Endoscopic-guided or cotton-tipped applicator nasal anesthesia for transnasal esophagogastroduodenoscopy?

Unsedated transnasal esophagogastroduodenoscopy (EGD) is emerging as a viable alternative to conventional sedated EGD in a number of clinical settings. The success of this technique depends upon careful patient selection, the endoscope technology available and selection of the optimal method of topical nasal anesthesia. This Practice Point commentary discusses a randomized, prospective study by Hu that compared endoscopic-guided nasal anesthesia with cotton-tipped applicator nasal anesthesia for unsedated transnasal EGD in Taiwanese patients. In this study, endoscopic-guided nasal anesthesia was associated with superior patient tolerability, less epistaxis, better visualization capacity and a shorter procedure time compared with cotton-tipped applicator nasal anesthesia. This study was, however, performed at a single center by a single investigator and involved a single racial group without patient crossover. It is well recognized that nasal cavity anatomical differences exist between white and Asian individuals. It is our opinion that the most important factor for successful unsedated transnasal EGD is the size of the outer diameter of the endoscope.