Original Research

A New Trend in the Management of

Esophageal Foreign Body: Transnasal
Esophagoscopy

Otolaryngology
Head and Neck Surgery
14
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2015
Reprints and permission:
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DOI: 10.1177/0194599815580757
http://otojournal.org

Chun-Wen Shih, MD1, Chung-Yu Hao, MD1, Yu-Jung Wang, MD1,

and Sheng-Po Hao, MD, FICS1,2

No sponsorships or competing interests have been disclosed for this article.

Abstract
Objectives. (1) To analyze the outcomes of patients with esophageal foreign body managed by transnasal esophagoscopy.
(2) To review the value of lateral neck X-ray.
Study Design. Case series with chart review.
Setting. Tertiary referral center, Shin Kong Wu Ho-Su Memorial
Hospital, Taipei, Taiwan.
Subjects and Methods. Lateral neck X-ray was used for initial
screening in patients suspected of having an esophageal foreign body between 2007 and 2013. Rigid esophagoscopy
was used as standard for further investigations before July
2010 and transnasal esophagoscopy after July 2010.
Results. From January 2007 to June 2010, 43 patients who
were suspected of having an esophageal foreign body under
lateral neck X-ray received rigid esophagoscopy, 31 of
whom were found to have an esophageal foreign body.
From July 2010 to December 2013, 302 patients underwent
transnasal esophagoscopy, and an esophageal foreign body
was noted in only 52 of these patients. In the 302 patients
who underwent transnasal esophagoscopy, the sensitivity
and specificity of having an esophageal foreign body by lateral neck X-ray were 59% and 83%, respectively.
Conclusion. The introduction of transnasal esophagoscopy
has changed the diagnosis and management for an esophageal foreign body. Transnasal esophagoscopy is a quick
and safe procedure that can be performed under local
anesthesia. Transnasal esophagoscopy could replace lateral neck X-ray to become the initial screening procedure
and a useful treatment for patients with an esophageal
foreign body.

Keywords
esophageal foreign body, transnasal esophagoscopy, rigid
esophagoscopy, lateral neck X-ray
Received October 30, 2014; revised March 3, 2015; accepted March
17, 2015.

efore 1996, otolaryngologists usually performed rigid

endoscopy to remove an esophageal foreign body
(EFB) transorally, with the patients under general
anesthesia in an operation room.1 After 1996, otolaryngologists
began to perform esophagoscopy utilizing an ultrathin flexible
scope passed transnasally,2 with the patients not sedated and
under only topical anesthesia. This approach is called transnasal esophagoscopy (TNE). As TNE is mainly performed in the
office, skilled assistants or complicated monitoring procedures
are not necessary. Indications for TNE include evaluation and
possible removal of a foreign body (FB) and evaluations of
caustic ingestion, globus pharyngeus, chronic cough, cervical
dysphagia, and head and neck cancer. Traditionally, lateral
neck X-ray has been used as the first-line diagnostic tool for
an EFB. The benefit of an X-ray is that it is quick and convenient to perform. However, after the era of TNE, the efficacy
of lateral neck X-ray needs to be reevaluated.
The aim of this study was to compare the value of TNE
with rigid esophagoscopy for an EFB and to reevaluate the
efficacy of lateral neck X-ray.

Materials and Methods

This retrospective study was conducted at Shin Kong Wu
Ho-Su Memorial Hospital, Taiwan, from January 2007 to
December 2013. The Institutional Review Board of the hospital approved approved the protocol for this study. Our
hospital is a tertiary referral center, and our department has
been equipped with a transnasal endoscopy unit (PentaxVE1580K) since June 2010. The study subjects included male
and female patients of all ages who were admitted to our
unit with a suspected ingested FB. For each patient, lateral
neck X-ray was used for initial screening in the emergency
room. Otolaryngologists were consulted, and they checked
1

