Cricopharyngeal dysfunction: A systematic review comparing outcomes of dilatation, botulinum toxin injection, and myotomy

Dysphagia in Head and Neck Cancer

Dysphagia is a common symptom in patients with head and neck cancer that can significantly impact health outcomes and quality of life. The origin of dysphagia in these patients is often multifactorial, making diagnosis and management especially complex. The evaluating otolaryngologist should be well versed with the patient's neoplasm, comorbidities, and treatment history alongside dysphagia-specific imaging modalities. Management is often dynamic, requiring frequent monitoring, interprofessional collaboration, and a variety of supportive and invasive measures to achieve optimal outcomes.

Zebras in Adult Dysphagia Workup: Where to Look When You Think You Have Looked Everywhere

While many patients who present with dysphagia have a clinically identifiable cause of dysphagia, the etiology of swallowing difficulty is oftentimes a diagnostic enigma. The aim of this article is to review possible etiologies of dysphagia when objective evidence of dysphagia is lacking. Included in this discussion are cricopharyngeal spasm, retrograde cricopharyngeal dysfunction, muscle tension dysphagia, dysphagia secondary to medications, and functional dysphagia.

Safety of a Novel Upper Esophageal Sphincter Balloon Dilator

OBJECTIVE

The shape of esophageal dilators has not changed in over 350 years. Clinical and animal research suggests that the upper esophageal sphincter (UES) is not round but approximates a kidney shape and that cylindrical dilators may be suboptimal. The Infinity UES Dilation System has been developed specifically for the anatomic configuration of the UES. This study evaluates the safety of the UES-specific Infinity Dilation System.

METHODS

All patients undergoing dilation of the UES between January 1, 2022 and September 1, 2023 were included. Demographics, procedure indication, dilator type, minor adverse events, and major complications were abstracted. Minor adverse events, complications, and maximum dilation dimension (mm) were compared between groups.

RESULTS

A total of 477 patients were included. Eight hundred and seventy-three total UES dilations were performed. The primary indications for UES dilation were cricopharyngeus muscle dysfunction (43%) and stenosis from radiation toxicity (40%). Twenty-three percent (202/873) of dilations were performed with an Infinity balloon, 31% (270/873) were performed using two conventional balloons placed side by side, and 46% (401/873) were performed with one singleton conventional balloon. The average maximum dilation dimension was 33 (±4.7) mm for Infinity balloons, 32 (±3.8) mm for two side-by-side balloons, and 18 (±3.4) mm for singleton balloons. There were three major complications with conventional balloons and none with Infinity balloons. There were no significant differences in minor adverse events between groups.

CONCLUSIONS

A UES-specific esophageal dilator provides a greater maximum dilation dimension and appears to be at least as safe as dilation with a single cylindrical balloon designed to dilate the esophagus.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2024.

Comprehensive assessment and treatment strategies for dysphagia in the elderly population: Current status and prospects

As the population ages, the prevalence of dysphagia among older adults is a growing concern. Age-related declines in physiological function, coupled with neurological disorders and structural changes in the pharynx associated with aging, can result in weakened tongue propulsion, a prolonged reaction time of the submental muscles, delayed closure of the laryngeal vestibule, and delayed opening of the upper esophageal sphincter (UES), increasing the risk of dysphagia. Dysphagia impacts the physical health of the elderly, leading to serious complications such as dehydration, aspiration pneumonia, malnutrition, and even life-threatening conditions, and it also detrimentally affects their psychological and social well-being. There is a significant correlation between frailty, sarcopenia, and dysphagia in the elderly population. Therefore, older adults should be screened for dysphagia to identify both frailty and sarcopenia. A reasonable diagnostic approach for dysphagia involves screening, clinical assessment, and instrumental diagnosis. In terms of treatment, multidisciplinary collaboration, rehabilitation training, and the utilization of new technologies are essential. Future research will continue to concentrate on these areas to enhance the diagnosis and treatment of dysphagia, with the ultimate aim of enhancing the quality of life of the elderly population.

Cricopharyngeus muscle dysfunction: a poorly defined disorder from diagnosis to treatment

PURPOSE

Cricopharyngeus muscle dysfunction (CPMD) is a common clinical occurrence with very few clear diagnostic criteria and multiple pathways for treatment. Incidence of CPMD is not known, but some data suggest around 25% of people with dysphagia experience some degree of CPMD, which negatively impacts swallowing safety and efficiency. Workup and treatment of CPMD can require multidisciplinary collaboration across laryngologists, speech-language pathologists with training in dysphagia management, and gastroenterologists. The purpose of this paper is to review what is known about CPMD and identify areas of future research in CPMD diagnosis and treatment.

METHODS

An overview of CPMD, relative treatments and disorders, and a discussion of future areas of research needed to improve clinical care of CPMD.

RESULTS

Details regarding historical background, pathophysiology and treatment practiced for CPMD are included.

CONCLUSION

In summary, CPMD is a poorly defined disease due to a lack of understanding of its pathophysiology and the lack of consensus diagnostic criteria. Well-designed, prospective clinical trials are necessary to develop a better understanding of clinical incidence of CPMD, impact of the disorder on oropharyngeal swallowing, and how to approach treatment of the disorder surgically or in conjunction with therapy directed by a specialized speech-language pathologist.

The Hyoid Bone Kinematics in Dysphagic Stroke Patients: Instantaneous Velocity, Acceleration and Temporal Sequence Matters

Hyoid bone excursion (HBE) is one of the most critical events in the pharyngeal phase of swallowing. Most previous studies focused on the total displacement and average velocity of HBE. However, HBE during swallowing is not one-dimensional, and the change of velocity and acceleration is not linear. This study aims to elucidate the relationship between the instantaneous kinematics parameters of HBE and the severity of penetration/aspiration and pharyngeal residue in patients with stroke. A total of 132 sets of video-fluoroscopic swallowing study images collected from 72 dysphagic stroke patients were analyzed. The maximal instantaneous velocity, acceleration, displacement, and the time required to reach these values in the horizontal and vertical axes were measured. Patients were grouped according to the severity of the Penetration-Aspiration Scale and the Modified Barium Swallow Impairment Profile- Pharyngeal Residue. The outcome was then stratified according to the consistencies of swallowing materials. Stroke patients with aspiration were associated with a lower maximal horizontal instantaneous velocity and acceleration of HBE, a shorter horizontal displacement, and prolonged time to maximal vertical instantaneous velocity compared to the non-aspirators. In patients with pharyngeal residue, the maximal horizontal displacement of HBE was decreased. After stratification according to bolus consistencies, the temporal parameters of HBE were more significantly associated with aspiration severity when swallowing thin bolus. Meanwhile spatial parameters such as displacement had a bigger influence on aspiration severity when swallowing viscous bolus. These novel kinematic parameters of HBE could provide important reference for estimating swallowing function and outcomes in dysphagic stroke patients.

