Transnasal esophagoscopy findings: Interspecialty comparison

Otolaryngology–Head and Neck Surgery (2009) 140, 812-815

ORIGINAL RESEARCH—LARYNGOLOGY AND NEUROLARYNGOLOGY

Transnasal esophagoscopy findings: Interspecialty comparison Michael T. Falcone, MD, C. Gaelyn Garrett, MD, James C. Slaughter, DrPH, and Michael Vaezi, MD, PhD, Nashville, TN Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. ABSTRACT INTRODUCTION: Otolaryngologists implement transnasal esophagoscopy (TNE) to assess esophageal pathology. Previous studies using TNE are largely retrospective and deal with select patient populations. The prevalence of esophageal pathology in patients presenting with throat symptoms to an otolaryngology voice center is presently unknown. OBJECTIVE: To assess the prevalence of esophageal pathology in this population and determine the interobserver variability of the findings reviewed by an otolaryngologist and a gastroenterologist. STUDY DESIGN: A prospective study. SETTING: This study was conducted in a laryngology/voice subspecialty clinic. SUBJECTS AND METHODS: Fifty patients with throat symptoms presenting to the voice center were asked prospectively to undergo TNE. The findings were videotaped and reviewed by an otolaryngologist and a gastroenterologist blinded to the patients’ presenting complaint. RESULTS: Hoarseness was the most common presenting symptom (68%). According to the gastroenterologist, the prevalence of esophageal findings was: z-line irregularity suspicious for Barrett esophagus (12%), esophagitis (10%), hiatal hernia (32%), and esophageal stricture (10%). The percent agreement for a normal study was 72 percent. The percent agreement for various pathological findings were as follows: Barrett esophagus 86 percent, esophagitis 88 percent, hiatal hernia 76 percent, and esophageal stricture 96 percent. For an abnormal study, the percent agreement was 80 percent. CONCLUSION: Esophageal abnormalities are common in patients presenting to a voice subspecialty clinic. © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

T

he field of esophagology was born more than a century ago following the invention of the distal-lighted, rigid esophagoscope by an otolaryngologist, Chevalier Jackson. Prior to the introduction of the flexible, fiber-optic endoscope, esophagology fell under the scope of otolaryngology. In the 1930s, Schindler, a gastroenterologist, developed the

first flexible, non–fiber-optic gastroscope. More than two decades later, Hirschowitz, another gastroenterologist, unveiled the first flexible fiber-optic esophagoscope. This period marked a transition in which the gastroenterologist became chiefly responsible for managing disorders of the esophagus. Generally, rigid esophagoscopy is performed under general anesthesia, whereas flexible esophagoscopy can be tolerated with conscious sedation. Lately, transnasal esophagoscopy (TNE) has attracted increasing attention.1 In recent years, the association of gastroesophageal reflux (GER) with laryngeal signs and symptoms has been under investigation.2,3 Many patients present to the otolaryngologist with symptoms thought to be attributed to laryngopharyngeal reflux (LPR) without overt symptoms of GER. This patient population in conjunction with the otolaryngologist’s knowledge of intranasal anatomy and expertise in office-based, unsedated procedures has sparked a renaissance of esophagology within the field of otolaryngology. However, there are currently no blinded assessments of technical ability of otolaryngologists to identify specific esophageal pathology in head-to-head comparison with the expert esophagologists. Additionally, the prevalence of esophageal pathology in patients presenting with throat symptoms to an academic voice center is not well studied.

MATERIALS AND METHODS This research protocol was approved by the Vanderbilt University Medical Center Institutional Review Board. Consecutive adult patients presenting to the voice center were invited to undergo TNE between September 2006 and November 2007. Eligibility for participation was based on the presence of throat symptoms including hoarseness, sore throat, cough, dysphagia, and/or globus sensation. Exclusion criteria included prior esophagogastroduodenoscopy and pregnancy. Patients were randomly assigned an identification number. Topical anesthetic (tetracaine/phenylephrine for the nasal cavity and nasopharynx, and benzocaine/

Received October 8, 2008; revised January 26, 2009; accepted February 4, 2009.

0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.02.008

Falcone et al

Transnasal esophagoscopy findings . . .

Table 1 Descriptive statistics (N ⴝ 50) Age Sex: female Symptoms Hoarseness Sore throat Cough Throat clearing Dysphagia Globus sensation

39.25 49.00 57.00* 54% (27) 68% 22% 22% 8% 4% 8%

(34) (11) (11) (4) (2) (4)

Numbers that follow percentages are frequencies. Some subjects (32%) reported more than one symptom, so the sum of the frequencies of individual symptoms will add up to more than 100%. *a b c represent the lower quartile a, the median quartile b, and the upper quartile c for continuous variables.

