Transnasal esophagoscopy: a position statement from the American Bronchoesophagological Association (ABEA)

Patient Reported Outcomes and Objective Swallowing Assessments in a Multidisciplinary Dysphagia Clinic

OBJECTIVES/HYPOTHESIS

Dysphagia encompasses a complex compilation of symptoms which often differ from findings of objective swallowing evaluations. The purpose of this investigation was to compare the results of subjective dysphagia measures to objective measures of swallowing in patients evaluated in a multidisciplinary dysphagia clinic.

STUDY DESIGN

Prospective cohort study.

METHODS

The study cohort included all patients evaluated in the multidisciplinary dysphagia clinic over 24 months. Participants were evaluated by a multidisciplinary team including a laryngologist, gastroenterologist, and speech-language pathologist. Evaluation included a videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), and transnasal esophagoscopy (TNE). Data collected included diet (FOIS), Eating Assessment Tool (EAT-10) score, Reflux symptom index (RSI) score, and the findings of the VFSS exam.

RESULTS

A total of 75 patients were included in the analysis. The average EAT-10 score was 16.3 ± 2.1, RSI was 21.4 ± 0.6, and FOIS score was 6.0 ± 1.33. VFSS revealed impairments in the oral phase in 40% of the cohort, pharyngeal in 59%, and esophageal in 49%. Abnormalities were noted in one phase for 32%, in 2 phases in 32%, and three phases in 18%. Patients with abnormal pharyngeal findings on VFSS had significantly higher EAT-10 scores (P = .04). Patients with abnormal oral findings on VFSS were noted to have significantly lower FOIS scores (P = .03).

CONCLUSIONS

Data presented here demonstrate a relationship between patient reported symptoms and objective VFSS findings in a cohort of patients referred for multidisciplinary swallowing assessment suggesting such surveys are helpful screening tools but inadequate to fully characterize swallowing impairment.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1088-1094, 2021.

Pre-screening for bariatric surgery patients: comparative effectiveness of transnasal endoscopy versus esophagogastroduodenoscopy

BACKGROUND

Endoscopic evaluation is frequently performed before bariatric surgery to identify foregut pathology that may alter procedure selection. Transnasal endoscopy (TNE) is an alternative to esophagogastroduodenoscopy (EGD). The objective of this study was to compare TNE to EGD.

METHODS

Patients who underwent TNE or EGD before bariatric surgery from January 2012 through April 2019 were reviewed. Statistical analyses included Chi-square, Wilcoxon two-sample, and Fisher's exact tests. A p value < 0.05 was considered significant.

RESULTS

Three hundred and forty-five patients underwent preoperative screening (63% EGD, 37% TNE) before bariatric surgery. Mean age and preoperative body mass index in the TNE and EGD groups were 46.2 ± 12.4 vs 45.5 ± 11.6 years (p = 0.58) and 46.5 ± 7.1 vs. 45.5 ± 6.1 kg/m² (p = 0.25), respectively. Three TNEs were aborted, resulting in a success rate of 98%. Of patients who underwent EGD, 1 (0.5%) visited the emergency department (ED), and 7 (3%) called the nurse with post-procedure concerns. There were no ED visits or nurse calls from patients who underwent TNE. The median total time in the procedure room was 77 (57-97) min for EGD vs. 26 (8-33) min for TNE (p < 0.001). One patient who underwent TNE required subsequent EGD. Mean charge per patient for EGD and TNE was $5034.70 and $1464.00, respectively.

CONCLUSIONS

TNE was associated with less post-procedure care, shorter procedure time and fewer charges compared to EGD. TNE could be considered an initial screening tool for patients undergoing bariatric surgery, while EGD could be used selectively in patients with abnormal TNE findings.

Early gastric cancer diagnostic ability of ultrathin endoscope loaded with laser light source

BACKGROUND

Conventionally, the low luminous intensity, low image resolution, and difficulty in operation have been reported with the ultrathin endoscope. However, it has markedly advanced recently. The improvement of the diagnostic ability is expected.

AIM

To compare the early gastric cancer diagnostic ability of an ultrathin endoscope loaded with a laser light source and that of the conventional endoscope.

