Changes in Pharyngeal Width Over Time as an Indicator of Dysphagia in Stroke Patients

Objective

To verify the pharyngeal width at rest as a measurement that could be used to assess changes in the degree of dysphagia over time in stroke patients.

Methods

In a cohort of stroke patients, we performed serial measurements of the pharyngeal width at the midpoints of the second (C2) and third (C3) cervical vertebral bodies using lateral neck X-rays while the patients were at rest. The JOSCYL width, a parameter named after the first initial of each developers’ surname and defined as the average value of the upper and lower pharyngeal widths, was used to formulate the JOSCYL scale, which was calculated as the JOSCYL width × 100/neck circumference. All patients also underwent serial videofluoroscopic swallowing studies (VFSSs). The Spearman correlation analysis was used to detect correlations between the serial VFSS results, JOSCYL widths, and JOSCYL scale values.

Results

Over time, we observed significant positive and negative correlations of change in the JOSCYL width and scale with changes in the Penetration-Aspiration Scale and the Dysphagia Outcome and Severity Scale scores, respectively.

Conclusion

The JOSCYL width and JOSCYL scale clearly reflected changes in dysphagia in stroke patients over time. These parameters may provide an easier method for evaluating whether post-stroke dysphagia has been alleviated.

Effect of Resonance Tube Technique on Oropharyngeal Geometry and Voice in Individuals with Parkinson's Disease

OBJECTIVE

To verify the immediate effect of the flexible resonance tube vocal technique on the oropharyngeal geometry and vocal acoustic parameters of individuals with Parkinson's disease (PD) and to study the correlation between oropharyngeal geometry and the intensity and fundamental frequency (f0) parameters of the voice.

METHODS

Forty individuals participated-20 with PD and 20 healthy individuals, with a mean age of 60.95 (± 5.69) years. There were 10 men and 10 women in each group. All underwent pharyngometric analysis of the vocal tract and voice acoustics parameters before and after use of the vocal technique with a flexible resonance tube.

RESULTS

After the technique, there was a reduction in pharyngeal cavity volume only in females in the healthy group, a reduction in shimmer values in females in both groups and males in PD group and an improvement in noise parameters in females in the PD group. There was a negative correlation between vocal tract volume and intensity, between f0 and vocal tract volume, between f0 and oropharyngeal junction area, between f0 and oral cavity volume as well as a positive correlation between oral cavity length and f0.

CONCLUSION

The vocal technique with the flexible resonance tube applied to individuals with PD improved the subjects' voice quality in the perceptual and acoustic voice parameters. Regarding the oropharyngeal geometry, it was possible to observe its correlation with the parameters of vocal intensity and frequency in the studied population.

Cardiopharyngeal mesoderm origins of musculoskeletal and connective tissues in the mammalian pharynx

Cardiopharyngeal mesoderm (CPM) gives rise to muscles of the head and heart. Using genetic lineage analysis in mice, we show that CPM develops into a broad range of pharyngeal structures and cell types encompassing musculoskeletal and connective tissues. We demonstrate that CPM contributes to medial pharyngeal skeletal and connective tissues associated with both branchiomeric and somite-derived neck muscles. CPM and neural crest cells (NCC) make complementary mediolateral contributions to pharyngeal structures, in a distribution established in the early embryo. We further show that biallelic expression of the CPM regulatory gene Tbx1, haploinsufficient in 22q11.2 deletion syndrome patients, is required for the correct patterning of muscles with CPM-derived connective tissue. Our results suggest that CPM plays a patterning role during muscle development, similar to that of NCC during craniofacial myogenesis. The broad lineage contributions of CPM to pharyngeal structures provide new insights into congenital disorders and evolution of the mammalian pharynx.