Guidelines for the Use of Botulinum Toxin in Otolaryngology From the Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force

The Korean Society of Laryngology, Phoniatrics and Logopedics created a task force to establish clinical practice guidelines for the use of botulinum toxin (BT) in otolaryngology. We selected 10 disease categories: spasmodic dysphonia, essential vocal tremor, vocal fold granuloma, bilateral vocal fold paralysis, Frey's syndrome, sialocele, sialorrhea, cricopharyngeal dysfunction, chronic sialadenitis, and first bite syndrome. To retrieve all relevant papers, we searched the CORE databases with predefined search strategies, including Medline (PubMed), Embase, the Cochrane Library, and KoreaMed. The committee reported 13 final recommendations with detailed evidence profiles. The guidelines are primarily aimed at all clinicians applying BT to the head and neck area. In addition, the guidelines aim to promote an improved understanding of the safe and effective use of BT by policymakers and counselors, as well as in patients scheduled to receive BT injections.

The robot can break bars with the best of them: a novel approach to treating cricopharyngeal bars with myotomy

INTRODUCTION

Failure of the cricopharyngeus to relax results in oropharyngeal dysphagia, which over time results in hypertrophy and increased risk for aspiration. Open myotomy is one definitive treatment option, however there are several drawbacks attributable to the long neck incision, ± drain placement, and invasiveness of the procedure. We aim to share our experience using the DaVinci robotic platform to perform a minimally invasive cricopharyngeal myotomy, which has never been described before in the literature.

METHODS

All robotic cricopharyngeal myotomies performed in adult patients by a single surgeon from 2021 to 2022 were retrospectively reviewed. No patients were excluded. Outcomes of interest included length of procedure, time to diet resumption, hospital length of stay, complications, symptom improvement at follow-up, and symptom recurrence.

RESULTS

Eight robotic cricopharyngeal myotomies were performed. The median age was 65 years old (62-91) and mostly female (n = 5, 56%) with a median BMI of 28.9 kg/m2 (21.7-39.5). The median procedure length was 113 min (94-141) and there were no intraoperative complications. All patients underwent a post-procedural esophagram with no leaks were identified. All patients were started on clear liquids in recovery and transitioned to full liquids prior to discharge. All but one patient was subsequently discharged home on the same day as procedure. All patients had routine 2-week post-operative follow-up in addition to phone follow-up at a later date (6-11 months post-operative). All patients reported resolution of symptoms. There were no complications or readmissions. No instances of recurrence were reported. On cost analysis, the minimally invasive robotic approach allows for an outpatient procedure with similar cost to an open approach with a one-night stay.

CONCLUSION

Our experience with the novel technique of minimally invasive robotic cricopharyngeal myotomy for cricopharyngeal bars with cervical dysphagia is safe, efficacious, less invasive, and cost saving, with excellent patient outcomes.

Postoperative Complications and Reoperative Surgery in the Treatment of Patients With Zenker Diverticulum

Importance

The association of the surgical approach, surgical specialty, and other factors with the outcomes of surgical treatment of Zenker diverticulum (ZD) have been debated in the literature.

Objectives

To explore the outcomes of 3 different surgical methods used in the management of ZD and determine the associations between patient characteristics, such as preoperative comorbidities and treatment outcomes.

Design, Setting, and Participants

This retrospective, population-based cohort study examined patient records of patients who underwent surgical treatment for ZD from the Care Register for Healthcare database in Finland between January 1996 and December 2015. Data review and analysis were completed in 2021.

Exposure

Surgical treatment for ZD.

Main Outcome and Measures

Complications of surgical procedures used in the management of ZD.

Results

In this study, 1044 patients (median [IQR] age, 70.0 [22.0-98.0] years; 416 female individuals [39.8%]) surgically treated for ZD were identified. Most patients (606 [58.0%]) had no preoperative comorbidities. A total of 67 (6.4%) complications were recorded, with a mortality rate of 0.9%. The likelihood of complications was associated with patient age (t [1042] = 2.28; Cohen d, 0.29; 95%, CI 0.04, 0.54), surgical approach (Cramer V = 0.14 [95% CI 0.07-0.21]), and surgical specialty (Cramer V, 0.16; 95% CI, 0.06-0.28). The median (IQR) length of stay in association with the primary surgical intervention was 3.0 (0-85.0) days. Length of stay was associated with patient age (Cramer V, 0.14; 95% CI, 0.06-0.25), especially in patients older than 90 years, surgical approach (F [2, 466.2] = 26.9; ηp2 = 0.08; 95% CI, 0.05-0.11), and surgical specialty (F [4, 22.1] = 11.0; ηp2 = 0.07; 95% CI, 0.04-0.10). Reoperation was associated with the initial surgical approach (Cramer V, 0.18; 95% CI, 0.12-0.23) and surgical specialty (Cramer V, 0.14; 95% CI, 0.09-0.21).

Conclusions and Relevance

The results of this cohort study suggest that the outcomes of surgical management depended on the surgical approach, surgical specialty, and patient age. Overall, surgical treatment may be considered safe and may be considered for all patients with symptomatic ZD.

Clinical Practice Guidelines for Oropharyngeal Dysphagia

OBJECTIVE

Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one's physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia.

METHODS

Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology.

RESULTS

Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended.

CONCLUSION

This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

Pediatric Neurogastroenterology and Motility Disorders: What Role Does Endoscopy Play?

Although pediatric neurogastroenterology and motility (PNGM) disorders are prevalent, often debilitating, and remain challenging to diagnose and treat, this field has made remarkable progress in the last decade. Diagnostic and therapeutic gastrointestinal endoscopy emerged as a valuable tool in the management of PNGM disorders. Novel modalities such as functional lumen imaging probe, per-oral endoscopic myotomy, gastric-POEM, and electrocautery incisional therapy have changed the diagnostic and therapeutic landscape of PNGM. In this review, the authors highlight the emerging role of therapeutic and diagnostic endoscopy in esophageal, gastric, small bowel, colonic, and anorectal disorders and disorders of gut and brain axis interaction.