METHODS

The target subjects were 375 consecutive patients who underwent endoscopy at our hospital for post-endoscopic submucosal dissection follow-up of gastric cancer from January to August 2018. During endoscopy, the ultrathin endoscope was used in 140 patients (37.3%), and the conventional endoscope was used in 235 patients (62.7%). Patient background was adjusted using the propensity score matching method, and gastric cancer detection ability was evaluated in the two groups.

RESULTS

The gastric cancer detection rate was 7.8% in the ultrathin endoscope group and 7.0% in the conventional endoscope group, and the mean intragastric observation time was 4.1 ± 1.7 min in the ultrathin endoscope group and 4.1 ± 1.9 min in the conventional endoscope group, showing no significant differences between the groups. Moreover, the biopsy implementation rate was 31.8% in the ultrathin endoscope group and 41.1% in the conventional endoscope group, and the biopsy prediction rate was 17.9% and 13.2%, respectively, showing no significant differences between the groups.

CONCLUSION

The gastric cancer diagnostic ability of the ultrathin endoscope loaded with a laser light source was comparable to that of the conventional endoscope. The observation time was also comparable. Thus, endoscopy using the ultrathin endoscope loaded with the laser light source would be the first option in screening examinations of gastric cancer due to its low invasion.

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.

Eosinophilic oesophagitis: a systematic review for otolaryngologists

BACKGROUND

Eosinophilic oesophagitis is a chronic, immune/antigen-mediated oesophageal disease, only recently, but increasingly, recognised in the world literature. It is diagnosed and managed primarily by medical gastroenterologists and allergy specialists, and is a distinct disease entity, affecting both children and adults. Few studies have been published in otolaryngology journals, although otolaryngologists will encounter patients with undiagnosed eosinophilic oesophagitis. Patients may present with dysphagia, bolus obstruction or with other ENT disorders, such as atopic rhinitis, reflecting the underlying systemic allergic disorder.

OBJECTIVE

This paper systematically reviews the evidence base published on the epidemiology, clinical presentation, diagnosis, treatment and prognosis of eosinophilic oesophagitis, particularly as it relates to otolaryngology practice.

Impact of Otolaryngology in the diagnosis of early oesophageal malignancy

INTRODUCTION

A large number of patients present in Otolaryngology clinics with vague upper gastro intestinal symptoms, some potentially originating from the oesophagus. In the United Kingdom there is no consensus for investigation protocols. The concern is that diagnosis of early oesophageal malignancy can be delayed with detrimental effects to the prognosis of the patient. The aim of this paper is to attempt to establish the impact of Ear Nose and Throat (ENT) work up in the diagnostic pathway of these patients.

METHODS

Retrospective analysis of case notes of newly diagnosed oesophageal carcinoma over a 15 month period.

RESULTS

Sixty five patients with a new diagnosis of oesophageal carcinoma were identified from the upper GI cancer network. A cohort of 7 patients was initially referred to ENT with related symptoms. Delays occurred at different stages during the course of their diagnostic pathways. Only 2 patients were diagnosed from ENT prior to referral to upper GI.

CONCLUSION

We support the creation of one stop clinics incorporating the use of transnasal oesophagoscopy. The current literature is discussed.

Transnasal oesophagoscopy: diagnostic and management outcomes in a prospective cohort of 257 consecutive cases and practice implications

OBJECTIVES

To determine the success rate, patient tolerability and impact of introducing transnasal oesophagoscopy on clinical practices.

DESIGN

Prospective cohort with review of electronic patient records for outcomes.

SETTING

UK tertiary centre Otolaryngology Department.

PARTICIPANTS

The cohort comprised of two hundred and fifty-seven patients, 128 females (50%) and 129 males (50%) with an age range of 20-91 years; mean age 59 years (sd 13.6).

MAIN OUTCOME MEASURES

Success rates, indications, findings and outcomes of patients undergoing transnasal oesophagoscopy and impact on rigid examinations of the pharynx and oesophagus were also considered.

