TNE – Transnasal Esophagoscopy Is the Best and Safest Endoscopy Choice for Acid Reflux

Who Should Get Upper Endoscopy?

Middle-aged people with acid reflux, both respiratory (aka LPR) and esophageal (GERD), should have at least one esophageal screening examination to determine if they have significant esophageal pathology. If the reflux is long-standing and/or started at a young age, I suggest endoscopy at age 40, sometimes younger; otherwise screening endoscopy in refluxers should be done at age 50.

Note: Esophagoscopy is not how to diagnose reflux; it is done to check for esophageal pathology secondary to reflux; most people have normal examinations.

Today’s Bogus “State of the Art” for Endoscopy?

If you have reflux symptoms, your primary care physician (PCP) is probably going to send you to a gastrointestinal (GI) specialist, and the GI is going to recommend sedated endoscopy, EGD (esophagogastroduodenoscopy). It will likely be performed in a surgicenter (ASC, ambulatory surgery center), possibly one owned by the GI doctor … with a massive conflict of interest? There are many problems with this …

First, there are risks associated with anesthesia. During EGD, the patient is sedated, and serious complications may occur, even death. Adverse effects from EGD are reported in as many as 1:200 patients, and mortality rates are as high as 1 in every 2000 patients. Remember, this is how Joan Rivers died. 

Second, there is inconvenience undergoing anesthesia, because that day is lost and you will need someone to pick you up after the EGD; and you’re not allowed to drive (or operate heavy machinery) until the next day.

Third, EGD is performed in an outpatient clinic, either an ASC or hospital. Both charge a facility fee in addition to the standard professional fee, making it more costly.

Finally, EGD is not the best, most cost-effective diagnostic for acid reflux.

There is a better option, TNE (Transnasal Esophagoscopy). That is the technology that I used in my practice to examine thousands of patients without them needing to rearrange their entire day to have a basic screening diagnostic procedure performed. FYI: The procedure itself only takes about 10-15 minutes; however, it takes time for nasal anesthesia and pre- and post-examination counseling and discussion. The whole thing takes about an hour.  

TNE should completely replace sedated endoscopy, EGD, since it is cheaper, safer, and as accurate (maybe better) for diagnosis, especially for Barrett’s Esophagus, than EGD. It is in every way superior.

What Is Transnasal Esophagoscopy (TNE)?

In 1999, the Pentax Corporation gave me one of their first ultra-thin, flexible esophagoscopes for examination of the throat, esophagus, and stomach. Because this thin scope was put through the nose, it was called trans-nasal.

TNE is performed in the office while you’re awake and comfortable. You don’t need to be sedated, or anesthetized, “put to sleep.” You will walk out of the office on your own power as soon as the procedure is complete and you have discussed the findings. FYI: Most people with respiratory reflux have normal esophageal exams.

In the hands of an experienced doctor, with numbing of the nose (the only thing that might otherwise hurt), TNE is painless and almost everyone tolerates it well. The actual procedure takes less than 15-minutes (even if biopsies are taken) and TNE requires no recovery time. Also, TNE is completely safe. Unlike EGD, no one has ever died from it and there aren’t any serious complications either. And TNE is comparable to EGD in terms of accuracy of diagnosis.  

How GIs Have Maintained Their Outdated “The State of The Art”?

In the 1970’s, the Olympus Company made quality endoscopes which allowed GI doctors to perform upper endoscopy (EGDs) and colonoscopies. I’ll bet when those scopes came out some GI said, “Wow! There’s gold in them thar hills!” If so, they would have been right … today, GI endoscopy is a multi-billion-dollar business.

I’m astounded that in a country that supposedly prioritizes scientific progress and innovation that sedated EGD is still considered the “State of the Art” decades after evidence tells us otherwise. The GI position on reflux is wrong for the following reasons:

Gastroenterologists falsely believe that reflux is a chronic disease. I know this isn’t true because I have personally cured thousands of patients with GERD and respiratory reflux through diet and lifestyle changes; see my book Dropping Acid.

Some GI opinion-leaders don’t “believe” that one can throat reflux (respiratory reflux aka LPR) at all, and adamantly maintain the position that reflux symptoms are heartburn and indigestion and that reflux is an esophageal disease, period. Really?!