Migration of an Ingested Fish Bone to the Submandibular Gland: A Case Report and Literature Review

Background

Fish bone is one of the most common foreign bodies that gets lodged in the upper digestive tract, often located in the tonsil, epiglottis, pear-shaped fossa, and esophagus, where it may be easily located on routine inspection and removed. The forcible swallowing of food such as rice balls after ingesting fish bones by mistake may lead to the migration of the fish bone from the pharynx, throat, or esophagus to the surrounding tissues. Migration most commonly occurs to the soft tissues of the neck, even to the thyroid gland, but migration to the submandibular gland has rarely been reported.

Conclusions

Foreign body ingestion may cause a series of complications and endanger a patient's life. Cases require high awareness and attentiveness on the part of the first physician to diagnose and manage the condition, and appropriate health education should be imparted to the patient.

Oral HPV Infection Is Common Worldwide, but Risk of Infection Differs by Sex, Continent, Population at Infection, and Year

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

The epidemiology of oral human papillomavirus infection in healthy populations: A systematic review and meta-analysis. Tam S, Fu S, Xu L, Krause KJ, Lairson DR, Miao H, Sturgis EM, Dahlstrom KR. Oral Oncol 2018;82:91-9.

SOURCE OF FUNDING

The University of Texas MD Anderson, Christopher and Susan Damico chair in Viral Associated Malignancies, Lyda Hill Foundation, HPV-Related Cancers Moonshot program, Steifel Oropharyngeal Research Fund.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data.

Novel treatment for mild and moderate velopharyngeal insufficiency using implantable AlloDerm for posterior pharyngeal wall augmentation and review of surgical repair techniques

PURPOSE

Mild and moderate velopharyngeal insufficiency is a relatively common structural defect of the velopharyngeal sphincter that occurs congenitally or secondarily to various medical conditions resulting in speech inadequacy. Currently, multiple surgical methods exist to treat mild and moderate velopharyngeal insufficiency; however, the revision rates are high and the outcomes are variable. This case series describes a novel technique using implantable AlloDerm to repair the posterior pharyngeal wall to treat mild and moderate velopharyngeal insufficiency.

MATERIALS AND METHODS

This paper presents four patients with mild or moderate velopharyngeal insufficiency who were treated with implantable AlloDerm in the posterior pharyngeal wall at a large, safety-net hospital in New England from 2000 to 2019. Additionally, a review of surgical repair techniques for velopharyngeal insufficiency was conducted with synthesis of a qualitative overview.

RESULTS

There were sufficient follow-up data in three of these patients. All three reported subjective improvements in symptoms after the procedure. One patient had implant extrusion one month following the procedure with subsequent removal.

CONCLUSION

Ultimately, implantable AlloDerm for posterior pharyngeal wall augmentation is a useful, low risk method for treating mild to moderate velopharyngeal insufficiency.

Insights into the feeding behaviors and biomechanics of Varroa destructor mites on honey bee pupae using electropenetrography and histology

Feeding behaviors and biomechanics of female Varroa destructor mites are revealed from AC-DC electropenetrography (EPG) recordings of mites feeding from Apis mellifera honey bee pupae and histology of mite internal ingestion apparatus. EPG signals characteristic of arthropod suction feeding (ingestion) were identified for mites that fed on pupae during overnight recordings. Ingestion by these mites was confirmed afterwards by observing internally fluorescent microbeads previously injected into their hosts. Micrographs of internal ingestion apparatus illustrate the connection between a gnathosomal tube and a pharyngeal lumen, which is surrounded by alternating dilator and constrictor muscles. Inspection of EPG signals showed the muscularized mite pharyngeal pump operates at a mean repetition rate of 4.5 cycles/s to ingest host fluids. Separate feeding events observed for mites numbered between 23 and 33 over approximately 16 h of recording, with each event lasting ~10 s. Feeding events were each separated by ~2 min. Consecutive feeding events separated by either locomotion or prolonged periods of quiescence were grouped into feeding bouts, which ranged in number from one to six. Statistical analyses of EPG data revealed that feeding events were prolonged for mites having lower pharyngeal pump frequencies, and mites having prolonged feeding events went unfed for significantly more time between feeding events. These results suggest that mites may adjust behaviors to meet limitations of their feeding apparatus to acquire similar amounts of food. Data reported here help to provide a more robust view of Varroa mite feeding than those previously reported and are both reminiscent of, as well as distinct from, some other acarines and fluid-feeding insects.