RESULTS

Transnasal oesophagoscopy has a high success rate of 97%; it is well tolerated by patients, and poor views are uncommon. Pathology was detected in 44% of patients. The most common indications for transnasal oesophagoscopy were unexplained throat symptoms (50%) and dysphagia (25%). Common positive findings were hiatus hernia (7%), Barrett's oesophagus (5%), dysmotility (5%) and oesophageal candidiasis (5%). Following transnasal oesophagoscopy, 59% of patients were discharged to their referring clinician, 17% continued to undergo otolaryngology follow-up, and 13% were referred to our gastrointestinal colleagues. Following the introduction of transnasal oesophagoscopy, there was a reduction in the number of rigid examinations of the pharynx and oesophagus in the subsequent years, despite an increase in total referrals.

CONCLUSIONS

Transnasal oesophagoscopy is a well-tolerated procedure that allows otolaryngologists to make management decisions on common referrals swiftly in the clinic setting avoiding unnecessary investigations, follow-up and referral.

Laryngopharyngeal reflux: paradigms for evaluation, diagnosis, and treatment

OBJECTIVE

This study aimed to describe current patterns for diagnosis and treatment of laryngopharyngeal reflux (LPR) and analyze differences between laryngologists and non-laryngologists.

METHODS

American Academy of Otolaryngology-Head and Neck Surgery and American Broncho-Esophagological Association members were invited to complete an online survey regarding evaluation, diagnosis, and treatment of LPR. Subgroup analysis was performed to identify differences between respondents who completed laryngology fellowships (LF) and those who did not (NL).

RESULTS

Of 159 respondents, 40 were LF. Video documentation of laryngopharyngeal exams was almost universal among LF (97% vs 38%, P < .0001). Use of rigid (100%, P = .002) and flexible distal-chip technologies (94%, P = .004) was more common among LF. Diagnostic criteria were similar between the groups, with symptoms of heartburn, globus, and throat clearing thought most suggestive of LPR. Adjunctive tests most commonly used were barium esophagram and dual-probe pH testing with impedance. Laryngology fellowship-trained respondents used dual pH probes with impedance more often (P = .004). They were more likely to prescribe twice daily proton pump inhibitors with concurrent H2-blocker medication initially (P = .004) and to treat for longer than 4 weeks (P = .0003).

CONCLUSION

Otolaryngologists are in agreement on symptoms and physical features of LPR; however, significant differences exist between laryngologists and non-laryngologists on the use of adjunctive testing and treatment strategies.

Practical Applications of In-Office Fiberoptic Transnasal Esophagoscopy in the Initial Evaluation of Patients with Squamous Cell Cancer of the Head and Neck

We conducted a study to analyze the effectiveness of trans-nasal esophagoscopy (TNE) as an alternative to operative endoscopy (OE) for the evaluation of primary head and neck cancers and for the surveillance of synchronous esophageal cancers. Our study population was made up of 96 consecutively presenting patients—75 men and 21 women, aged 45 to 88 years (mean: 64)—who were treated at our institution for squamous cell cancer of the head and neck. Of this group, 42 patients had been evaluated with TNE and 54 with OE. More OEs were performed inpatients with an unknown primary (26 vs. 3). Incidental findings on TNE included 3 cases of gastritis, 2 cases each of hiatal hernia and esophagitis, 1 case of Barrett esophagus, and 1 inlet patch. No incidental findings were reported during OE. Primary cancers were biopsied by TNE through a port on the endoscope in 4 patients; 2 of these cancers were in the tongue base, 1 in the hypopharynx, and 1 in the aryepiglottic fold. After the initial visit, patients in the TNE group waited significantly fewer days for their endoscopy than did those in the OE group (median: 6.5 vs. 16; p < 0.05). Conversely, patients in the OE group waited significantly fewer days for treatment following endoscopy (median: 12 vs. 20; p < 0.05). However, there was no significant difference between the TNE patients and the OE patients in the total number of days comprising the their entire course of management, from the initial visit to definite treatment (median: 27.5 and 33 days, respectively; p = 0.7). We conclude that TNE is a reasonable alternative to OE for the initial screening for synchronous esophageal cancers inpatients with squamous cancers of the head and neck. OE is preferred for the initial workup of unknown primary cancers and for large tongue base cancers. The rate of detection of clinically relevant incidental findings is higher with TNE. Biopsy is possible during TNE for all subsites within the upper aerodigestive tract.

