Esophagram findings in cervical esophageal stenosis: A case-controlled quantitative analysis

Esophageal stenosis in head and neck cancer patients: Imaging's accuracy to predict dilation response

OBJECTIVES

The primary goal of this study was to examine how well findings of cervical esophageal stenosis on modified barium swallow (MBS) and esophagram correlate with clinical improvement following dilation in patients with a history of head and neck (H&N) cancer.

METHODS

A retrospective review was performed at an academic hospital. The study population included H&N cancer patients with a history of neck dissection surgery who underwent esophageal dilation from 2010 to2018. Pre and postdilation swallowing function was assessed. The Functional Outcomes Swallowing Scale (FOSS) and Functional Oral Intake Scale (FOIS) were used as outcome measures.

RESULTS

The 95 patients were included. All patients had imaging prior to dilation. Post-dilation FOSS and FOIS scores were significantly improved (P < .001). In identifying the patients that would have improvement from dilation, esophagram and MBS had average sensitivities of 81% and 82%, respectively. The negative predictive value (ie, the ability of a normal esophagram or normal MBS to exclude patients that would not improve with dilation) was only 46% and 38%, respectively. When the specific finding of aspiration on MBS was considered, the positive predictive value (PPV) (ie, the ability of an MBS positive for aspiration to predict that a patient would benefit from dilation) was 87% (P = .03). When only the specific finding of stenosis on esophagram was considered, the PPV of improvement post-dilation was 58% (P = .97). The delay in time from imaging to dilation was significantly longer in those who had an unidentified stenosis (false negative) on imaging when compared to those who did not (46.8 ± 35.2 days vs 312.6 ± 244.1 days, P < .001).

CONCLUSION

In high risk patients for cervical esophageal stenosis, such as those with a history of H&N cancer and open neck surgery with or without radiation, MBS and esophagram appear to have mixed reliability as predictors of response to esophageal dilation. In these patients, a "negative" result on MBS and esophagram may not be diagnostically accurate enough to exclude patients from consideration of dilation.

LEVEL OF EVIDENCE

IIb.

[GERD and adjuvant radio-chemotherapy predespose to recurrent voice prosthesis leakage]

After total laryngectomy, regaining ability to speech is a keystone in regards of life quality. Voice prostheses have been shown to be a sufficient tool for satisfying communication, although frequent replacements of prostheses are burdening certain patients. Therefore, a more accurate understanding of mechanisms of prosthetic leakage is urgently needed.

METHODS

We performed a retrospective analysis of 58 Patients after laryngectomy. Additionally, we analyzed pre- and post-therapeutic CT-scans of 22 Patients regarding pharyngeal stenosis.

RESULTS

In 40 Patients, at least one replacement of voice prosthesis was documented during observation period, median device life was 235 days. Patients treated with adjuvant radiotherapy (RT) showed a significantly longer device life than patients with adjuvant radio-chemotherapy (RCT, p = 0.002). Furthermore, patients suffering of gastroesophageal reflux disease (GERD) showed a significantly shortened device life (p = 0.04).17 patients (42.5 %) suffered of clinically relevant stenosis of the neopharynx, which was treated with dilatation in 14 patients (82 %) and did not affect prosthesis device life.

CONCLUSION

GERD is a risk factor for shortened voice prosthesis' device life and therefore should be treated effectively after laryngectomy. Also, adjuvant RCT predisposes a shortened device life.Stenosis is observed frequently after laryngectomy but does not affect device life when effectively treated.

The Prevalence of Cricopharyngeal Webs in Elderly Cadavers

OBJECTIVE

Cricopharyngeal webs (CPW) are a frequent cause of solid food dysphagia. They are difficult to diagnose and are often missed on swallowing fluoroscopy. The prevalence of CPWs is uncertain. The purpose of this study was to determine the prevalence of CPWs in elderly cadavers.

METHODS

Direct laryngoscopy and cervical esophagoscopy were performed in 19 embalmed cadavers by independent two-clinician consensus. Cadaver demographics and the presence and laterality of a CPW were recorded. The prevalence of CPW was calculated, and the size of the cricopharyngeus muscle (CPM) was quantified.

RESULTS

The mean age of the cohort was 83 ( ± 12) years. Fifty-three percent were female, and the mean body mass index was 19.7 ( ± 3). The causes of death were cardiovascular disease (10 of 19), cancer (5 of 19), and respiratory failure (4 of 19). A CPW was present in 68% (13 of 19) of cadavers. Forty-seven percent (9 of 19) had a unilateral web, and 21% (4 of 19) had a bilateral web. There was no laterality predominance (P > 0.05). Forty-two percent (8 of 19) had no CPM prominence; 32% (6 of 19) had a small/moderate CPM prominence; and 26% (5 of 19) had a significant CPM prominence.

CONCLUSION

The prevalence of cricopharyngeal webs in elderly cadavers is high (68%). The clinician should maintain a high index of suspicion for CPWs in patients with no other identifiable etiology of solid food dysphagia.

LEVEL OF EVIDENCE

3b Laryngoscope, 129:63-66, 2019.