Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative

OBJECTIVES

The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication.

METHODS

Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management.

RESULTS

There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26).

CONCLUSIONS

Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction.

LEVEL OF EVIDENCE

Level III Laryngoscope, 134:2678-2683, 2024.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study

OBJECTIVE

To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD).

METHODOLOGY

Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate.

RESULTS

One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively.

CONCLUSION

Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:97-102, 2024.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review

OBJECTIVE

To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD).

METHODS

Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report.

RESULTS

A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03).

CONCLUSION

KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2110-2115, 2023.

Breathiness and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) in Patients Undergoing Medialization Laryngoplasty With or Without Arytenoid Adduction

OBJECTIVES

We hypothesized that, in patients with unilateral vocal fold paralysis (UVFP), the auditory-perception of breathiness measured with Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) would be higher preoperatively in patients who undergo medialization laryngoplasty (ML) with arytenoid adduction (AA) compared to ML alone. We further hypothesized that increased breathiness would correlate with increased glottal area at maximum glottal closure.

STUDY DESIGN

Retrospective chart review.

METHODS

CAPE-V recordings were rated by expert judges in 105 subjects with UVFP (47 ML+AA and 58 ML). Component scores of the CAPE-V prior to laryngeal framework surgery and those at 3 and/or 12 months postoperatively were compared. Assessment of glottal area width during maximum glottal closure was attempted.

RESULTS

Breathiness scores prior to laryngeal framework surgery were significantly greater in UVFP patients having ML+AA compared to ML only (P < 0.001). Roughness was greater for ML only (P = 0.003). At 3 months, adjusted for age and previous injection laryngoplasty, the ML+AA group showed greater improvement for breathiness (P <0.001), loudness (P < 0.001), strain (P = 0.037), and pitch (P = 0.039), while the ML only group showed greater improvement in roughness (P = 0.009). Results were similar at 12 months. Only 26% of glottal area widths were ratable using methods previously described; therefore, no further analysis was attempted.

CONCLUSIONS

In patients with UVFP baseline perception of breathiness is greater in those clinically selected for ML+AA compared to ML only. Glottal area measurements were not representative of the UVFP cohort and more stringent criteria are needed for valid and reliable glottal area assessment when using clinical flexible stroboscopic exams. Findings support the idea that surgeons may be making decisions about AA based, to at least some degree, on auditory perceptual evaluation of voice.

Development and characterisation of an experimental recurrent laryngeal nerve injury model for the study of viral gene therapy

OBJECTIVES

To develop and characterise an experimental model of recurrent laryngeal nerve injury for the study of viral gene therapy.

METHODS

Twenty rats underwent unilateral recurrent laryngeal nerve injury. After vocal fold mobility was observed, larynges were serially sectioned, and immunohistochemical techniques were employed to stain for neurofilament and motor endplates in order for a blinded investigator to determine the percentage of nerve-endplate contact, as a histological indicator of an intact neuromuscular connection.

RESULTS

All animal procedures resulted in complete, ipsilateral vocal fold paralysis that recovered by three weeks. The mean nerve-endplate contact percentage was 11.6 per cent at one week, 53.9 per cent at two weeks, 88.6 per cent at three weeks, 81.7 per cent at four weeks and 86.6 per cent at five weeks. The differences between results at week one and week three were statistically significant (p < 0.01). The mean nerve-endplate contact percentage on the control side was 86.8 per cent.

CONCLUSIONS

There was a dramatic, measurable decrease in nerve-endplate contact percentage following crush injury to the recurrent laryngeal nerve. Spontaneous recovery was observed by three weeks post-injury. This model will be used to investigate the potential therapeutic role of viral gene therapy for the treatment of recurrent laryngeal nerve injury.