All About Transnasal Endoscopy

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi everyone and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today we're going to talk about a topic we have not talked about in the past and that's transnasal endoscopy. And I'm very pleased to have Dr. Sophia Patel, who's a pediatric gastroenterologist here at Cleveland Clinic Children's. And welcome to the podcast, Dr. Patel.

Dr. Sophia Patel: Thank you. I appreciate the chance to be interviewed.

Dr. Scott Steele: So, we always like to start with all of our guests a little bit more about you. So can you tell us a little bit about your background, where you're from, where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Sophia Patel: Absolutely. I'm actually a native Ohioan. I was born in Northeast Ohio in Bryan, Ohio, actually, which is the land of Dum Dum suckers, which a lot of people love. And I went to college at Kent State. I did a combined program and graduated from medical school within seven years of graduating high school, at NEOMED. And from there, I came here to Cleveland Clinic Children's and I did my pediatrics residency here followed by my pediatric gastroenterology fellowship. And after graduation, I became very interested in the eosinophilic diseases of the esophagus. And that led me to my interest in doing transnasal endoscopies. So that's what led us here.

Dr. Scott Steele: As we talked about a little bit before, on this episode, we're going to discuss this procedure called transnasal endoscopy. So at a high level, what is this procedure? Who's it for? And what does it help treat?

Dr. Sophia Patel: That's a wonderful question. I was lucky to have a very good mentor with Dr. Paul Bryson, who is a otolaryngologist, who is the other person at Cleveland Clinic who does this procedure. He primarily does it in patients who have a higher level of esophageal types of cancers. And in the pediatric population, it's actually been used since about early 2015 in evaluating patients without sedation who need scopes for repeated endoscopies for eosinophilic esophagitis.

So those patients are frequently needing scopes up to three to four times a year to evaluate disease process, and also to take a look and see what their eosinophil counts look like, which helps us guide how we treat those patients and what medication changes they may need. So an endoscopy in pediatrics can be very invasive. Most of those patients have to get put to sleep under anesthesia. The whole process takes anywhere from two to four hours with fasting the night before, coming in, getting put to sleep with propofol and having to go through a procedure, which is anxiety inducing for our pediatric patients. Fortunately, this procedure can be done unsedated. They don't have to fast for a long period of time. And it's very quick, easy in and out.

Dr. Scott Steele: So, you just mentioned some of the benefits for that, especially within younger patients. But how do you convince the kids that I'm going to take this long tube and I'm going to put it down your nose. Does that take a lot of convincing too? Because the benefits are there.

Dr. Sophia Patel: It does sometimes. Yeah, it does. As you can imagine, a lot of times ENTs sometimes will kind of spring it on you when you go into the office visit. I tend to take a little bit more proactive approach where I talk with them about it. We discuss how they shouldn't feel anything. We numb their nose and their throat very well. They can still feel, obviously, some sensations. And our hope is that with the other data that we have from Dr. Friedlander's group, who is out in Colorado, that using virtual reality goggles has been very helpful as well.

So they're actually not able to watch you do the scope. They're watching Netflix or they're playing a game. So a lot of times, distracting them is going to be the best way that we can get them to agree. And we are starting with patients who are a little bit older. So our 15 and older population is kind of our target right now. A lot of times it's the parents that really agree more than the kids. The kids are like, oh no, it was fine the last time. I fell asleep. And the parents are like, no, you missed school. I had to miss work. I had to bring you in. You had to stay home the whole day. You couldn't go to soccer practice. So it does, it's a risk benefit ratio. Most of them do eventually end up agreeing to going through with the procedure though.

Dr. Scott Steele: So I'm a patient or a family member that's coming in to see you for this procedure. Walk me through important steps that need to be taken prior to this procedure.

Dr. Sophia Patel: So luckily because it's such a not-so-invasive procedure, there's not a lot to do. So, you only have to have woken up and not eaten breakfast. The patients typically are not going to be ones that need dilation or something like that more advanced type of procedure. They come in, we meet with them and we do history and physical exam, make sure they haven't had any recent illnesses. And then we spray their nose and mouth with the lidocaine spray, which helps numb everything and they're not able to feel as much. The patient then gets to put on their reality goggles. And we have a trained nurse that works with us as well. And so while they're watching their video, we insert the tube into their nose. And the tube is very small, they're two and a half millimeters. So it goes in through the mouth. We have them swallow a few times so we can help with getting it into the esophagus. And then from there we're able to visualize, take photos, do the biopsies, which again are not painful. They may feel some tugging sensations. And then the scope is over after that and we let them rinse their mouth out if they need to. They take the goggles off and they can walk out of the office and go home.

Dr. Scott Steele: Fantastic. So truth or myth? A transnasal endoscopy typically lasts about 15 minutes and you can return to your normal activities afterwards.

Dr. Sophia Patel: Yeah. That's truth. So they come in, they meet with us, we move them to our endoscopy room. Possibly they'll be just seen immediately there in that room as well. And luckily, because it's such a quick and easy procedure, most people tolerate it very well. It has very few long term side effects, or even short term, during the right after the post-procedural time. And those patients do really great. They're allowed to leave. We do schedule a follow up to discuss the pathology results, which we're able to get during the procedure. And hopefully we can fix their eosinophil esophagitis while we're at it.

Dr. Scott Steele: So, what is kind of that sweet spot? When would this procedure be considered for a child?