Adaptation of peroral endoscopic myotomy for cricopharyngeal bar

Video 1Step-by-step performance of the cricopharyngeal myotomy.

Evaluating intramuscular neural distribution in the cricopharyngeus muscle for injecting botulinum toxin

OBJECTIVES

The objective of this study was to determine the area in the cricopharyngeus muscle (CPM) where botulinum neurotoxin (BoNT) can be injected safely and effectively by evaluating neural distribution in the CPM.

METHODS

Eleven specimens of the CPM were gathered from human cadavers. The anatomical relationship between the posterior cricoarytenoid muscle (PCAM) and the CPM was evaluated. Myelinated nerve fibers in the CPM were stained using modified Sihler's method. The CPM was classified into five zones according to the area accessible within the CPM via transcutaneous and transluminal approaches for BoNT injection as follows: i) lateral area including upper area (zone 1) and lower area (zone 2); ii) posterolateral area including upper area (zone 3) and lower area (zone 4); and iii) posterior area (zone 5). Neural distribution originating from the pharyngeal plexus and the extralaryngeal branches of recurrent laryngeal nerve (EBRLN) within each classified zone in stained specimens was determined.

RESULTS

Six specimens (12 lateral areas, 12 posterolateral areas, and 6 posterior areas) were suitable for evaluating neural distribution within the CPM. Zone 1 was adjacent to the PCAM the most in all specimens. Nerve endings originating from the EBRLN were observed on four sides of zone 2 (33.3%, 4/12 sides) in three specimens (3/6, 50%). Neural distribution originating from the pharyngeal plexus was found on ten sides (83.3%, 10/12 sides) of zone 3 in five specimens (83.3%, 5/6 specimens) and on nine sides (75.0%, 9/12 sides) of zone 4 in five specimens (83.3%, 5/6 specimens).

CONCLUSION

The posterolateral area (zone 3 and zone 4) is thought to be the most suitable area for alleviating the spasticity of CPM with a minimum dose of BoNT.

Acupuncture combined with balloon dilation for post-stroke cricopharyngeal achalasia: A meta-analysis of randomized controlled trials

Background

The purpose of this study was to systematically evaluate the effectiveness of acupuncture combined with balloon dilatation in patients with post-stroke cricopharyngeal achalasia (CPA) according to the effective rate, videofluoroscopy swallowing study (VFSS) score and standardized swallowing function assessment scale (SSA) score through Meta-analysis.

Methods

English and Chinese language literature published before July 24,2022 were searched in ten electronic databases. The identified articles were screened, data were extracted, and the methodological quality of the included trials was assessed. Using RevMan 5.4.1 software to perform Meta-analysis.

Results

10 studies with 517 patients with post-stroke CPA were included. Meta-analysis showed that the effective rate of the experience group was higher than that of the control group [OR = 0.62; 95% CI (2.32, 13.05); I 2 = 0%; p = 0.0001]. Compared to the control group, the SSA score was lower in the experience group [MD = -4.22; 95% CI (-4.57, -3.87); I 2 = 42%; p < 0.00001]. In terms of VFSS scores, the experience group showed greater efficacy differences than control group [MD = 1.53; 95% CI (1.32, 1.75); I 2 = 0%; p < 0.00001]. The subgroup analysis of VFSS score based on the average course of disease (<1 month vs. ≥1 month) showed no significant difference. The subgroup analysis based on average age (>60 years vs. ≤60 years) showed the VFSS score of the experience group was significantly higher than that of the control group, and the effect may be better in the subgroup older than 60 years. The subgroup analysis based on the treatment course (>30 days vs. ≤30 days) showed the VFSS score of the experience group was significantly higher than that of the control group, and the effect may be better in the subgroup the treatment course>30 days.

Conclusion

Acupuncture combined with balloon dilatation may be an effective method for treating post-stroke CPA. Compared with balloon dilatation, acupuncture combined with balloon can significantly improve the swallowing function of patients, and it is also effective for patients of different courses, ages, and treatment course, while patients over 60 years old and the treatment course over 30 days may have better clinical outcomes.

Cricopharyngeal muscle origin transection for oropharyngeal dysphagia, a novel surgical technique

BACKGROUND

Cricopharyngeal myotomy improves pharyngeal dysphagia by resecting the cricopharyngeal muscle.

METHODS

Our procedure, cricopharyngeal muscle origin transection (CPM-OT) is performed through a midline skin incision at the cricoid cartilage level under local anesthesia.

CONCLUSIONS

Sixteen patients demonstrated preservation of vocal fold movement without laryngeal nerve injury immediately after CPM-OT in the awake state during aspiration prevention surgery using the glottic closure technique. Postoperative videofluoroscopic examination of swallowing revealed the cricopharyngeal bar was absent and pharyngeal passage of the bolus and Food Intake LEVEL Scale was improved in all patients. CPM-OT is a feasible and less invasive treatment option.

The Effects of Adding Di-Tan Decoction (DTD) and/or Electroacupuncture (EA) to Standard Swallowing Rehabilitation Training (SRT) for Improving Poststroke Dysphagia (PSD): A Pilot, Single-Centred, Randomized Trial

OBJECTIVES

To evaluate the effect of adding Di-tan decoction (DTD) and/or electroacupuncture (EA) to standard swallowing rehabilitation training (SRT) on improving PSD.

METHODS

In total, 80 PSD patients were enrolled and randomly assigned to the DTD, EA, DTD + EA or control group at a 1 : 1 : 1 : 1 ratio. All patients received basic treatment and standard SRT. The DTD group received DTD orally, the EA group received EA, the DTD + EA group received both DTD and EA simultaneously, and the control group received only basic treatment and standard SRT. The interventions lasted for 4 weeks. The outcome measurements included the Standardized Swallowing Assessment (SSA) and Swallowing-Quality of Life (SWAL-QOL), performed and scored from baseline to 2, 4, and 6 weeks after intervention, and the Videofluoroscopic Dysphagia Scale (VDS), scored at baseline and 4 weeks after intervention. Scores were compared over time by repeated-measures analysis of variance (ANOVA) among all groups. Interactions between interventions were explored using factorial design analysis.