aminobenzoate/tetracaine for the oropharynx) was applied. The technique is well described in the literature.4-7 Unsedated TNE (using the Olympus EndoEYE flexible video transnasal esophagoscope partial expiratory flow-volume) was performed and videotaped by an otolaryngologist unfamiliar with the patient’s history. Blinded to the patient’s identity and presentation, an esophageal expert (M.V.) and an otolaryngologist (C.G.G.) reviewed and interpreted each video. The interpreters were asked to review the video for presence or absence of the following pathology: columnar mucosa suspicious for Barrett esophagus (z-line irregularity), esophagitis (Los Angeles grades A through D), hiatal hernia, esophageal stricture, presence of patulous gastroesophageal (GE) junction, or esophageal diverticulum, and whether the study was poorly performed. No grading for the findings was required. The data were collected by a third physician (M.F.) who was not involved in the interpretation or analysis. Patients suspected of having columnar mucosa underwent unsedated upper GI endoscopy (EGD) by the esophagologist, and the suspicious mucosa was biopsied. Presence of Barrett mucosa was confirmed by the presence of intestinal metaplasia on histology.

813 Statistical analysis was performed for prevalence of esophageal findings by a statistician blinded to patients’ clinical presentation. Paired data were analyzed with the McNemar test for association and summarized by the percent agreement and kappa (␬) scores. Kappa scores were interpreted as the following: 0.00 – 0.20, slight; 0.21– 0.40, fair; 0.41– 0.60, moderate; 0.61– 0.80, substantial; and 0.81– 1.00, almost perfect agreement. Confidence intervals (CIs) were calculated by means of the bootstrap procedure.

RESULTS Fifty patients underwent TNE at the Vanderbilt Voice Center (Table 1). The median age was 49 years (inner quartile range 39 to 57 years). Twenty-seven patients (54%) were female. Hoarseness was the most common presenting symptom (68%) followed by sore throat (22%), cough (22%), throat clearing (8%), globus sensation (8%), and dysphagia (4%). Table 2 lists the prevalence of esophageal findings by each interpreter, as well as the percent agreement and kappa scores. Fifty percent of patients were identified as having normal esophageal findings by the esophageal expert, which was similar to the otolaryngologist’s findings (42%). Columnar mucosa (Barrett esophagus) was suspected less often by the esophagologist (12%) than by the otolaryngologist (18%). Identification of esophagitis followed a similar trend (Table 2). Of the six patients suspected of having columnar mucosa according to the esophagologist’s review of the TNE video, only one (2%) patient had biopsy-confirmed Barrett esophagus. This patient was among those suspected of Barrett esophagus by the TNE evaluation of the otolaryngologist as well. The esophagologist was more likely to identify presence of hiatal hernia (32%) than was the otolaryngologist (20%). The agreement was moderate (␬ ⫽ 0.44) for normal findings between the esophagologist and otolaryngologist with a percent agreement of 72 percent (Table 2). The presence of hiatal hernia was the most frequently cited

Table 2 Interpretation results of TNE, percent agreement, and kappa value Frequency Finding

Otolaryngologist (C.G.G.)

Esophagologist (M.V.)

% Agreement

Kappa estimate

95% CI

Normal Barrett esophagus Esophagitis Hiatal hernia Esophageal stricture Patulous GE junction Esophageal diverticulum Poor study

21 9 7 10 3 0 1 7

25 6 5 16 5 1 1 7

72 86 88 76 96 98 100 100

0.44 0.45 0.43 0.39 0.73 0 1 1

[0.19, 0.68] [0.07, 0.78] [0.01, 0.84] [0.13, 0.7] [NA, NA] [NA, NA] [NA, NA] [NA, NA]

NA, not applicable.

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Otolaryngology–Head and Neck Surgery, Vol 140, No 6, June 2009

abnormal TNE finding. The percent agreement (kappa scores) for various pathological findings was as follows: Barrett esophagus 86 percent (␬ ⫽ 0.45); esophagitis, 88 percent (␬ ⫽ 0.43); hiatal hernia, 76 percent (␬ ⫽ 0.39); esophageal stricture, 96 percent (␬ ⫽ 0.73); patulous gastroesophageal junction, 98 percent (␬ ⫽ 0); and esophageal diverticulum, 100 percent (␬ ⫽ 1). Seven studies were deemed as poor quality and could not be interpreted (percent agreement 100%, ␬ ⫽ 1). The frequency that the reviewers agreed exactly on all findings for any individual video was 54 percent (95% CI, 40%, 68%). The otolaryngologist reported more findings than the esophagologist on 48 percent of the videos. When identifying videos as normal versus abnormal, the reviewers were 1.8 times more likely to agree than disagree (95% CI, 0.6, 9.0).

