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Kuuskoski J, Vanhatalo J, Hirvonen J, Rekola J, Aaltonen L, Järvenpää P. Inter-rater reliability and clinical relevance of subjective and objective interpretation of videofluoroscopy findings. Laryngoscope Investig Otolaryngol 2024; 9:e1298. [PMID: 38974605 PMCID: PMC11222653 DOI: 10.1002/lio2.1298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Accepted: 06/09/2024] [Indexed: 07/09/2024] Open
Abstract
Background Dysphagia is commonly evaluated using videofluoroscopy (VFS). As its ratings are usually subjective normal-abnormal ratings, objective measurements have been developed. We compared the inter-rater reliability of the usual VFS ratings to the objective measurement VFS ratings and evaluated their clinical relevance. Methods Two blinded raters analyzed the subjective normal-abnormal ratings of 77 patients' VFS. Two other blinded raters analyzed the objective measurements of pharyngeal aerated area with bolus held in the oral cavity (PAhold), the pharyngeal area of residual bolus during swallowing (PAmax), the pharyngeal constriction ratio (PCR), the maximum pharyngoesophageal segment opening (PESmax), pharyngoesophageal segment opening duration (POD), airway closure duration (ACD), and total pharyngeal transit time (TPT). We evaluated the inter-rater agreement in the subjective ratings and the objective measurements. Clinical utility analysis compared the measurements with the VFS findings of pharyngeal phase abnormality, penetration/aspiration, and cricopharyngeal relaxation. Results In the pharyngeal findings, the subjective analysis inter-rater agreement was mainly moderate to strong. The strongest agreements were on the pharyngeal residues and penetration/aspiration findings. The objective measurements had fair to good inter-rater agreement. Clinical utility analysis found statistically significant connections between TPT and pharyngeal phase abnormality, normal PCR and lack of penetration/aspiration, and normal PESmax and normal cricopharyngeal relaxation. Conclusions The subjective analysis had moderate to strong inter-rater agreement in the pharyngeal VFS findings, especially concerning pharyngeal residues and penetration/aspiration detection, reflecting the efficacy and safety of swallowing. The objective measurements had fair to good inter-observer reproducibility and could thus improve the reliability of VFS diagnostics. Level of evidence 4.
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Affiliation(s)
- Jonna Kuuskoski
- Department of Otorhinolaryngology—Head and Neck SurgeryTurku University Hospital and University of TurkuTurkuFinland
| | - Jaakko Vanhatalo
- Department of RadiologyTurku University Hospital and University of TurkuTurkuFinland
| | - Jussi Hirvonen
- Department of RadiologyTurku University Hospital and University of TurkuTurkuFinland
- Faculty of Medicine and Health TechnologyTampere University Hospital and Tampere UniversityTampereFinland
| | - Jami Rekola
- Department of Otorhinolaryngology—Head and Neck SurgeryTurku University Hospital and University of TurkuTurkuFinland
| | - Leena‐Maija Aaltonen
- Department of Otorhinolaryngology—Head and Neck SurgeryHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Pia Järvenpää
- Department of Otorhinolaryngology—Head and Neck SurgeryHelsinki University Hospital and University of HelsinkiHelsinkiFinland
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Randall DR, Young-Speirs M, Walker K. Association of the "Jet Phenomenon" with Positive Symptom Outcome Following Surgical Treatment of Cricopharyngeus Muscle Dysfunction. Dysphagia 2023; 38:1440-1446. [PMID: 37093277 DOI: 10.1007/s00455-023-10573-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/31/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Cricopharyngeus muscle dysfunction (CPMD) is a common cause for progressive dysphagia and can lead to dietary restriction, reduced nutrition, weight loss, and pneumonia. Controversy exists whether CPMD is best managed with primary surgical treatment of the cricopharyngeus muscle and who represents a good surgical candidate. METHODS Retrospective review of patients diagnosed with CPMD who underwent surgical treatment were evaluated through prospectively collected pre- and postoperative Eating Assessment Tool-10 (EAT-10) and Functional Oral Intake Scale (FOIS). Videofluoroscopic swallowing studies (VFSS) were reviewed for presence or absence of a high-pressure barium stream through the upper esophageal sphincter, termed the jet phenomenon (JP). RESULTS We identified 42 patients with CPMD who underwent surgical treatment and had serial Eating Assessment Tool (EAT-10) measures obtained pre- and postoperatively. Mean EAT-10 scores improved by 12.1 points (95%CI = 8.6-15.6), p < 0.0001. There was a significantly greater improvement among patients with JP (|∆EAT-10|= 17.0, 95%CI = 12.5-21.4) compared to those without (|∆EAT-10|= 6.2, 95%CI = 1.6-10.8), p = 0.0013. Patients with JP also showed improved FOIS score (p = 0.0023) while those without JP did not. CONCLUSION This study provides the initial report on the utility of JP as a VFSS feature that is strongly associated with improved outcomes following surgical treatment of CPMD. Further work determining the physiologic correlates responsible for JP will help clarify its predictive capabilities. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Derrick R Randall
- Section of Otolaryngology-Head & Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Peter Lougheed Centre, Outpatient Dysphagia Clinic, Calgary, AB, Canada.