Sidebar: A study of 200 patients with reflux reveals that 17% had heartburn sometimes and only 7% had it as their chief complaint. For every GERD patient, there were/are four respiratory reflux (LPR) patients.

After years of diagnosing and treating patients, running my own reflux testing lab (using accurate pH-testing technology), and systematically documenting and reporting my clinical findings, the evidence that reflux does indeed get into the throat is absolutely 100% undeniable.

For Reflux … Gastroenterologists Are Like Dinosaurs; But Unlike Dinosaurs, They Deserve to Die Out

GIs hijacked reflux and maintained their heartburn business model for so long that no other physicians, including those who deal with the consequences of respiratory reflux and respiratory diseases, e.g., otolaryngologists, pulmonologists, also remain clueless about the link between respiratory reflux and respiratory disease.

The GI treatment plan for reflux is not really any treatment at all. It’s a symptom amelioration plan that does nothing to address the problem, the root cause. I believe that GIs made so much money using the 1970s protocol ― stick a scope down patients and then put them on pills ― that they had no incentive to change or innovate. FYI: GIs make an average of almost $450,000 a year, more than any other internal medicine specialist. That’s almost as much as most surgeons make.

For almost 50 years (1975-2023), the GI “heartburn business model” hasn’t changed; it’s a scoping and some pills. No surprise: GIs have no tests or treatments for respiratory reflux, and most of them don’t even recognize it.

How GI Sabotaged the Competition (TNE)

GI sabotaged TNE! Here’s what happened. When I began performing TNE, Medicare physician reimbursement was about three-times the EGD rate; that is because TNE had no facility fee, and it was done in the doctor’s office. Perhaps this was Medicare’s way of encouraging TNE as a less-expensive alternative to EGD.

In 2014, Medicare reimbursement for TNE was crushed under GI influence. Physician reimbursement for TNE was lowered to $83, and a completely unwarranted facility fee suddenly appeared. So, if a doctor did TNE in her office, she would receive only $83, and could not charge the facility fee. In my opinion, this was GI’s way of destroying the competition … because they recognized that TNE was a threat to EGD. Is this not essentially monopolistic restraint of trade!

TNE is cheaper, safer, and better-for-patients technology than EGD, and it needs to replace EGD as the preferred esophageal screening procedure for patients with acid reflux. Furthermore, I would propose that in the future primary care physicians be trained to perform TNE … or … another option would be to have physician assistants trained to do the TNE procedures under physician supervision.

How Do I Get TNE?

Unfortunately, finding a doctor-endoscopist who performs TNE may take some effort. Please do not contact me to ask for specific recommendations. I don’t have a list of doctors in the country that perform TNE so I can’t help you that way. However, here’s how you might find a TNE doctor in your area…

Get online and search for a Medical School Otolaryngology Department. For example, if you want to find a doctor who performs TNE in New York, you can search for “Otolaryngology Mount Sinai.” Alternatively, you can search for “Otolaryngology and transnasal esophagoscopy and New York.”

Then call the Otolaryngology department and ask the receptionist if you can speak to a clinical person, perhaps a nurse or physician assistant to find out if they have a reflux specialist doctor who performs TNE. If they don’t, ask if they can recommend a local doctor who does do TNE.

Medicare Awaken & Call to Action

It is high time for Medicare to review TNE coding, increase its reimbursement, and discontinue paying facility fees for it. TNE could then grow and someday replace EGD.

Transnasal esophagoscopy (TNE) is the future of upper endoscopy; however, the reimbursement of under $100 is too low, and acts as an enormous disincentive; I would suggest a physician fee of about $500, which is less than the professional and facility fees for EGD, and the facility fee reimbursement for TNE should be discontinued.

Dear Reader: Please consider writing to your Congressman and Senator letting them know you demand better access to TNE. Also, you could email Xavier Becerra, Secretary of Health and Human Services, email: Xavier.Becerra@hhs.gov, and Chiquista Brooks-LaSure, Administrator for the Centers for Medicare and Medicaid Services (CMS). She oversees Medicare and her email is: Chiquista.Brooks-LaSure@hhs.gov.