Aspiration after partial laryngectomy: cineradiographic studies

Manometric Studies of the Upper Esophageal Sphincter

The pharyngoesophageal sphincter (PES) has been studied extensively using the standard three lumen esophageal catheter. Studies using this catheter are nonreproduciible because intraluminal pressure in the PES is dependent on the orientation of the catheter. This difficulty was overcome when a multiluminal catheter was developed by Winans. In this work we used a modification of this multiluminal catheter to study the PES in 6 normal patients and in 13 patients who had undergone partial laryngeal surgery. Pressure profiles in the six normal patients revealed a marked increase in intraluminal pressure in the anterior-posterior direction. This is explained by the anatomy of the cricopharyngeal muscle which does not insert in a median raphe. These readings were reliable and reproducible. The operative patients included nine subtotal supraglottic laryngectomies and four partial laryngopharyngectomies. Eight patients had a cricopharyngeal myotomy and five did not. Pre- and postoperative measurements in this series revealed a marked decrease in PES pressure in those patients who had a myotomy; however, all patients were decannulated and swallowed postoperatively without clinical evidence of aspiration. All future manometric studies of the PES should employ a multilumined catheter in order that the differential pressures in the upper esophagus are recorded.

Influence of dosimetric and clinical criteria on the requirement of artificial nutrition during radiotherapy of head and neck cancer patients

PURPOSE/OBJECTIVE(S)

Intensification of radiotherapy and chemotherapy for head-and-neck cancer (HNC) may lead to increased rates of long term dysphagia as a severe side effect. Mucositis and consequent swallowing problems require artificial nutrition in many HNC patients undergoing radiotherapy or chemoradiation. It is unknown, which predict factors for prophylactic PEG tube insertion appear useful.

MATERIALS/METHODS

From an institutional database, 101 patients (72 male, 29 female, mean age 59.5years) were identified who underwent radiotherapy or chemoradiation for HNC. Primary end point of the investigation was the need for artificial nutrition for more than 4days during radiotherapy. Dose volume parameters of defined normal tissue structures potentially of relevance for swallowing ability as well as clinical factors were used to develop a predictive model using a binary multiple logistic regression model.

RESULTS

Whereas several dosimetric and clinical factors were significant predictors for the need of artificial nutrition on univariate analysis, on multivariate analysis only three factors remained independently significant: mean dose to the oropharynx+1cm circumferential margin, ECOG performance state (0-1 vs. 2-4), and the use of chemotherapy (yes vs. no).

CONCLUSIONS

Using a 3 parameter model we could distinguish HNC-patients with different risks for the need of artificial nutrition during radiotherapy. After independent validation, the model could be helpful to decision on prophylactic PEG tube insertion.

Increased likelihood of long-term gastrostomy tube dependence in head and neck cancer survivors without partners

BACKGROUND

We evaluated factors associated with long-term dependence on percutaneous endoscopic gastrostomy (PEG) tubes.

METHODS

One hundred fifty-four patients receiving treatment at the University of Alabama at Birmingham between 2002 and 2004 who underwent PEG tube placement were identified through retrospective review of medical records. Using binary logistic regression, we evaluated the association of various factors on long-term dependence on PEG tubes.

RESULTS

A total of 25.3% of survivors remained PEG tube-dependent at 12 months. The odds of long-term PEG tube-dependence were greater for those who did not have partners compared with those who had partners (odds ratio [OR], 3.33; p = .004), for patients who received radiation therapy (OR, 6.21; p = .018), and for those who had a tracheotomy in place for longer than 30 days (OR, 4.328; p = .035).

CONCLUSION

Data suggest that interventions targeted at reducing long-term dependence on PEG tubes take into account not only treatment-related factors, but also the important role that social support plays.

Rehabilitation of dysphagia following head and neck cancer

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.