| | | | - Kim Walker
- Peter Lougheed Centre, Outpatient Dysphagia Clinic, Calgary, AB, Canada
- Speech Language Pathology, Department of Allied Health, South Health Campus, Calgary, AB, Canada
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Al Ghamdi SS, Bejjani M, Hernández Mondragón OV, Parsa N, Yousaf MN, Aghaie Meybodi M, Ghandour B, Krustri C, Phalanusitthepha C, Ngamruengphong S, Nieto JM, Khashab MA. Peroral endoscopic myotomy for management of cricopharyngeal bars (CP-POEM): a retrospective evaluation. Endoscopy 2022; 54:498-502. [PMID: 34710910 DOI: 10.1055/a-1646-1151] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cricopharyngeal bars (CPBs) are a unique etiology of oropharyngeal dysphagia. Symptomatic patients are managed with endoscopic dilation or surgical myotomy. Cricopharyngeal peroral endoscopic myotomy (CP-POEM) is an emerging technique for the management of dysphagia due to CPBs. This study evaluated technical success, clinical success, adverse events, and long-term recurrence following CP-POEM. METHODS Consecutive patients who underwent POEM for management of CPBs between May 2015 and December 2020 at four tertiary care centers were included. Primary outcome was clinical success (defined as improvement of dysphagia score to ≤ 1). Secondary outcomes were technical success, rate and severity of adverse events, procedure duration, and symptom recurrence. RESULTS 27 patients (mean age 69 years; 10 female) underwent CP-POEM during the study period. The most common presenting symptoms at the time of index procedure were dysphagia (26; 96.3 %) and regurgitation (20; 74.1 %). Clinical and technical success were achieved in all patients. Mild/moderate adverse events occurred in two patients (7.4 %). CP-POEM significantly reduced the median dysphagia score. CONCLUSIONS CP-POEM was a safe and effective treatment for symptomatic CPBs. Although symptom recurrence was low, long-term outcome data are needed. CP-POEM should be considered as a management option for symptomatic CPBs at centers with POEM expertise.
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Affiliation(s)
- Sarah S Al Ghamdi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Division of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | - Nasim Parsa
- University of Missouri Health System, Columbia, Missouri, United States
| | | | - Mohammad Aghaie Meybodi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | | | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Jose M Nieto
- Borland Groover Clinic Advanced Therapeutic Endoscopy Center and Baptist Medical Center, Jacksonville, Florida, United States
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
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4
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Seino Y, Miyamoto S, Nakayama M, Yamashita T, Miles A, Allen JE. Characteristics that predict penetration - aspiration in elderly patients following supracricoid laryngectomy with cricohyoidoepiglottopexy - a videofluoroscopic study. J Laryngol Otol 2021; 136:1-23. [PMID: 34702394 DOI: 10.1017/s0022215121003236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjectiveThis study aimed to determine the incidence of laryngeal penetration and aspiration in elderly patients who underwent supracricoid laryngectomy with cricohyoidoepiglottopexy for laryngeal cancer.MethodA retrospective analysis of dynamic videofluoroscopic swallowing studies was performed in patients who had received supracricoid laryngectomy with cricohyoidoepiglottopexy as a treatment for laryngeal cancers. Digital analysis of videofluoroscopic swallowing studies included measurements of displacement and timing related to swallowing safety.ResultsVideofluoroscopic swallowing studies from 52 patients were analysed. All participants were male and over 65 years old. Studies were performed five years after surgery. Among 52 videofluoroscopic swallowing studies, analysis showed that elevated pharyngeal constriction ratio (pharyngeal constriction ratio more than 0.0875, odds ratio = 5.2, p = 0.016), reduced pharyngoesophageal sphincter opening time (pharyngoesophageal sphincter open less than 0.6 seconds, odds ratio = 11.6, p = 0.00018) and reduced airway closure time (airway close less than 0.6 seconds, odds ratio = 10.6, p = 0.00057) were significantly associated with aspiration.ConclusionDeteriorated pharyngeal constriction, shortened airway closure and reduced pharyngoesophageal sphincter opening time are key factors for predicting laryngeal penetration or aspiration after supracricoid laryngectomy with cricohyoidoepiglottopexy.
