Women and transnasal endoscopy

Abstract

It was with great interest that I read the articles on transnasal endoscopy by Zaman et al.1Zaman A Hahn M Hapke R Knigge K Fennerty MB Katon RM A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoendoscope.Gastrointest Endosc. 1999; 49: 279-284Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, Dumortier et al.2Dumortier J Ponchon T Scoazec J-Y Moulinier B Zarker F Paliard P et al.Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance.Gastrointest Endosc. 1999; 49: 285-291Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, and Craig et al.3Craig A Hanlon J Dent J Schoeman M A comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients.Gastrointest Endosc. 1999; 49: 292-296Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar and the accompanying editorial4Sivak Jr, MV The nose: Is this the route to improving esophagogastroduodenoscopy [editorial]?.Gastrointest Endosc. 1999; 49: 395-398Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar in the March 1999 issue of Gastrointestinal Endoscopy . Regarding gender-based issues of tolerance and acceptance of endoscopic procedures, I would like to highlight an area adequately discussed. It is that women do not tolerate peroral or transnasal EGD as well as men because the female nasopharynx is smaller than that of men. A clear relationship has been established between instrument diameter and discomfort during intubation regardless of whether it is peroral or transnasal. Zaman et al. noted that transnasal EGD was associated with significantly more pain on insertion than peroral EGD (6 mm endoscopes). No gender differences were seen but numbers were small. They also cited the data of Mulcahy et al.5Mulcahy HE Alstead EM McKenzie C Riches A Kiely M Farthing MJG et al.A randomized trial of a 5.5mm vs 9.5mm diameter videogastroscope in unsedated upper GI endoscopy [abstract].Gastrointest Endosc. 1997; 45: AB54Abstract Full Text PDF Scopus (6) Google Scholar that an ultrathin (5.9 mm diameter) endoscope is better tolerated perorally than a standard 9.5 mm upper endoscope. Craig et al.3Craig A Hanlon J Dent J Schoeman M A comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients.Gastrointest Endosc. 1999; 49: 292-296Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar note that their 5.3 mm endoscope was easier to pass transnasally than their 5.9 mm endoscope which was associated with more failures and more epistaxis. Craig et al. also notes that once intubation has been achieved tolerance was the same for nasal or oral intubation. No gender differences in tolerance were reported, again a small sample. Dumortier et al.2Dumortier J Ponchon T Scoazec J-Y Moulinier B Zarker F Paliard P et al.Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance.Gastrointest Endosc. 1999; 49: 285-291Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar noted that women tolerated transnasal EGD less well and were more likely to require a transoral EGD (both done with 6 mm instruments). They comment that the high frequency of failure of transnasal EGD in women may be due to anatomic factors, specifically smaller nasal diameter. It is not clear whether the failed transnasal EGDs failed in women because of nasal pain, but the authors note outright inability to traverse the nasal passages with the endoscope. A different method of topical nasal anesthesia (cotton pledgets with a 5% lidocaine-0.002% naphazoline solution) was used in this study compared with that of Zaman et al. (nasal spray of 1% phenylephrine/4% lidocaine) and Craig et al. (lidocaine spray). This may or may not play a role. Women, on average, have a smaller facial and oropharyngeal structure than men. It is no surprise then that they would be less tolerant, on average, of nasal and oral intubation with a given diameter instrument than men. This may help to explain the rather contradictory information to date that women are less tolerant of upper endosocopy than men but overall have a higher pain tolerance. It would also lead one to the conclusion that transnasal endoscopy in women, and perhaps everyone, is best performed with the smallest instrument available (5.3 mm), other technical issues aside. The study of endoscopic tolerance between the sexes may best be served by examining the data such as that on anatomy rather than speculating about personality.