Pharyngeal dimensional changes in class II malocclusion treatment when using Forsus® or intermaxillary elastics - An exploratory study

OBJECTIVE

Pharyngeal airway obstruction can facilitate some forms of sleep disorder breathing (SDB) in susceptible children, especially in those having class II malocclusion. Changes in the anatomic areas surrounding the pharyngeal region during orthodontic treatment could hypothetically impact the pharyngeal airway dimensions. Management of a class II malocclusion on a growing individual with either intermaxillary elastics or different removable or fixed class II appliance designs have been proposed over the last century. The objective of this retrospective exploratory cohort study is to investigate to what extent the class II malocclusion treatment with either intermaxillary elastics (IME) or Forsus® fatigue resistance device (FFRD) leads to changes in oropharyngeal airway dimensions.

MATERIALS AND METHODS

Twenty-nine patients diagnosed as class II with an average age of 12.7years were included in this study, (11 males, 18 females). The sample was divided into group 1: IME and group 2: FFRD. CBCT's scans before (T1) and after treatment (T2) were obtained and analysed using Dolphin software. Reliability was obtained using Intraclass Correlation Coefficient (ICC). Descriptive statistics, ANOVA and paired t-test were used for analysis.

RESULTS

Intra-rater reliability test was excellent in all measurements for both groups. There were no statistically significant differences in pharyngeal airway dimensions between both groups (P=0.919). A statistically significant correlation was found for sex, where male patients had the highest increase in oro-space area (ORS), and in oropharyngeal volume. Children under 14-year-old in IME group showed statistically negative correlation for sub-mandibular (SM) and for ORS, meaning the younger the greatest increase. Additionally, individuals younger than 14years had a statistically significant increase in the vertical dimension.

CONCLUSIONS

Both orthodontic treatment approaches appear to be associated with a similar increase in oropharyngeal airway dimensions. Male patients under 14-year-old had a greater significant increase compared to female patients and older children. Normal pharyngeal dimensions changes were not accounted for.

Two week wait referral criteria - heading in the right direction?

OBJECTIVES

The National Institute for Health and Care Excellence referral guidelines prompting urgent two-week referrals were updated in 2015. Additional symptoms with a lower threshold of 3 per cent positive predictive values were integrated. This study aimed to examine whether current pan-London urgent referral guidelines for suspected head and neck cancer lead to efficient and accurate referrals by assessing frequency of presenting symptoms and risk factors, and examining their correlation with positive cancer diagnoses.

METHODS

The risk factors and symptoms of 984 consecutive patients (over a six-month period in 2016) were collected retrospectively from urgent referral letters to University College London Hospital for suspected head and neck cancer.

RESULTS

Only 37 referrals (3.76 per cent) resulted in a head and neck cancer diagnosis. Four of the 23 recommended symptoms demonstrated statistically significant results. Nine of the 23 symptoms had a positive predictive value of over 3 per cent.

CONCLUSION

The findings indicate that the current referral guidelines are not effective at detecting patients with cancer. Detection rates have decreased from 10-15 per cent to 3.76 per cent. A review of the current head and neck cancer referral guidelines is recommended, along with further data collection for comparison.

Technical update of barbed pharyngoplasty for retropalatal obstruction in obstructive sleep apnoea

BACKGROUND

Barbed pharyngoplasty aims to reduce lateral retropalatal obstruction by pulling up the soft palate anterolaterally. However, barbed pharyngoplasty can be less efficient in some cases of obstructive sleep apnoea, especially in the presence of an elongated uvula with redundant tissues over it. This paper describes an attempt to overcome this drawback by modifying barbed pharyngoplasty, using a single continuous suture technique.

