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Journal of the Formosan Medical Association (2015) xx, 1e2

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journal homepage: www.jfma-online.com

LETTER TO THE EDITOR

A prospective randomized study comparing

transnasal and peroral 5-mm ultrathin
endoscopy
To the Editor,
1

We read with great interest the study by Lin et al. The

authors conducted a prospectively randomized trial to
compare patient tolerance, acceptance, and satisfaction of
esophagogastroduodenoscopy (EGD) between transnasal
(TN) and peroral (PO) routes using a 5-mm video endoscope
(GIF-XP260N; Olympus Optical Co., Ltd., Tokyo, Japan).
They reported that there were no significant differences
between TN and PO regarding the overall procedure
discomfort, satisfaction, and acceptability. However, there
were six failures (5.7%) of nasal intubation and two cases of
nasal bleeding (2%) among TN-EGD procedures compared
with the PO-EGD group, among whom all patients
completed EGD successfully without any adverse events.
We also have been using the same endoscope to evaluate
the upper aerodigestive tract from the nasal cavity, pharynx, larynx, and the esophagus for more than 1000 head
and neck cancer patients since 2007.2 From our experience,
the failure of this ultrathin endoscope to pass the nasal
cavity is extremely rare (<1%), either by gastrointestinal
specialists or by ear, nose, and throat (ENT) doctors.2
Compared with Lin et al1 and other methods,3 we apply a
different way to topically anesthetize the nasal cavity,
which is a very common and simple practice in the ENT
clinic.4 We use a cotton pledget (China Surgical Dressings
Center Co., Ltd, Changhua, Taiwan), measuring
6 cm  2 cm in size (Figure 1A), which was soaked in a
mixture (1:1) of 1% cocaine and 0.1% epinephrine before
2010, and a mixture (1:1) of 2% xylocaine and 0.1%
epinephrine after 2010.4 The reason why we use this
method is that the cotton pledget makes good contact with
the nasal mucosa and is sufficiently long. It evenly distributes the decongestant and anesthetic onto the entire surface of the nasal turbinates and septum so that marked
Conflicts of interest: The authors have no conflicts of interest
relevant to this article.

nasal mucosal shrinkage with large intranasal space is

achieved for the endoscope to pass through without severe
pain.4 Regarding the details of this technique, we open the
external nostril by use of the ENT nasal speculum and place
one piece of cotton pledget in each side of the nasal cavity
between the nasal septum and the turbinates by use of the
ENT nasal forceps, with/without the headlight illumination

Figure 1 (A) The cotton pledget used for topical anesthesia

of the nasal cavity; and (B) the cotton pledget being placed in
the nasal cavity using ENT nasal forceps.

http://dx.doi.org/10.1016/j.jfma.2015.09.004
0929-6646/Copyright 2015, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Please cite this article in press as: Wang C-P, et al., A prospective randomized study comparing transnasal and peroral 5-mm ultrathin
endoscopy, Journal of the Formosan Medical Association (2015), http://dx.doi.org/10.1016/j.jfma.2015.09.004

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2
(Figure 1B). After 10 minutes, the cotton pledget is
removed. Secondly, the operator has to choose the more
patent nasal cavity with the most room for the endoscope
to pass through, and then pass the endoscope through
either the middle meatus between the inferior and middle
turbinates or the inferior meatus between the inferior
turbinate and the nasal floor. Thirdly, more lubricate gel
containing 2% xylocaine is needed during the procedure,
and not only in the beginning, compared with the transoral
approach.
Epistaxis during the procedure is an issue, but is seldom
too severe to continue the examination through the nasal
cavity, especially when using the cotton pledget with 0.1%
epinephrine for preparation. We experienced less than 10
head and neck cancer patients with severe epistaxis during
the examination, however, the bleeding stopped quickly
without hemodynamic or airway compromise by use of this
cotton pledget with 0.1% epinephrine.
This method may appear difficult for gastrointestinal
doctors, however, it is actually a very simple technique that
every doctor can do, not just ENT doctors. I would suggest
trying this technique or conducting another prospectively
randomized trial to compare the difference between this
method and the spray or cotton-tipped applicator method.

References
1. Lin LF, Ma KZ, Tu HL. A prospective randomized study comparing
transnasal and peroral 5-mm ultrathin endoscopy. J Formos Med
Assoc 2014;113:371e6.
2. Wang CH, Lee YC, Wang CP, Chen CC, Ko JY, Han ML, et al. Use
of transnasal endoscopy for screening of esophageal squamous

Letter to the Editor

cell carcinoma in high-risk patients: yield rate, completion rate,
and safety. Dig Endosc 2014;26:24e31.
3. Hu CT. Endoscopic-guided versus cotton-tipped applicator
methods of nasal anesthesia for transnasal esophagogastroduodenoscopy: a randomized, prospective, controlled study.
Am J Gastroenterol 2008;103:1114e21.
4. Lee YC, Wang CP. Cotton pledget method for nasal decongestive
anesthesia prior to transnasal endoscopy. Am J Gastroenterol
2008;103:3212e3.

Cheng-Ping Wang
Department of Otolaryngology, National Taiwan University
Hospital and National Taiwan University, College of
Medicine, Taipei, Taiwan
Graduate Institute of Pathology, National Taiwan
University College of Medicine, Taipei, Taiwan
Jenq-Yuh Ko
Department of Otolaryngology, National Taiwan University
Hospital and National Taiwan University, College of
Medicine, Taipei, Taiwan
Yi-Chia Lee*
Department of Internal Medicine, National Taiwan
University Hospital and National Taiwan University,
College of Medicine, Taipei, Taiwan
*Corresponding author. Department of Internal Medicine,
National Taiwan University Hospital, 7 Chung-Shan South
Road, Taipei, Taiwan.
E-mail address: yichialee@ntu.edu.tw (Y.-C. Lee)
29 August 2015

Please cite this article in press as: Wang C-P, et al., A prospective randomized study comparing transnasal and peroral 5-mm ultrathin
endoscopy, Journal of the Formosan Medical Association (2015), http://dx.doi.org/10.1016/j.jfma.2015.09.004