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Affiliation(s)
- Yutomo Seino
- Department of Otorhinolaryngology, Kitasato University School of Medicine
| | - Syunsuke Miyamoto
- Department of Otorhinolaryngology, Kitasato University School of Medicine
| | - Meijin Nakayama
- Department of Otolaryngology-Head and Neck Surgery, Yokohama City University
| | - Taku Yamashita
- Department of Otorhinolaryngology, Kitasato University School of Medicine
| | - Anna Miles
- Otolaryngology, North Shore Hospital, Auckland
| | - Jacqui E Allen
- Professional Teaching Fellow- Speech Science, The University of Auckland
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Cariati M, Chiarello MM, Cannistra' M, Lerose MA, Brisinda G. Gastrointestinal Uses of Botulinum Toxin. Handb Exp Pharmacol 2020; 263:185-226. [PMID: 32072269 DOI: 10.1007/164_2019_326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.
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Affiliation(s)
- Maria Cariati
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Marco Cannistra'
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Giuseppe Brisinda
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy. .,Department of Surgery, "Agostino Gemelli" Hospital, Catholic School of Medicine, Rome, Italy.
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6
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Randall DR, Evangelista LM, Kuhn MA, Belafsky PC. Improved symptomatic, functional, and fluoroscopic outcomes following serial "series of three" double-balloon dilation for cricopharyngeus muscle dysfunction. J Otolaryngol Head Neck Surg 2018; 47:35. [PMID: 29764478 PMCID: PMC5952613 DOI: 10.1186/s40463-018-0278-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 04/29/2018] [Indexed: 11/22/2022] Open
Abstract
Background Cricopharyngeus muscle dysfunction (CPMD) is a common cause of dysphagia. We employ a progressive series of three double-balloon dilations separated by 4–6 weeks between procedures as a primary treatment option. The purpose of this study was to evaluate subjective, functional and objective improvement in swallowing after three serial dilations for CPMD. Methods We retrospectively evaluated patients between June 1, 2014, and June 30, 2016, who underwent a series of three double-balloon dilations for CPMD. Pre- and post-dilation Eating Assessment Tool-10 (EAT-10), Functional Oral Intake Scale (FOIS), pharyngeal constriction ratio, pharyngeal area, and pharyngoesophageal segment (PES) opening were compared. Results Seventeen patients with CPMD underwent serial double-balloon dilation procedures separated by one month. Mean age of the cohort was 73.5 (SD ± 13.3) years, and 53% were female. The mean EAT-10 improved from 24.7 (SD ± 7.8) to 15.9 (SD ± 10.2) [p = 0.0021]. Mean FOIS improved from 5.4 (SD ± 1.4) pre- to 6.3 (SD ± 0.9) post-treatment (p = 0.017). Mean UES opening increased from 1.05 (SD ± 0.34) cm to 1.48 (SD ± 0.41) cm (p = 0.0003) in the anteroposterior fluoroscopic view and from 0.58 (SD ± 0.18) to 0.76 (SD ± 0.30) cm (p = 0.018) in the lateral view. Pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength, improved from 0.49 (SD ± 0.37) to 0.24 (SD ± 0.15) (p = 0.015), however pharyngeal area (PA) was unchanged. Conclusions A progressive series of three double-balloon dilations for cricopharyngeus muscle dysfunction resulted in improved patient reported dysphagia symptom scores and objective fluoroscopic swallowing parameters.
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Affiliation(s)
- Derrick R Randall
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA. .,Section of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, T2W 3K2, Canada.
| | - Lisa M Evangelista
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Maggie A Kuhn
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
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7
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Schrey A, Airas L, Jokela M, Pulkkinen J. Botulinum toxin alleviates dysphagia of patients with inclusion body myositis. J Neurol Sci 2017; 380:142-147. [DOI: 10.1016/j.jns.2017.07.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/06/2017] [Accepted: 07/23/2017] [Indexed: 12/19/2022]
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8
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Allen J, Blair D, Miles A. Assessment of videofluoroscopic swallow study findings before and after cricopharyngeal myotomy. Head Neck 2017. [PMID: 28644552 DOI: 10.1002/hed.24846] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Cricopharyngeal myotomy is a treatment for obstructive cricopharyngeal bar and Zenker's diverticulitis. Little is reported regarding contrast study findings and their correlation with patient symptoms. METHODS All patients treated by cricopharyngeal myotomy underwent a preoperative and postoperative videofluoroscopic swallow study (VFSS) and completed the self-reported Eating Assessment Tool (EAT-10). Studies were analyzed quantitatively. RESULTS Forty cricopharyngeal myotomies were performed (mean age 76 years; SD 8.72) all for dysphagia. Symptomatic improvement (change in EAT-10 scores) occurred in 95% (38/40). Presurgical versus postsurgical VFSS demonstrated significantly improved pharyngoesophageal segment opening, pharyngeal constriction ratio, and pouch residue (P < .01). Symptomatic improvement was unrelated to the presence of retained barium. CONCLUSION Both symptomatic and objective improvement in swallowing measures occurs after cricopharyngeal myotomy. Pouch remnants and retained barium are seen postoperatively but do not correlate with reported symptoms. Routine follow-up barium studies may be needed to establish a new baseline and allow for comparison if future symptom recurrence occurs.