Swallowing function outcomes following nonsurgical therapy for advanced-stage laryngeal carcinoma

The purposes of this study were to (1) evaluate swallowing function using both subjective and objective measures in patients treated nonsurgically for stages III and IV laryngeal squamous cell carcinoma, (2) assess the effect of time from treatment completion on swallowing function, and (3) assess sequelae associated with modality of treatment. To achieve these objectives, a retrospective study of 14 patients was conducted. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed and evaluated by three independent judges for seven functional criteria: standing secretions, valleculae spillage, valleculae residue, postcricoid residue, laryngeal penetration, aspiration, and cough. Patient interviews were performed to establish patient perception of swallowing and his/her current posttreatment diet. Results revealed that each patient exhibited swallowing abnormalities in at least one of the seven objective functional categories studied. Ten patients suffered from variable degrees of dysphagia, ranging from mild to severe, on all measures. No significant differences were noted between those patients with less than or greater than 12 months posttreatment. Common treatment sequelae included PEG tube placement for nutritional supplementation, tracheostomy placement for airway security and/or pulmonary toilet, repeated episodes of aspiration pneumonia requiring hospital admission, and radiation-induced oropharyngeal stricture. Further studies using subjective and objective swallowing function measures for patients treated with alternative chemoradiation regimens versus surgery (with or without adjuvant therapies) for advanced stage laryngeal cancer are needed.

Resultados funcionales de la laringectomía supraglótica láser

OBJECTIVES

To analyse the functional outcome of patients with supraglottic carcinomas treated by transoral laser surgery.

METHODS

The clinical records of 55 patients who underwent transoral laser surgery were reviewed. Swallowing capacity, surgical complications, requirements for tracheotomies, percentage of decannulations, laryngeal paralysis, stenosis, aspiration associated pneumonia, time to remove the nasogastric tube and postsurgical stay in hospital were the studied variables.

RESULTS

52% of the patients had a normal or within functional limits swallowing performance. 18% suffered aspiration pneumonia. 13% developed a laryngeal stenosis. 7% suffered of laryngeal palsy. 18 tracheostomies were performed, of them 10 could be reverted. The mean time to remove the nasogastric tube was 9 days. The mean hospital stay was 23 days.

CONCLUSIONS

The main functional advantages of transoral laser surgery for supraglottic carcinoma, when compared with the conventional approach, are a lower incidence of temporary tracheotomies, a faster removal of the nasogastric feeding tube, and a lower incidence of pharyngocutaneous fistulas (0%).

Factors predictive of poor functional outcome after chemoradiation for advanced laryngeal cancer

OBJECTIVE

The study goal was to determine whether pretreatment parameters can be used to predict poor outcomes related to laryngeal function among survivors after organ preservation therapy for advanced laryngeal cancer.

DESIGN

A retrospective analysis of patients treated in an ongoing chemoradiation trial.

SETTING

Academic tertiary care referral medical center. PATIENDS AND METHODS: Among the 65 patients receiving concomitant intra-arterial cisplatin and radiation therapy for stage III and IV laryngeal cancer between 1993 and 1999, we identified 45 who were available for follow-up and were disease free 6 months after the completion of therapy. A nominal logistic regression analysis was performed to study the effect of age, gender, T and N classification, vocal cord fixation, massive cartilage destruction, and neck dissection on the likelihood of requiring a tracheostomy tube for breathing and/or a gastrostomy tube for feeding at 6 months after the completion of therapy.

MAIN OUTCOME MEASURE

Persistent use of gastrostomy tube feedings and/or tracheostomy at 6 months after the completion of therapy.

RESULTS

Sixteen patients (36%) required a feeding tube and/or a tracheostomy (tracheostomy 13, gastrostomy 13, both 10). Regression analysis of all pretreatment factors indicated vocal cord fixation as being the strongest predictor of a poor functional outcome (defined as the persistent need for a feeding tube and/or tracheostomy at 6 months after therapy). Among the 27 patients in this subset, 15 (56%) had a poor functional outcome. In contrast, only 1 (6%) of 18 patients without vocal cord fixation had poor laryngeal function. Although the history of pulmonary disease was not a significant parameter by itself, when combined with vocal cord fixation, 6 of 8 patients had a poor functional outcome.

