and demonstrated that it is highly sensitive for detection of high-grade dysplasia. 6,7 Furthermore, a prospective, randomized, crossover study in patients with high-grade dysplasia or early cancer in Barrett’s esophagus, indigo carmine chromoendoscopy and NBI were found to be com- parable as adjuncts with high-resolution endoscopy in identification of subtle lesions. 8 Therefore, TNE with in- tegrated NBI may serve to improve diagnostic capabilities in ENT practice. A prospective TNE investigation com- paring white light illumination with NBI will assess whether NBI technology will be useful in overcoming the current incongruence between endoscopic and his- tologic diagnosis of Barrett’s esophagus in the hands of the otolaryngologist. KOUROSH PARHAM, MD, PHD Division of Otolaryngology Department of Surgery University of Connecticut Health Center Farmington, Connecticut BIBLIOGRAPHY 1. Postma GN, Cohen JT, Belafsky PC, et al. Transnasal esopha- goscopy: revisited (over 700 consecutive cases). Laryngo- scope 2005;115:321–323. 2. Andrus JG, Dolan RW, Anderson TD. Transnasal esophagos- copy: a high-yield diagnostic tool. Laryngoscope 2005;115: 993–996. 3. Halum S, Postma GN, Bates DD, Koufman JA. Incongruence between histologic and endoscopic diagnoses of Barrett’s esophagus using transnasal esophagoscopy. Laryngoscope 2006;116:303–306. 4. Saeian K, Staff DM, Vasilopoulos S, et al. Unsedated transna- sal endoscopy accurately detects Barrett’s metaplasia and dysplasia. Gastrointest Endosc 2002;55:472– 478. 5. Gono T, Yamazaki K, Doguchi N, et al. Endoscopic observation of tissue by narrowband illumination. Optical Rev 2003;10: 211–215. 6. Kara MA, Ennahachi M, Fockens P, et al. Detection and classification of the mucosal and vascular patterns (mu- cosal morphology) in Barrett’s esophagus by using nar- row band imaging. Gastrointest Endosc 2006;64: 155–166. 7. Sharma P, Bansal A, Sharad M, et al. The utility of a novel narrow band imaging endoscopy system in patients with Barrett’s esophagus. Gastrointest Endosc 2006;64: 167–175. 8. Kara MA, Peters FP, Rosmolen WD, et al. High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett’s esophagus: a prospective randomized crossover study. Endoscopy 2005;37:929 –936. Nasal Obstruction, Sleep Disorder, and Fatigue: Cause and Effect Remain Elusive Dear Editor: Udaka et al. 1 documented an association between nasal obstruction, increased daytime sleepiness, and di- minished quality of life. A re-analysis of my previously published data supports their findings. 2 In a case-controlled study of 297 consecutive general medical out-patients under the age of 40 years presenting for a physical examination, 146 (49%) complained of unilateral or bilateral nasal obstruction when asked to breathe from one nostril while occluding the other nostril. When compared with the group without nasal obstruction, this group was characterized by excessive daytime sleepiness (24% vs. 11%; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.4 –5.1) and fatigue (34% vs. 11%; OR, 4.1; 95% CI, 2.2–7.6). Chronic rhinosinusitis (CRS) symptoms were also more common in this group (frontal headache [23 vs. 5%; OR, 5.4; 95% CI, 2.4 –12.2], facial pressure [34 vs. 13%; OR, 3.4; 95% CI, 1.9 – 6.1], and postnasal drip [34 vs. 16%; OR, 2.8; 95% CI, 1.6 – 4.8]). Self-described sleep problems, however, were not more common in patients with nasal obstruction (14 vs. 11%; OR, 1.3; 95% CI, 0.7–2.7). As also noted by Udaka et al., the body mass index was the same in patients with and without nasal obstruction. Because approximately 80% of patients with CRS are fatigued, 3 it is possible that nasal obstruction is simply a marker for a CRS, a possibility also mentioned by the authors. Although sleep disturbance is associated with nasal obstruction and CRS, it is not clear that this is the only or major cause of fatigue noted in these groups. Other possibilities include a systemic response to sinus and na- sal inflammation, psychological distress, and a reflex re- sponse to nasal irritation. Of interest, topical intranasal steroid use has been as- sociated with reduced nasal congestion, diminished daytime somnolence, and improved sleep quality in patients with perennial allergic rhinitis. 4 Topical intranasal steroids, how- ever, did not reduce fatigue in patients with rhinitis and chronic fatigue syndrome, a relatively uncommon but severe form of unexplained chronic fatigue, although it also did not reduce the symptoms of rhinitis in this group. 5 ALEXANDER C. CHESTER, MD Department of Medicine Georgetown University Hospital Washington, DC BIBLIOGRAPHY 1. Udaka T, Suzuki H, Kitamura T, et al. Relationships among nasal obstruction, daytime sleepiness, and quality of life. Laryngoscope 2006;116:2129 –2132. 2. Chester AC. Symptoms of rhinosinusitis in patients with un- explained chronic fatigue or bodily pain: a pilot study. Arch Intern Med 2003;163:1832–1836. 3. Bhattacharyya N. The economic burden and symptom mani- festations of chronic rhinosinusitis. Am J Rhinol 2003;17: 27–32. 4. Gurevich F, Glass C, Davies M, et al. The effect of intranasal steroid budesonide on the congestion-related sleep distur- bance and daytime somnolence in patients with perennial allergic rhinitis. Allergy Asthma Proc 2005;26:268 –274. 5. Kakumanu SS, Mende CN, Lehman EB, et al. Effect of topical nasal corticosteroids on patients with chronic fatigue syn- drome and rhinitis. J Am Osteopath Assoc 2003;103: 423– 427. In Reference to: Relationships Among Nasal Obstruction, Daytime Sleepiness, and Quality of Life In Reply: Thank you for the opportunity to respond to the com- ments from Dr. Chester regarding our publication in the Laryngoscope 117: May 2007 Letters to the Editor 954