Transnasal esophagoscopy

Assessing Dysphagia in the Adult

This article explores the landscape of dysphagia assessment in adults. Dysphagia, a complex condition affecting the lifespan and many health conditions, significantly compromises individuals' quality of life. Dysphagia is often underdiagnosed, emphasizing the need for comprehensive assessment methods to ensure timely and accurate intervention. It encompasses clinical history, physical examination, clinical and instrumental swallow evaluations. Procedures within each of these modalities are reviewed, highlighting strengths, limitations, and contribution toward a complete understanding of dysphagia, ultimately guiding effective intervention strategies for improved patient outcomes.

[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.

Disposable Gastrointestinal Scopes: A Systematic Review

OBJECTIVE

Endoscopes are an essential tool in the diagnosis, screening, and treatment of gastrointestinal diseases. In 2019, the Food and Drug Administration issued a news release, recommending that duodenoscope manufacturers and health care facilities phase out fully reusable duodenoscopes with fixed endcaps in lieu of duodenoscopes that are either fully disposable or those that contain disposable endcaps. With this study, we systematically reviewed the published literature on single-use disposable gastrointestinal scopes to describe the current state of the literature and provide summary recommendations on the role of disposable gastrointestinal endoscopes.

MATERIALS AND METHODS

For our inclusion criteria, we searched for studies that were published in the year 2015 and afterward. We performed a literature search in PubMed using the keywords, "disposable," "reusable," "choledochoscope," "colonoscope," "duodenoscope," "esophagoscope," "gastroscope," and "sigmoidoscope." After our review, we identified our final article set, including 13 articles relating to disposable scopes, published from 2015 to 2023.

RESULTS

In this review, we show 13 articles discussing the infection rate, functionality, safety, and affordability of disposable gastrointestinal scopes in comparison to reusable gastrointestinal scopes. Of the 3 articles that discussed infection rates (by Forbes and colleagues, Ridtitid and colleagues, and Ofosu and colleagues), each demonstrated a decreased risk of infection in disposable gastrointestinal scopes. Functionality was another common theme among these articles. Six articles (by Muthusamy and colleagues, Bang and colleagues, Lisotti and colleagues, Ross and colleagues, Kang and colleagues, and Forbes and colleagues) demonstrated comparable functionality of disposable scopes to reusable scopes. The most reported functionality issue in disposable scopes was decreased camera resolution. Disposable scopes also showed comparable safety profiles compared with reusable scopes. Six articles (by Kalipershad and colleagues, Muthusamy and colleagues, Bang and colleagues, Lisotti and colleagues, Luo and colleagues, and Huynh and colleagues) showed comparable rates of AEs, whereas 1 article (by Ofosu and colleagues) demonstrated increased rates of AEs with disposable scopes. Lastly, a cost analysis was looked at in 3 of the articles. Two articles (by Larsen et al and Ross and colleagues) remarked that further research is needed to understand the cost of disposable scopes, whereas 1 article (by Kang and colleagues) showed a favorable cost analysis.

CONCLUSIONS

After a review of the literature published since the 2015 Food and Drug Administration safety communication, disposable scopes have been shown to be effective in decreasing infection risks while maintaining similar safety profiles to conventional reusable scopes. However, more research is required to compare disposable and reusable scopes in terms of functionality and cost-effectiveness.

Assessment and Treatment of Pain during In-Office Otolaryngology Procedures: A Systematic Review

OBJECTIVE

To qualitatively assess practices of periprocedural pain assessment and control and to evaluate the effectiveness of interventions for pain during in-office procedures reported in the otolaryngology literature through a systematic review.

DATA SOURCES

PubMed, CINAHL, and Web of Science searches from inception to 2018.

REVIEW METHODS

English-language studies reporting qualitative or quantitative data for periprocedural pain assessment in adult patients undergoing in-office otolaryngology procedures were included. Risk of bias was assessed via the Cochrane Risk of Bias or Cochrane Risk of Bias in Non-Randomized Studies of Interventions tools as appropriate. Two reviewers screened all articles. Bias was assessed by 3 reviewers.

RESULTS

Eighty-six studies describing 32 types of procedures met inclusion criteria. Study quality and risk of bias ranged from good to serious but did not affect assessed outcomes. Validated methods of pain assessment were used by only 45% of studies. The most commonly used pain assessment was patient tolerance, or ability to simply complete a procedure. Only 5.8% of studies elicited patients' baseline pain levels prior to procedures, and a qualitative assessment of pain was done in merely 3.5%. Eleven unique pain control regimens were described in the literature, with 8% of studies failing to report method of pain control.

CONCLUSION

Many reports of measures and management of pain for in-office procedures exist but few employ validated measures, few are standardized, and current data do not support any specific pain control measures over others. Significant opportunity remains to investigate methods for improving patient pain and tolerance of in-office procedures.

Cost analysis of office-based transnasal esophagoscopy

Purpose

Although office-based transnasal esophagoscopy has been investigated extensively, a cost analysis is still lacking. We performed a cost analysis combined with feasibility study for two diagnostic processes: patients with globus pharyngeus and/or dysphagia, and hypopharyngeal carcinoma.