CONCLUSION

Pretreatment parameters may be used to predict a poor functional outcome after chemoradiation. Because of the high likelihood of poor function, laryngeal cancer patients seeking organ preservation therapy with chemoradiation should be cautioned if they present with a fixed vocal cord.

Pharyngoesophageal pressure in patients with swallowing disorders

We developed and tested a pressure transducer to correctly determine swallowing pressure at different sites in the pharynx. In normal individuals three pressure peaks were obtained in the mesopharynx, hypopharynx and cervical esophagus, respectively. A patient with central dysphagia demonstrated markedly low mesopharyngeal and hypopharyngeal swallowing pressure. One tongue cancer patient who had undergone right hemiglossectomy, including partial resection of the root of the tongue and bilateral superior neck dissection, had markedly low swallowing pressure in the mesopharynx and vallecula area. Another supraglottic cancer patient treated by supraglottic horizontal partial laryngectomy showed extremely low swallowing pressure in the supraglottic area. Based on our findings, we suggest that measurements using a pressure transducer such as the one described here should be used in combination with radiographic study to diagnose swallowing anomalies correctly. Data obtained with the pressure transducer will allow the clinician to identify the site responsible for postoperative dysphagia as well as its severity, and facilitate planning of reconstructive surgery when required.

Preoperative risk assessment for gastrostomy tube placement in head and neck cancer patients

BACKGROUND

The presentation and definitive surgical treatment of head and neck malignancies have varying impact on postoperative recovery and return of swallowing function, which heretofore has not been well defined.

METHODS

We performed a retrospective chart review of 142 patients who underwent extirpative surgery for head and neck cancer.

RESULTS

Factors significantly associated with the need for long-term postoperative nutritional support (p < .05) included heavy alcohol use, tongue base involvement and surgery, pharyngectomy, composite resection, reconstruction with a myocutaneous flap, radiation therapy, tumor size, and moderately-to-poorly differentiated histology. Heavy alcohol users were at an absolute risk for gastrostomy tube dependence; patients who underwent radiation therapy, flap reconstruction, tongue base resection, and pharyngectomy were at a two to sevenfold increased risk for gastrostomy tube dependence, respectively.

CONCLUSIONS

High-risk patients based on these criteria should receive a feeding gastrostomy at the time of their initial surgical therapy.

Complications after laryngeal surgery: videofluoroscopic evaluation of 120 patients

AIM

Videofluoroscopic assessment of the spectrum and incidence of swallowing complications after state-of-the-art laryngeal cancer surgery.

MATERIALS AND METHODS

We retrospectively studied videofluoroscopic examinations of 120 patients (94 men, 26 women; mean age, 58 years) with suspected complications after laryngeal resection (partial laryngectomy, 65; total laryngectomy, 55). Swallowing function (i.e., oral bolus control, laryngeal elevation and closure, presence of pharyngeal residue, aspiration) and structural abnormalities such as strictures, fistulas and tumour recurrence were assessed by videofluoroscopy.

RESULTS

Abnormalities were found in 110 patients, including strictures in nine, fistulas in six and mass lesions in 13 patients. Aspiration was found in 63 patients overall (partial laryngectomy, 61/65; total laryngectomy, 2/55), occurring before swallowing in five, during swallowing in 34, after swallowing in nine and at more than one phase in 15 patients. Pharyngeal paresis was detected in three and pharyngeal weakness in 19 patients. Pharyngo-oesophageal sphincter dysfunction was observed in 10 cases.

CONCLUSION

Aspiration is a very common complication after partial laryngeal resection. It is mainly caused by incomplete laryngeal closure, sphincter dysfunction or pharyngeal pooling. Videofluoroscopy is the only radiological technique able to identify both disordered swallowing function and structural changes after laryngeal resection. Detection of these complications is crucial for appropriate further therapy.Kreuzer, S. H. (2000). Clinical Radiology55, 775-781.