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Affiliation(s)
- Jacqui Allen
- Department of Otolaryngology, Waitemata District Health Board, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Dora Blair
- Department of Otolaryngology, Waitemata District Health Board, Auckland, New Zealand
| | - Anna Miles
- Department of Speech Science, Psychology, and Science, University of Auckland, Auckland, New Zealand
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Lee JW, Randall DR, Evangelista LM, Kuhn MA, Belafsky PC. Subjective Assessment of Videofluoroscopic Swallow Studies. Otolaryngol Head Neck Surg 2017; 156:901-905. [DOI: 10.1177/0194599817691276] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective The videofluoroscopic swallow study (VFSS) is the gold standard diagnostic tool to evaluate oropharyngeal dysphagia. Although objective measurements on VFSS have been described, there is no universal method of analysis, and the majority of clinicians use subjective interpretation alone. The purpose of this investigation was to evaluate the accuracy of subjective VFSS analysis. Study Design Double-blinded experiment. Setting Tertiary care laryngology center. Subjects and Methods Seventy-six de-identified videos from VFSS evaluations of patients with dysphagia were presented to blinded, experienced speech-language pathologists and laryngologists individually. Evaluators rated each video as normal or abnormal for hyoid elevation (HE), pharyngeal area (PA), pharyngeal constriction ratio (PCR), and pharyngoesophageal segment opening (PESo). A blinded investigator assessed evaluators’ inter- and intrarater agreement and compared their responses to objectively measured results for these parameters to examine accuracy. Results Evaluators correctly classified only 61.5% of VFSS videos as normal or abnormal, with moderate interrater agreement (κ = 0.48, P < .0001). Intrarater agreement was highly variable (κ = 0.43-0.83). Accuracy was greatest for PCR (71.6%), with poorer performance for HE (61.3%), PESo (59.2%), and PA (45.3%). Interrater agreement was moderate for all parameters, with greater concordance for PCR (κ = 0.59) and PESo (κ = 0.54) and less for HE (κ = 0.40) and PA (κ = 0.44). Evaluators unanimously agreed on a correct interpretation of a VFSS only 28% of the time. Conclusion Subjective assessment of VFSS parameters is inconsistently accurate when compared with objective measurements, with accuracy ratings ranging from 45.3% to 71.6% for specific parameters. Inter- and intrarater reliability for subjective assessment was moderate and highly variable.
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Affiliation(s)
- Janet W. Lee
- Center for Voice and Swallowing, Department of Otolaryngology–Head and Neck Surgery, University of California–Davis, Sacramento, CA, USA
| | - Derrick R. Randall
- Center for Voice and Swallowing, Department of Otolaryngology–Head and Neck Surgery, University of California–Davis, Sacramento, CA, USA
- Section of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Canada
| | - Lisa M. Evangelista
- Center for Voice and Swallowing, Department of Otolaryngology–Head and Neck Surgery, University of California–Davis, Sacramento, CA, USA
| | - Maggie A. Kuhn
- Center for Voice and Swallowing, Department of Otolaryngology–Head and Neck Surgery, University of California–Davis, Sacramento, CA, USA
| | - Peter C. Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology–Head and Neck Surgery, University of California–Davis, Sacramento, CA, USA
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10
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Allen J, Belafsky PC. Gastroesophageal Reflux Disease, Globus, and Dysphagia. Dysphagia 2017. [DOI: 10.1007/174_2017_139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Henderson M, Miles A, Holgate V, Peryman S, Allen J. Application and Verification of Quantitative Objective Videofluoroscopic Swallowing Measures in a Pediatric Population with Dysphagia. J Pediatr 2016; 178:200-205.e1. [PMID: 27568657 DOI: 10.1016/j.jpeds.2016.07.050] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/14/2016] [Accepted: 07/28/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the feasibility of obtaining and utilizing objective measures of timing and displacement from videofluoroscopy performed in pediatrics. STUDY DESIGN Children (n = 121; mean age 38 months, range 9 days-21 years, SD 4 years) referred for videofluoroscopy were recruited. All underwent a standardized protocol including a mid-feed 20-second loop recorded at 25 frames per second. Videos were analyzed using objective digital measures of timing and displacement. Radiation dose was recorded. RESULTS Quantitative measures were obtained in all children. Maximum opening of the pharyngoesophageal segment and timing measures were correlated with increasing age. Values were congruent with validated adult data. Mean radiation time was 1.58 minutes (range 0.15-3.47, SD 0.66), and mean radiation dose was 30.16 cGycm2 (range 6.5-85 SD 15.17). Radiation dose (P = .21) and radiation time (P = .72) were not significantly different using the increased frame rate compared with an age-matched cohort (n =100) prior to protocol change. CONCLUSIONS Objective quantitative measures of swallowing measurements can be obtained successfully from pediatric videofluoroscopy performed at high frame rates, without increasing radiation dose. Measures are biologically consistent, reproducible, demonstrate internal cross-correlation, and mirror adult data. These measures have potential to support targeted management and objective monitoring of change by pediatric feeding teams in the future.
