Unsedated transnasal endoscopy (uTNE) is a procedure in which a health care provider uses an endoscope—a thin, flexible tube equipped with a camera and light—to examine the upper gastrointestinal (GI) tract in children, adolescents, and adults. The upper GI tract is made up of the esophagus, stomach, and duodenum—the first part of the small intestine. uTNE is used to assess, diagnose, monitor, and/or treat conditions that affect the upper GI tract, including eosinophilic esophagitis and gastroesophageal reflux disease (GERD). During the procedure, the provider is able to visually examine the upper GI tract and take biopsies.

During a uTNE, the provider inserts the endoscope into the nose, down the throat, and into the stomach and the duodenum. The camera at the end of the scope sends video to a monitor in the procedure room, allowing the provider to visually examine the lining of the upper GI tract.

Unlike a traditional upper GI endoscopy (a procedure used to examine the esophagus, stomach, and small intestine via an endoscope that is inserted through the mouth), uTNE does not involve IVs or sedatives. Because patients are not sedated for uTNE, recovery is faster, complications associated with sedation are avoided, and people can return to normal activities soon afterward.

“Transnasal endoscopy is an easy way to evaluate the upper GI tract without the risks of anesthesia,” says Yale Medicine pediatric gastroenterologist Alex Koral, MD. “The procedure is short and patients can quickly return to their normal activities without requiring a long recovery time.”

uTNE is a medical procedure for examining the esophagus, stomach, and small intestine. It is an alternative to upper endoscopy, sometimes called endoscopy, upper GI endoscopy, or esophagogastroduodenoscopy (EGD). Both procedures are used to examine the upper GI tract, though there are differences between them.

In most cases, during upper endoscopy, patients are given an IV sedative that relaxes them and makes them unaware of the procedure. In a traditional upper endoscopy, the provider inserts an endoscope that is around 10 millimeters (0.39 inches) in diameter into the patient’s mouth (thinner endoscopes are used for small children), then passes it down the esophagus and into the stomach and duodenum. During the procedure, the provider visually examines the lining of the upper GI tract. Small surgical instruments can be inserted through the endoscope and used by the provider to biopsy tissues or perform other treatments and interventions.

uTNE differs from upper endoscopy in a few important ways. In uTNE, an ultrathin endoscope—around 3 to 6 millimeters (about 0.11 to 0.23 inches) in diameter and 600 to 1100 millimeters (about 24 to 43 inches) in length for adults and 2.8 to 4.2 millimeters (about .11 to .17 inches) in diameter for children and adolescents—is inserted into the nose, rather than the mouth. Inserting the tube into the nose is less likely to prompt a gag reflex than inserting it into the mouth.

Also, unlike a traditional upper endoscopy, uTNE does not involve sedation (though an anesthetic spray or gel is applied to the nose and mouth to reduce pain and improve patient comfort during the procedure).

Because sedatives are not used, patients are alert throughout the procedure, have a faster recovery, avoid complications related to the use of sedatives and anesthesia, and can resume normal activity as soon as they are discharged from the clinic.

Some clinics and other locations that provide uTNE offer children and adolescents entertainment options to help distract them during the procedure. Options may include virtual reality (VR) goggles or video goggles that patients wear to watch videos, headphones to listen to music or other programs, and/or a television.

In all, uTNE is an effective, safe, and well-tolerated procedure for examining the upper GI tract.

In children and adolescents, uTNE has been used to assess and manage the following conditions:

• Eosinophilic esophagitis (a condition in which eosinophils, a type of immune cell, build up in the esophagus where they cause inflammation and symptoms, such as difficulty swallowing, reflux, and vomiting)
• Difficulty swallowing (dysphagia)
• Barrett’s esophagus (a condition in which tissue lining the esophagus is replaced by tissue that is similar to the intestinal lining)
• Candida esophagitis (inflammation of the esophagus due to an infection by Candida, a type of yeast)
• Abdominal pain
• GERD
• Celiac disease

In adults, uTNE has been used to assess and manage a broader range of conditions than for children and adolescents, including:

• Difficulty swallowing
• Feeling of a lump in the throat (known as globus sensation or globus pharyngeus)
• GERD or reflux symptoms
• Barrett’s esophagus
• Eosinophilic esophagitis
• Vomiting
• Stomach cancer
• Esophageal varices (enlarged veins in the esophagus)
• Peptic ulcers in the stomach and/or duodenum (gastroduodenal ulcers)
• Heliobacter pylori infection (a type of bacteria that infects the stomach and results in peptic ulcers, inflammation of the stomach lining, and stomach cancer)
• Celiac disease

uTE may also be used for other reasons such as the placement of a nasoenteral feeding tube (a tube that is inserted through the nose and delivers food to the stomach or small intestine).

Though uTNE is a safe, well-tolerated procedure, complications are possible, including:

• Nosebleeds (typically mild and stops within a few minutes after the procedure)
• Fainting
• Vomiting
• Nasal or throat pain
• Upper GI bleeding
• Perforation (hole) of the esophagus, stomach, or small intestine

The health care provider will provide patients with instructions on how to prepare for the uTNE.

Instructions may vary from one clinic to another, but in general, patients should stop eating and drinking at least two hours prior to the procedure. This helps ensure that the stomach is empty during the procedure, which allows the health care provider to better visualize the stomach lining. Emptying the stomach also reduces the risk of vomiting during the procedure, which can cause food or liquid to get into the lungs, where it can result in an infection. Small sips of water may be taken up to two hours before the uTNE.

Before the procedure begins, an anesthetic spray or gel will be applied to the patient’s nostrils and mouth to reduce pain and discomfort during the procedure.

With the patient seated in an upright position or lying on their left side, the health care provider will insert a lubricated, ultrathin endoscope into the patient’s nose, into the esophagus, into the stomach, and possibly into the duodenum. Patients can breathe and talk during the procedure. For pediatric patients, parents may accompany them during the procedure.

The provider examines the upper GI tract as the endoscope passes through each section. Small instruments can be passed through the endoscope so the provider can collect tissue biopsies or perform other procedures. During the procedure, the provider may pump air into the upper GI tract. This is done to help the provider better visualize the tissues along the length of the upper GI tract, though it may make the patient feel bloated.

At the end of the procedure, the provider removes the endoscope. A uTNE usually takes around 10 to 20 minutes to complete.

In general, patients recover quickly from a uTNE procedure. Before getting discharged, a health care provider will ensure that there is no bleeding or pain.

Patients can resume eating and drinking when the local anesthetic spray or gel wears off, usually within half an hour of completing the procedure. After leaving the clinic, patients can resume normal activities without restrictions.

“Yale is one of the first programs nationally to perform this procedure on children and the first on the East Coast,” says Dr. Koral. “Providers at Yale are recognized locally and nationally for their experience performing uTNE.”