Dr. Sophia Patel: So, the patient that would be a good candidate for this procedure would be someone who has already had a scope, that's been put to sleep for a scope, and a patient who is just getting monitored for long term treatment outcomes. So, we're looking for the patient who has not had very significant symptoms. If they've had dysphasia more than two to three times a week, it is possible that they could have a dilation needed and we may have to convert it to a different type of scope.

Patients who are actively having food getting stuck also would be a patient that might not be the best candidate. Because if there is, again, a narrowing or a stricture, then that's not something we can fix with the scope. And that does put them at a little bit of a higher risk than a normal patient would be at. But these patients that we typically see are going to be the ones who have been on treatment for at least several months. They're comfortable with the procedure. They've had the scope done sedated so they're aware of what will happen afterwards. And they typically have fairly good control of their symptoms and we're kind of doing it just for monitoring essentially.

Dr. Scott Steele: So you mentioned that you're doing some of this in kind of 15 years or older, but why might this procedure be a better option for even a younger patient? Or what are the indications for that population?

Dr. Sophia Patel: Yeah, that's a great question. So many of the anesthesia studies that we have looking at patients who are under the age of five, most often, there are higher risks of developing other bad neurocognitive outcomes from anesthesia. Obviously there are risks of aspiration in getting put to sleep. A lot of patients have allergies to anesthesia medication. So in the younger population, that would be a really great option, too, in the future because then we don't have to put them to sleep for those cases.

They do have to be a little bit more compliant with the actual scope. So it's a little bit more difficult to get a five year old to agree to it than a 12 year old. So, definitely we're starting with the older patient population, but I think we could expand it to the younger families as well.

Dr. Scott Steele: So are there any advancements on the horizon in terms of transnasal endoscopy?

Dr. Sophia Patel: Yeah. That's a great question. I think in itself it's kind of a newer procedure. And what we've talked about in our department is also using it for patients for monitoring who've had tracheoesophageal fistula repairs. Patients who have tracheostomy tubes already get ENT evaluations. So it might be a good idea to do it in our airway clinic, which it can be very useful because then those patients who are at very high risk of getting put under anesthesia can just have this very simple procedure done and they don't have to worry about that, too. So, that's definitely on the horizon for us.

Dr. Scott Steele: Okay. So now it's time for our quick hitters, when we get to know our guests a little bit better. So Sophia, tell me a little bit about what's your favorite food?

Dr. Sophia Patel: Oh, my favorite food. That's tough. I'm going to say mac and cheese, like a good mac and cheese, especially from Lucky's in Cleveland. So, anyone that's coming to Cleveland, highly recommend the mac and cheese from Lucky's for brunch.

Dr. Scott Steele: I got to interrupt here and say there's nothing like the good old out of the box mac and cheese. I'm sorry about that.

Dr. Sophia Patel: I agree with you.

Dr. Scott Steele: What is your favorite sport to watch and or play?

Dr. Sophia Patel: Favorite sport to play is tennis. I played a lot in high school and now I have a six year old who's getting really into it. So it's fun to play with him too, just out on our driveway. And favorite sport to watch would probably be, I'm a Browns fan. So I'm going to put that out there. I don't love watching football, though. I probably enjoy watching tennis, too, and trying to keep up with more Cleveland sports. So baseball, football, Cavaliers, love Cavaliers basketball, too.

Dr. Scott Steele: That's great. So despite the recent pandemic, what's your favorite travel destination?

Dr. Sophia Patel: Oh, that's a great question. So in the last year we went to Disney World, which was really fun. Because again, I have two small kids, so they had a great time, too. I will say overall favorite travel destination is Iceland. Went there a couple years ago. It's a beautiful country. Amazing hiking. Every turn is like a waterfall. It's beautiful. So I would definitely say that's one of my favorite destinations that I've been to.

Dr. Scott Steele: Oh, we just took the family back two months ago. And so finally -

Dr. Sophia Patel: Oh nice.

Dr. Scott Steele: Finally, to wind up, tell us something you like about living here in beautiful Northeast Ohio.

Dr. Sophia Patel: Oh, you can't beat the summers in Cleveland. It's just amazing. You get to drive five minutes and get to the lake, hang out on the beach. And then we have so many amazing activities, just outdoors and playgrounds and outdoor, just fun places to hang out, Van Aken district. I live near Crawford park, we're there's quite a lot. And then just the people here, they're all just wonderful. And I can't imagine myself living anywhere else.

Dr. Scott Steele: That's fantastic. Amen to that. So what's a final take home message for our listeners regarding the transnasal endoscopy.

Dr. Sophia Patel: Yeah. So we're really excited to get it started here at Cleveland Clinic Children's, especially in our eosinophil esophagitis clinic. And I didn't mention I'm the co-director of that clinic. And we're really excited to bring it to hopefully help patients get back to their normal lives a little bit faster. That's always our goal here to make people feel better and we really care about trying to get people to feel better faster.

Dr. Scott Steele: Well, that's great. And so for more information about Cleveland Clinic children's gastroenterology, hepatology and nutrition department, please visit ClevelandClinicChildrens.org/GI. That's ClevelandClinicChildrens.org/GI. You can also call us at 216.444.5437. That's 216.444.5437. Dr. Patel, thanks so much for joining us on Butts and Guts.

Dr. Sophia Patel: Thank you so much. I appreciate the invitation.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.