Management of globus pharyngeus

Globus pharyngeus is a common ENT condition. This paper reviews the current evidence on globus and gives a rational guide to the management of patients with globus. The aetiology of globus is still unclear though most ENT surgeons believe that reflux whether acidic or not plays a significant role. Though proton pump inhibitors are used extensively in practice, there is little evidence to support their efficacy. Most patients with globus can be discharged after simple office investigations. The role of pepsin-induced laryngeal injury is an exciting concept that needs further study. Given the benign nature of globus pharyngeus, in most cases, reassurance rather than treatment or extensive investigation with rigid oesophagoscopy or contrast swallows is all that is needed. We need more research into the aetiology of globus.

Globus Pharyngeus: Effectiveness of Treatment with Proton Pump Inhibitors and Gabapentin

Objectives:

This study was performed to investigate the effectiveness of treatment of globus pharyngeus with proton pump inhibitors, gabapentin, or both.

Methods:

The subjects all presented with globus pharyngeus during the years 2006 to 2011. The inclusion criteria included a chief (primary) complaint of globus pharyngeus; a trial of proton pump inhibitor therapy for at least 2 months and/or a trial of gabapentin for at least 2 weeks; and at least 1 follow-up visit. We reviewed 331 charts; 87 patients met the criteria. The response to treatment was graded as none, partial, or complete.

Results:

Seventy-seven percent of all patients had improvement. Sixty-seven percent of patients had a partial or complete response from aggressive reflux management. Sixty-six percent of patients who had a trial of gabapentin reported improvement. Eight of 14 patients who did not improve with aggressive reflux management improved with gabapentin.

Conclusions:

A majority of patients with globus pharyngeus can be helped by treating reflux or neuralgia. A trial of gabapentin should be considered for patients who do not respond or only partially respond to reflux management.

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.

Improved Tracheoesophageal Prosthesis Sizing in Office-Based Tracheoesophageal Puncture

Objectives:

Tracheoesophageal puncture (TEP) for postlaryngectomy speech is increasingly being performed as an office-based procedure. We review our experience with office-based TEP and compare outcomes with those of operating room—based TEP. Our hypothesis was that office-based TEP results in improved prosthesis sizing, reducing the number of visits dedicated to prosthesis resizing.

Methods:

A retrospective chart review was performed of all patients who underwent secondary TEP at our institution from 2001 to 2008. The primary dependent measure was the change in the length of the voice prosthesis. We also evaluated the number of visits made to the speech-language pathologist for resizing before a stable prosthesis length was achieved, and the number of days between voice prosthesis placement and the date a stable prosthesis length was observed.

Results:

Thirty-one patients were included in this study. There was a significant difference in prosthesis length change between patients who had office-based TEP and patients who had operating room—based TEP (p < 0.001). In addition, the office-based cohort required fewer visits to the speech-language pathologist for TEP adjustments before a stable TEP length was achieved (p < 0.001).

Conclusions:

Voice prosthesis sizing was better in patients who had office-based TEP than in patients who had operating room—based TEP. This outcome is likely due to the lesser degree of swelling of the tracheoesophageal party wall in the office-based procedure.

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.

Comparison of the diagnostic utility of the ultrathin endoscope and the conventional endoscope in early gastric cancer screening

Currently, transnasal esophagogastroduodenoscopy using an ultrathin endoscope is being widely carried out as a screening test for early gastric cancer. We compared the diagnostic utility of ultrathin esophagogastroduodenoscopy with that of conventional esophagogastroduodenoscopy in detecting 42 lesions of early gastric cancer that had a diameter of <or=20 mm. Only 27 lesions (64%) could be accurately diagnosed using ultrathin esophagogastroduodenoscopy. In nine lesions (22%), we failed to discern whether they were malignant. Six lesions (14%) could not even be detected. We found that the diagnostic utility of ultrathin esophagogastroduodenoscopy was inadequate, especially in the case of lesions that were located in the upper third region of the stomach and variegated lesions. In conclusion, the diagnostic utility of ultrathin esophagogastroduodenoscopy might be lower than that of conventional esophagogastroduodenoscopy in terms of screening for early gastric cancer. The disadvantages of ultrathin esophagogastroduodenoscopy should be taken carefully into consideration while examining lesions.

