The indications for transnasal esophagoscopy (TNE) can be divided into two main categories: those with esophageal and those with extraesophageal requirements for the procedure. These indications can be further subclassified into diagnostic and therapeutic categories. The relative esophageal indications established by the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG) are summarized in Table 1.1 (1,2). Warning signs necessitating early endoscopy include dysphagia, bleeding, choking, chest pain, and weight loss (1). Although the ASGE indications predict endoscopic findings and serve as a useful benchmark, significant endoscopic diagnoses have been reported in up to 28% of endoscopies that did not meet ASGE criteria (3). Strict adherence to these guidelines can miss important pathology, and the ultimate decision to perform endoscopy must be tailored to the individual clinical scenario.