The Prevalence of Cricopharyngeal Webs in Elderly Cadavers

Surgical Nonresponders in Zenker Diverticulum and Lower Esophageal Pathology (POUCH Collaborative)

OBJECTIVE

To identify characteristics of patients who have poor improvement in symptoms following surgical management of Zenker Diverticulum (ZD).

METHODS

Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgical repair of ZD between August 2017 and January 2024. Patient demographics, esophagrams, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were obtained from a REDCap database. t-tests, Wilcoxon rank sum tests, Chi-square or Fisher's exact tests were used to compare the characteristics. Patients with <50% improvement in their EAT-10 scores were deemed surgical nonresponders (SNRs). Those with ≥50% improvement in their EAT-10 scores were deemed surgical responders (SRs).

RESULTS

A total of 184 patients were prospectively followed after undergoing either open or endoscopic surgical management. Twenty-two patients (12%) were deemed SNRs. Preoperative presence of a hiatal hernia was statistically significant characteristic between the SNRs (63.6%) and SRs (32.1%) (p = 0.004). Size of the ZD and history of previous ZD surgery was not a significant characteristic. The length of stay and complication rate were not statistically different between the groups.

CONCLUSION

Coexistent esophageal pathology may lead to poor symptomatic improvement following ZD surgery. Preoperative workup of other esophageal disorders is recommended to detect likely SNRs. For SNRs, further esophageal workup may be necessary to evaluate for other esophageal causes related to poor symptomatic improvement following ZD surgery.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2024.

Fluoroscopic Swallowing Abnormalities in Dysphagic Patients Following Anterior Cervical Spine Surgery

Objectives:

To evaluate the precise objective fluoroscopic abnormalities in persons with dysphagia following anterior cervical spine surgery (ACSS).

Methods:

129 patients with dysphagia after ACSS were age and sex matched to 129 healthy controls. All individuals underwent videofluoroscopic swallow study (VFSS). VFSS parameters abstracted included upper esophageal sphincter (UES) opening, penetration aspiration scale (PAS), and pharyngeal constriction ratio (PCR). Other data collected included patient-reported outcome measures of voice and swallowing, number of levels fused, type of plate, vocal fold immobility, time from surgery to VFSS, and revision surgery status.

Results:

The mean age of the entire cohort was 63 (SD ± 11) years. The mean number of levels fused was 2.2 (±0.9). 11.6% (15/129) were revision surgeries. The mean time from ACSS to VFSS was 58.3 months (±63.2). The majority of patients (72.9%) had anterior cervical discectomy and fusion (ACDF). For persons with dysphagia after ACSS, 7.8% (10/129) had endoscopic evidence of vocal fold immobility. The mean UES opening was 0.84 (±0.23) cm for patients after ACSS and 0.86 (±0.22) cm for controls ( P > .0125). Mean PCR was 0.12 (±0.12) for persons after ACSS and 0.08 (±0.08) for controls, indicating significant post-surgical pharyngeal weakness ( P < .0125). The median PAS was 1 (IQR 1) for persons after ACSS as well as for controls. For ACSS patients, PCR had a weak correlation with EAT-10 ( P < .0125).

Conclusion:

Chronic swallowing dysfunction after ACSS appears to be secondary to pharyngeal weakness and not diminished UES opening, the presence of aspiration, vocal fold immobility, or ACSS instrumentation factors. Level of Evidence: 3b

Three-dimensional analysis of the human pharyngoesophageal sphincter

OBJECTIVES

Dysfunction of the pharyngoesophageal segment (PES) is a common cause of oropharyngeal dysphagia. Surgical dilation of the PES uses cylindrical dilators that expand radially in a circular shape. Animal studies, however, suggest that the PES is kidney-shaped. The purpose of this investigation was to evaluate the 3D shape of the human PES with a novel casting method.

METHODS

A platinum-cured liquid silicone polymer was infused under pressure into the upper aerodigestive tract of nine fresh human cadavers to construct 3D casts of the maximally distended PES. Cross-sectional and volumetric analysis were performed using computed tomography and serial sectioning of the models. Canonical variate analysis was used to identify the shape features that best distinguishes the PES from the cervical esophagus.

RESULTS

The mean age of the cadavers was 77.9 (SD ± 10.6) years, with 67% women. Analysis of the casts confirms that the human PES possesses a kidney-shaped structure at maximal distention, which is discretely different from the adjacent esophagus (P < 0.001). The posterior body of the cricoid cartilage formed the anterior wall of the PES, which provided a rigid structure responsible for preservation of the kidney shape during distention. The diameter of the maximally distended PES at the cricopharyngeus was highly variable (range = 0.86-4.68 cm² ; SD = 1.33 cm² ).

CONCLUSION

The data suggest that the human PES is not round and that targeted expansion at the level of the cricopharyngeus with an eccentrically shaped dilator may provide improved distention.

LEVEL OF EVIDENCE

4 Laryngoscope, 2019.