Department of OtorhinolaryngologyHead and Neck Surgery, Shin Kong

Wu Ho-Su Memorial Hospital, Taipei, Taiwan
2
Medical School, Fu-Jen Catholic University, Taipei, Taiwan
This article was presented at the 2014 AAO-HNSF Annual Meeting & OTO
EXPO; September 21-24, 2014; Orlando, Florida.
Corresponding Author:
Sheng-Po Hao, MD, FICS, Shin Kong Wu Ho-Su Memorial Hospital, No. 95,
Wen Chang Road, Shih Lin District, Taipei City, Taipei city, 111, Taiwan.
Email: [email protected]

2
the local findings for each case. Mirror examination or laryngoscopy was used for each case to evaluate the pharynx
and the larynx to see if a FB was present.
Patients received rigid esophagoscopy for a suspected
EFB before June 2010. However, after the introduction of
TNE, the policy for the management of an EFB changed.
As before, each patient who presented with a suspected
EFB received a lateral neck X-ray in the emergency room
and was then evaluated by an otolaryngologist. If no FB
was found in the pharynx or larynx, the patient then
received TNE instead of rigid esophagoscopy to see if an
EFB was present. We reviewed all patients files with full
notations for the following data: age, sex, type of FB, anatomic location of the FB, treatments, and outcomes (complications and success and mortality rates). All statistics were
analyzed by chi-square test.

OtolaryngologyHead and Neck Surgery

Figure 1. Assessment and management of a foreign body.

EFB, esophageal foreign body; FB, foreign body; PE, physical examination; TNE, transnasal esophagoscopy.

Transnasal Esophagoscopy Technique

Intranasal anesthesia and decongestion were achieved using
a solution comprising half 2% lidocaine and half 0.1% epinephrine, followed by a short spray of 10% lidocaine to the
oropharynx. During each examination, the patients were
fully awake and sitting upright. In this study, all TNE procedures were performed with a Pentax flexible endoscope
(VE-1580K, Pentax Precision Instrument Co, Orangeburg,
New York). A lidocaine gel was used as a lubricant on the
endoscope.
As the examination began, the endoscope was advanced
along the patent side of the common meatus into the nasopharynx and turned inferiorly to allow visualization of the
orohypopharynx and supraglottic area. The endoscope was
guided into the pyriform sinus; the patient was then asked
to burp and swallow the endoscope to examine the postcricoid area; and the endoscope was finally gently pushed into
the esophagus. The entire length of the esophagus was evaluated until the gastroesophageal junction. Slow withdrawal
of the endoscope allowed for reevaluation of the esophagus
and the postcricoid area.
If an EFB was observed under TNE, it was removed by
grasping with forceps via the walking channel. In cases
where the EFB was too large or sharp or where esophageal
laceration was observed with suspected possible perforation,
rigid esophagoscopy was arranged to remove the EFB
(Figure 1).

Results
From January 2007 to June 2010, 43 patients who were suspected of having an EFB after examination by an otolaryngologist and lateral neck X-ray (27 men and 16 women; mean
age, 53.26 years; range, 18 to 74 years) received rigid esophagoscopy. All lateral neck X-rays showed a suspected EFB, and
72.1% (31 of 43) of the patients were found to have an EFB,
all of which were removed successfully via rigid esophagoscopy. No major complications (eg, mediastinitis, perforated
esophagus) were noted after rigid esophagoscopy.
A total of 302 patients (162 men and 140 women; mean
age, 51.84 years; range, 14 to 85 years) were enrolled from

Table 1. Type of Foreign Body.

Type

Fish bone
Chicken bone
Pork bone
Food bolus
Pill with wrapper
Tooth
Tablet
Coin
Total

