Reporting the how, where, and grading of nasomucosal injury after transnasal endoscopy

We read with interest the article by Mori et al. [1] on their proposal for grading nasomucosal injury from grade 0 (no injury), grade 1 (mucosal redness), grade 2 (oozing hemorrhage), to grade 3 (overt bleeding). A reporting system to record nasal injury/bleeding after ultrathin transnasal esophagogastroduodenoscopy (UT-EGD) is important for the next pre-exam reference. There are several solid data showing UT-EGD to be a safe procedure with minor complications [2], which contradict Mori’s statement about “lack of data regarding its safety.” Thus, the American Society for Gastrointestinal Endoscopy report on UT-EGD published 10 years ago may require amendment.

A grading scale for defining difficulty of insertion through the middle or inferior nasal meatus is also important because it may be correlated with the severity of nasomucosal injury/bleeding. Oozing hemorrhage (Mori grade 2) may become overt bleeding (Mori grade 3) within seconds ([Fig. 1], panels A1 to A4), thus careful observation of this subtle change is mandatory.

Fig. 1 Hu grading scale of nasomucosal bleeding. Panel A shows the subtle change of bleeding from Mori grade 2 to Mori grade 3 (A1 to A3; dotted arrows represent gradual change) in 36 seconds; it soon becomes confined with tender suction (A4). Panel B demonstrates grade 1 injury (mucosal redness, B1), Hu grade 2 confined hemorrhage (B2), and Hu grade 3 unconfined anterior bleeding (B3 to B4). Panel C reveals Hu grade 3 unconfined posterior bleeding (C1 to C4; solid arrows represent rapid dynamic change).

The term “oozing” is inappropriate because it indicates progressive bleeding. Grade 1 epithelial injury presents as mucosal redness ([Fig. 1], panel B1). Nevertheless grade 2 should be unambiguously re-defined as “confined hemorrhage” around the injury site inside the nasal cavity ([Fig. 1], panel B2), and grade 3 as “unconfined bleeding” that oozes to the extent that blood comes out from the nostril (anterior epistaxis; [Fig. 1], panels B3 and B4) and/or drains into the hypopharynx (posterior epistaxis; [Fig. 1], panels C1 to C4).

Endoscopists should try to avoid unconfined grade 3 bleeding. First, epistaxis is always annoying to patients and frustrating to endoscopists. Second, a nosebleed back to the hypopharynx may cause suffocation. The mechanisms of nasal bleeding during nasal anesthesia, insertion or extubation, should also be reported (to define “how”). From our study the highest incidence of bleeding was in the inferior nasal turbinate; the second most frequent site of bleeding was from the anterior nasal septum, which is known as the Little’s area or Kiesselbach’s plexus (to describe “where”) [3]. Above all, endoscopists need a universal reporting system that not only shows severity of nasomucosal injury and bleeding but also should detail “how and where” so that these complications may be avoided in the next transnasal endoscopy.

Competing interests: None

References

• 1 Mori A, Ohashi N, Maruyama T. et al . A proposal for grading nasomucosal injury as a complication of transnasal endoscopy.  Endoscopy. 2008;  40 Suppl 2 E60
• 2 Tatsumi Y, Harada A, Matsumoto T. et al . Current status and evaluation of transnasal esophagogastroduodenoscopy.  Dig Endosc. 2009;  21 141-146
• 3 Hu C T. Endoscopic-guided versus cotton-tipped applicator methods of nasal anesthesia for transnasal esophagogastroduodenoscopy: a randomized, prospective, controlled study.  Am J Gastroenterol. 2008;  103 1114-1121