RESULTS

(1) The effective rates (ERs) for PSD treatment were higher in the DTD, EA and DTD + EA groups than in the control group (all P < 0.05). The ER was higher in the DTD + EA group than in the DTD or EA group (both P < 0.05). (2) There were significant group effects, time effects and interactions for the SSA and SWAL-QOL scores (all P < 0.05). All groups showed decreasing trends in SSA scores and increasing trends in SWAL-QOL scores over time from baseline to 6 weeks after intervention (all P < 0.01). (3) Factorial design analysis for ΔVDS showed that there was a significant main effect for DTD intervention (F = 11.877, P < 0.01) and for EA intervention (F = 29.357, P < 0.01). However, there was no significant interaction effect between DTD and EA (F = 0.133, P = 0.717). Multiple comparisons showed that the DTD, EA and DTD + EA groups all had higher ΔVDS values than the control group (P < 0.05). The DTD + EA group had a higher ΔVDS than the DTD or EA group (both P < 0.05). (4) Most adverse reactions were mild and transient.

CONCLUSIONS

Adding DTD or EA to SRT can better improve PSD than applying SRT alone. Adding DTD and EA simultaneously can accelerate and amplify the recovery of swallowing function versus DTD or EA alone, and both are effective and safe treatments, alone or jointly, for PSD and are a powerful supplement to routine treatments.

Assessment and treatment of neurogenic dysphagia in stroke and Parkinson's disease

PURPOSE OF REVIEW

Neurogenic dysphagia worsens quality of life and prognosis of patients with different neurological disorders. Management of neurogenic dysphagia can be challenging. This review provides a comprehensive overview of current evidence on screening, diagnosis, and treatment of neurogenic dysphagia in stroke and Parkinson's disease, suggesting clues for clinical practice.

RECENT FINDINGS

The pros and cons of diagnostic techniques are discussed in the light of updated evidence. Findings from recent meta-analyses of different treatment approaches, including traditional dysphagia therapy, peripheral and central neurostimulation techniques, and treatment with botulinum toxin, are critically discussed, emphasizing inconsistencies and controversial issues.

SUMMARY

Screening tests and clinical swallow examination should be routinely performed in neurological patients at risk for dysphagia. In patients testing positive for dysphagia, first-line instrumental investigations, represented by fiberoptic endoscopic evaluation of swallowing or videofluoroscopic swallow study, should be performed to confirm the presence of dysphagia, to assess its severity, and to inform the treatment. Second-line and third-line instrumental methods can be used in selected patients to clarify specific pathophysiological aspects of oropharyngeal dysphagia. Treatment strategies should be personalized, and combination of traditional dysphagia therapy with innovative treatment approaches may increase the chance of restoring effective and safe swallowing.

The efficacy and safety of catheter balloon dilatation in the treatment of dysphagia after stroke: A protocol for systematic review and meta-analysis

BACKGROUND

Dysphagia is a serious complication after stroke, which has a significant influence on the health as well as life quality of global people. Patients with dysphagia tend to be a higher risk rate of an aspiration than general person. Catheter balloon dilatation is an additional therapy for treating dysphagia in recent years, which can improve the symptom of achalasia of cricopharyngeal muscle. This research will be used for confirming the efficacy and safety of the catheter balloon dilatation for resolving dysphagia.

METHODS

We intend to search literature related to the research in different databases, for instance, China National Knowledge Infrastructure, Wanfang Data, PubMed, Cochrane Library, and Embase up to January 2022. Literature selection, data collection, as well as assessment of bias risk, will be carried out by 2 independent researchers. Data analysis will be conducted by using Stata and review manager 5.4.

RESULTS

The results will be submitted to a peer-reviewed journal.

CONCLUSION

The research will verify whether or not catheter balloon dilatation can improve dysphagia by submitting high-quality data syntheses.

REGISTRATION NUMBER

CRD42022358433.

Botulinum toxin injection combined with traditional swallowing rehabilitation improved cricopharyngeal dysfunction in neuromyelitis optica spectrum disorder: A case report

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune diseases of the central nervous system, and often influence optic nerve and medulla oblongata. Previous studies found out that brain abnormalities were not rare in these patients. Medulla oblongata (MO) was commonly involved and usually located at dorsal part. Patients who diagnosed NMOSD with MO lesions were more likely to have dysphagia. Previous reports indicated that the symptoms and signs of NMOSD patients could be controlled after immunosuppressive therapy. This patient was a 49-year-old Asian woman presented with recurrent vomiting and diagnosed NMOSD with MO involvement. However, after immunotherapy in other hospital, she still suffered from dysphagia. She then came to our department and completed videofluoroscopic swallowing study (VFSS) and high-resolution pharyngeal manometry (HRPM). Her UES was not opening with aspiration and the UES residue pressure was higher than normal range, we figured that she had cricopharyngeal (CP) dysfunction. Then the SLP gave her traditional treatment, including catheter balloon dilation. But she failed improvement after treatment for 2 weeks. Then the clinicians decided to inject botulinum toxin (BTX) into her CP muscles, which needed specific location and appropriate dosage. Her UES residue pressure decreased after three times BTX injection. During this time, her SLP adjusted the treatment strategies based on her VFSS and HRM results. Combined BTX injection with traditional treatment, she can now eat food orally without restrictions. This case report we presented can provide treatment strategies for similar patients with dysphagia.

Botulinum toxin A injection using ultrasound combined with balloon guidance for the treatment of cricopharyngeal dysphagia: analysis of 21 cases

BACKGROUND

As an upper oesophageal sphincter (UES) dysfunction disorder, cricopharyngeal achalasia (CPA) is a common cause of dysphagia and is associated with an increased risk of pulmonary complications. The aim of this study was to investigate the effectiveness and safety of BTX-A injection using ultrasound combined with balloon guidance for the treatment of CPA caused by stroke.

METHODS

A total of 21 patients diagnosed with CPA were treated with BTX-A injection into the cricopharyngeal muscle using ultrasound combined with balloon guidance. Primary outcome measures, including the functional oral intake scale (FOIS), videofluoroscopic dysphagia scale (VDS) and penetration aspiration scale (PAS), which are quantitative measures for a video fluoroscopic swallowing study (VFSS), and scores of the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were assessed from baseline to 12 weeks after treatment. Repeated measures analysis of variance was used to compare the scores between time points.

RESULTS

BTX-A injection led to improved dysphagia symptoms and scores in 19 patients (90.48%). Among them, 5 cases were cured (23.81%), 11 cases showed significant improvement (52.38%), and 3 cases showed improvement (14.29%). Two cases were absolutely ineffective (9.52%). Compared with the scores prior to treatment, the scores on the FOIS, VDS, PAS, SAS and SDS significantly improved beginning at 3 days (p < .05) and lasting for at least 12 weeks after injection.