METHODS

Thirty-four patients were assigned to two groups based on the surgical procedure performed. Those with an elongated uvula were treated with modified barbed pharyngoplasty (n = 17); the others were treated with barbed pharyngoplasty (n = 17). Pre- and post-operative quality of life questionnaires, and questionnaires concerning diet, pain and return to activity, were completed. Pre- and post-operative polysomnography was performed as an objective measurement.

RESULTS

There was no significant difference between barbed pharyngoplasty and modified barbed pharyngoplasty in terms of outcomes. However, reductions in the apnoea/hypopnea index, Epworth Sleepiness Scale and snoring visual analogue scale scores were greater in the modified barbed pharyngoplasty group.

CONCLUSION

Modified barbed pharyngoplasty is a safe and feasible method, and eliminates the need for surgical resection of the redundant soft tissues around the uvula while lifting up the uvula base.

Using Google Trends to understand information-seeking behaviour about throat cancer

OBJECTIVE

Many people seek health information from internet sources. Understanding this behaviour can help inform healthcare delivery. This study aimed to review Google Trends as a method for investigating internet-based information-seeking behaviour related to throat cancer in terms of quantity, content and thematic analysis.

METHOD

Data was collected using Google Trends. Normalised data was created using the search terms 'throat cancer', 'cancer', 'HPV', 'laryngeal cancer' and 'head and neck cancer'. The search data was used to analyse the temporal and geographical interest pattern of these terms from 2004 to 2015.

RESULTS

Three important peaks in searches for 'throat cancer' were identified. The first and greatest increase in interest was in September 2010, and there were also peaks in June 2013 and in October 2011.

CONCLUSION

Internet-search analysis can provide an insight into the information-seeking behaviour of the public. Mass media can hugely affect this information-seeking behaviour. Possessing tools to investigate and understand information-seeking behaviour may be used to improve healthcare delivery.

Thyroxin and calcitonin secretion into thyroid venous blood is regulated by pharyngeal mechanical stimulation in anesthetized rats

The effects of the pharyngeal non-noxious mechanical stimulation on the secretion of immunoreactive thyroxin (iT4), immunoreactive calcitonin (iCT), and immunoreactive parathyroid hormone (iPTH) into thyroid venous blood were examined in anesthetized rats. Secretion rates of iT4, iCT, and iPTH were calculated from their concentration in thyroid venous plasma and the plasma flow rate. A mechanical stimulation was delivered to the pharynx by a rubber balloon placed on the tongue that was intermittently pushed into the pharyngeal cavity. Pharyngeal stimulation increased iT4 and iCT secretion, but iPTH secretion was unchanged. The secretion responses were abolished by transecting the superior laryngeal nerves (SLNs) bilaterally. The activities of the thyroid parasympathetic efferent nerves and the afferent nerves in the SLN increased significantly during pharyngeal stimulation. These results indicate that pharyngeal mechanical stimulation promotes thyroxin and calcitonin secretion from the thyroid gland by a reflex increase in SLN parasympathetic efferent activity, triggered by excitation of SLN mechanoreceptive afferents.

The oral gland, a new exocrine organ of termites

Termites have a rich set of exocrine glands. These glands are located all over the body, appearing in the head, thorax, legs and abdomen. Here, we describe the oral gland, a new gland formed by no more than a few tens of Class I secretory cells. The gland is divided into two secretory regions located just behind the mouth, on the dorsal and ventral side of the pharynx, respectively. The dominant secretory organelle is a smooth endoplasmic reticulum. Secretion release is under direct control of axons located within basal invaginations of the secretory cells. The secretion is released through a modified porous cuticle located at the mouth opening. We confirmed the presence of the oral gland in workers and soldiers of several wood- and soil-feeding species of Rhinotermitidae and Termitidae, suggesting a broader distribution of the oral gland among termites. The oral gland is the smallest exocrine gland described in termites so far. We hypothesise that the oily secretion can either ease the passage of food or serve as a primer pheromone.

