One-hundred thirty seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to Feb 2009 were prospectively analyzed in this study. The study group was composed of 68 men and 69 women (mean age, 55.28 years; range 19 to 78 years). Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (PPI) (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1 (Table 1). We excluded the patients who had esophagogastrofiberscopy for last one year. To assess patient's subjective discomfort, a visual analogue scale (VAS) was used for patient's satisfaction (0, worst; 5, fair; 10, best), and pain score during esophagoscopy (0, no; 1, mild; 2, moderate; 3, most severe pain). This study was reviewed and approved by the ethics committee of two institutions. All participants were given detailed explanation of the study from researchers, and provided written informed consent relevant to this investigation.

Participants of LPRD were interviewed in search of symptoms relevant to LPRD. A common self-administered questionnaire, the Reflux Symptom Index (RSI) developed by Belafsky et al. [1], was used during the interview for symptom assessment. Subject with a summed up RSI larger than 13 is considered to positive. Experienced otolaryngologists (EJC and SWL) evaluated the appearance using a laryngoscope and assessed laryngeal findings according to the Reflux Finding Score (RFS) [2]. Total scores can range from 0 (normal) to 26 (worst), and RFS in total of more than 7 is regarded as positive.

Topical nasal anesthesia and decongestion was achieved with intranasal pontocaine and neosynephrine, and a short spray of 10% benzocaine was used in the oropharynx for further analgesia. Patients were examined fully awake and sitting upright with a Pentax flexible endoscope (VE-1530, Pentax Precision Instrument Co., Orangeburg, NY, USA). A lidocaine gel is used as a lubricant on the endoscope. The endoscope was advanced along the floor of the nose into the nasopharynx and turned inferiorly to allow visualization of the nasopharynx, oropharynx, supraglottis, and glottis. The patient was then asked to burp and swallow several times to allow visualization of the postcricoid space, and the endoscope was gently advanced until it was seen and felt to enter the esophagus. The entire length of the esophagus was evaluated after air insufflation, with special attention to the gastroesophageal junction. Slow withdrawal of the endoscope allowed re-evaluation of the esophagus and the best examination of the postcricoid area. If mucosal lesions or irregularities are noted, biopsy forceps are passed through the working channel and multiple biopsies are obtained.

Pearson χ² tests were used for dichotomous variables, whereas t-tests were used for continuous variables. All tests were two-tailed using the SPSS ver. 13.0 (SPSS Inc., Chicago, IL, USA). A P-value less than 0.05 was considered significant.

Fifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). One hundred and two patients underwent TNE for screening examination for LPRD. Forty-two patients (41.1%) were found to have pathology (esophagitis, 41; esophageal diverticulum, 1), and the remaining 60 patients (58.9%) had no identifiable pathology. Nine patients were examined to look for a cause of dysphagia. Pharyngeal or esophageal stricture was seen in four patients. These patients were dilated successfully with esophageal balloon dilator (CRE esophageal balloon dilator, Boston Scientifics, Natick, MA, USA). Esophageal cancer was confirmed in one patient with dysphagia using subsequent directed biopsy. Esophagitis was confirmed in two patients with dysphagia. TNE was used to investigate metachronous lesions or routine follow-up screening in seventeen head and neck cancer patients. One second primary cancer was identified during the routine follow-up after total laryngectomy. Four patients were examined to look for a cause of blood tinged saliva. Positive finding was identified in one patient (esophagitis). We could not notice any positive finding in patients with vocal fold paralysis.

The average pain score on a VAS (0, no; 1, mild; 2, moderate; 3, most severe pain) was tolerable (mean score, 1.13±0.78), and the patients' satisfaction score (0, worst; 5, fair; 10, best) was fair (mean score, 6.34±1.49) (Table 2).

The procedure had to be abandoned in no patient. There was no significant complication in any of the patients. Three patients (2%) suffered from a vasovagal syncope due to direct stimulation of vagus nerve during TNE (Table 2).