CONCLUSIONS

Ultrasound with balloon-guided BTX-A injection is probably a relatively safe, easy, and effective technique for the treatment of CPA caused by stroke, with better visualization of the injection procedure. A well-designed controlled trial with a larger sample size is needed for more convincing conclusions.

Swallowing kinematic analysis might be helpful in predicting aspiration and pyriform sinus stasis

Aspiration due to dysphagia can lead to aspiration, which negatively impacts a patient’s overall prognosis. Clinically, videofluoroscopic swallow study (VFSS) is considered the gold-standard instrument to determine physiological impairments of swallowing. According to previously published literature, kinematic analyses of VFSS might provide further information regarding aspiration detection. In this study, 449 files of VFSS studies from 232 patients were divided into three groups: normal, aspiration, and pyriform sinus stasis. Kinematic analyses and between-group comparison were conducted. Significant between-group differences were noted among parameters of anterior hyoid displacement, maximal hyoid displacement, and average velocity of hyoid movement. No significant difference was detected in superior hyoid displacement. Furthermore, receiver-operating characteristic (ROC) analyses of anterior hyoid displacement, velocity of anterior hyoid displacement, and average velocity of maximal hyoid displacement showed acceptable predictability for detecting aspiration. Using 33.0 mm/s as a cutoff value of average velocity of maximal hyoid displacement, the sensitivity of detecting the presence of aspiration was near 90%. The investigators therefore propose that the average velocity of maximal hyoid displacement may serve as a potential screening tool to detect aspiration.

Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System

Importance

The incidence of Zenker diverticulum has been established; previous estimates have been extrapolated from small institutional cohorts.

Objective

To describe the population-wide incidence of Zenker diverticulum over a 20-year period and characterize management strategies across specialties and treatment settings.

Design, Setting, and Participants

This retrospective national cohort study was conducted from January 1, 1996, through December 31, 2015, and reviewed patient records from the Care Register for Healthcare in Finland, from which patients with Zenker diverticulum were identified. The data were analyzed in October 2021.

Exposures

Zenker diverticulum.

Main Outcome and Measure

The incidence of Zenker diverticulum per 100 000 person-years.

Results

A total of 2736 patients (median [IQR] age at diagnosis 72.0 [19-106] years; 1278 women [46.7%]) were identified, making the annual incidence of Zenker diverticulum in Finland 2.9/100 000 person-years. Men had higher incidence (3.7/100 000 person-years) compared with women (2.3/100 000 person-years), with an incidence rate ratio of 1.61 (95% CI, 1.48-1.76; P < .001). Within the study population, 1044 patients (38.2%) underwent surgical treatment and 227 (8.3%) underwent 2 or more surgeries. The choice of initial operative approach depended on the medical specialty (Cramer V = 0.41) and on specific catchment area (Cramer V = 0.41). Overall, endoscopic approaches for initial operations were most popular.

Conclusions and Relevance

The cohort study results found that the incidence of Zenker diverticulum was 2.9/100 000 person-years. Most patients with Zenker diverticulum did not undergo definitive therapy. Some hospital districts and some medical specialties were more likely to opt for conservative treatment than others. The choice of operative approach depended more on physician-level factors rather than patient profiles.

Cricopharyngeal Myotomy in National Surgical Quality Improvement Program (NSQIP): Complications for Otolaryngologists Versus Non-otolaryngologists

Objective: Comparing outcomes after cricopharyngeal myotomy (CM) performed by otolaryngologists (OTO) and non-otolaryngologists (NO).

Methods: A retrospective analysis of the 2014-19 ACS-NSQIP database (American College of Surgeons National Surgical Quality Improvement Program) of patients who underwent open CM (CPT code 43030) as their primary procedure. Analyzed variables include medical comorbidities, operative time, the total length of stay, readmission, reoperation, concurrent procedures, postoperative complications, and postoperative diagnoses. 183 patients were included, 97 (53%) females and 86 (47%) males. 120 had surgery by OTO and 63 by NO. 

Results: There were no differences in preoperative morbidity. OTO had more outpatient surgeries compared to NO (p<.001). OTO had a longer mean operating time (p=.008). OTO had a higher proportion of concurrent laryngeal procedures and other unspecified procedures compared to NO, while NO had a higher proportion of concurrent esophageal procedures (p=.028). The total length of stay was not significantly different between the two groups. 5.8% OTO and 7.9% NO patients were readmitted for a related reason (p=.586). Complications were similar between the two groups (p>.05). NO had more postop diagnoses of acquired diverticula and achalasia of the stomach cardia, while OTO had more diagnoses of dysphagia and muscular dystrophy (p<.001). 

Conclusion: There were differences in the surgical setting, length of procedure, concurrent procedures, and postop diagnoses between NO and OTO surgeons but similar complication rates.

Upper Gastrointestinal Functional and Motility Disorders in Children

Children with disorders affecting the sensory and motor functions of the esophagus will present primarily with swallowing dysfunction, dysphagia, and chest pain, and those with disorders affecting the normal function of the stomach will present with symptoms like abdominal pain, nausea, and vomiting. Recent advances in the mechanisms of disease and technology have increased our understanding of gastrointestinal physiology and that knowledge has been applied to develop new diagnostic studies and therapeutic interventions. We present an overview of the clinical presentation, diagnosis, and treatment of common primary and secondary functional and motility disorders affecting the upper gastrointestinal tract in children.

Comparison studies of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in the treatment of neurogenic cricopharyngeal muscle dysfunction

BACKGROUND

Cricopharyngeal muscle dysfunction (CPD) management has been challenging in clinical practice.

OBJECTIVE

To compare the efficacy and safety of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in treating CPD.

METHODS

Forty patients with CPD were randomly divided into two groups, namely the botulinum toxin injection group (BTX group) and balloon dilatation group (BD group). Patients in the BTX group received a single ultrasound-guided injection of 50 units of botulinum toxin type A, while the BD group received dilatation therapy five times per week, consecutively for two weeks. Relative opening percentage of the upper esophageal sphincter (UES), the penetration-aspiration scale (PAS), and the Dysphagia Outcome Severity Scale (DOSS) were evaluated by a videofluoroscopic swallowing study (VFSS) at baseline, 1-month, and 3-months posttreatment. The Functional Oral Intake Scale (FOIS) and Standardized Swallowing Assessment (SSA) were also used to evaluate participants' swallowing function at baseline and the 1-week, 2-week, 1-month, and 3-month follow-ups.