[High-resolution manometry of pharyngeal swallowing dynamics]

BACKGROUND

To transport a bolus from the mouth into the stomach, regular contraction of the pharyngeal muscles and a coordinated function of the upper esophageal sphincter (UES) are necessary. The muscle contraction generates intraluminal pressure, which pushes the bolus continuously forward. In contrast to imaging studies, manometric methods enable assessment of intraluminal pressure buildup and the function of the muscles involved. These methods were initially established for the esophagus and have been used increasingly in the pharynx for 7-8 years. Pharyngeal high-resolution manometry (pHRM) allows pressure measurements in high spatial and temporal resolution, and assessment of pharyngeal swallowing dynamics.

OBJECTIVE

An overview is given of the implementation, evaluation, and interpretation of the pHRM data, as well as of the current state of research.

MATERIALS AND METHODS

PubMed and Scopus were searched for the keywords "high-resolution manometry" and "pharynx" or "upper esophageal sphincter". Original articles, reviews, and book chapters on the subject pHRM were included.

RESULTS

Swallowing pressure conditions in the pharynx and the UES can be assessed by pHRM. The spatiotemporal pressure plot gives an overview of changes in pharyngeal motor function. Determination of swallowing parameters enables a sophisticated evaluation of swallowing; a comparison with normal values permits delimitation of pathologies.

CONCLUSION

Although several swallowing parameters still need to be further evaluated for clinical routine, a pHRM study should nowadays always be carried out for a comprehensive evaluation of the swallowing process.

High-Resolution Pharyngeal Manometry and Impedance: Protocols and Metrics-Recommendations of a High-Resolution Pharyngeal Manometry International Working Group

High-resolution manometry has traditionally been utilized in gastroenterology diagnostic clinical and research applications. Recently, it is also finding new and important applications in speech pathology and laryngology practices. A High-Resolution Pharyngeal Manometry International Working Group was formed as a grass roots effort to establish a consensus on methodology, protocol, and outcome metrics for high-resolution pharyngeal manometry (HRPM) with consideration of impedance as an adjunct modality. The Working Group undertook three tasks (1) survey what experts were currently doing in their clinical and/or research practice; (2) perform a review of the literature underpinning the value of particular HRPM metrics for understanding swallowing physiology and pathophysiology; and (3) establish a core outcomes set of HRPM metrics via a Delphi consensus process. Expert survey results were used to create a recommended HRPM protocol addressing system configuration, catheter insertion, and bolus administration. Ninety two articles were included in the final literature review resulting in categorization of 22 HRPM-impedance metrics into three classes: pharyngeal lumen occlusive pressures, hypopharyngeal intrabolus pressures, and upper esophageal sphincter (UES) function. A stable Delphi consensus was achieved for 8 HRPM-Impedance metrics: pharyngeal contractile integral (CI), velopharyngeal CI, hypopharyngeal CI, hypopharyngeal pressure at nadir impedance, UES integrated relaxation pressure, relaxation time, and maximum admittance. While some important unanswered questions remain, our work represents the first step in standardization of high-resolution pharyngeal manometry acquisition, measurement, and reporting. This could potentially inform future proposals for an HRPM-based classification system specifically for pharyngeal swallowing disorders.

Morphological variation of the velum in children and adults using magnetic resonance imaging

PURPOSE

The purpose of this study was to investigate variations in velar shape according to age, sex, and race using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

The study sample consisted of 170 participants (85 children, 85 adults) between 4 and 34 years of age. Velar morphology was visually classified using midsagittal MRI scans for each participant by 2 independent raters. Inter- and intra-rater reliability was assessed. Statistical analyses were performed to identify correlations of velar shape with sex, age, and race.

RESULTS

The most frequent velar shape was "butt" for both adults (41%) and children (58%) in this study. The least common shapes for adults were "leaf" and "S." The children did not exhibit any "leaf" or "straight" velar shapes. A statistically significant difference was noted for age with respect to velar shape (P=0.014). Sex and race were found to have no significant impact on velar shape in this study.

CONCLUSION

When using MRI to evaluate velar morphology, the "butt" shape was most common in both children and adults. Velar shape varied significantly with age, while race and sex did not have a significant impact.