Patterns of swallowing after supraglottic laryngectomy

OBJECTIVE

To understand the anatomical and physiological basis for early recovery of swallowing function after supraglottic laryngectomy.

STUDY DESIGN

Retrospective review.

METHODS

The records of nine patients who had undergone supraglottic laryngectomy at the Stratton Veteran's Administration Hospital (Albany, NY) between 1994 and 1998 were reviewed. Videofluoroscopic swallowing studies were obtained on all patients as early as was safely possible and were reviewed by a multidisciplinary team of physicians, nurses, and speech pathologists with regard to anatomical and functional differences between successful and unsuccessful recovery of swallowing function.

RESULTS

Five of nine patients resumed regular diets including thin liquids within 1 year of surgery; three patients remained dependent on enteral support. Swallowing success was most closely associated with short oropharyngeal transit time and an anterosuperior position of the larynx. Laryngeal positioning, tongue base mobility, and placement and coordination of the bolus for maximum swallowing efficiency can be improved with time and speech therapy.

CONCLUSIONS

Factors that placed patients at significantly higher risk for aspiration included low laryngeal position and delayed oropharyngeal transit time. Tight lingual-laryngeal closure did not completely prevent aspiration. At the time of the initial surgical procedure it may be important to position the laryngeal remnant as far superior and anterior under the tongue base as possible.

A novel approach to laryngeal suspension after partial laryngectomy

OBJECTIVES

Supraglottic laryngectomy is a well-established surgical therapy for selected carcinomas of the larynx and hypopharynx. Most compromised by this procedure and its variations is the laryngeal mechanism that protects the lower respiratory tract from aspiration. Laryngeal suspension serves to compensate for the loss of the resected laryngeal elevator muscles by pulling the larynx upward and forward beneath the tongue base. In this study we describe a method of laryngeal suspension in supraglottic laryngectomy using a cartilage-anchored suture carrier device.

STUDY DESIGN

Report of this novel approach to laryngeal suspension using seven suture anchors in two patients undergoing supraglottic laryngectomy.

METHODS

Seven Mitek Micro anchors (Mitek, Westwood, MA) were used to perform laryngeal suspension in two patients undergoing supraglottic laryngectomy. Our technique is compared with traditional methods. Operative data as well as postoperative functional results are reviewed.

RESULTS

Laryngeal suspension using suture anchors was successful, with failure of only one anchor. Oral alimentation was quickly reestablished in both patients. There were no perioperative or postoperative complications.

CONCLUSIONS

We describe a novel approach to laryngeal suspension that overcomes some of the technical challenges inherent in traditional suturing techniques. This novel approach is technically easier and more efficient than traditional methods and accomplishes distribution of stress forces on the thyroid cartilage remnant.

Contemporary diagnosis of the dysphagic patient

A variety of tests are available to aid in the diagnosis and management of dysphagia. In this article the advantages and disadvantages of many of these tests are described. Special attention is given to the videoendoscopic swallowing study (VESS). An overall treatment plan is described.

Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy

The nature of swallowing problems was examined in nine patients treated primarily with external-beam radiation and adjuvant chemotherapy for newly diagnosed tumors of the head and neck. All subjects underwent videofluorographic examination of their swallowing. Three analyses were completed, including the following: observations of motility disorders, residue, and aspiration; temporal analyses; and biomechanical analyses. Oropharyngeal swallow efficiency was calculated for the first swallow of each bolus. Swallow motility disorders were observed in both the oral and pharyngeal stages. Seven of the nine patients demonstrated reduced posterior tongue base movement toward the posterior pharyngeal wall and reduced laryngeal elevation during the swallow. Oropharyngeal swallow efficiency measures were significantly lower in the nine irradiated patients than in age-matched normal subjects. Between patients and normal subjects, significant differences were found in the measures of timing and distance of pharyngeal structural movements during the swallow, as well as in the measures of coordination during the swallow. Although treatment of head and neck cancer with external-beam radiation is designed to provide cancer cure and preserve organ functioning, oral and pharyngeal motility for swallow can become compromised if external-beam radiation treatment is provided to either the larynx or tongue base regions.