RESULTS

A generalized estimating equation (GEE) model revealed the significant main effect for time in UES, PAS, DOSS, FOIS, and SSA compared to baseline (P <0.05), while no group-by-time interactions (except for the PAS assessment) or main effect for treatment was detected among the above multiple variances. No systematic complications or severe adverse effects were noted.

CONCLUSION

Both ultrasound-guided botulinum toxin type A injections and balloon dilatation therapy have been proven as safe and effective treatments for CPD patients. Future clinical trials with longer follow-up periods and more participants are warranted.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

The Effect of Combined Guidance of Botulinum Toxin Injection with Ultrasound, Catheter Balloon, and Electromyography on Neurogenic Cricopharyngeal Dysfunction: A Prospective Study

BACKGROUND

Cricopharyngeal botulinum toxin (BTX) injection is one of the treatments for neurogenic cricopharyngeal dysfunction (CPD). We conducted this prospective study to investigate the effect and safety of BTX injection for neurogenic CPD with a novel guidance.

METHODS

Twenty-one patients with neurogenic CPD whose symptoms did not reduce after conventional swallowing therapy were included in this study. The impact of BTX injection on the swallowing function of the patients was evaluated.

KEY RESULTS

After the injection, the Functional Oral Intake Scale (FOIS) score increased in 17 of 21 patients (80.9%), which ranged from 1 to 3 (P < 0.001). Moreover, there was a significant reduction in the UES opening impairment (P < 0.01), UES residual pressure (P < 0.05), duration of UES relaxation, penetration-aspiration scale score (P < 0.05), secretion (P < 0.05), vallecular residue (P < 0.01), and left (P < 0.05) and right (P < 0.05) pyriform sinus residue. With at least 6 months of follow-up, we found that FOIS continued to increase in patients who showed improvement after the injection (i.e., FOIS 5-7 points), while it remained unchanged in patients without improvement after the injection. There were no side effects reported in this study.

CONCLUSION & INFERENCES

BTX injection into the cricopharyngeal muscle guided by ultrasound, catheter balloon, and electromyography possibly has a long-lasting effect that can effectively and safely improve the swallowing function of patients with neurogenic CPD.

Design and implementation of botulinum toxin on cricopharyngeal dysfunction guided by a combination of catheter balloon, ultrasound, and electromyography (BECURE) in patients with stroke: study protocol for a randomized, double-blinded, placebo-controlled trial

Background

Cricopharyngeal dysfunction (CPD) occurs in various neurological disorders, especially stroke. The treatment approaches of CPD include swallowing training, cricopharyngeal dilation, botulinum toxin (BTX) injection, and cricopharyngeal myotomy. BTX injection into the cricopharyngeal muscle is effective and safe for some patients with dysphagia, with a success rate between 43 and 100% (mean = 76%). However, well-designed randomized controlled clinical trials are needed to verify its efficacy and safety for the treatment of CPD. The objective of this study is to explore the efficacy and safety of BTX for neurogenic cricopharyngeal achalasia, when administering an injection into the cricopharyngeal muscle guided by a novel precise positioning method, that combines ultrasound, catheter balloon, and electromyography (BECURE).

Methods

BECURE is a single-center randomized, placebo controlled, double-blinded, superiority clinical trial. To detect a significant difference between the 2 groups, a sample size of 44 patients is estimated. The intervention is BTX versus placebo, with 1:1 randomization. The randomization sequence from 1 to 44 was generated using the Statistical Package for Social Sciences. The study is divided into two phases. In the first phase, patients will be injected with BTX or the placebo. In the second phase, patients who received a placebo injection and those who did not respond to the first BTX injection will receive an injection of BTX. The primary outcome is the score of the Functional Oral Intake Scale (FOIS). The secondary outcomes are as follows: upper esophageal sphincter (UES) residual pressure, UES resting pressure, duration of UES relaxation, velopharyngeal and laryngopharyngeal peak pressure, UES opening, pharyngeal construction ratio, residue of bolus in the epiglottis valley or piriform sinus, and penetration and aspiration.

Discussion

Dysphagia is a common complication of stroke. There is lack of high-quality evidence for the efficacy of BTX in treating neurogenic CPD. This study will clarify whether BTX injection into the cricopharyngeal muscle can be effective and safe for patients with stroke and CPD.

Trial registration

Chinese Clinical Trial Register (ChiCTR1900025562). Registered on September 1, 2019.

Non-aesthetic uses of botulinum toxin in the head and neck

INTRODUCTION

The use of botulinum toxin in the specialty of aesthetic surgery in the head and neck is well known. However, it has also been used for other conditions affecting the head and neck, and in recent years its use, as well as the number of relevant applications, has expanded enormously.

REVIEW

This article presents a summary of the current range of uses in the laryngeal, pharyngeal, cervical, oromandibular and facial muscles and salivary glands. We highlight particular conditions focusing on dystonia (laryngeal, craniocervical, oromandibular and cervical), multiple system atrophy, migraines, facial nerve palsy, post-laryngectomy, cricopharyngeal dysphagia, Zenker's diverticulum, retrograde cricopharyngeal dysfunction disorder, sialorrhea and gustatory sweating (Frey's syndrome).

CONCLUSION

This article should aid the ear, nose and throat surgeon garner knowledge about the range of uses for botulinum toxin in the head and neck.

Cricopharyngeal Myotomy in Inclusion Body Myositis: Comparison of Endoscopic and Transcervical Approaches

OBJECTIVE

Inclusion body myositis (IBM) is a progressive inflammatory myopathy with dysphagia as a debilitating sequalae. Otolaryngologists are consulted for surgical candidacy when there are findings of cricopharyngeal dysfunction. We aim to compare transcervical cricopharyngeal myotomy (TCPM) versus endoscopic cricopharyngeal myotomy (ECPM) in the IBM population with particular focus on objective swallow study outcomes, complications, and recurrence rates.

METHODS

A retrospective cohort study was performed on IBM patients who underwent TCPM or ECPM (1981-2020) in the Department of Otolaryngology at a tertiary academic center with a high volume IBM referral base. Videofluoroscopic swallow studies, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and follow-up visits. Baseline patient characteristics, intraoperative data, and postoperative course were recorded.