DISCUSSION The use of TNE is increasing in the otolaryngology community. An economic driving force may be one important reason. However, long-term clinical success of performing this test relies more on correctly identifying esophageal pathology, especially Barrett mucosa. In this study, we compared the esophageal pathology interpretation between an otolaryngologist and an esophageal expert. We found that esophageal abnormalities were common in a group of patients presenting to a subspecialty voice center. Roughly half of the studies revealed one or more findings. Interestingly, for all diagnoses except hiatal hernia, the otolaryngologist was more likely than the esophagologist to suspect an abnormality. This is an important point because missed diagnoses, especially for Barrett esophagus, have significant clinical implications. When identifying Barrett esophagus in this study, the otolaryngologist suspected columnar mucosa in 9 of 49 (18%) compared with the gastroenterologist who suspected 6 of 49 (12%). The percent agreement (kappa score) for this diagnosis between the interpreters was 86 percent (␬ ⫽ 0.45), which is in the moderate category. More importantly, one of the six patients suspected of having columnar mucosa had biopsy-confirmed Barrett epithelium, and this patient was among those suspected by the otolaryngologist’s initial TNE evaluation. Thus, the prevalence of Barrett mucosa in this population of patients was 1 of 50 (2%). Overall, the kappa values for most identified esophageal pathology were within the moderate to substantial agreement ranges. The wide CI for the kappa values suggests that larger studies may be necessary to further substantiate these findings. Barrett esophagus is a well-known risk factor for the development of esophageal adenocarcinoma (EA). The incidence of EA is on the rise, with 0.5 percent of patients with Barrett esophagus undergoing malignant change each year.8 Patients with Barrett esophagus demonstrating lowgrade dysplasia are at a 12 percent risk of developing EA over the following 5 years. High-grade dysplasia increases

that risk to 25 percent.9 At diagnosis, most patients with EA are symptomatic and have a 5-year survival rate of ⬍10 percent.10 In a study by Reavis et al,11 symptoms consistent with LPR were more predictive of the presence of EA than were symptoms typically associated with GER. This suggests that patients with EA may present to an otolaryngologist earlier than to a gastroenterologist. TNE may play an important role in identifying at-risk patients as well as in detecting EA earlier, thereby improving survival. The diagnosis of Barrett esophagus should not be made at endoscopy but on the basis of histology. The socioeconomic impact of rendering a diagnosis of Barrett esophagus at TNE, which later is disproved by biopsy, may be too hard for patients. Increases in patient insurance rates and dropped coverage are potential adverse impacts of an erroneous initial diagnosis. Compared with conventional sedated transoral upper endoscopy, unsedated TNE has demonstrated equal accuracy in the detection of Barrett esophagus.12,13 However, the level of training required to be competent in identifying and establishing the correct diagnosis is currently unknown. One challenge ahead is the reconciliation of discrepancies between the endoscopic diagnosis and the histologic diagnosis of Barrett esophagus. The results of previous studies are mixed regarding this agreement. In 1989 Woolf et al14 published a study of 23 patients in whom endoscopic and histological agreement was 91 percent (␬ ⫽ 0.72). In a study of 109 patients, Endlicher et al15 later reported this agreement to be 42 percent with a sensitivity of 62 percent and specificity of 84 percent. In 2006 Johansson et al16 issued a study of 120 patients in which endoscopic-histological agreement was 86 percent. However, in this case the kappa value demonstrated fair agreement at 0.31. The aforementioned studies used conventional endoscopy. Finally, in a study using TNE, Halum et al17 published results of 30 percent agreement in 20 patients with endoscopic findings suspicious for Barrett esophagus. These results once again highlight the impact of correct documentation of the findings as columnar-appearing mucosa and not Barrett esophagus until confirmed by histology.

CONCLUSION Esophageal abnormalities are common in patients presenting to a voice subspecialty clinic. Performing TNE is relatively easy; however, interpretation of the findings is challenging. Interpretations of TNE findings may vary within a specialty or between specialties. Especially with regard to Barrett esophagus, discrepancies between the endoscopic diagnosis and histological diagnosis pose a challenge. Our study showed a higher likelihood of suspicion for Barrett esophagus by the otolaryngologist, which is reassuring. An interdisciplinary approach is the cornerstone of good care no matter who performs the procedure.

Falcone et al

Transnasal esophagoscopy findings . . .

AUTHOR INFORMATION From the Departments of Otolaryngology–Head and Neck Surgery (Drs Falcone and Garrett) and Biostatistics (Dr Slaughter), and the Division of Gastroenterology, Hepatology and Nutrition (Dr Vaezi), Vanderbilt University Medical Center. Corresponding author: Michael Vaezi, MD, PhD, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37232. E-mail address: [email protected]. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Chicago, Illinois, September 23, 2008.

AUTHOR CONTRIBUTIONS Michael T. Falcone, data collection, data analysis and interpretation, manuscript writing and editing; C. Gaelyn Garrett, development of study design, data analysis and interpretation, manuscript writing and editing; James C. Slaughter, statistical analysis, manuscript editing; Michael Vaezi, development of study design, data analysis and interpretation, manuscript writing and editing.

DISCLOSURES Competing interests: C. Gaelyn Garrett, consultant: Osteotech Sponsorships: Michael Vaezi, research funding: Takeada, Restech, AstraZeneca;

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