Methods

Prospective cohort study.

Results

Forty-one procedures were performed, of which 35 were fully completed. The procedure was well tolerated with mild complaints such as nasal or pharyngeal pain and burping. Four complications occurred: two minor epistaxis and two vasovagal reactions. In patients with globus pharyngeus and/or dysphagia, transnasal esophagoscopy resulted in a cost saving of €94.43 (p 0.026) per procedure, compared to our regular diagnostic process. In patients with suspicion of hypopharyngeal carcinoma, cost savings were €831.41 (p 0.000) per case.

Conclusions

Cost analysis showed that office-based transnasal esophagoscopy can provide significant cost savings for the current standard of care. Furthermore, this procedure resulted in good patient acceptability and few complications.

Office-based transnasal esophagoscopy biopsies for histological diagnosis of head and neck patients

OBJECTIVES/HYPOTHESIS

To present yield of transnasal esophagoscopy (TNE) biopsies of upper aerodigestive tract (UADT) lesions and define the role of TNE as a safe alternative to rigid endoscopy.

STUDY DESIGN

Retrospective case series.

METHODS

All patients who underwent TNE-guided biopsies attempted over a 2-year period were included. Patients were identified using coding records and outpatient diaries. Demographic data were recorded as well as the histological diagnosis and additional histological diagnostic procedures.

RESULTS

During the observation period, 134 TNE-guided procedures were attempted. The procedure could not be completed in 19 patients. There were 102/115 (89%) patients who did not require further interventions for histological diagnosis of the tumor. The most common biopsied area was the larynx (53), followed by the tongue base (29). The most common malignancy was invasive squamous cell carcinoma in 42/115 (36.5%).

CONCLUSIONS

The work presented in this article strongly suggests that TNE-guided biopsy is a valuable diagnostic tool for patients suspected of having carcinoma of the UADT.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2721-2726, 2019.

Transnasal Esophagoscopy-Our Experience

Introduction  Transnasal esophagoscopy (TNE) is a widely used tool both in the diagnosis and treatment of patients presenting complaints within the head and the neck. This is because this investigative adjunct examination provides the advantage of visualizing above the level of the cricopharyngeus muscle when compared to the more widely used esophagogastroduodenoscopy (EGD).

Objectives  We have assessed if the implementation of TNE within a district general hospital (DGH) was feasible, and investigated if the resources of our patients could be better directed away from other investigations such as barium swallow and EGD in favor of this novel technique. The TNE technique has been largely applied in central teaching hospitals within the United Kingdom, but there are still no published reports of a DGH investigating its applicability in this smaller-sized clinical environment.

Method  We have analyzed our theater database to find all the patients who had undergone TNE, and recorded their reason for presenting, the preceding investigations, and the procedural findings.

Results  In most cases, the TNE was conducted without technical issues, and we were able to identify positive findings in 43% of the patients who underwent Esophagogastroduodenoscopy (EGD). We were able to treat patients successfully during the investigation when a cricopharyngeal stricture or narrowing was found. A normal EGD did not preclude further investigations with TNE. All but one of our patients were treated as day-case procedures.

Conclusion  Transnasal esophagoscopy can be successfully delivered within a DGH. A previous EGD does not mean that the TNE will not reveal positive findings due to its superior visualization of the pharynx and the upper esophagus.

Current Indications for Transnasal Esophagoscopy: An American Broncho-Esophagological Association Survey

INTRODUCTION:

The aim of this study was to evaluate the current indications for and clinical factors influencing the use of transnasal esophagoscopy (TNE).

METHODS:

An online survey was sent to American Broncho-Esophagological Association members, including questions on demographics, indications, and factors influencing the use of TNE.

RESULTS:

Sixty of 251 members (24%) completed the survey. Ninety-three percent of respondents reported academic practices, while 98% practice in medium to large urban settings. Thirty-five (58%) completed laryngology fellowships. Mean monthly TNE procedure count was 7.15 (range, <1-35). The most common indications were dysphagia (82%), biopsy (50%), and laryngopharyngeal reflux (47%). Chronic cough, head and neck cancer screening, gastroesophageal reflux (GER), and tracheoesophageal puncture were also commonly reported indications (44% each). For laryngopharyngeal reflux and GER, most respondents perform TNE for recalcitrant disease following a medical trial of at least 3 months. Long-standing GER symptoms, documentation of GER on pH and impedance testing, and abnormal findings on previous esophagoscopy lead to greater TNE use. Specific dysphagia indications included abnormal esophagographic findings (70%), history or examination localizing to the esophagus (60%), solid dysphagia only (53%), and solid and/or liquid dysphagia (40%). The primary sites most likely to prompt TNE use for head and neck cancer surveillance were the esophagus (92.3%) and hypopharynx (84.6%). Balloon dilation was the most common indication for which respondents do not currently perform TNE but would like to (n = 8).

