology was evident, it was at the level of or below the cricopharyngeus.
Day Case versus Inpatient
One patient was admitted for observation overnight. The rest of the patients were admitted as day-case procedures.
Local versus General Anesthesia
All cases were performed with local anesthesia.
Previous Barium Swallow
From the total of 23 patients, 6 (26%) had undergone prior investigation with barium swallow. All of these patients had persistent dysphagia after no pathology was identified on the swallow test. Through the TNE, three out of these six patients were found to have a pathology, including cricopharyngeal spasm and esophageal candidiasis.
Reflux Disease
Gastroesophageal or laryngopharyngeal reflux disease were not commented on in any of the TNEreports, indicating that this was not a common finding.
Indication
The most common reason for the performance of TNE was dysphagia 57% (13) and globus 22% (5), followed by submandibular mass, odynophagia, dyspnea, choking and hoarseness, each with an incidence of 4% (1).
Discussion
Evidence regarding the use of TNE remains confined largely to retrospective case series or cross-sectional studies in larger teaching hospitals.[3] The need for prospective randomized trials comparing TNE to oral esophagoscopy in the investigation of particularly esophageal and gastric pathologies remains. This is a small case series presenting our initial findings and experiences with a new technique available to us for which resources are limited, and that has restricted our output.
Synopsis of Key New Findings
We have demonstrated that we are able to diagnose benign pathologies and successfully treat cricopharyngeal strictures using balloon dilation. Several patients had previously undergone an EGD, and while the findings during the TNE were mirrored in the majority of cases, one patient was found to have an upper esophageal problem. This leads to a clinical conundrum, as it makes it difficult to preclude patients from investigation with TNE who have undergone previous esophagoscopy via oral intubation, as well as selecting patients for TNE, as there are advantages of this technique over EGD, which include visualization of the pharynx and upper esophagus. Ultimately, we have decided that a normal EGD does not necessarily mean that the TNO findings will be the same. In the cases in which there are ongoing symptoms after an initial EGD, a TNE can offer an alternative investigation, despite its similarity.
Clinical Applicability of This Study
What is clear is that TNE is gradually becoming a useful adjunct examination in otolaryngology, as its potential uses are wide ranging. An example of this is to perform in a clinical setting a tracheoesophageal puncture after laryngectomy via the Seldinger technique.[6] It also results in improved sizing of the subsequent voice prosthesis when compared to those created under general anesthesia.[7] It can also be employed to aid the removal of esophageal foreign bodies, a problem that currently requires either referral to gastroenterology for endoscopy or a general anesthetic for a rigid esophagoscopy with associated higher morbidity.[8]
Conclusion
We have successfully developed a TNE service within a DGH. In the present study, we have demonstrated clinical success in using balloon dilation as an adjunct examination to this investigative technique. It appears that prior investigation in the form of a normal EGD does not preclude a further examination through a TNE. It also poses the question as to whether gastroenterologists should perform a TNE as the primary investigation of choice in the future.