Complications of supraglottic laryngectomy for carcinomas of the supraglottis and the base of the tongue

The medical records of patients with either a supraglottic carcinoma (n = 193) or a base of tongue carcinoma (n = 56) who underwent a supraglottic laryngectomy were studied. Because of aspiration total laryngectomy was required in 9.8% and 21.4% of patients with supraglottic and base of tongue carcinomas, respectively, being related to locally advanced stage of disease in the base of tongue and to an age older than 65 years in the case of supraglottic carcinomas. The non-decannulation rates were 23.8% and 50% in supraglottic and base of tongue tumours respectively. Post-operative radiotherapy did not influence the decannulation rate, but advanced local disease and age did. Post-operative mortality in the first month after the operation was 2.6% in supraglottic tumours and 3.6% in base of tongue tumours.

Dysphagia after pharyngolaryngeal cancer surgery. Part I: Pathophysiology of postsurgical deglutition

Eighty-one patients were examined after laryngopharyngeal cancer surgery with a sequential computer manometry system using 4-channel-pressure probes. The general swallowing coordination is neither a matter of the oropharyngeal pressure thrust nor of the pharyngeal transit time, but mainly depends on swallowing initiation. The points of interest are both the pharyngeal inlet and outlet. The topographic correlates are the base of the tongue and the upper esophageal sphincter (UES). Resections of the base of the tongue lead to a decrease of volume available for pressure generation, thus reducing the tongue driving force. The swallowing reflex is uncoordinated resulting in dyskinesia of the UES. Compensation may be achieved with a stronger oropharyngeal thrust and/or repeated swallows. Distal resections alter the pharyngoesophageal segment so that a functional obstruction results, combined with lower pressure amplitudes in the hypopharynx, reducing the pressure gradient necessary for bolus flow. This increasing resistance can be overcome by higher propulsive forces in the base of the tongue region. In case of additional lingual defects, deglutition is subject to decompensation, highlighting the major role of the tongue as a pressure generator for bolus passage.

Mechanisms of recovery of swallow after supraglottic laryngectomy

This study examines oropharyngeal swallow disorders and measures of pharyngeal and laryngeal movement during deglutition from videofluorographic studies of oropharyngeal swallow in 9 patients who had undergone supraglottic laryngectomy and 9 age-matched normal subjects. The swallows of surgical patients were examined at 2 weeks and 3 months postoperatively. Two critical factors in recovery of swallowing were identified: (a) airway closure at the laryngeal entrance, that is, the space between the arytenoid cartilage and the base of the tongue, and (b) the movement of the tongue base to make complete contact with the posterior pharyngeal wall. When patients achieved these two functions, they returned to normal swallowing. The duration of tongue base contact to the posterior pharyngeal wall and extent of anterior movement of the arytenoid increased significantly from 2 weeks to 3 months in the surgical patients. At 2 weeks postsurgery, patients who had undergone supraglottic laryngectomy exhibited significantly shorter airway closure and tongue base to pharyngeal wall contact, reduced laryngeal elevation, increased width of cricopharyngeal (CP) opening, and later onset of airway closure and tongue base movement than normal subjects. These significant differences remained at 3 months postoperatively, although swallow measures were moving toward normal in the patients who had undergone supraglottic laryngectomy. Comparison of patients not eating at 2 weeks with patients at the time of first eating revealed significantly longer duration of tongue base contact to the pharyngeal wall, longer duration of airway closure, and greater movement of the arytenoid in patients who were eating. Results indicate that the focus of swallowing therapy after supraglottic laryngectomy should be on improvement of posterior movement of the tongue base and anterior tilting of the arytenoid to close the airway entrance and improve bolus propulsion (in the case of the tongue base).

Factors influencing functional outcome in supraglottic laryngectomy

BACKGROUND

The relationship between preoperative pulmonary function tests (PFTs) and postoperative aspiration and deglutition complications in supraglottic laryngectomy (SL) has not been adequately analyzed. The effects of numerous other variables are either controversial or have not been studied.