CONCLUSIONS:

TNE indications have not been well established. According to respondents from the American Broncho-Esophagological Association, TNE is most commonly used for dysphagia and laryngopharyngeal reflux and slightly less so for GER and head and neck cancer screening and surveillance. Several clinical indicators were identified that influence the decision to perform TNE.

Quantifying Laryngopharyngeal Reflux in Singers: Perceptual and Objective Findings

This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and oropharyngeal pH levels in singers. We hypothesized that reported symptoms would correlate with objective measures of pH levels from the oropharynx, including the number and total duration of reflux episodes. Twenty professional/semiprofessional singers completed the Reflux Symptom Index (RSI) and underwent oropharyngeal pH monitoring. Mild, moderate, or severe pH exposure was recorded during oropharyngeal pH monitoring. Correlations were performed to examine potential relationships between reflux symptoms and duration of LPR episodes. Symptom severity did not correlate with pH levels; however, we found a number of covariances of interest. Large sample sizes are necessary to determine if true correlations exist. Our results suggest that singers may exhibit enhanced sensitivity to LPR and may therefore manifest symptoms, even in response to subtle changes in pH. This study emphasizes the importance of sensitive and objective measures of reflux severity as well as consideration of the cumulative time of reflux exposure in addition to the number of reflux episodes.

The role of transnasal oesophagoscopy in the management of globus pharyngeus and non-progressive dysphagia

Introduction Transnasal oesophagoscopy is a relatively new method of examining the upper aerodigestive tract via the nasal passage as an outpatient procedure without the need for sedation. It has been shown to be a well tolerated, safe and accurate technique, that can therefore be used in the investigation of patients thought to have globus pharyngeus and other non sinister causes of dysphagia. Methods A total of 150 consecutive patients undergoing transnasal oesophagoscopy were analysed retrospectively. Results The main indications for this procedure were non-progressive dysphagia (n=68, 45%) and globus pharyngeus (n=60, 40%). Transnasal oesophagoscopy was normal in 65% of patients and 42% of patients were discharged from clinic at the same appointment with no further investigation. The most common positive findings were laryngeal erythema (13%) and oesophagitis (10%). Conclusions Transnasal oesophagoscopy is a useful adjunct to the management of patients with the symptoms of globus pharyngeus and non-progressive dysphagia.

Evaluation of Middle and Distal Esophageal Diverticuli with Transnasal Esophagoscopy

To emphasize the utility of office-based transnasal esophagoscopy (TNE) in the evaluation of patients with swallowing complaints, we present 2 case reports and a review of the literature. The 2 patients both presented with complaints of chronic dysphagia, globus sensation, and a sensation of “food sticking” with swallowing. The patients were counseled to undergo esophagoscopy. Informed consent was obtained. The nasal cavities and pharynx were anesthetized with topical 4% lidocaine hydrochloride solution. Transnasal esophagoscopy was performed. The procedure was well tolerated by the patients. Esophagoscopy revealed diverticuli in various segments of the esophagus, including the midesophageal and distal areas. The cause of the patients' complaints could be well attributed to the endoscopic findings. No morbidity was associated with the TNE examination. A review of the literature concerning office-based TNE was performed. We found no published reports of middle or distal esophageal diverticuli detected on routine office TNE. We conclude that transnasal esophagoscopy is a relatively safe and efficient tool that can be used in the office setting for evaluation of swallowing complaints.

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

Objectives

Transnasal esophagoscopy (TNE) is a relatively new diagnostic procedure in the evaluation of patients with globus sensation and dysphagia. Enabling doctors to examine all of the upper aerodigestive system without the need for sedation, this technique is becoming more popular among otolaryngology specialists. The aim of this study is to evaluate the practicability of TNE and tolerability of patients to the test.

Methods

The study group consisted of 314 patients who were admitted to the swallowing center of a tertiary medical institution with the symptoms of dysphagia and globus sensation. In addition to other diagnostic procedures, patients were informed of the TNE and the necessary consents were obtained. Before the examination, patients were asked to foresee the level of discomfort they would presumably feel, according to the information they had. After the TNE, patients were asked to score the real level of discomfort they experienced during the test. A visual analog scale was used to note the levels. The duration of the tests and any complications were also noted.

Results

We could not perform TNE in 12 of the 314 patients due to nasal obstruction, intractable retching and vasovagal syncope (7, 4, and 1 patients, respectively). The average discomfort score foreseen before the test was 4.7±1.4 (mean±standard deviation). The post-procedure discomfort score was 1.6±1.1, and the difference was statistically significant (P<0.001). The average time to perform the TNE was 5 minutes (range, 3 to 13 minutes). Except for minor epistaxis in 7 patients (2%), no complications occurred.

Conclusion

According to our results, TNE is an easy and well-tolerated procedure, it may be logical to tell the patient that the procedure will be less annoying and irritating than they assume. It is also a time saving procedure with low complication rates.

Patient Tolerance of In-Office Pulsed Dye Laser Treatments to the Upper Aerodigestive Tract

INTRODUCTION: Recent advances in technology have facilitated a movement toward unsedated in-office treatment of laryngeal, tracheal, and esophageal lesions. The objective of this study was to determine patient tolerance of inoffice pulsed-dye laser (PDL) treatment of upper aerodigestive tract pathoses via the transnasal esophagoscope.