41
20
12
4
3
1
1
1
83

49.4
24.1
14.5
4.8
3.6
1.2
1.2
1.2
100

July 2010 to December 2013. All 302 patients underwent

TNE because there was no evidence of an FB seen in the
pharynx or larynx either by local findings or by lateral neck
X-ray. Of these 302 patients, 52 (17.2%) were found to
have an EFB, 36 (69.2%) of whom had the EFB removed
directly under TNE either by forceps removal (n = 21) or by
advancement down into the stomach (n = 15). The remaining 16 (31.8%) patients had the EFB removed via rigid esophagoscopy because of a large or sharp EFB or a possibly
perforated esophagus; these EFBs included 8 fish bones, 3
chicken bones, 2 pork bones, and 3 pills (Table 1). None of
the patients who received TNE or rigid esophagoscopy had
any major complications.
Under rigid esophagoscopy, 21 EFBs were found in the
cervical esophagus and 10 in the intrathoracic esophagus.
Under TNE, 24 EFBs were found in the cervical esophagus,
19 in the intrathoracic esophagus, and 9 in the abdominal
esophagus near the gastroesophageal junction. There was a
significant difference in the location of the EFB before and
after TNE (x2 = 7.1367, df = 2, P = .0282).
All 345 patients received lateral neck X-rays. The reports
from the radiologist were reviewed and compared to the

Shih et al

Table 2. Lateral Neck X-ray Findings, n (%).a

EFB in X-ray
No EFB in X-ray
Total

True EFB

No EFB

Total

49
34
83 (24.1)

45
217
262 (75.9)

94 (27.2)
251 (72.8)
345 (100)

Abbreviation: EFB, esophageal foreign body.

a
Lateral neck X-ray compared to esophagoscopy: x2 = 53.628, df = 1,
P \.0001.

results of TNE or rigid esophagoscopy. The sensitivity of

lateral neck X-rays was 59.0%, meaning that 49 patients
presented with true EFBs according to lateral neck X-rays
(a total of 83 EFBs). Most true EFBs not seen in lateral
neck X-ray were radiolucent fish bones (29 of 34). Ninetyfour cases of an EFB were seen in lateral neck X-rays, 49
of which were true EFBs. The positive predictive value of
lateral neck X-ray was 52.1% (49 of 94), with a specificity
of 82.8% (217 of 262). There was a significant statistical
difference between lateral neck X-ray and esophagoscopy
(P \ .0001; Table 2). In addition, among the 302 patients
who received TNE, an EFB was not found in 251 lateral
neck X-rays; however, 34 of these 251 (13.5%) were found
to have an EFB in TNE.

Discussion
FB ingestion and food bolus impaction are common.3-5 The
majority of ingested FBs will pass spontaneously, and preendoscopic studies have shown that 80% of foreign objects
will likely pass without the need for an intervention.6
The esophagus is divided into 3 parts anatomically: the cervical, intrathoracic, and abdominal esophagus. There are 3
external compressions of the esophagus relative to the nasal
ala: the aortic arch at 24 to 26 cm, the left mainstem bronchus
at 29 to 30 cm, and the diaphragmatic hiatus at 41 to 43 cm.
In the current study, most EFBs were found in the cervical
esophagus (45 of 83), and there was a significant difference in
the location of the EFB before and after the introduction of
TNE (P = .0282). Before the era of TNE, it was difficult to
evaluate the intrathoracic and abdominal esophagus because of
a lack of suitable instruments and because the patients would
visit a gastroenterologist for further evaluation. After the introduction of TNE, an EFB in the intrathoracic and abdominal
esophagus can easily be diagnosed and managed.
In the current study, 302 patients were suspected of
having ingested an FB but did not have evidence of a pharyngeal or laryngeal FB in local findings or lateral neck
X-ray. Of these 302 patients, 52 (17.2%) were found to
have an EFB by TNE.
When a patient presented with suspected FB ingestion,
an otolaryngologist was first consulted to evaluate the
patients upper aerodigestive tract. Traditionally, local findings, laryngoscopy, and lateral neck X-ray are used to initially evaluate the patient. If an EFB was suspected from the
lateral neck X-ray, rigid esophagoscopy was suggested.