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Affiliation(s)
- Mandy Henderson
- Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand; Speech Science, The University of Auckland, Auckland, New Zealand
| | - Anna Miles
- Speech Science, The University of Auckland, Auckland, New Zealand.
| | - Victoria Holgate
- Speech Science, The University of Auckland, Auckland, New Zealand
| | - Sophia Peryman
- Radiology, Waitemata District Health Board, Auckland, New Zealand
| | - Jacqui Allen
- Speech Science, The University of Auckland, Auckland, New Zealand; Otolaryngology, Waitemata District Health Board, Surgery, University of Auckland, Auckland, New Zealand
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Marks SL, Douthitt KL, Belafsky PC. Feasibility of flexible endoscopic evaluation of swallowing in healthy dogs. Am J Vet Res 2016; 77:294-9. [PMID: 26919601 DOI: 10.2460/ajvr.77.3.294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess feasibility of flexible endoscopic evaluation of swallowing (FEES) in awake dogs, determine whether specific variables associated with the oropharyngeal phase of swallowing can be recognized, and evaluate the safety and tolerability of FEES. ANIMALS 6 healthy client-owned large- and giant-breed adult dogs. PROCEDURES A topical anesthetic was applied to the nasal passage of each dog, and a fiberoptic endoscope was passed transnasally until the tip of the scope was positioned in the oropharynx. All dogs voluntarily drank colored water followed by consumption of a commercial canned diet and then a kibble diet mixed with food color. During each swallow, laryngeal and pharyngeal anatomic structures were evaluated and depth of bolus flow prior to the pharyngeal phase of swallowing was assessed. Evidence of bolus retention in the vallecula or pyriform sinuses and laryngeal penetration of the bolus were recorded. RESULTS FEES was completed without major adverse events and was tolerated well by all 6 dogs. Mild, self-limiting epistaxis was noted for 2 dogs. The nasopharynx, oropharynx, and hypopharynx were observed in all dogs; movement of food boluses through the esophagus was observed in 2 dogs, and food boluses in the stomach were visible in 1 dog. Pharyngeal and laryngeal function was considered physiologically normal in all dogs. CONCLUSIONS AND CLINICAL RELEVANCE FEES appeared to be a feasible diagnostic tool for use in large- and giant-breed dogs. Studies are warranted in dogs with oropharyngeal dysphagia to determine whether FEES can be tolerated and whether it can augment videofluoroscopy findings.
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Van Abel KM, Tombers NM, Krein KA, Moore EJ, Price DL, Kasperbauer JL, Hinni ML, Lott DG, Ekbom DC. Short-term Quality-of-Life Outcomes following Transoral Diverticulotomy for Zenker’s Diverticulum. Otolaryngol Head Neck Surg 2015; 154:322-7. [DOI: 10.1177/0194599815616078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 10/16/2015] [Indexed: 11/15/2022]
Abstract
Objective To prospectively analyze quality-of-life outcomes following transoral diverticulotomy with cricopharyngeal myotomy (DCPM) for Zenker’s diverticulum (ZD). Study Design Prospective single-group study. Settings Tertiary academic institution. Subjects and Methods A prospective multicenter study performed from January 1, 2012, to July 1, 2014, included 18 patients presenting with ZD undergoing DCPM. Standardized questionnaires—including the 10-item Eating Assessment Tool (EAT-10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI)—were completed preoperatively and at 3 and 6 months postoperatively. Videofluoroscopic studies were obtained and analyzed by our senior speech-language pathologist, who was blinded to the clinical outcomes. Results Eighteen patients were included (11 women; mean age, 72.6 years; range, 53-86 years). All patients had ZD on preoperative videofluoroscopic swallowing studies. The most common comorbidities included hypertension (10 of 18, 55.6%), dyslipidemia (8 of 18, 44.4%), hiatal hernia (6 of 18, 33.3%), and gastroesophageal reflux disease (5 of 18, 27.8%). Median preoperative RSI was 27 (interquartile range [IQR], 22.5-31.5); FOSS, 2 (IQR, 2-3); and EAT-10, 21.5 (IQR, 13.5-27.5). The 3-month questionnaire (88.9% completion) demonstrated an improved median RSI of 5 (IQR, 1-7.5; P < .001), FOSS of 0 (IQR, 0; P < .001), and EAT-10 of 0 (IQR, 0-3; P < .001). Fourteen patients (77.8%) completed the 6-month questionnaire, demonstrating a median RSI of 4 (IQR, 0-8), FOSS of 0 (IQR, 0-0.5), and EAT-10 of 1 (IQR, 0-3). While regurgitation decreased following surgery ( P = .007), nighttime cough did not ( P = .25). Conclusion This study supports an improvement in functional outcome and quality of life in patients with ZD undergoing DCPM.