METHODS: Three hundred twenty-eight unsedated in-office PDL cases were performed at a university-based tertiary referral center in 131 patients. These procedures were performed for various upper aerodigestive pathoses, including recurrent respiratory papillomatosis, chronic granulomas, and recurrent leukoplakia. Eighty-nine subjects completed a phone survey concerning their discomfort level after the PDL procedure. They were also asked specific questions about recovery time, pain medication, and preference of operating room versus inoffice procedures.

RESULTS: The average comfort score was 7.4 (10 being minimal discomfort). Eighty-four percent did not use any pain medication; 87% stated that, if possible, they would prefer to undergo unsedated inoffice procedures rather than surgeries under general anesthesia for further treatment of their upper aerodigestive tract pathosis.

CONCLUSIONS: Unsedated transnasal treatment of upper aerodigestive tract pathoses is readily accepted and well-tolerated by otolaryngology patients. Patients overwhelmingly prefer the inoffice PDL over surgeries under general anesthesia.

Wireless pH testing as an adjunct to unsedated transnasal esophagoscopy: The safety and efficacy of transnasal telemetry capsule placement

OBJECTIVES: The introduction of 48-hour wireless pH testing offers clinicians a new alternative for the objective documentation of reflux. The success of transnasal wireless pH capsule placement has not been previously described. The purpose of this investigation was to describe our experience with transnasal wireless pH capsule placement.

METHODOLOGY: All patients undergoing unsedated transnasal esophagoscopy and wireless pH capsule placement between January 1, 2003 and July 31, 2003 were prospectively evaluated. Data concerning patient tolerance, success of capsule placement and function, complications, and pH recordings were collected.

RESULTS: During this time, 46 persons were evaluated. The mean age of the cohort was 52 years. Of the patients, 50% were male. The indications for the procedure were chronic cough (18/46), gastro-esophageal reflux disease (18/46), and larygopharyngeal reflux (10). Of the procedures performed, 85% (39/46) were successful. Complications included epistaxis (2/46), laryngospasm (2/46), and vasovagal reaction (1/46).

CONCLUSIONS: The transnasal placement of a wireless pH capsule is a safe and effective diagnostic adjunct to unsedated transnasal esophagoscopy.

Transoesophageal ultrasound and computer tomographic assessment of the equine cricoarytenoid dorsalis muscle: Relationship between muscle geometry and exercising laryngeal function

REASONS FOR PERFORMING STUDY

Early detection of recurrent laryngeal neuropathy (RLN) is of considerable interest to the equine industry.

OBJECTIVES

To describe two imaging modalities, transoesophageal ultrasound (TEU) and computed tomography (CT) with multiplanar reconstruction to assess laryngeal muscle geometry, and determine the relationship between cricoarytenoid dorsalis (CAD) geometry and function.

STUDY DESIGN

Two-phase study evaluating CAD geometry in experimental horses and horses with naturally occurring RLN.

METHODS

Equine CAD muscle volume was determined from CT scan sets using volumetric reconstruction with LiveWire. The midbody and caudal dorsal-ventral thickness of the CAD muscle was determined using a TEU in the same horses; and in horses with a range of severity of RLN (n = 112).

RESULTS

Transoesophageal ultrasound was able to readily image the CAD muscles and lower left:right CAD thickness ratios were observed with increasing disease severity. Computed tomography based muscle volume correlated very closely with ex vivo muscle volume (R² = 0.77).

CONCLUSIONS

Computed tomography reconstruction can accurately determine intrinsic laryngeal muscle geometry. A relationship between TEU measurements of CAD geometry and laryngeal function was established. These imaging techniques could be used to track the response of the CAD muscle to restorative surgical treatments such as nerve muscle pedicle graft, nerve anastomosis and functional electrical stimulation.

A New Trend in the Management of Esophageal Foreign Body: Transnasal Esophagoscopy

OBJECTIVES

(1) To analyze the outcomes of patients with esophageal foreign body managed by transnasal esophagoscopy. (2) To review the value of lateral neck X-ray.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.

SUBJECTS AND METHODS

Lateral neck X-ray was used for initial screening in patients suspected of having an esophageal foreign body between 2007 and 2013. Rigid esophagoscopy was used as standard for further investigations before July 2010 and transnasal esophagoscopy after July 2010.

RESULTS

From January 2007 to June 2010, 43 patients who were suspected of having an esophageal foreign body under lateral neck X-ray received rigid esophagoscopy, 31 of whom were found to have an esophageal foreign body. From July 2010 to December 2013, 302 patients underwent transnasal esophagoscopy, and an esophageal foreign body was noted in only 52 of these patients. In the 302 patients who underwent transnasal esophagoscopy, the sensitivity and specificity of having an esophageal foreign body by lateral neck X-ray were 59% and 83%, respectively.

