Unsedated transnasal esophagoscopy: a sensitive and safe outpatient screening tool

This study and the retrospective review of patient records was approved by the King Chulalongkorn Memorial Hospital (651/58) and the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University (approval No. 182/2015/023/ 58). In this descriptive study we retrospectively reviewed the records of patients who underwent transnasal esophagoscopy at King Chulalongkorn Memorial Hospital without sedation from September 2011 to March 2014. The same endoscopic technique was used by the 2 examining otolaryngologists (P. Sombuntham and W. Rawangban). Primary Indication was recorded according to the patients’ chief complaint. Clinical findings and complications were retrieved from patient medical records. All patients had signed a standard preoperative informed consent form and had been provided an overview of the reasons and likely benefits from undergoing this procedure.

We retrospectively reviewed the cases of 58 patients with complete clinical records. The mean age of these patients was 57.4 years (range 18-84 years) and the cohort comprised 43 (74%) men and 15 (26%) women. Before the procedure 35 patients (60%) had a diagnosis of head or neck cancer (Table 1). As shown in Table 2, indications for TNE included second primary tumor surveillance, dysphagia, clinical staging of head and neck cancer, and change in voice problems.

Esophageal lesions were detected in 5 patients. Figure 1 shows abnormal findings in the esophagus. Tissue biopsy was obtained in all patients with biopsy forceps through a utility channel. Only 1 patient had a positive result for squamous cell carcinoma. Four patients had to undergo rigid esophagoscopy under general anesthesia for additional tissue biopsy. Overall esophageal cancer was found in 5/58 patients (9%). Three of 34 patients (9%) had second primary cancers.

Figure 1

All of the patients were able to complete the exam. Complications were reported in 2 patients (3%), one with hypotension following viscous 2% lidocaine ingestion, but required no treatment, and the other had major bleeding from esophageal cancer that required blood transfusion.

Advances in flexible endoscope technology has led to the development of a distal-chip, small caliber flexible esophagoscope, which has been a useful tool for evaluation of head and neck cancer and other indications. Transnasal esophagoscopy became more popular among otolaryngologists in an office setting. Giving its feasibility, low cost, and safety without sedation, it is similar to an examination using a flexible nasolaryngopharyngoscope in an otolaryngology or ear, nose, and throat (ENT) outpatient clinic.

To our knowledge our study is the first of TNE without sedation in Thailand. In our institution, most patients who underwent TNE had head and neck cancer, and indications for or second primary surveillance. As a tertiary care hospital, the majority of head and neck patients were referred from secondary care hospitals for treatments after initial diagnosis by tissue biopsy under sedation was done elsewhere. TNE reduces the risk from repeated sedation and gave direct visualization of second or recurrent primary esophageal cancer, which can occur in 1.3% to 18% of cases [7-11]. Our study found a similar rate (9%) with complication rate (3%) that was comparable to that reported by other authors. Our preliminary study found TNE to be a safe and efficient procedure in examination of the upper aerodigestive tract. Although in our experience, tissue biopsies were often nondiagnostic and further rigid esophagoscopy was required. This procedure offers more convenience than conventional procedures, is hospitalization-free for most patients, and reduces health care costs.

Other indications for transnasal esophagoscopy include dysphagia, second primary cancer surveillance, globus pharyngeus, or head and neck cancer staging [4, 7, 12-19]. Belafsky et al. described unsedated-TNE experience in 100 patients in a study that showed patient acceptance under topical anesthesia [1]. Their study was one of the early studies reporting this procedure performed by otolaryngologists. Postma et al. [3] initially reviewed the utility of TNE in head and neck patients when compared with standard panendoscopy followed by a larger study (of 611 patients) in 2005 [20]. Therapeutic use of TNE in tracheoesophageal injury and dilation of esophageal stricture was also reported. This revealed the efficacy and expanded practical use of TNE in clinical settings. Safety is a major concern in unsedated TNE.

Hypotension as a side effect of lidocaine and major bleeding from the site of biopsy were found in our experience in selected patients. However, only minor complications were reported in previous studies [2, 16, 19-23]. Nose bleeding occurred in less than 2%. Other complications including nausea, lightheadedness, and vasovagal reactions. A tight nasal vault was described in one report [1].

Although TNE has many advantages compared to conventional methods, many otolaryngologists remain unfamiliar with it. TNE required further training and experience.

TNE without sedation in an office setting is a safe and effective procedure for many indications such as screening for head and neck cancer, swallowing problems, and esophageal cancer. This procedure is comparable to rigid esophagoscopy in selected patients. TNE should be used as a surveillance screening tool for head and neck cancer patients.