Formant Frequencies, Cephalometric Measures, and Pharyngeal Airway Width in Adults With Congenital, Isolated, and Untreated Growth Hormone Deficiency

OBJECTIVE

Adult subjects with isolated growth hormone deficiency (IGHD) due to a mutation in the growth hormone releasing hormone receptor gene exhibit higher values formant frequencies. In normal subjects, a significant negative association between the formant frequencies and the reduction of linear craniofacial measurements, especially of maxilla and mandible, has been reported. This suggests smaller pharyngeal width, despite low prevalence of obstructive sleep apnea syndrome. Here we evaluate their pharyngeal airway width, its correlation with vowel formant frequencies, and the correlation between them and the craniofacial measures.

SUBJECTS AND METHODS

A two-step protocol was performed. In the first case-control experiment, aimed to assess the pharyngeal width, we compared nine adult IGHD and 36 normal statured controls. Both upper and lower pharyngeal widths were measured. The second step (assessment of pharyngeal width) was performed only in the IGHD group.

RESULTS

Upper and lower pharyngeal widths were similar in IGHD and controls. In IGHD subjects, the lower pharyngeal width exhibited a negative correlation with F1 [a] and a positive correlation with mandibular length. There were negative correlations between F1 and F2 with linear and positive correlations with the angular measures.

CONCLUSIONS

Pharyngeal airway width is not reduced in adults with congenital, untreated lifetime IGHD, contributing to the low prevalence of obstructive sleep apnea syndrome. The formant frequencies relate more with cephalometric measurements than with the pharyngeal airway width. These findings exemplify the consequences of lifetime IGHD on osseous and nonosseous growth.

Imaging of Neck Visceral Trauma

The neck visceral space is a complex region housing several vital structures. Diagnostic imaging plays an important role in the evaluation of neck visceral injuries. Many injuries are initially missed by both clinicians and radiologists because of their infrequency and the high likelihood of other more obvious injuries. Understanding which diagnostic modality to apply at given point in the work-up; recognizing relevant clinical signs, symptoms, and injury mechanisms; and knowing pertinent direct and indirect imaging findings of injury allow radiologists to either directly render the correct diagnosis or choose the most appropriate tool for doing so.

A comparative study of the pharyngeal plate of Apoidea (Hymenoptera: Aculeata), with implications for the understanding of phylogenetic relationships of bees

The pharyngeal plate is a morphological complex with extensive anatomical variation among bees and, therefore, potential as a source of phylogenetic information. The pharyngeal plate of bees is divided into four morphologically distinct regions: sitophore, hypopharyngeal lobe, pharyngeal rods, and median oral plate. In this work we illustrate and document in detail for the first time the pharyngeal plate of 43 bee species, providing descriptions of the morphological variation and contrasting these findings with representatives of apoid wasps (Crabronidae and Sphecidae). We evaluate and discuss the potential of this structure as a rich source of morphological information in the context of bee phylogeny and any research potentially impacted by comparative morphological data. The shape of the hypopharyngeal lobe is highly variable among suprageneric taxa of bees and can be readily employed to characterise taxa at various levels. We argue that the global patterns in the variation of the pharyngeal plate can provide information for phylogenetic inference within bees and constructed and coded 10 characters that encompass the most noticeable morphological differences discussed herein.

Predictive Value of Pharyngeal Width at Rest (JOSCYL Width) for Aspiration in Elderly People

Objective

To develop a new tool for aspiration risk prediction based on pharyngeal width at rest in older adults with symptoms of aspiration.

Methods

Lateral cervical spine roentgenograms were obtained from 33 older adult patients who complained of dysphagia and from 33 healthy, age-matched controls. Pharyngeal width at rest was measured at two points. We named the average of these two pharyngeal widths ‘JOSCYL Width’, calculated ‘JOSCYL Scale’, and compared these parameters between dysphagia and control groups. Correlations of individual JOSCYL Width and JOSCYL Scale, with Penetration Aspiration Scale (PAS) and Dysphagia Outcome and Severity Scale (DOSS) scores were analyzed for the dysphagia group. To determine optimal cutoff points for predicting aspiration, a receiver operating characteristic curve analysis was performed on JOSCYL Width and JOSCYL Scale.