CONCLUSION

The introduction of transnasal esophagoscopy has changed the diagnosis and management for an esophageal foreign body. Transnasal esophagoscopy is a quick and safe procedure that can be performed under local anesthesia. Transnasal esophagoscopy could replace lateral neck X-ray to become the initial screening procedure and a useful treatment for patients with an esophageal foreign body.

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.

Immunoserologic pepsin detection in the saliva as a non-invasive rapid diagnostic test for laryngopharyngeal reflux

BACKGROUND

The most common tool for the diagnosis of laryngopharyngeal reflux (LPR) is still 24-hours esophageal pH monitoring; there is lack of non-invasive, less expensive and accurate diagnostic tools for this frequent disease.

AIMS

To evaluate the accuracy of immunoserologic pepsin detection in the saliva for the diagnosis of LPR.

STUDY DESIGN

Cross-sectional study.

METHODS

A two channeled 24-hour esophageal pH monitoring catheter was placed in patients with a suspicion of LPR. During the 24-hour period, each patient gave one sample of sputum for the immunoserologic pepsin detection test. Pathologic gastroesophageal reflux (GER) findings, LPR findings, pH score in the proximal and distal probes when the sputum sample was given were recorded. The sensitivity, specificity, positive and negative predictive values of the pepsin detection test were analyzed and compared to pH monitoring scores.

RESULTS

The study group consisted of 20 patients who met the criteria. A positive pepsin detection test was elicited from 6 patients. The sensitivity and specificity of the pepsin detection test was 33% and 100%, respectively. A positive predictive value of 100% was recorded. When the pH results of the pepsin positive patients (PPP) and the rest of the study group in the proximal probe at the sample time were compared, the PPP had an apparent acidic pH value compared to the pepsin negative patients (pH: 3.26 for the PPP, pH: 6.81 for the pepsin negative patients).

CONCLUSION

Pepsin detection in the saliva is a recent method and becoming increasingly popular. Because of the benefits and ease of application, a positive salivary pepsin test in a patient suspected of having LPR can be a cost effective, accurate and alternative diagnostic method. Increasing the daily number of sputum samples may increase the sensitivity of the test.

The Role of Transnasal Esophagoscopy in ENT Office: A Prospective, Multicenter Study in Korea

Objectives

The purpose of study was to report the current role of transnasal esophagoscopy (TNE) in Korea.

Methods

One hundred thirty-seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to February 2009 were prospectively analyzed. Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1.

Results

Fifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). Forty-two patients (41.1%) were found to have pathology (esophagitis, n=41; esophageal diverticulum, n=1) during the screening examination for LPRD. There were no significant complications in any of the patients.

Conclusion

TNE is a high-yield diagnostic and therapeutic modality available to otolaryngologists for use on awake patients in the office setting.

Changes in the quality of life of patients with laryngopharyngeal reflux after treatment

OBJECTIVE/HYPOTHESIS

To assess changes in the symptoms and quality of life (QOL) of patients diagnosed with laryngopharyngeal reflux (LPR) after proton pump inhibitor (PPI) treatment.

STUDY DESIGN

Prospective study.

METHODS

One hundred eighty patients diagnosed with LPR were evaluated. All patients were prescribed Lansoprazole (15 mg) twice daily for 12 weeks. The Reflux Symptom Index (RSI), Reflux Finding Score (RFS), Short-Form 36-Item Health Survey version 2.0 (SF-36), and LPR-health-related quality of life (HRQOL) were collected from each patient at the initial visit and at 4- and 12-week follow-up visits.

RESULTS

Significant improvement was observed in RSI and RFS scores after treatment. The LPR-HRQOL score also showed gradual improvement after PPI treatment in the voice, cough, throat clearing, swallowing, and overall impact of acid reflux. Although each domain of the SF-36 had a low score at the baseline visit, seven domains of the SF-36 had improved, except for the physical functioning domain.

CONCLUSIONS

We found that RSI, RFS, and most categories in the LPR-HRQOL and SF-36 improved 12 weeks after initiating PPI treatments. These findings indicate that PPI treatment for 3 months could improve the QOL of patients diagnosed with LPR.

Office removal of a subglottic bread clip

Objective. The presence of an upper airway foreign body is an emergent, potentially life-threatening situation that requires careful but rapid evaluation and management. Organic or nonorganic material may typically be found in the pyriform sinuses or tongue base or may be aspirated directly into the tracheobronchial tree. We present here an unusual case report of a patient who accidentally ingested a plastic bread clip that was lodged in his subglottis for 15 months and report successful removal in the office under local anesthesia. Methods. Mucosal anesthesia was achieved with inhaled 4% lidocaine spray. Flexible laryngoscopic removal of the foreign body was then successfully accomplished. Results. The patient's symptoms resolved completely following removal, with no sequelae. Conclusions. Office removal of airway foreign bodies is feasible and can be safely done with adequate topical anesthesia, but great caution and emergency planning must be exercised.

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.

Transnasal tracheoscopy

OBJECTIVES/HYPOTHESIS

Unsedated transnasal tracheoscopy (TNT) has emerged as a technique in otolaryngology-head and neck surgery for an awake airway examination in the office setting. This study investigates the safety, procedural success rate, indications, and findings of TNTs performed over a 3-year period at an academic medical center.

