Clinical Esophagology and Transnasal Esophagoscopy

Review by L Flood
Middlesborough, UK

The advent of transnasal oesophagoscopy, however we agree to spell it, did suggest to many of us the potential for a significant expansion in our specialty. Perhaps we could now drive our colleagues in gastroenterology below the diaphragm and we would no longer consider the cricopharyngeus to be our boundary. Somehow though, in the UK, adoption has been far from universal, whether because of investment, training or simple time-pressure needs. Indeed, although many an ENT symptom is attributed to reflux, the study of oesophageal physiology and pathology is still something of an afterthought in our training schemes.

This is an attractively presented hardback book, which very much concentrates on the first half of the title, with but one chapter on transnasal oesophagoscopy itself. However, that was where I started my reading and learnt much. The author freely admits that the indications, other than for true dysphagia, remain ‘less well defined’. I will freely confess I had never appreciated that a reduced symptom of heartburn is potentially a danger signal indicating that mucosal sensation has been reduced by worsening metaplasia. It is worth quoting that ‘over 80 per cent of patients with globus and a negative endoscopy can be managed conservatively, without the need for medication trials or further diagnostic testing’, to alone justify the economic case for adoption.

The procedure is nicely described, with a review of the characteristics of each of the three commercially available endoscopes. Communication skills are emphasised, if the patient is to ‘swallow a large strand of spaghetti’. I liked that. There follows a description of the technique of flexible endoscopic evaluation of swallowing (‘FEES’), which was much more familiar than the delightfully termed ‘GOOSE’ (Guided Observation of Swallowing in the Esophagus) which would be spoiled by a UK spelling. Again, the procedure is explained in detail, with many a pearl of wisdom. Safety and patient preference are stressed as superior to ‘traditional’ sedated per-oral endoscopy, with equal diagnostic accuracy.

So far then, this has been just one chapter, but for me it was the highlight and very convincing. Reading on, it did strike me that there was much more to this, and that it was a study of the oesophagus written by, and very much aimed at, an otolaryn- gologist. Coverage starts with normal anatomy and physiology, but stressing radiological, manometric and pH studies of function. Endoscopic colour photography and monochrome imaging abounds, but especially memorable are the many illustrations of high-resolution manometry pressure topography plots. These are colourful indeed and reminiscent of a 1970s Grateful Dead album cover, whilst actually making far more sense.

The last half of the book then deals with such disorders as oesophagitis, strictures and diverticula, reflux, and tumours. A personal favourite here was that on Barrett’s oesophagus. Notably, its 28 references include one from 2017, suggesting the work is well updated. Again, there is the reminder that it is the reduced sensation of heartburn we must watch out for and not the converse.

This book makes for very easy reading. It covers a somewhat neglected territory in UK otolaryngology practice and it is cleverly written to appeal to our specialty. I cannot count how many times I read something and thought ‘I did not know that’, which must be a significant recommendation, I hope.

Amazon Link: Clinical Esophagology and Transnasal Esophagoscopy
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