We conducted a study to analyze the effectiveness of transnasal esophagoscopy (TNE) as an alternative to operative endoscopy (OE) for the evaluation of primary head and neck cancers and for the surveillance of synchronous esophageal cancers. Our study population was made up of 96 consecutively presenting patients-75 men and 21 women, aged 45 to 88 years (mean: 64)-who were treated at our institution for squamous cell cancer of the head and neck. Of this group, 42 patients had been evaluated with TNE and 54 with OE. More OEs were performed in patients with an unknown primary (26 vs. 3). Incidental findings on TNE included 3 cases of gastritis, 2 cases each of hiatal hernia and esophagitis, 1 case of Barrett esophagus, and 1 inlet patch. No incidental findings were reported during OE. Primary cancers were biopsied by TNE through a port on the endoscope in 4 patients; 2 of these cancers were in the tongue base, 1 in the hypopharynx, and 1 in the aryepiglottic fold. After the initial visit, patients in the TNE group waited significantly fewer days for their endoscopy than did those in the OE group (median: 6.5 vs. 16; p < 0.05). Conversely, patients in the OE group waited significantly fewer days for treatment following endoscopy (median: 12 vs. 20; p < 0.05). However, there was no significant difference between the TNE patients and the OE patients in the total number of days comprising their entire course of management, from the initial visit to definite treatment (median: 27.5 and 33 days, respectively; p = 0.7). We conclude that TNE is a reasonable alternative to OE for the initial screening for synchronous esophageal cancers in patients with squamous cancers of the head and neck. OE is preferred for the initial workup of unknown primary cancers and for large tongue base cancers. The rate of detection of clinically relevant incidental findings is higher with TNE. Biopsy is possible during TNE for all subsites within the upper aerodigestive tract.