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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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.
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Passtheendoscopeparalleltothefloorofthenoseorbetweenthemiddleandinferior
turbinates(seeimagebelow).
Advancementofthescopeintranasallyparalleltothenasalfloor.
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Whenthenasopharynxisreached,turntheflexiblescopedownward(seeimagesbelow).
Closelyobservethenasopharynx,hypopharynx,andglottisforanyabnormalities.[17]
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Advancementofthescopeatthelevelofthenasopharynx.
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Advancementofthescopepastthebaseofthetongue.
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Assoonasthehypopharynxisreached,askthepatienttoflexhisheadforwardtoreachhis
chest.Atthattime,askthepatienttoswallow.Thisrelaxesthecricopharyngeus.[16]Seeimages
below.
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Flexibleendoscopepassingintothehypopharynx.
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Scopepassingthroughthecricopharyngeusasthepatientisaskedtoswallow.
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Underdirectvisualization,advancethescopethroughthecervicalesophagustowardthecardia.
Askingthepatienttophonateavowelfacilitatesentryofthescopethroughtheesophagogastric
junction.Thismaneuverrelaxestheloweresophagealsphincterandalsoallowsmovementof
thediaphragm.[17]
Rotatethescope360whileangulatingupwardtolookforthegastroesophagealjunctionand
thegastriccardia.ThisiscalledtheJmaneuver.[17]Seeimagesbelow.
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360degreerotationofthescopetoviewthegastroesophagealjunction(Jmaneuver).
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Airinsufflationtoviewthestomach.
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Scopeatthelevelofthegastroesophagealjunctionandstomach.
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Removetheendoscopegently,usingintermittentinsufflationandsuction,whiletakingcloselook
attheesophageallumen(seeimagesbelow).[17]
Slowwithdrawalofthescopewithcarefulattentiontothemonitor.
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Airinsufflationinthestomach.
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Slowwithdrawalofthescopeallowscarefulvisualizationoftheesophagealmucosa.
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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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