Swallowing Characteristics in Zenker's-like Diverticulum After Anterior Cervical Spine Surgery

Prediction of Pharyngeal 3D Volume Using 2D Lateral Area Measurements During Swallowing

This study evaluated the validity of pharyngeal 2D area measurements acquired from the lateral view for predicting the actual 3D volume in healthy adults during swallowing. Seventy-five healthy adults (39 females, 36 males; mean age 51.3 years) were examined using 320-row area detector computed tomography (320-ADCT). All participants swallowed a 10 mL honey-thick barium bolus upon command while seated in a 45° semi-reclining position. Multi-planar reconstruction images and dynamic 3D-CT images were obtained using Aquilion ONE software. Pharyngeal 2D area and 3D volume measurements were taken before swallowing and at the frame depicting maximum pharyngeal constriction. Pharyngeal volume before swallowing (PVhold) was accurately predicted by 2D area (R2 = 0.816). Adding height and sex to the model increased R2 to 0.836. Regarding pharyngeal volume during maximum constriction (PVmax), 2D area also exhibited acceptable predictive power (R2 = 0.777). However, analysis of statistical residuals and outliers revealed a greater tendency for prediction errors when there is less complete constriction of the pharynx as well as asymmetry in bolus flow or movement. Findings highlight the importance of routinely incorporating anterior-posterior views during VFSS exams. Future work is needed to determine clinical utility of pharyngeal volume measurements derived from 320-ADCT.

Recurrent Zenker's Traction Diverticulum After Cervical Spine Surgery: Lessons Learned

This is a report of our institutional experience regarding pharyngoesophageal diverticula formation following anterior cervical spine surgery (ACSS). It is a retrospective chart review of institutional patients from January 2008 to May 2020. Patients at our institution were identified by our two senior authors. Inclusion criteria included patients > 18 years old, a history of prior ACSS, and a confirmed diagnosis of pharyngoesophageal diverticulum with radiographic imaging. Three patients were identified to have an ACSS-related diverticulum. The case presentations describe surgical management and the subsequent postoperative course. One patient had a particularly complicated course with recurrent diverticulum formation despite prior excision. The patient continued to have dense scar tissue adhering the posterior esophageal wall to the nearby cervical spine plates, despite prior excision and rotation of nearby tissue. This difficult case demonstrated the need for an open and aggressive approach. ACSS-related diverticula that form in patients with a history of prior anterior cervical spine surgery appear to be a form of traction diverticulum due to dense scar tissue that adheres the pharyngoesophageal mucosa to the adjacent cervical spinal plate. This type of diverticulum differs from Zenker's diverticulum. Surgical management is recommended to resolve patients' symptoms.

Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) is an effective treatment for surgical failures or non-operative patients

BACKGROUND

Symptomatic Zenker's diverticulum (ZD) occurs mostly in the elderly, who often have significant comorbidities, and poor neck hyperextension, putting them at high risk for surgical management while also increasing the potential of technical failure. Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) offers a safe approach to this problem with high technical and clinical success rates. There are limited data on its use following a failed surgical approach or in patients unfit for a surgical approach. The aim of this study was to assess clinical and technical outcomes of FEIT-Z in patients who were non-operative candidates or refused or failed surgical management.

METHODS

Patients who underwent FEIT-Z from January 2015 to February 2019 at a tertiary referral center were included. Patient demographics, prior ZD surgical history, procedural data, dysphagia scores, clinical success, and adverse events (AE) were collected. Univariable analysis was performed to assess differences between pre- and post-FEIT-Z dysphagia scores.

RESULTS

30 patients undergoing FEIT-Z were included. Seven had a prior failed ZD surgical approach, 6 refused surgical management, and 17 were deemed to be non-operative candidates based on medical comorbidities. Mean age was 78.4 (± 12.1) and 36.7% were male. Technical success of FEIT-Z was 96.7%. There was a significant improvement in dysphagia scores after FEIT-Z: 2.3 (± 0.64) vs. before, 0.4 (± 0.76) (p < 0.001). Long-term clinical success was achieved in 73.3% of patients. Adverse events were seen in 23.3% of patients; however, these were graded as mild in 85.7% of patients. One microperforation was managed with antibiotics.

CONCLUSION

FEIT-Z is a safe procedure with low adverse events and a high rate of technical and clinical success. FEIT-Z can be done in patients who fail previous surgical treatment, refuse a surgical approach, or are not surgical candidates due to medical comorbidity or other factors.

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study

OBJECTIVE

To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula.

METHODOLOGY

Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance.

RESULTS

A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03).

CONCLUSION

ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1349-1355, 2023.

Heterogeneous Presentations of Pharyngoesophageal Diverticula Occurring after Cervical Spine Surgery

Dysphagia after anterior cervical spine surgery (ACSS) may be secondary to pharyngoesophageal diverticulum. Our objectives are to (1) highlight the heterogeneity in clinical presentation, (2) discuss pathophysiology and management, and (3) present a comprehensive literature review of these diverticula. All patients undergoing pharyngoesophageal diverticulum repair between 2013 and 2019 were identified. Cases with ACSS history underwent detailed review of clinical presentation, assessment, and management. Literature review and analysis of all reported ACSS-associated pharyngoesophageal diverticula was performed. Two hundred forty-three cases of pharyngoesophageal diverticulum repair were performed during the study period; 13 cases were ACSS-associated. Four types of clinical presentation were identified: (Type A) Spinal hardware present, with videofluoroscopic evidence of exposed hardware; (Type B) Spinal hardware present, without videofluoroscopic evidence of exposed hardware; (Type C) Spinal hardware absent due to prior spinal hardware removal or ACSS performed without hardware; and (Type D) Concurrent esophago-esophageal fistula (EEF) present. All of our cases were evaluated using modified barium swallow study and esophagoscopy and definitively managed with endoscopic diverticulotomy. Literature review identified 21 cases of ACSS-associated pharyngoesophageal diverticulum repair from 18 publications. The majority of cases were identified using barium esophagram (N = 18, 86%) and managed with open diverticulectomy (N = 19, 90%). There were no reports of EEF. ACSS-associated pharyngoesophageal diverticulum must be evaluated with fluoroscopy and endoscopy, which determine presentation type. Presentation type guides management. Esophageal perforation requires hardware removal and perforation repair with flap placement. Endoscopic diverticulotomy was found essential to definitive management.Level of Evidence: 4.

Treatment of type II odontoid fracture in the elderly

Odontoid fractures constitute the commonest cervical spinal fracture in the elderly. There are varied management approaches with paucity of robust evidence to guide decision-making. We review the case of a 92-years-old man with traumatic Grauer type II B odontoid fracture treated with anterior cannulated screw fixation. Postoperatively, he was noted to have dysphagia due to a zenker’s diverticulum. Further history revealed repair of a zenker’s diverticulum ~40 years prior. Cervical spine images and video fluoroscopy demonstrated a recurrent zenker’s diverticulum. After re-excision of the recurrent zenker’s diverticulum his dysphagia resolved. This unique case describes dysphagia due to recurrent zenker’s diverticulum presenting after anterior cannulated screw fixation for type II B odontoid fracture. The dysphagia was diagnosed and treated in close collaboration with speech and language therapists and otorhinolaryngologist. This underscores the importance of holistic approach to the elderly patient with odontoid fractures.

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