RESULTS

Forty-one patients were identified (18 TCPM; 23 ECPM). There was no significant difference in the recurrence rates, complications, hospitalization length, operative time, or return to preoperative diet between approaches. For the 12 patients (11 ECPM; 1 TCPM) that had subjective swallow data, there was a statistically significant difference in the pre and postoperative scores for EAT-10, RSI, and FOSS (P < .05). There was a statistically significant improvement in the degree of narrowing between pre and postoperative imaging for both approaches (P < .05).

CONCLUSION

Both TCPM and ECPM are safe approaches for the management of dysphagia in patients with IBM with objective evidence of cricopharyngeal dysfunction. Cricopharyngeal myotomy is a durable technique that has demonstrated improved subjective and objective outcomes in this patient population.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2426-E2431, 2021.

Surgical rehabilitation of swallowing with polydimethylsiloxane injections after open partial horizontal laryngectomy: Long-term functional results and quality of life

BACKGROUND

Swallowing disorders are common problems after partial laryngectomy. The aim of this study is to illustrate the long-term functional results of rehabilitation of swallowing by polydimethylsiloxane (PDMS) injection.

METHODS

Twenty-eight patients with dysphagia after partial laryngectomy who underwent injection of PDMS for rehabilitation of swallowing were included in the study. Impairment of swallowing and quality of life (QoL) were investigated with questionnaires: M. D. Anderson Dysphagia Inventory (MDADI) and Performance Status Scale for Head and Neck Cancer (PSS-HNC). Functional results at fiberoptic endoscopic evaluation of swallowing (FEES) were analyzed using a modified penetration-aspiration scale.

RESULTS

Mean follow-up was 8.5 years. Twenty-six patients showed an improvement at questionnaires (p < 0.001). Median improvement was 6 (p < 0.001) in the modified penetration-aspiration scale. Total laryngectomy was required in one patient.

CONCLUSIONS

PDMS injection is a good option for rehabilitation of swallowing in case of dysphagia after partial laryngectomy. It improves QoL and the results persist after a long follow-up period.

European white paper: oropharyngeal dysphagia in head and neck cancer

Purpose

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

Methods

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

Results

Twenty-four sections on HNC-specific OD topics.

Conclusion

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Dysphagia in adult myopathies

Dysphagia (impaired swallowing) is not a rare problem in various neuromuscular disorders, both in the pediatric and the adult patient population. On many occasions such patients are first presented to other medical specialists or health professionals. Disorders of deglutition are probably underrecognized in patients with a neuromuscular disease as a result of patient's and doctor's delay. This review will focus on dysphagia in adults suffering from a myopathy. Dysphagia in myopathies usually affects the oropharyngeal phases which rely mostly on voluntary muscle activity of the mouth, pharynx and upper esophageal sphincter. Dysphagia is known to contribute to a reduction of quality of life and may also lead to increased morbidity and mortality. The review includes an overview on symptomatology and tools of assessments, and elaborates on dysphagia in specific hereditary and acquired myopathies.

Swallowing Outcomes in 7 Patients Following Endoscopic Cricopharyngeal Myotomy With Primary Closure

Cricopharyngeal spasm and pharyngeal pouch can result in severe dysphagia symptoms that can have a significant impact on a patient's quality of life. Several surgical interventions have been demonstrated including balloon dilatation, botox injection, and open and endoscopic cricopharyngeal myotomy. The aim of this case series is to describe our technique for endoscopic cricopharyngeal myotomy and compare pre- and postoperative swallowing outcomes using objective swallowing questionnaires in a small series of patients. Seven patients diagnosed with cricopharyngeal spasm or grade 1 pharyngeal pouch on barium swallow were prospectively observed. MD Anderson Dysphagia inventory (MDADI) and Dysphagia handicap index (DHI) were given to patients before and after their operation. All patients underwent the same surgical technique with the cricopharyngeal bar divided and the defect closed with dissolvable sutures. Mean inpatient stay was 7 days (range 1-8) and mean time to resumption of soft diet was 4 (range 1-7) days. All patients resumed oral diet before discharge. MDADI scores showed improvement across all domains, however only the emotional score achieved statistical significance (P = .04). Dysphagia handicap index scores showed a statistically significant improvement across functional, emotional, and total domains. Postoperative chest infection treated with oral antibiotics occurred in 3 patients (43%) and no other complications were documented. In conclusion, endoscopic cricopharyngeal myotomy with primary sutured endoscopic closure can result in a significant benefit to patient's swallowing symptoms, emotional well-being, and quality of life.

Simultaneous double balloon dilatation using double channel therapeutic endoscope in patients with cricopharyngeal muscle dysfunction: An observative study

The role of endoscopic balloon dilatation (EBD) using double-balloon catheters in patients with cricopharyngeal muscle dysfunction (CPD) is still unclear. Thus, the aim of this study was to compare the functional outcomes between patients receiving EBD and rehabilitative balloon swallowing (RBS).A total of 36 patients with CPD, who visited a teaching hospital from February 2014 to June 2017, were included in the study. Among them, 12 patients with severe dysphagia underwent EBD. After propensity score matching, 24 patients who underwent RBS were selected for comparison. We compared the effects of EBD and RBS using 4 functional swallowing parameters: functional dysphagia scale score, penetration-aspiration scale score, pharyngeal transit time, and percentage of pharyngeal remnant (PR) at baseline and after the first and second treatments. Using simple and multiple regression, we examined the associations between EBD/RBS and changes of 4 parameters after the treatments since the baselineAll functional parameters significantly decreased after RBS and EBD (P < .05). After the first therapy session, significant differences in the pharyngeal transit time (P = .034), percentage of PR (P = .008), and penetration-aspiration scale score (P = .014) were observed in the EBD group, compared with those in the RBS group. The regression analysis showed significant improvements in the PR after EBD compared with that after RBS (β = 0.95, SE = 0.31, P = .005).EBD may be an alternative treatment for patients with severe CPD. A significant improvement would be expected in such patients with PR.

Cricopharyngeal myotomy for cricopharyngeus muscle dysfunction after esophagectomy

Background

Pharyngoesophageal dysphagia sometimes develops after esophagectomy. However, severe dysphagia after esophagectomy due to cricopharyngeus muscle dysfunction is a rare complication. There are no recommended clinical treatments for cricopharyngeus muscle dysfunction after esophagectomy. We report a case of myotomy for cricopharyngeus muscle dysfunction after esophagectomy.