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Affiliation(s)
- Kathryn M. Van Abel
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Nicole M. Tombers
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Kari A. Krein
- Department of Speech and Language Pathology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Eric J. Moore
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Daniel L. Price
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jan L. Kasperbauer
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Michael L. Hinni
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David G. Lott
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Dale C. Ekbom
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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Endoscopic-guided injection of botulinum toxin into the cricopharyngeus muscle: our experience. The Journal of Laryngology & Otology 2015; 129:990-5. [DOI: 10.1017/s0022215115002327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:To assess the efficacy of endoscopic-guided botulinum toxin injection into the cricopharyngeus muscle and evaluate the duration of its effects.Methods:A 3-year prospective study of 12 patients undergoing injection of botulinum toxin was conducted, with a telephone survey to assess dysphagia pre-operatively, and at 1, 3 and 6 months post-treatment, using the MD Anderson Dysphagia Inventory.Results:Median age was 66.2 years. Causes of cricopharyngeal dysphagia included idiopathic cricopharyngeal hypertrophy (67 per cent), previous cerebrovascular accident (17 per cent), cranial nerve palsy (8 per cent) and previous chemoradiotherapy to the neck (8 per cent). There were no complications. Two patients had repeat injections after six months. There was significant improvement in MD Anderson Dysphagia Inventory scores at one and three months versus pre-operative scores (73.1 ± 14.9 vs 46.9 ± 7.6, p = 0.0001, and 65.1 ± 11.5 vs 46.9 ± 7.6, p = 0.0001), but not at six months (51.0 ± 11.0 vs 46.9 ± 7.6, p = 0.14).Conclusion:Endoscopic-guided injection of botulinum toxin into the cricopharyngeus muscle is a safe and effective method for treating cricopharyngeal muscle dysfunction, lasting up to six months.
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Jamal N, Erman A, Chhetri DK. Partial Epiglottoplasty for Pharyngeal Dysphagia due to Cervical Spine Pathology. Otolaryngol Head Neck Surg 2015; 153:586-92. [PMID: 26315313 DOI: 10.1177/0194599815601025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/27/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the role of epiglottoplasty in patients with pharyngeal dysphagia due to pharyngeal crowding from cervical spine pathology and to assess swallowing outcomes following epiglottoplasty. STUDY DESIGN Retrospective case series. SETTING Academic tertiary care medical center. SUBJECTS AND METHODS Dysphagia can occur in patients with cervical spine pathology because of hypopharyngeal crowding. Swallowing studies, such as modified barium swallow study and fiberoptic endoscopic evaluation of swallowing, may demonstrate a nonretroflexing epiglottis owing to cervical spine osteophytes or hardware, thus impeding pharyngeal bolus transit. We performed partial epiglottoplasties in a series of these patients. A retrospective review of swallowing outcomes was performed to assess the efficacy of this surgery in this patient population. RESULTS Epiglottic dysfunction causing dysphagia due to cervical spine pathology was diagnosed by modified barium swallow study and/or fiberoptic endoscopic evaluation of swallowing in 12 patients. Findings included hypopharyngeal crowding because of cervical osteophytes (n = 8) or cervical hardware (n = 4) associated with absent epiglottic retroflexion and retained vallecular residue. Partial epiglottoplasty resulted in significant reduction of vallecular residue and a significant increase in functional swallow outcomes without an increase in swallow morbidity. CONCLUSION There is a role for partial epiglottoplasty in patients with dysphagia attributed to hypopharyngeal crowding from cervical spine pathology. Surgery enables reduced vallecular residue and improved functional swallowing outcomes.
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Affiliation(s)
- Nausheen Jamal
- Department of Otolaryngology-Head and Neck Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrew Erman
- Departments of Audiology and Speech, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Dinesh K Chhetri
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
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Arenaz Búa B, Olsson R, Westin U, Rydell R, Ekberg O. Treatment of cricopharyngeal dysfunction: a comparative pilot study. BMC Res Notes 2015; 8:301. [PMID: 26159167 PMCID: PMC4498531 DOI: 10.1186/s13104-015-1266-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 06/30/2015] [Indexed: 01/30/2023] Open
Abstract
Background Cricopharyngeal dysfunction is a narrowing at the level of the upper oesophageal sphincter caused by failed or incomplete sphincter opening as a result of lack of pharyngoesophageal coordination or reduction in the muscular compliance of the upper oesophageal sphincter. Oropharyngeal dysphagia is a typical symptom. Videomanometry allows direct comparison of pressure readings with dynamic anatomy during swallowing. Methods This is a prospective randomized pilot study that compares the effect of balloon dilatation and laser myotomy in cricopharyngeal dysfunction. We used videomanometry as an objective measure and the Swedish version of Sydney Swallowing Questionnaire as patient’s self-assessment at baseline and 1 and 6 months after treatment. Results The UES sagittal diameter increased from 5.6 mm pre-operatively to 8.4 mm 6 months post-operatively with no differences between treatment groups. Preoperative mean Sydney Swallowing Questionnaire score was 770 and 6 months post-operative score 559, with no difference between the treatments in our cohort. Conclusion Cricopharyngeal dysfunction treatment by either laser myotomy or balloon dilatation improved upper oesophageal sphincter opening during at least 6 months. Trial registration: ISRCTN84905610, date: 081214
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Affiliation(s)
- Beatriz Arenaz Búa
- Division of Logopedics, Phoniatrics and Audiology, Department of Clinical Sciences, Lund University, Skane University Hospital, Jan Waldenströmsgata 18, 205 02, Malmö, Sweden. .,Division of Ear, Nose and Throat Diseases, Head and Neck Surgery, Department of Clinical Sciences, Lund University, Skane University Hospital, Jan Waldenströmsgata 18, 205 02, Malmö, Sweden.
