How we do it: transnasal fibreoptic oesophagoscopy

Superior Laryngeal Nerve Block in Transcutaneous Vocal Fold Injection: A Pilot Study

OBJECTIVES

Topical lidocaine remains the mainstay for anesthesia in transcutaneous vocal fold injection (VFI). While using topical lidocaine, laryngologists sometimes encounter uncontrolled reflexes or poor compliance. Superior laryngeal nerve block (SLNB) provides deep and rapid anesthesia on the larynx above the vocal folds and abolishes the glottic closure reflex. Herein, we present a pilot study to evaluate the feasibility and safety of SLNB for transcutaneous VFI and explored its usefulness.

METHODS

Fifty-nine patients were prospectively anesthetized with SLNB during transcutaneous VFI for unilateral vocal fold paralysis. In the SLNB group, 0.5 to 1 mL of 2% lidocaine was infiltrated on bilateral SLNs through the thyrohyoid membrane. As the control group, we included previous 47 patients who underwent VFI with topical lidocaine. In the control group, 10% lidocaine spray was applied to the laryngopharyngeal mucosa. Demographic data, laryngeal exposure, patient compliance, procedural interruption, and complications were investigated. Patient compliance was evaluated based on the frequency of cough and swallowing during VFI procedures.

RESULTS

SLNB enabled endoscopic contact on the epiglottis and pharyngeal wall without gag reflex and provided good exposure of the procedure field on the vocal folds. In the SLNB group, the laryngeal exposure is significantly better than in the control (P = 0.005). The frequency of cough and swallowing was significantly lower in the SLNB group than in the control (P < 0.001). The number of procedural interruptions was lower in the SLNB group than in the control (P < 0.001). There was no acute or delayed complication related to SLNB such as bleeding, hematoma, delayed sensory/swallowing problems, or unscheduled hospital visits.

CONCLUSIONS

SLNB might be safe and effective for anesthesia in transcutaneous VFI. SLNB could be a good anesthetic option for patients with poor compliance despite the sufficient application of topical lidocaine.

LEVEL OF EVIDENCE: 4

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.

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.

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.

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.

[The possibilities of reflux disease diagnosis by the ear, nose and throat specialist]

Reflux disease has gained in importance over the last decade since we know that many of the symptoms and diseases of the upper aerodigestive tract might be associated with reflux. However, a distinction needs to be made between extraesophageal reflux (EER) and gastroesophageal reflux disease (GERD). There are several techniques available for the diagnosis of EER. Furthermore, there are various pH monitoring devices to determine acid contamination of the larynx and the pharynx. In addition, flexible transnasal esophagoscopy is a practicable technique for the rapid examination of reflux, its cause as well as the diagnosis of reflux-induced mucosal changes in the esophagus. The present article describes the instruments used for the diagnosis of reflux against the background of our own experience and the international literature.

The diagnosis and management of globus pharyngeus: our perspective from the United Kingdom

PURPOSE OF REVIEW

To review recent literature on diagnostic and treatment options for globus pharyngeus.

RECENT FINDINGS

There are no controlled studies looking at the use of proton pump inhibitors specifically for globus. The small volume of level I evidence has failed to demonstrate superiority of proton pump inhibitors over placebo for treatment of laryngopharyngeal reflux symptoms (including globus). A recent pilot nonplacebo-controlled study has shown promising results for treating laryngopharyngeal reflux symptoms with liquid alginate suspension. The role of cognitive-behavioural therapy may hold hope for patients with refractory symptoms. A small randomized trial showed promising results for treating globus with speech therapy, but larger trials are required. There is no evidence for the use of antidepressants or anxiolytics.

SUMMARY

After many decades of interest, the most popular organic theory that 'a lump in the throat' is reflux related is still challenged by lack of strong evidence for empiric antacid treatment of this symptom. Globus pharyngeus is a clinical diagnosis and not a diagnosis of exclusion and overinvestigating these patients is unnecessary. Complete history and otolaryngological examination, fibreoptic laryngoscopy or transnasal oesophagoscopy with reassurance and monitoring of symptom progress with validated symptom questionnaires appear to remain the mainstay of management.