STUDY DESIGN

Retrospective chart review.

METHODS

After institutional review board approval, billing records were reviewed for patients who underwent TNT from 2007-2009 in the University of Wisconsin-Madison Department of Otolaryngology-Head and Neck Surgery. Hospital charts for these patients were obtained, and data regarding patient demographics, complications, procedural success rate, indications, and findings were recorded.

RESULTS

Sixty-eight TNTs were performed on 44 patients over the last 3 years (25 males, 19 females; age range, 16-91 years). No complications were noted. Ninety-one percent of procedures were able to be completed. Indications for TNT were to: 1) detect airway stenosis or pathology, 2) evaluate the larynx and trachea prior to airway surgery, 3) monitor postoperative results of airway interventions, and 4) evaluate the airway prior to tracheotomy tube decannulation.

CONCLUSIONS

TNT is a safe procedure that can be performed on the unsedated patient using only topical anesthesia and is an attractive alternative to rigid bronchoscopy. The procedural success rate was high, indicating good patient tolerance. The indications for TNT, including its use as a tool for surgical planning, have become better defined. TNT has become a standard tool in the management of patients with airway pathology in our practices.

Utility of panendoscopy for the detection of unknown primary head and neck cancer in patients with a negative PET/CT scan

We conducted a retrospective review of the records of 23 patients who had been diagnosed with regionally metastatic head and neck squamous cell carcinoma from an unknown primary tumor. Our goal was to assess the utility of panendoscopy in locating the primary tumor in those patients whose positron-emission tomography/computed tomography (PET/CT) findings were negative. Overall, we found that PET/CT had correctly identified the unknown primary in 12 of the 23 patients (52%); panendoscopy confirmed this finding in all 12. Of the remaining 11 patients, however, panendoscopy located the primary tumor in only 1 (9%). In this era of cost containment and ongoing advances in imaging and transnasal esophagoscopy, it is important to revisit the workup of an unknown primary in patients with a negative PET/CT scan. There are various advantages and disadvantages to performing panendoscopy with biopsy in patients with an unknown primary and a negative PET/CT scan, but our results and the findings of others indicate that it will detect the primary in only about 10% of these cases. We recommend careful selection of patients who are to undergo panendoscopy for the routine workup of an unknown primary.

Impact of Nissen fundoplication on laryngopharyngeal reflux symptoms

The reliability of Nissen fundoplication for the successful treatment of laryngopharyngeal reflux (LPR) symptoms remains in question. The purpose of this study was to assess the effect that antireflux surgery has on a variety of LPR symptoms as well as the patient's perceived success of surgical intervention. A retrospective review of all antireflux surgeries between 1998 and 2008 provided a patient base for a survey in which patients ranked pre- and postoperative LPR symptoms in addition to patient satisfaction with the outcome. Of the 611 patients identified and sent the evaluation forms, 244 responses (40%) were obtained. The percentage of patients with symptom improvement after surgery were: heartburn (90.1%), regurgitation (92.6%), voice fatigue (75.2%), chronic cough (76.3%), choking episodes (83.1%), sore throat (82.9%), lump in throat (77.4%), repetitive throat clearing (72.8%), and adult-onset asthma (59.6%). Twenty per cent with repetitive throat clearing and 30 per cent with adult-onset asthma had no improvement in symptoms. Eighty-one per cent considered surgery to be a success. Comparison of those who claimed the operation was successful with those who claimed it was not revealed no difference in demographics, primary diagnosis, procedure type, or reflux symptom index score. There was a statistically significant difference in patient-perceived outcome according to the length of time since surgery. More than 88 per cent in the "not successful" group had an operation greater than 4 years prior as compared with only 70 per cent in the "successful" group (P = 0.020). Nissen fundoplication is an effective treatment for most LPR symptoms, although patients with adult-onset asthma and repetitive throat clearing appear to benefit least from surgical intervention.

Detection of metachronous esophageal squamous carcinoma in patients with head and neck cancer with use of transnasal esophagoscopy

BACKGROUND

The use of transnasal esophagoscopy was examined for detecting metachronous esophageal squamous carcinoma in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

In all, 398 transnasal esophagoscopies were performed in 293 previously treated patients with HNSCC between December 2007 and January 2009.

RESULTS

Metachronous esophageal squamous carcinoma was detected in 15 (5.1%) patients. The prevalence rate was 15.9% (7/44) in patients with hypopharyngeal cancer, significantly higher than the 8.3% (2/24) with laryngeal, 7.1% (3/42) with oropharyngeal, and 1.6% (3/183) with oral cancer (p = .001). The stage distributions of esophageal squamous carcinoma were I-II in 12 (80%) and III-IV in 3 (20%) patients. Subsequently, curative strategies were performed in 13 (87%) patients.

CONCLUSIONS

Transnasal esophagoscopy can be used as a routine survey technique in patients with HNSCC to detect metachronous esophageal squamous carcinoma, especially in those with hypopharyngeal cancer.