| | - Rolf Olsson
- Diagnostic Centre of Imaging and Functional Medicine, Department of Clinical Sciences, Lund University, Skåne University Hospital, 205 02, Malmö, Sweden.
| | - Ulla Westin
- Division of Ear, Nose and Throat Diseases, Head and Neck Surgery, Department of Clinical Sciences, Lund University, Skane University Hospital, Jan Waldenströmsgata 18, 205 02, Malmö, Sweden.
| | - Roland Rydell
- Division of Logopedics, Phoniatrics and Audiology, Department of Clinical Sciences, Lund University, 221 85, Lund, Sweden. .,Division of Ear, Nose and Throat Diseases, Head and Neck Surgery, Department of Clinical Sciences, Lund University, 221 85, Lund, Sweden.
| | - Olle Ekberg
- Diagnostic Centre of Imaging and Functional Medicine, Department of Clinical Sciences/Medical Radiology, Skåne University Hospital, Lund University, 205 02, Malmö, Sweden.
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Brisinda G, Sivestrini N, Bianco G, Maria G. Treatment of gastrointestinal sphincters spasms with botulinum toxin A. Toxins (Basel) 2015; 7:1882-916. [PMID: 26035487 PMCID: PMC4488680 DOI: 10.3390/toxins7061882] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/10/2015] [Accepted: 05/21/2015] [Indexed: 02/05/2023] Open
Abstract
Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Nicola Sivestrini
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giuseppe Bianco
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Giorgio Maria
- Department of Surgery, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168 Rome, Italy.
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Laser surgery for Zenker's diverticulum: European combined study. Eur Arch Otorhinolaryngol 2015; 273:183-8. [PMID: 25567345 DOI: 10.1007/s00405-014-3486-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/25/2014] [Indexed: 12/17/2022]
Abstract
Surgical intervention is the gold standard of treatment for Zenker's diverticulum. The aim of this study was to examine the role of laser surgery in a large number of patients with this pathological entity. The data of 91 consecutive patients treated due to Zenker's diverticulum with the aid of CO2 laser in three institutions (Homburg/Saar and Marburg, Germany/Athens, Greece) during the last 10 years were retrospectively analyzed. Parameters examined were sex, age, preoperative symptoms, length of operation and complications, revision surgery necessity and degree of patient satisfaction. All patients had a minimum follow-up of one year. Dysphagia was the most common preoperative symptom (78 %). The most common minor complication was dental injury (6.6 %), but a serious complication in form of emphysema was observed in only two patients (2.2 %). A surgical revision was necessary in 8 (8.8 %) of the treated patients. The majority of treated patients was free of symptoms (86.8 %), or presented mild symptoms (9.9 %) one year after intervention, and only three patients (3.3 %) were dissatisfied. Our study shows that laser treatment of Zenker's diverticulum is an efficient operative technique associated with low complications rates and significant improvement of patients' symptoms in most of the examined cases.
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Jones CA, Knigge MA, McCulloch TM. Speech pathologist practice patterns for evaluation and management of suspected cricopharyngeal dysfunction. Dysphagia 2014; 29:332-9. [PMID: 24500663 DOI: 10.1007/s00455-013-9513-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 12/30/2013] [Indexed: 11/27/2022]
Abstract
Speech pathologists are often the first professionals to identify signs of a cricopharyngeal (CP) dysfunction and make recommendations for further care. There are many care options for patients with CP dysfunction, but it is unclear how certain interventions are used in practice. A paper-based survey employing two clinical cases involving suspected CP dysfunction (Case 1 with adequate pharyngeal strength and Case 2 with coexisting pharyngeal weakness) was sent to members of American Speech-Language Hearing Association's Special Interest Group 13. Respondents ranked the order of management approaches (swallowing therapy, further evaluation, and referral to another medical professional) and selected specific interventions under each approach that they would recommend for each case. Completed surveys from 206 respondents were entered into analysis. The majority of the respondents recommended swallowing therapy as a first approach for each case (Case 1: 64 %; Case 2: 88 %). The most prevalent swallowing exercises recommended were the Shaker (73 %), effortful swallow (62 %), and Mendelsohn maneuver (53 %) for Case 1 and effortful swallow (92 %), Shaker (84 %), and tongue-hold swallow (73 %) for Case 2. 76 % of respondents recommended a referral for Case 1, while 38 % recommended the same for Case 2. Respondents with access to more types of evaluative tools were more likely to recommend further evaluation, and those with access to only videofluoroscopy were less likely to recommend further evaluation. However, the high degree of variability in recommendations reflects the need for best practice guidelines for patients with signs of CP dysfunction.