METHODS

A retrospective chart review was performed on 46 SL patients, analyzing preoperative PFTs and arterial blood gases, demographic factors, stage of disease, extended resections, cricopharyngeal myotomy, hyoid preservation, neck dissection, and postoperative radiotherapy with regards to aspiration and deglutition problems.

RESULTS

Eighteen (39%) patients had no problems, 15 (33%) had moderate problems, and 13 (28%) had severe problems; of these, 39 (85%) were ultimately successful with no further swallowing dysfunction, whereas seven (15%) suffered intractable aspiration difficulties. Decreasing FEV1/FVC was significantly correlated with a poorer outcome, as was a greater number of pack-years of smoking. The effect of FEV1/FVC was shown to be independent from pack-years, whereas the converse was not clearly demonstrated. Extensions of the standard procedure did not correlate significantly with increased problems.

CONCLUSIONS

An FEV1/FVC less than 50% signifies a greater risk for severe aspiration and deglutition complications, although it must be regarded as one factor among many in determining operability. With careful attention to reconstruction, extensions of the standard SL procedure can be safely performed.

Dysphagia following head and neck cancer surgery

Surgical resection of head and neck cancer results in predictable patterns of dysphagia and aspiration due to disruption of the anatomic structures of swallowing. Common procedures undertaken in the treatment of head and neck cancer include tracheostomy, glossectomy, mandibulectomy, surgery on the palate, total and partial laryngectomy, reconstruction of the pharynx and cervical esophagus, and surgery of the skull base. An overview is presented of normal swallowing physiology, as well as swallowing perturbations that are frequently encountered in postoperative head and neck cancer patients.

The videoendoscopic swallowing study: an alternative and partner to the videofluoroscopic swallowing study

A new, physical examination-based videoendoscopic method of evaluation can enhance considerably the understanding and efficiency of clinicians working with patients with swallowing difficulties. Using the fiberoptic nasolaryngoscope, evaluation of structure and function of palate, pharynx, and larynx, along with sensation of the laryngopharynx, is carried out. Next, patients' swallowing capabilities are assessed as they ingest various food consistencies. This method, formerly called videoendoscopic evaluation of dysphagia (VEED), but perhaps more appropriately termed videoendoscopic swallowing study (VESS) has particular value for patients who cannot undergo the videofluoroscopic swallowing study (VFSS)--for example, because they are bedfast--or those whose swallowing function is changing so rapidly (after a stroke or surgery) as to call for frequent reassessments. This technique is often useful during the initial consultation with new patients complaining of dysphagia, as a "stand alone" method of diagnosis and management. Less frequently, VESS findings, along with patient history, will indicate when VFSS should also be obtained. VESS will orient the examiner to the nature and severity of the problem even in this latter circumstance. In follow-up circumstances, VESS is generally more useful than the VFSS. Case presentations are utilized to illustrate the usefulness of VESS as compared to VFSS.

Recovery of postoperative swallowing in patients undergoing partial laryngectomy

This study assessed the achievement of postoperative swallowing in patients undergoing partial laryngectomy surgery. Oropharyngeal swallow efficiency was used to predict time to achievement of outcome. Fifty-five patients were followed for up to 1 year in two hemilaryngectomy and four supraglottic laryngectomy groups. Within 10 days of healing, a videofluoroscopic evaluation enabled the measurement of swallowing efficiency. Times to achievement of oral intake, removal of feeding tube, preoperative diet, and normal swallow were analyzed using actuarial curves. Patients with hemilaryngectomies achieved swallowing rehabilitation sooner than patients with nonextended supraglottic laryngectomies (p < .05) who, in turn, achieved swallowing function sooner than did patients undergoing supraglottic laryngectomies with tongue base resection (p < .05). Median time to attainment of preoperative diet in these three groups was 28 days, 91 days, and > 335 days, respectively. Higher early postoperative oropharyngeal swallow efficiency was related to earlier achievement of oral food intake and of preoperative diet (p < .05). Results show that the time course for swallowing rehabilitation covers an extended postoperative period. In some surgical groups, functional swallowing and eating may be achieved within 3 months of surgery while for other types, significant impairment remains up to 9 months postoperatively Early radiographic assessments of swallowing function are useful in predicting the time to swallow recovery. Recovery of swallowing ability may be delayed in patients who have not achieved oral intake before radiotherapy is started.

Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow

The modified barium swallow is currently the most comprehensive, widely available, and easily interpreted technique for the evaluation of patients with dysphagia by the head and neck surgeon. However, it requires the facilities, personnel, and use of a radiology suite, a trained speech pathologist, and exposure of the patient to radiation. It would therefore be helpful to have an adjunctive, physician based, nonradiographic method of examination that could provide information similar to and possibly even more complete than that supplied by the modified barium swallow. Such an adjunctive method could help otolaryngologist-head and neck surgeons confronted by a new patient with swallowing difficulties to orient themselves to the nature and severity of the problem while waiting for the modified barium swallow to be scheduled, performed, and reviewed. It could also be a helpful tool for management of patients with cancer of the head and neck, whose swallowing function may change rapidly in the early postoperative period. In such cases, intervals between modified barium swallow examinations (dictated by concern over radiation exposure) may be too far apart to allow up-to-the-minute decisions on case management. Finally, some patients who may be too ill to travel to the radiology suite might benefit from a bedside procedure that would yield information about swallowing function similar to that provided by the modified barium swallow. Videoendoscopic evaluation of dysphagia (VEED) is a protocol I developed and have used regularly since 1984. Experience with this method of dysphagia evaluation has shown that it answers the needs outlined above. Its usefulness also goes beyond that of the modified barium swallow by providing a more detailed understanding of the component anatomic and functional deficits that comprise a given patient's swallowing problem, information about upper aerodigestive tract sensory deficits, and a means for visual feedback training of pharyngeal and laryngeal musculature. The protocol is reviewed here. Case reports illustrating the clinical usefulness of VEED as an adjunct to the modified barium swallow are also presented, and the relative strengths and weaknesses of VEED and the modified barium swallow are compared.

Approaches to the patient with aspiration and swallowing disabilities

Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.

Modification of compensatory swallowing in a supraglottic laryngectomy patient

Results are presented for repeated videofluoroscopic and scintigraphic examinations of a supraglottic laryngectomy patient, illustrating the successful use and later changes in a compensatory swallow. Issues in patient management are outlined, stressing the importance of interaction between radiologists and dysphagia therapists in the rehabilitation of such patients.

Supraglottic laryngectomy: short- and long-term functional results

A supraglottic laryngectomy offers the possibility of resection of a large portion of the larynx leaving the true vocal cords. From 57 supraglottic laryngectomies performed between 1971 and 1984 in the Department of Otolaryngology and Head and Neck Surgery of the University of Nijmegen, the 5- and 10-year actuarial survival rates were 80% and 59%, respectively. The deaths after 5 years were not directly related to the original tumour. The functional results with respect to the voice were excellent. In this study particular attention has been paid to the postoperative results with regard to swallowing and aspiration. More than half of the patients (56%) had occasional complaints of aspiration, especially when taking liquids. It is concluded that supraglottic laryngectomy is an excellent alternative, especially for the treatment of extensive supraglottic tumours without involvement of the true vocal cords.

Deglutition following supraglottic horizontal laryngectomy

In order to determine factors that may contribute to deglutition problems following supraglottic horizontal laryngectomy or its modified techniques, clinical records of 38 patients were studied. Contribution of the following factors was investigated: age; sex; tumor classification; radical neck dissection; extent of and symmetry in removal of the aryepiglottic folds, arytenoid cartilages, and false folds; removal of the base of the tongue, hyoid bone, and a part of the vocal folds; extent of removal of the epiglottis and thyroid cartilage; cricopharyngeal myotomy; and some complications and concomitant diseases. The results suggest that removal of the arytenoid cartilage and asymmetrical removal of the false folds contribute to deglutition problems. We conclude that the standard supraglottic horizontal laryngectomy associated with surgical approximation of the larynx to the base of the tongue and cricopharyngeal myotomy does not usually cause serious deglutition problems. When the arytenoid cartilage is removed, reconstruction of the structure is required for the prevention of severe aspiration.

