Background and Aims:
Catheter based high-resolution esophageal manometry (HRM) remains the gold standard diagnostic test for evaluation of suspected esophageal motility disorders. Despite its widespread use, testing is uncomfortable with the ideal topical anesthetic regimen to maximize patient tolerance not well defined in the literature. Intranasal and/or gargle and swallow viscous lidocaine is commonly used but frequently encountered patient discomfort often leads to failure of study completion and necessitates a second line test of esophageal function. As part of a quality improvement initiative prompted by frequent aborted procedures in our motility clinic, we changed our anesthetic protocol to one used by our otolaryngology colleagues consisting of 4% lidocaine plus 0.05% oxymetazoline topical intranasal spray along with viscous 2% lidocaine oral gargle and swallow. We then evaluated for an increase in procedural success rates.

Methods:
We retrospectively reviewed charts for patients who underwent HRM at our institution for the evaluation of dysphagia, chest pain, or refractory GERD. Patients that underwent HRM from April 2022 to November 2022 had been anesthetized with 2% viscous lidocaine administered via syringe both intranasally and orally consistent with the standard pre-procedure practice in our motility lab. We subsequently looked at manometries performed after November 2022 following the implementation of an alternate pre-procedure regimen using viscous 2% lidocaine gargle and swallow along with viscous 4% lidocaine plus 0.05% oxymetazoline delivered intranasally via a syringe with an atomizer attachment. Studies were included sequentially over this period except for on two occasions when catheter placement was attempted by a technician on the first day of training. Primary outcomes included success rate and necessity of second tier testing after a failure.

Results:
The study included a total of 100 patients, 48 of which had received the traditional standard treatment with viscous 2% lidocaine, and 52 receiving the new anesthetic regimen. Toleration rates were notably higher in the post-implementation group (85% vs. 66.6%) and there was a statistically significant difference in the need for second tier tests (Esophagogastroduodenoscopy with Impedance Planimetry (Endoflip^TM) or Barium Esophagram) required to further evaluate patient symptoms, 15 (31.3%) vs. 6 (11.5%) (CI 95%, p=0.021).

Conclusions:
The use of 4% lidocaine-0.05% oxymetazoline topical spray via nasal atomizer in addition to oral viscous 2% lidocaine both improves the tolerance of HRM and reduces the cost, delay in diagnosis, and additional time investment required for second-line testing, which ultimately may not provide a diagnosis. Head-to-head prospective studies are required to assess optimal topical anesthetics prior to HRM.

Samuel Owen

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