1/31/2017 TransnasalEsophagoscopy:Overview,Indications,Contraindications

TransnasalEsophagoscopy
Updated:Feb22,2016
Author:MohamadRChaaban,MD,MBA,MSCR,FACS,FAAOAChiefEditor:ArlenDMeyers,MD,
MBAmore...

OVERVIEW

Overview
Transnasalflexibleesophagoscopyisahelpfultoolthatreducesdiagnosticdelaysandtheneedfor
endoscopyundergeneralanesthesia.[1]Itisasafeandwelltoleratedprocedurethatcanbe
performedunderlocalanesthesiaandintheoutpatientsetting.[2,3,4]Theprocedurecanbe
performedfordiagnosticandtherapeuticpurposes.Transnasalesophagoscopyrequiresnosedation.
[2,3] Itisahighlycosteffectivetoolthatiseasilylearned.[3,5]

Indications
Theindicationsfortransnasalflexibleesophagoscopyincludethefollowing:

Dysphagia(reportedasthemostcommonindication)[6,7]
Screeningtoolforpatientwithrefluxorglobussensation[8,9,7]Aprospectivemulticenter
crosssectionalstudyhasevenrecommendeditforuseintheprimarycarepopulation,with38%
oftheparticipantsreportedwithesophagealfindingsthatalteredtheirmanagement.[10]
Screeningtoolinpatientswithheadandneckcancer[8]Inaddition,itcanbeusedforthe
detectionofmetachronousesophagealsquamouscellcarcinoma(SCC)intheesophagus.[11]
Evaluationofapossibleforeignbody[8]
Proceduressuchasdilationofastrictureorinjectionofbotulinumtoxinintheloweresophageal
sphincter[12]
Cough[6]
Tracheoesophagealpuncturereplacementunderdirectvision,[8]withexcellentspeech
outcomes[13]
Extrinsicesophagealcompression[6]
Candidiasis[6]
Foreignbodyremoval[14]Thiswasonceconsideredasacontraindication,buttransnasal
esophagoscopyisnowbeingincreasinglyusedasdiagnosticandtherapeutictoolforthe
extractionofforeignbodieswithquickdischargeofpatientsinlessthananhour.[15]

Contraindications
Transnasalesophagoscopymaybecontraindicatedinpatientswithbleedingdiathesisorabnormal
coagulationprofile.[16]

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1/31/2017 TransnasalEsophagoscopy:Overview,Indications,Contraindications

Anesthesia
Seethelistbelow:

Afterpositioningthepatientandobtaininginformedconsent,startexaminingthenasalcavities.
Spraythemorepatentnostrilwitha1:1ratioofoxymetazoline(Afrin)0.05%andlidocaine
(Xylocaine)4%.
Thenspraytheoropharynxwithlidocaine(Xylocaine)10%andaskthepatienttoswallow
immediately.
Lubricatetheendoscopewithviscouslidocaine2%.[8]

Equipment
Seethelistbelow:

Localanestheticandoxymetazolinesprays
Viscouslidocaine
Adistalvideochiptransnasalendoscopewithacamerabuiltintoitstip(eg,Pentax80Kseries
digitalvideoendoscope[5.1mmdiameter])[2]
Suction,irrigation,andinsufflationallattachedtotheendoscope(inthedistalvideochip
endoscope)orlinkedtotheEndoSheath(inanaddoncameratransnasalendoscope)[2]
Televisionmonitor
Videocassetterecorder
Lightsource
Pentaxbiopsyforceps

Positioning
Seethelistbelow:

Seatthepatientuprightonatreatmentcouchacrossfromtheendoscopist.[2]
Theendoscopestackiskeptbehindthepatient,inviewoftheendoscopist.[2]
Ifpatientsafetyisinquestion,thepatientshouldliedownonthecouchforresuscitation,if
needed.[2]

Technique
Seethelistbelow:

Explaintheproceduretothepatientandobtaininformedconsent.
Checkallequipmentbeforebeginningtheprocedure(seeimagebelow).

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Checkingallinstrumentsiscrucialbeforestartingtheendoscopy.
ViewMediaGallery
Passtheendoscopeparalleltothefloorofthenoseorbetweenthemiddleandinferior
turbinates(seeimagebelow).

Advancementofthescopeintranasallyparalleltothenasalfloor.
ViewMediaGallery
Whenthenasopharynxisreached,turntheflexiblescopedownward(seeimagesbelow).
Closelyobservethenasopharynx,hypopharynx,andglottisforanyabnormalities.[17]

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Advancementofthescopeatthelevelofthenasopharynx.
ViewMediaGallery

Advancementofthescopepastthebaseofthetongue.
ViewMediaGallery
Assoonasthehypopharynxisreached,askthepatienttoflexhisheadforwardtoreachhis
chest.Atthattime,askthepatienttoswallow.Thisrelaxesthecricopharyngeus.[16]Seeimages
below.

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1/31/2017 TransnasalEsophagoscopy:Overview,Indications,Contraindications

Flexibleendoscopepassingintothehypopharynx.
ViewMediaGallery

Scopepassingthroughthecricopharyngeusasthepatientisaskedtoswallow.
ViewMediaGallery
Underdirectvisualization,advancethescopethroughthecervicalesophagustowardthecardia.
Askingthepatienttophonateavowelfacilitatesentryofthescopethroughtheesophagogastric
junction.Thismaneuverrelaxestheloweresophagealsphincterandalsoallowsmovementof
thediaphragm.[17]
Rotatethescope360whileangulatingupwardtolookforthegastroesophagealjunctionand
thegastriccardia.ThisiscalledtheJmaneuver.[17]Seeimagesbelow.

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360degreerotationofthescopetoviewthegastroesophagealjunction(Jmaneuver).
ViewMediaGallery

Airinsufflationtoviewthestomach.
ViewMediaGallery

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Scopeatthelevelofthegastroesophagealjunctionandstomach.
ViewMediaGallery
Removetheendoscopegently,usingintermittentinsufflationandsuction,whiletakingcloselook
attheesophageallumen(seeimagesbelow).[17]

Slowwithdrawalofthescopewithcarefulattentiontothemonitor.
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Airinsufflationinthestomach.
ViewMediaGallery

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Slowwithdrawalofthescopeallowscarefulvisualizationoftheesophagealmucosa.
ViewMediaGallery

Pearls
Comparedtothetransoralesophagogastroduodenoscopy(EGD),thetransnasalroutehasthe
advantageofnotstimulatingtheuvulaandtheposteriorpartofthetongue,thusnotstimulatingthe
gagreflex.[18]

Mostcomplicationsencounteredinregularsedatedoralendoscopyareusuallyduetosedation.
Cardiopulmonarycomplicationsaccountforover50%ofcomplications.[5]

Complications
Complicationsmayincludethefollowing:

Transientanteriorepistaxis[2](reportedtobethemostfrequentcomplication[3])
Vomitingorgagging[16]
Vasovagalsyncope[8]
Bleedingandinfection(ifabiopsyisperformed)
Esophagealperforation(Thisisaveryrarecomplication,reportedonceintheliteraturesofar.
[19] )

Laryngospasm[20]

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