Manofluorography of deglutition after supraglottic laryngectomy

Manofluorography (mano: manometry, fluoro: videofluoroscopy, graphy: picture) provides a simultaneous display of manometry and fluoroscopy on one video screen. This study uses manofluorography to analyze the swallowing patterns of nine patients who had undergone supraglottic laryngectomy. The results show that during swallowing the pharyngeal mechanism for preventing aspiration depends upon three processes: (1) tight lingual-laryngeal contact, (2) coordination of the swallowing reflex, and (3) tongue base and pharyngeal constrictor clearing of the hypopharynx and laryngeal inlet. Anterior suspension of the larynx under the tongue base serves to improve lingual-laryngeal contact. This close contact during deglutition protects the airway from the bolus and also opens the postcricoid region, aiding bolus passage into the esophagus. Impairment of the swallowing reflex, which can cause severe aspiration before the swallowing reflex is triggered, can be rehabilitated by swallowing therapy. Minor aspiration is commonly caused by impaired clearing of the superior hypopharynx after supraglottic laryngectomy.

Factors in successful deglutition following supraglottic laryngeal surgery

Aspiration is the major problem in deglutition associated with conservation laryngeal surgery. Closure of the glottic sphincter, depression of the epiglottis over the laryngeal inlet, elevation of the thyrohyoid complex under cover of the base of the tongue and appropriate relaxation of the cricopharyngeal muscle to permit unobstructed passage of food into the esophagus are important mechanisms that prevent food from entering the trachea. Partial laryngeal surgery can interfere with one or a combination of these mechanisms. Analysis of the records of all evaluable patients who underwent horizontal supraglottic resections from January 1976 to June 1981 was undertaken. The incidence of deglutition problems is reported. In addition, the effects of resection or preservation of the hyoid, arytenoid, base of tongue and branches of the vagus and the effect of cricopharyngeal myotomy upon ultimate swallowing function are analyzed.

Partial laryngectomy: analysis of associated swallowing disorders

Evaluation of postoperative swallowing ability in thirty-eight patients having had partial laryngectomy indicates that there are marked differences in the degree of dysphagia among individuals with similar surgical defects. This variation in swallowing disability, however, appears to have definable limits. Rehabilitation is possible for many patients disabled by postoperative dysphagia. A transoral surgical technic for reconstruction of the obliterated pyriform sinus is described.

Act of swallowing in the fixed larynx

In a 16-year-old female, complete stenosis of the larynx and hypopharynx developed as a consequence of the ingestion of lye cristals. Supraglotic laryngectomy, plastic surgery of the hypopharynx and antethoracic oesophagus were performed and the upper aero-digestive tract reconstructed. The dilated larynx remained fixed by the surrounding fibrous tissue, but the sphincteric action of the mobile vocal cords was partly salvaged. In that condition, the act of swallowing could be reestablished. The pathophysiology of this new mechanism of swallowing is discussed.

Alteration in esophageal motility after laryngectomy

Ten laryngectomees underwent esophageal motility studies to assess the effect of laryngectomy on esophageal function. When these patients are compared with controls, marked derangements in esophageal motility were noted in the upper esophageal sphincter (UES) and in the body of the esophagus. Lower esophageal sphincter (LES) function did not differ significantly from the controls. Dysphagia developed postoperatively in five of the ten laryngectomees. This preliminary analysis suggests that esophageal motility disturbances may be relatively frequent after laryngectomy and that these disturbances may be clinically significant. The theoretical basic for the motility abnormalities and areas of future research are discussed.