Results

Both JOSCYL Width and JOSCYL Scale of the dysphagia group were larger than those of the control group (p<0.001). The correlation between JOSCYL Width and severity of dysphagia was significant for the dysphagia group (PAS p=0.007; DOSS p=0.012). The correlation between JOSCYL Scale and the severity of dysphagia was also significant for the dysphagia group (PAS p=0.009; DOSS p=0.011). Optimal cutoffs for JOSCYL Width and JOSCYL Scale for predicting aspiration were 20.0 mm and 5.9, respectively.

Conclusion

JOSCYL Width and JOSCYL Scale can be new indicators for predicting aspiration in older adults. They are both precise and easy to use.

The gelatinase MMP-9like is involved in regulation of LPS inflammatory response in Ciona robusta

Matrix metalloproteinases (MMPs) are a family of endopeptidases collectively able to degrade the components of the extracellular matrix (ECM), with important roles in many biological processes, such as embryogenesis, normal tissue remodelling, angiogenesis and wound healing. New views on the function of MMPs reveal that they regulate inflammatory response and therefore might represent an early step in the evolution of the immune system. MMPs can affect the activity of cytokines involved in inflammation including TGF-β and TNF-α. MMPs are widely distributed in all kingdoms of life and have likely evolved from a single-domain protein which underwent successive rounds of duplications. In this study, we focused on the Ciona robusta (formerly known as Ciona intestinalis) MMP gelatinase homologue. Gene organization, phylogenetic analysis and 3D modeling supported the closest correlation of C. robusta gelatinase with the human MMP-9. Real-time PCR analysis and zymographic assay showed a prompt expression induced by LPS inoculation and an upregulation of enzymatic activity. Furthermore, we showed that before of the well-known increase of TGF-β and TNF-α levels, a MMP-9like boost occurred, suggesting a possible involvement of MMP-9like in regulating inflammatory response in C. robusta.

Pharyngeal Swallowing During Wake and Sleep

Sleep is associated with stages of relative cortical quiescence, enabling evaluation of swallowing under periods of reduced consciousness and, hence, absent volition. The aim of this study was to measure and characterize changes in the characteristics of pharyngeal swallows during sleep and wake using high-resolution manometry (HRM). Pharyngeal swallows were recorded with a ManoScan™ HRM in wake-upright, wake-supine, and sleep conditions in 20 healthy participants (mean 27 years; range 21-52). Velopharyngeal and hypopharyngeal segments were analysed separately. Contractile integral, mean peak pressure, inverse velocity of superior-to-inferior pharyngeal pressure, and time to first maximum pressure were analysed with custom-designed software. The supine-wake condition was compared to both upright-wake and sleep conditions using linear mixed effects models. No significant differences were found between supine-wake and upright-wake conditions on any measures. The mean peak pharyngeal pressure was lower during sleep than during the supine-wake condition for both the velopharynx (- 60 mmHg, standard error [SE] = 11, p < 0.001) and hypopharynx (- 59 mmHg, SE = 9, p = 0.001), as was the pharyngeal inverse velocity (- 12 ms/cm, SE = 4, p = 0.012) for the hypopharyngeal segment and the pharyngeal contractile integral (- 32 mmHg s cm, SE = 6, p < 0.001). No significant differences were found in time to the first pharyngeal maximum pressure. This study used HRM to characterize and compare pharyngeal pressures during swallowing in both wake and sleep conditions. No differences were found between upright and supine awake conditions, a finding important to pharyngeal manometric measures made during supine positioning, such as in fMRI. Higher pressures and longer time-related measures of volitional pharyngeal swallowing when awake indicate that cortical input plays an important role in modulation of pharyngeal swallowing.

Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions

OBJECTIVE

The fiber-guided carbon dioxide (CO₂) laser is a useful device for laryngopharyngeal surgery. The flexible CO₂ wave-guide laser has been developed and commercially available for several years. However, the transnasal use of CO₂ flexible wave-guided laser surgery through the instrument channel of a flexible endoscope (CO₂ TNFLS) is not permitted in Japan. This feasibility study aimed to assess the value and the safety of an in-office CO₂ TNFLS procedure.

METHODS

Patients with small laryngopharyngeal diseases were enrolled from June 2015. Eligible patients had indications with lesions generally localized superficial lesions such as the benign tumor, leukoplakia, and premalignant lesion-like carcinoma in situ (CIS). Patients were locally well anesthetized using xylocaine. After removing as much of the lesion(s) as possible with flexible forceps, the remainder of the lesions were evaporated using CO₂ TNFLS through the instrument channel of a flexible endoscope under local anesthesia.

RESULTS

Eighteen surgeries involving 13 patients, including 9 papilloma (7 recurrent respiratory papilloma [RRP]), 2 carcinoma in situ, 1 leukoplakia, and 1 large epiglottic cyst), were performed. Four patients with RRP required multiple surgeries. Except for 3 patients with RRP, all patients achieved disease control without additional intervention. All procedures were completed with no severe adverse events.

CONCLUSION

Office-based CO₂ TNFLS is safe and feasible for patients with laryngopharyngeal pathologies. It is especially valuable for RRP patients with small lesions to avoid surgery under general anesthesia.

A Device that Models Human Swallowing

The pharynx is critical for correct swallowing, facilitating the transport of both air and food transport in a highly coordinated manner, and aberrant co-ordination causes swallowing disorders (dysphagia). In this work, an in vitro model of swallowing was designed to investigate the role of rheology in swallowing and for use as a pre-clinical tool for simulation of different routes to dysphagia. The model is based on the geometry of the human pharynx. Manometry is used for pressure measurements and ultrasonic analysis is performed to analyze the flow profiles and determine shear rate in the bolus, the latter being vital information largely missing in literature. In the fully automated model, bolus injection, epiglottis/nasopharynx movement, and ultrasound transducer positioning can be controlled. Simulation of closing of the airways and nasal cavity is modulated by the software, as is a clamping valve that simulates the upper esophageal sphincter. The actions can be timed and valves opened to different degrees, resembling pathologic swallowing conditions. To validate measurements of the velocity profile and manometry, continuous and bolus flow was performed. The respective velocity profiles demonstrated the accuracy and validity of the flow characterization necessary for determining bolus flow. A maximum bolus shear rate of 80 s^-1 was noted for syrup-consistency fluids. Similarly, the manometry data acquired compared very well with clinical studies.

The Association of 3-D Volume and 2-D Area of Post-swallow Pharyngeal Residue on CT Imaging

Pharyngeal residue, the material that remains in the pharynx after swallowing, is an important marker of impairments in swallowing and prandial aspiration risk. The goals of this study were to determine whether the 2D area of post-swallow residue accurately represents its 3D volume, and if the laterality of residue would affect this association. Thirteen patients with dysphagia due to brainstem stroke completed dynamic 320-detector row computed tomography while swallowing a trial of 10 ml honey-thick barium. 3D volumes of pharyngeal residue were compared to 2D lateral and anterior-posterior areas, and a laterality index for residue location was computed. Although the anteroposterior area of residue was larger than the lateral area, the two measures were positively correlated with one another and with residue volume. On separate bivariate regression analyses, residue volume was accurately predicted by both lateral (R² = 0.91) and anteroposterior (R² = 0.88) residue areas, with limited incidence of high residuals. Half of the sample demonstrated a majority of pharyngeal residue lateralized to one side of the pharynx, with no effect of laterality on the association between areas and volume. In conclusion, the area of post-swallow pharyngeal residue was associated with volume, with limitations in specific cases. Direct measurement of pharyngeal residue volume and swallowing physiology with 3D-CT can be used to validate results from standard 2D instrumentation.