Case presentation

A 75-year-old man with mild dysphagia diagnosed with advanced esophageal cancer by esophagogastroduodenoscopy at a clinic was admitted to our hospital. He had occasional mild dysphagia when he swallowed solid foods. After chemotherapy, the patient underwent minimally invasive esophagectomy with regional lymph node dissection and was reconstructed with a gastric conduit and cervical anastomosis by the retrosternal route. Aspiration pneumonia developed after esophagectomy without paralysis of the vocal cords. In esophagoscopy, there was no stricture around the anastomosis. However, severe pharyngoesophageal dysphagia with cricopharyngeus muscle dysfunction was revealed by videofluoroscopic examination. Bilateral cricopharyngeal myotomy was performed because balloon dilations had failed. The histological findings revealed atrophy and fibrosis of the cricopharyngeus muscle fibers. Pharyngoesophageal dysphagia improved immediately after myotomy. The patient swallowed solid food easily without dysphagia 12 months after myotomy.

Conclusion

Dysphagia after esophagectomy was worsened by cricopharyngeus muscle dysfunction. Cricopharyngeus myotomy may lead to long improvement of pharyngo-oesophageal dysphagia after esophagetomy.

Dysphagia in Lateral Medullary Syndrome: A Narrative Review

Dysphagia is a common clinical feature of lateral medullary syndrome (LMS) and is clinically relevant because it is related to aspiration pneumonia, malnutrition, increased mortality, and prolonged hospital stay. Herein, the pathophysiology, prognosis, and treatment of dysphagia in LMS are reviewed. The pathophysiology, prognosis, and treatment of dysphagia in LMS are closely interconnected. Although the pathophysiology of dysphagia in LMS has not been fully elucidated, previous studies have suggested that the medullary central pattern generators coordinate the pharyngeal phases of swallowing. Investigation of the extensive neural connections of the medulla oblongata is important in understanding the pathophysiologic mechanism of dysphagia in LMS. Previous studies have reported that most patients with dysphagia in LMS have a relatively good prognosis. However, some patients require tube feeding for several months, even years, due to severe dysphagia, and little has been reported about conditions associated with a poor prognosis of dysphagia in LMS. Concerning specific therapeutic modalities for dysphagia in LMS, in addition to general modalities used for dysphagia treatment in stroke patients, non-invasive modalities, including repetitive transcranial magnetic stimulation and transcranial direct current stimulation, as well as invasive modalities, such as botulinum toxin injection, balloon catheter dilatation, and myotomy for relaxation of the cricopharyngeal muscle, have been applied. For the appropriate application of therapeutic modalities, clinicians should be aware of the recovery mechanisms and prognosis of dysphagia in LMS. Further studies on this topic, as well as studies involving large numbers of subjects on specific therapeutic modalities, should be encouraged.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Transcranial direct current stimulation improves the swallowing function in patients with cricopharyngeal muscle dysfunction following a brainstem stroke

OBJECTIVE

This study investigated the effects of transcranial direct current stimulation (tDCS) combined with conventional swallowing training on the swallowing function in brainstem stroke patients with cricopharyngeal muscle dysfunction (CPD).

METHODS

Twenty-eight brainstem stroke patients with CPD were assigned randomly to an anodal tDCS group or a sham tDCS group. The patients received anodal tDCS or sham tDCS over the bilateral oesophageal cortical area combined with simultaneous catheter balloon dilatation and conventional swallowing therapy for 20 days. Swallowing function was assessed using the functional oral intake scale (FOIS) and the functional dysphagia scale (FDS) and by measuring the pharyngoesophageal Segment Opening (PESO) before and immediately after the intervention.

RESULTS

Both groups showed a significant improvement in the FDS, FOIS and PESO scores immediately after the intervention (all p < .005). However, compared with the sham stimulation group, the anodal tDCS group showed greater improvements in the FDS, FOIS and PESO scores immediately after the intervention (all p < .005).

CONCLUSION

The bihemispheric anodal tDCS combined with simultaneous catheter balloon dilatation and conventional swallowing therapy effectively improves the swallowing function in patients with CPD caused by a brainstem stroke. tDCS may be an effective adjuvant therapy in CPD rehabilitation.

Pharyngeal Dystonia Misdiagnosed as Cricopharyngeal Dysphagia Successfully Treated by Pharmacotherapy

A 43-year-old woman suffered from drooling and dysphagia after a stroke in the left posterior inferior cerebellar artery territory. Videofluoroscopic swallowing study showed compatible findings of cricopharyngeal dysphagia. Despite the injection of botulinum neurotoxin, no symptom improvement was achieved and pharyngeal dystonia was considered as the cause. Medications for dystonia dramatically helped with saliva control and resulted in a small improvement in the progression of food from the pharyngeal to esophageal phase. After adjusting the drug dose, the patient was able to perform social activities without drooling. Moreover, she could consume food orally; however, this was limited to small amounts of liquid, and the main method of nutrition support was via an orogastric tube. Therefore, we suggest that physicians should make a differential diagnosis of combined dystonia in patients complaining of dysphagia by esophageal manometry and electromyography.

Gastrointestinal Dysmotility and the Implications for Respiratory Disease

Purpose of the review

Gastroesophageal reflux disease (GERD) is frequently implicated as a cause for respiratory disease. However, there is growing evidence that upper gastrointestinal dysmotility may play a significantly larger role in genesis of respiratory symptoms and development of underlying pulmonary pathology. This paper will discuss the differential diagnosis for esophageal and gastric dysmotility in aerodigestive patients and will review the key diagnostic and therapeutic interventions for this dysmotility.

Recent findings

Previous studies have shown an association between GERD and pulmonary pathology in children with aerodigestive disorders. Recent publications have demonstrated the presence of esophageal and gastric dysfunction, using fluoroscopic and nuclear medicine studies, in aerodigestive patients who commonly present to pulmonary and otolaryngology clinics. High-resolution impedance manometry (HRIM) has revolutionized our understanding of esophageal dysmotility and its role in pathogenesis of aspiration and esophageal dysfunction and subsequent respiratory compromise.

Summary

Esophageal and gastric dysmotility have a profound effect on development of respiratory symptoms and pulmonary sequalae in aerodigestive patients. However, our understanding of the pathophysiology is in its infancy. Prospective studies in are needed to address key clinical questions such as: What degree of dysmotility initiates respiratory compromise? What diagnostic tests and therapeutic options best predict aerodigestive outcomes?