Functional oesophagoscopy: endoscopic evaluation of the oesophageal phase of deglutition

BACKGROUND

The anatomy and function of the oropharynx and larynx during deglutition can be assessed using the flexible endoscope, but this evaluation does not provide information on the oesophagus. Guided observation of oesophageal swallowing enables extended dysphagia evaluation.

OBJECTIVE

To assess the diagnostic utility of guided observation of oesophageal swallowing in the evaluation of dysphagia.

STUDY DESIGN

Retrospective case series.

METHODS

Procedures for guided observation of oesophageal swallowing were reviewed for oesophageal findings and compared with fluoroscopy and manometry.

RESULTS

Twenty-one patients underwent guided observation of oesophageal swallowing and concurrent videofluoroscopy and/or manometry. No complications of the former procedure occurred. The results of guided observation of oesophageal swallowing concurred with those of fluoroscopy in 15/21 cases (71 per cent) and with those of manometry in five of six (83 per cent) cases. Guided observation of oesophageal swallowing revealed anatomic pathology contributing to dysphagia in 15/21 (71 per cent) patients. The procedure identified pathology not detected by fluoroscopy and manometry in 13/21 (62 per cent) patients.

CONCLUSION

Guided observation of oesophageal swallowing appears to be a safe diagnostic tool with which to evaluate the oesophageal phase of deglutition.

Transnasal route: new approach to endoscopy

Transnasal esophagogastroduodenoscopy (TN-EGD) has recently become one of the frequently used methods of upper gastrointestinal endoscopy in some countries. Changes in blood pressure, heart rate, and oxygen saturation are smaller for TN-EGD than for conventional transoral esophagogastroduodenoscopy, making it a safer procedure. Lower pain and gag reflex enable TN-EGD to be performed without conscious sedation. TN-EGD is applied in various gastrointestinal (GI) procedures such as percutaneous endoscopic gastrostomy, nasoenteric feeding tube placement, endoscopic retrograde cholangiopancreaticography with nasobiliary drainage and lithotripsy, long intestinal tube placement in small-bowel obstruction, esophageal manometry, foreign body removal, botulinum toxin injection for achalasia, esophageal varix evaluation with the aid of endoscopic ultrasonography, and the double-scope technique for endoscopic submucosal dissection. The establishment of standard training programs and nationwide guidelines, the dissemination of educational information, the improvement in endoscopy devices and accessories, and the availability of insurance coverage for the procedure will obviously further widen the adoption of TN-EGD.

Transnasal Esophagoscopy: White-Light versus Narrowband Imaging

Objectives:

Transnasal esophagoscopy (TNE) is rapidly becoming integrated into otolaryngological practice. A recent report has shown an incongruence between an endoscopic diagnosis of Barrett's esophagus and biopsy-proven Barrett's esophagus in patients with laryngopharyngeal reflux (LPR). The goal of this study was to determine whether performing TNE with narrowband imaging (NBI) improves on the diagnostic yield in the otolaryngologist's hands. Narrowband imaging involves the use of filtered light to enhance the mucosal microvasculature pattern and has been shown to be highly sensitive to detecting Barrett's esophagus under conventional esophagoscopy.

Methods:

A retrospective chart review of 111 patients with LPR who underwent TNE by the same otolaryngologist was carried out. Pentax EE-1580K (white light only) and Olympus GIF-N180 (with NBI) endoscopes were used in 58 and 53 patients, respectively. Microcup biopsy of the squamocolumnar junction was obtained when Barrett's esophagus was suspected.

Results:

Biopsy-proven Barrett's esophagus was found in 13.5% of the patients. According to white light only and NBI, 7 of 58 (12.1%) and 8 of 53 (15.1%), respectively, had biopsy-proven Barrett's esophagus. Three patients had dysplasia on biopsy (2.7%), and all of these cases were detected under NBI (5.7%).

Conclusions:

Narrowband imaging may be a useful adjunct in increasing the diagnostic sensitivity of TNE in the hands of the otolaryngologist.