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Affiliation(s)
- Corinne A Jones
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792-7375, USA
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Cervical oesophagostomy in patients with severe dysphagia following radiotherapy for nasopharyngeal carcinoma. The Journal of Laryngology & Otology 2014; 128:142-6. [PMID: 24472660 PMCID: PMC3941040 DOI: 10.1017/s0022215113003423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective: This study aimed to investigate the validity and feasibility of cervical oesophagostomy as a treatment for patients with severe dysphagia after radiotherapy for nasopharyngeal carcinoma. Methods: The study retrospectively analysed the clinical data, symptoms, physical signs, treatment and outcomes of 12 patients treated with cervical oesophagostomy for severe dysphagia after radiotherapy for nasopharyngeal carcinoma, from 2006 to 2010. Results: In all 12 cases, the oesophageal stoma remained stable, without any complications such as pharyngeal fistula or inflammation. No oesophageal stricture or granuloma growth was observed. All patients reported significant improvement in their nutritional status and quality of life after the oesophagostomy surgery. Conclusion: Cervical oesophagostomy is a valid and feasible method of treating severe dysphagia following radiotherapy for nasopharyngeal carcinoma. Oesophagostomy shows specific advantages over nasogastric tubing, gastrostomy and jejunostomy. Patients' nutrition and quality of life can be improved significantly if cervical oesophagostomy is executed in a timely fashion, especially in cases with severe trismus and multiple radiation-induced cranial nerve palsies unresponsive to rehabilitation.
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Lavin JM, Tieu D, Maddalozzo J. Complementary and integrative treatments: swallowing disorders. Otolaryngol Clin North Am 2013; 46:447-60. [PMID: 23764821 DOI: 10.1016/j.otc.2013.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Swallowing disorders are associated with many disease processes and are associated with significant morbidity and mortality. This article provides information regarding the various causes of swallowing disorders as well as medical, surgical, and integrative approaches to their management.
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Affiliation(s)
- Jennifer M Lavin
- Department of Otolaryngology-Head and Neck Surgery, Northwestern, University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Kelly EA, Koszewski IJ, Jaradeh SS, Merati AL, Blumin JH, Bock JM. Botulinum toxin injection for the treatment of upper esophageal sphincter dysfunction. Ann Otol Rhinol Laryngol 2013; 122:100-8. [PMID: 23534124 DOI: 10.1177/000348941312200205] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to review the dysphagia-related outcomes and quality of life in a series of patients with upper esophageal sphincter (UES) dysfunction treated with cricopharyngeal (CP) botulinum toxin (BTX) injection, and to identify patient characteristics or CP muscle histologic features that predict efficacy of BTX injection. METHODS A retrospective chart review was performed on patients with UES dysfunction who underwent CP BTX injection. Dysphagia-related quality-of-life questionnaires based on the Eating Assessment Tool (EAT-10) were mailed to patients. RESULTS Forty-nine patients (30 female, 19 male; average age, 59 +/- 16 years) with UES dysfunction have been treated at our institution with CP BTX injection since 2000. Seventeen of these patients also underwent CP myotomy. Injections of BTX were occasionally repeated after the treatment effect subsided, and the BTX dose varied widely (average, 39 +/- 19 units). Improvement in symptoms was noted by 65% of patients. The overall complication rate was minimal, although many patients complained of transient worsening of dysphagia after CP BTX injection. Biopsy specimens of the CP muscle were evaluated in the subset of patients with CP BTX injection who proceeded to myotomy, with results of neuropathic, myopathic, and mixed histologic subtypes. The EAT-10 scores demonstrated a general trend toward improved swallowing outcomes after CP BTX injection. CONCLUSIONS This study reviewed findings from the largest published series of BTX treatment of UES dysfunction and evaluated the efficacy, patient satisfaction, and complications of this procedure. Dysphagia-related quality-of-life outcomes appear to be improved after CP BTX injection.
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Affiliation(s)
- Elizabeth A Kelly
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Leong SC, Wilkie MD, Webb CJ. Endoscopic stapling of Zenker’s diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol 2012; 269:1877-84. [DOI: 10.1007/s00405-012-1945-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 01/20/2012] [Indexed: 11/29/2022]
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Gastroesophageal Reflux Disease, Globus, and Dysphagia. Dysphagia 2011. [DOI: 10.1007/174_2011_340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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