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.

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

OBJECTIVE

To review and summarize the current literature on transnasal esophagoscopy, and to compare information with conventional esophagoscopy.

DATA SOURCES

Medline (Ovid), book chapters.

REVIEW METHODS

A thorough review of the literature using the Medline database was performed with the following search terms: esophagoscopy, transnasal esophagoscopy, ultrathin endoscopy, and esophagoscope.

RESULTS

The literature seems to support the equivalence of transnasal esophagoscopy and conventional esophagoscopy in image quality and diagnostic capability. It also points to some potential advantages of transnasal esophagoscopy.

CONCLUSIONS

Transnasal esophagoscopy is a useful tool for accurate diagnosis and can be used in a variety of office procedures.

Endoscopic-guided versus cotton-tipped applicator methods of nasal anesthesia for transnasal esophagogastroduodenoscopy: a randomized, prospective, controlled study

BACKGROUND

Ultrathin transnasal esophagogastroduodenoscopy (UT-EGD) is well tolerated by patients, but the methods of nasal anesthesia are various.

AIM

To compare patient tolerance, safety, and adverse events between the endoscopic-guided (EGNA) and cotton-tipped applicator (CTNA) methods of nasal anesthesia.

METHODS

Between September 2005 and September 2006, we conducted a prospective, randomized, controlled study in a large tertiary referral hospital in eastern Taiwan. In total, 235 consecutive patients were randomly assigned to the CTNA group or EGNA group before unsedated UT-EGD. We compared demographic data, procedural discomfort using a validated 5-point visual analog scale, optical quality, total procedure time, and adverse events between the two groups.

RESULTS

After randomization and exclusion, 101 (43 men and 58 women) and 103 (44 men and 59 women) patients were allocated to the CTNA and EGNA groups, respectively. Baseline characteristics and periprocedural hemodynamics of patients in the two groups were similar. There was no statistical difference in insertion failure rates between the two methods (CTNA 10.9%vs EGNA 7.7%, P= 0.59). Pain scores during both anesthesia (2.3 +/- 0.4 vs 3.5 +/- 0.6, P < 0.001) and insertion (2.8 +/- 1.2 vs 3.8 +/- 1.8, P < 0.001) were significantly lower in the EGNA group; however, the sensation of bad taste was significantly worse in the EGNA group (2.3 +/- 1.3 vs 1.9 +/- 1.4, P= 0.040). Less epistaxis happened in the EGNA group than in the CTNA group. The EGNA method had a significantly better visual capacity and shorter procedure time. More patients in the EGNA group said they would like to receive the same procedure the next time.

CONCLUSION

Compared with the CTNA method, in which the taste of lidocaine gel was more acceptable, EGNA appeared to be more tolerable, caused less epistaxis, improved visualization capacity, and reduced procedure time.

The mucosal immune response to laryngopharyngeal reflux

RATIONALE

Laryngopharyngeal reflux (LPR) affects up to 20% of Western populations. Although individual morbidity is usually moderate, treatment costs are high and there are associations with other diseases, including laryngeal cancer. To date, there have been no studies of the mucosal immune response to this common inflammatory disease.

OBJECTIVES

To determine the mucosal immune response to LPR.

METHODS

We performed a prospective immunologic study of laryngeal biopsies from patients with LPR and control subjects (n = 12 and 11, respectively), and of primary laryngeal epithelial cells in vitro.

MEASUREMENTS AND MAIN RESULTS

Quantitative multiple-color immunofluorescence, using antibodies for lymphocytes (CD4, CD8, CD3, CD79, CD161), granulocytes (CD68, EMBP), monocytic cells (CD68, major histocompatibility complex [MHC] class II), and classical and nonclassical MHC (I, II, beta(2)-microglobulin, CD1d). Univariate and multivariate analysis and colocalization measurements were applied. There was an increase in percentage area of mucosal CD8(+) cells in the epithelium (P < 0.005), whereas other leukocyte and granulocyte antigens were unchanged. Although epithelial MHC class I and II expression was unchanged by reflux, expression of the nonclassical MHC molecule CD1d increased (P < 0.05, luminal layers). In vitro, laryngeal epithelial cells constitutively expressed CD1d. CD1d and MHC I expression were inversely related in all subjects, in a pattern which appears to be unique to the upper airway. Colocalization of natural killer T (NKT) cells with CD1d increased in patients (P < 0.01).

CONCLUSIONS

These data indicate a role for the CD1d-NKT cell axis in response to LPR in humans. This represents a useful target for novel diagnostics and treatments in this common condition.