However, the patient would have to be placed under general

anesthesia and would not be allowed to consume anything
for 8 hours. In addition, sophisticated patient monitoring and
skillful assistants would be required in the operation room. If
a lower-third EFB was suspected, we suggested that the
patient should visit a gastroenterologist for further endoscopic
evaluation. The limitation of rigid esophagoscopy is that it is
hard to reach the abdominal esophagus. Some patients
choose observation first even if an EFB is present on lateral
neck X-ray. After the introduction of TNE, otolaryngologists
were able to save time and costs not only when evaluating
the esophagus but also in managing the EFB directly.
Although the number of patients who received TNE
increased and 17.2% were found to have an EFB, the misdiagnosis rate decreased, and potentially prolonged EFB, esophageal perforations, and mediastinitis were prevented. In
Taiwan, potential legal disputes can arise if an EFB is not
found at the first visit, and TNE can help prevent this.
The advantages of TNE include the use of topical
anesthesia, its being and office-based and cost-saving procedure, and the time of fasting being reduced to 2 hours or
less, if done immediately. The patients are placed in an
upright position, and it is possible to secure the airway and
prevent secretion or food aspiration. Patient discomfort was
encountered, including nausea, vomiting, epistaxis, and
blood-tinged sputum; however, all patients tolerated the procedure, and all symptoms were relieved within 1 hour after
the examination.
The majority of EFBs can be removed directly under
TNE either by forceps through the nose or throat or by
advancement down into the stomach. However, 31.8% of
the EFBs diagnosed from TNE required removed via rigid
esophagoscopy owing to a large or sharp FB or possibly
perforated esophagus. TNE reduced the rate of rigid esophagoscopy from 100% to 31.8%.
Several studies discussed complications with regard to
EFB, and a few studies reported major complications, such
as mediastinitis and esophageal perforation.6,7 In our study,
there were no major complications in the patients who
received either TNE or rigid esophagoscopy. In our experience of TNE, minor complications such as epistaxis and
pharyngeal or laryngeal mucosal erosion are most commonly encountered. However, all of the patients tolerated
them, and the symptoms improved within 1 hour before
leaving the hospital.
Although some studies emphasized the importance of
imaging studies for an EFB, we found that the majority of
EFBs were radiolucent, and the sensitivity and positive predictive value of lateral neck X-rays were only 59.0% and
52.1%, respectively. People in Taiwan like to eat freshwater
fish such as Chanoschanos and Oreochromis mossambicus,
which contain numerous thin, tiny, and radiolucent bones
that may result in an increased risk of fish bone ingestion
compared to other studies.
The location of the EFB reflects the diagnostic difficulty
from an X-ray point of view. Most EFBs are seen in lateral
neck X-rays at the cervical esophagus, presenting as either a

4
radiopaque lesion or an air column. A thoracic EFB often
hides behind the mediastinal organ and is difficult to detect
on an X-ray. Computed tomography provides more information for thoracic EFBs; however, it is more expensive and
not cost-effective, because of the low positive rate. The cost
of TNE is about US $33, and the cost of lateral neck X-ray
about US $20 according to the National Health Insurance
Bureau in Taiwan; however the diagnostic value of TNE is
much higher than lateral neck X-ray.

Conclusion
FB ingestion is a common problem in otolaryngology daily
practice. It was difficult for otolaryngologists to evaluate
the esophagus before the era of TNE; however, TNE now
offers a direct and immediate solution to help evaluate the
esophagus for the patients presenting without an FB in their
upper aerodigestive tract. Patients need to receive only topical anesthesia, and they spend less fasting time than that
before the introduction of TNE. In this study, TNE reduced
the rate of rigid esophagoscopy from 100% to 31.8%, and it
was found to be superior to lateral neck X-rays because of
their low sensitivity and specificity. Because of the common
habit of eating freshwater fish in Taiwan, most FB ingestion
is fish bone related, and the majority of cases are radiolucent. Therefore, TNE is a more efficient and effective
method that can be a first-line tool to evaluate an EFB.
Author Contributions
Chun-Wen Shih, wrote article, collected data, and conducted analysis; Chung-Yu Hao, interpreted data, drafted article; Yu-Jung

OtolaryngologyHead and Neck Surgery

Wang, collected data, conducted analysis, revised article; Sheng-Po
Hao, revised article, designed study, gave final approval.

Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.

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