Common Diagnoses and Treatments in Professional Voice Users

Common problems among all patients seen by the laryngologist are also common among professional voice users. These include laryngopharyngeal reflux, muscle tension dysphonia, fibrovascular vocal fold lesions (eg, nodules and polyps), cysts, vocal fold scarring, changes in vocal fold mobility, and age-related changes. Microvascular lesions and their associated sequelae of vocal fold hemorrhage and laryngitis due to voice overuse are more common among professional voice users. Much more common among professional voice users is the negative impact that voice problems have on their ability to work, on their overall sense of well-being, and sometimes on their very sense of self. This article reviews the diagnosis and treatment options for these and other problems among professional voice users, describing the relevant roles of medical treatment, voice therapy, and surgery. The common scenario of multiple concomitant entities contributing to a symptom complex is underscored. Emphasis is placed on gaining insight into the "whole" patient so that individualized management plans can be developed. Videos of select diagnoses accompany this content online.

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

KEYPOINTS: Transnasal flexible laryngo-oesophagoscopy (TNFLO) is a safe and well-tolerated procedure that may be performed in a procedure room in the outpatient or day-case/main theatre setting. It requires a local anaesthetic and no sedation. It may be used to histologically diagnose or exclude pathology from the nose to the gastro-oesophageal junction. It provides a "one stop" diagnosis service, reducing diagnostic delays, the need for endoscopy under general anaesthesia, barium swallows and follow-up outpatient appointments. Therapeutic procedures such as vocal cord medialization, endolaryngeal laser surgery, insertion of speech prostheses and foreign body removal may be performed without general anaesthesia.

How we do it: transnasal fibreoptic oesophagoscopy

KEYPOINTS: Transnasal fibreoptic oesophagoscopy (TFO) allows the upper aerodigestive tract, from the nasal vestibule to the gastric cardia to be examined in the outpatients department without sedation. This permits patients with symptoms of upper aerodigestive pathology to be investigated at the initial consultation without the need for inpatient endoscopy or swallow studies. The technique is easily learned, and is statistically comparable with standard flexible nasoendoscopy in respect of procedural pain and discomfort. It is highly cost-efficient, paying for itself within 1 year, and thereafter leading to cost savings of over 80%. Its role can be expanded to encompass investigating patients with potentially malignant disease processes, as well as outpatients "panendoscopy" and biopsy, and a number of therapeutic interventions.

Incongruence between Histologic and Endoscopic Diagnoses of Barrett??s Esophagus Using Transnasal Esophagoscopy

OBJECTIVES

The symptoms, patterns of reflux, and clinical manifestations of laryngopharyngeal reflux (LPR) differ from those of gastroesophageal reflux disease (GERD) in many ways. The purposes of this study were to determine the prevalence of Barrett's esophagus in patients with LPR using transnasal esophagoscopy (TNE) and to determine if there is agreement between TNE clinical findings and pathology results when using TNE for Barrett's screening.

STUDY DESIGN

This study involved a retrospective review of the records of 200 consecutive patients with LPR undergoing esophageal screening.

METHODS

The prevalence of patients with findings clinically suspicious for Barrett's and the biopsy results for those patients were reviewed.

RESULTS

Of the 200 patients with LPR who were screened with TNE, 10% (20 of 200) had findings suspicious for Barrett's esophagus, and, of those, only 30% (six of 20) had biopsy-proven Barrett's metaplasia.

CONCLUSION

Although TNE may be a useful screening tool for Barrett's, there is incongruence between TNE findings and biopsy results, which likely reflects suboptimal biopsy methods with TNE. New biopsy techniques such as the CDx brush biopsy may enhance the sensitivity of TNE biopsies, and future studies are needed in this area.

Transnasal Esophagoscopy: A High-Yield Diagnostic Tool

OBJECTIVES

Transnasal esophagoscopy (TNE) reveals a wide range of esophageal findings. TNE technique, indications, outcomes, advantages, limitations, and impact on patient care are described.

STUDY DESIGN

Retrospective chart review.

METHODS

Charts of the first 30 patients to undergo TNE in an academic otolaryngology practice were reviewed. Technique details, patient demographics, and procedure indications and findings as well as the disposition of patients in this series are described. TNE limitations are discussed with areas for future development.

RESULTS

Thirty patients who underwent unsedated outpatient TNE by their otolaryngologist are described. TNE was directed toward select indications: dysphagia, screening esophagoscopy given long-standing gastroesophageal reflux (GER) or laryngopharyngeal reflux (LPR), and esophageal surveillance with a new diagnosis of head and neck squamous cell carcinoma. Positive findings included mucosal cobblestoning, Barrett's esophagus, esophagitis, gastritis, candidal esophagitis, esophageal diverticulum, postcricoid mass, patulous esophagus, and absence of secondary esophageal peristalsis. Outcomes included referral to a gastroenterologist for evaluation, with or without biopsy; direct laryngoscopy or esophagoscopy with biopsy by the otolaryngologist; planned cancer resection by the otolaryngologist; and medical management of GER/LPR by the otolaryngologist.

CONCLUSIONS

With appropriate selection criteria, TNE yields a high percentage of positive findings and wide range of esophageal abnormalities, directly impacting patient management. Available to otolaryngologists in the outpatient setting, TNE expedites interventions by providing a safe, effective alternative to rigid esophagoscopy under general anesthesia and flexible upper endoscopy with sedation. Patients will benefit from the integration of TNE into otolaryngologists' outpatient diagnostic armamentarium.