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Evangelista L, Nativ-Zeltzer N, Bewley A, Birkeland AC, Abouyared M, Kuhn M, Cates DJ, Farwell DG, Belafsky P. Functional Laryngectomy and Quality of Life in Survivors of Head and Neck Cancer With Intractable Aspiration. JAMA Otolaryngol Head Neck Surg 2024; 150:335-341. [PMID: 38451502 PMCID: PMC10921343 DOI: 10.1001/jamaoto.2024.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/15/2024] [Indexed: 03/08/2024]
Abstract
Importance Late effects of head and neck cancer (HNC) treatment include profound dysphagia, chronic aspiration, and death. Functional laryngectomy (FL) can improve patient survival and quality of life (QoL); however, removing a failing larynx for a noncancer reason is a difficult decision. Data regarding the ability of FL to improve self-perceptions of voice, swallowing, and QOL in survivors of HNC with intractable aspiration are inconclusive. Objective To investigate the association of FL with changes in self-reported perceptions of voice, swallowing, oral intake, QoL, and mood in survivors of HNC experiencing profound dysphagia and intractable aspiration. Design, Settings, and Participants This cohort study was conducted at a single academic institution and included survivors of HNC with profound swallowing dysfunction and intractable aspiration who underwent FL from July 2016 through March 2022. Of the initial 22 patients enrolled, 2 patients (15%) died of aspiration pneumonia before receiving FL. Data analyses were performed from July 2016 through March 2023. Main Outcomes and Measures Self-reported measures of voice using the VHI (30-item Voice Handicap Index), swallowing using the EAT-10 (10-item Eating Assessment Tool), functional oral intake scale using the FOIS (Functional Oral Intake Scale), and quality of life using the FACT-H&N (Functional Assessment of Cancer Therapy-Head & Neck) were assessed before FL and at 1, 3, and 6 months after FL. Mood states were evaluated using the POMS (Profile of Mood States, second edition), before FL and at 6 months after FL. Results The study analyses included 20 patients (mean [SD] age, 72.4 (7.0) years; 19 [95%] males and 1 [5%] female) who underwent FL and had complete data across all time points. Among these, 12 patients (60%) had received chemoradiation for oropharyngeal, 7 (35%) for laryngeal, or 1 (5%) for nasopharyngeal cancer. The mean (SD) time from completion of oncologic treatment to FL was 15.5 (5.5) years. Mean (SD) score on the EAT-10 improved from 33.2 (7.4) to 23.1 (10.8) at 1 month; 12.1 (9.1) at 3 months; and 8.3 (7.4) at 6 months, with a large effect size (η2 = 0.72; 95% CI, 0.54-0.80). Mean (SD) score on the FOIS improved from 2.0 (1.5) to 2.9 (1.7) at 1 month; 4.8 (2.5) at 3 months; and 5.2 (1.7) at 6 months, with a large effect size (η2 = 0.6; 95% CI, 0.38-0.71). Improvement in oral intake was achieved in 19 patients (95%), and feeding tubes were removed in 10 of 16 patients (63%) who were feeding tube-dependent; 6 patients (27%) continued to require supplemental tube feedings. Mean (SD) score on the VHI improved from 63.6 (34.0) to 86.9 (33.7) at 1 month; 71.3 (36.1) at 3 months; and 39.7 (26.9) at 6 months, with a large effect size (η2 = 0.42; 95% CI, 0.19-0.56). Seventeen patients (85%) were able to use a tracheoesophageal voice prosthesis for alaryngeal communication. Mean (SD) score on the FACT-H&N improved from 86.2 (17.8) to 93.6 (18.4) at 1 month; 109.0 (18.4) at 3 months; and 121.0 (16.8) at 6 months, with a large effect size (η2 = 0.64; 95% CI, 0.42-0.74). Mean (SD) score on the POMS improved from 58.9 (13.2) at baseline to 44.5 (9.9) at 6 months, with a large effect size (Cohen d = 1.04; 95% CI, 0.48-1.57). None of the patients experienced major complications of FL; 1 patient (5%) had a postoperative pharyngocutaneous fistula. Conclusions and Relevance The findings of this cohort study indicate that FL was associated with marked improvements in self-perception of voice and swallowing, functional oral intake, QoL, and mood state among survivors of HNC. These findings can serve as a framework for FL counseling among HNC survivors experiencing profound dysphagia and intractable aspiration.
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Affiliation(s)
- Lisa Evangelista
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Nogah Nativ-Zeltzer
- Department of Communication Disorders, Tel Aviv University, Tel Aviv, Israel
| | - Arnaud Bewley
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Andrew C. Birkeland
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Marianne Abouyared
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Maggie Kuhn
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - Daniel J. Cates
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
| | - D. Gregory Farwell
- Department of Otolaryngology–Head & Neck Surgery, Hospital of the University of Pennsylvania
| | - Peter Belafsky
- Department of Otolaryngology–Head & Neck Surgery, University of California, Davis Health System, Sacramento
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Nachalon Y, Broer M, Nativ-Zeltzer N. Using ChatGPT to Generate Research Ideas in Dysphagia: A Pilot Study. Dysphagia 2023:10.1007/s00455-023-10623-9. [PMID: 37907728 DOI: 10.1007/s00455-023-10623-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/20/2023] [Indexed: 11/02/2023]
Abstract
Current research in dysphagia faces challenges due to the rapid growth of scientific literature and the interdisciplinary nature of the field. To address this, the study evaluates ChatGPT, an AI language model, as a supplementary resource to assist clinicians and researchers in generating research ideas for dysphagia, utilizing recent advancements in natural language processing and machine learning. The research ideas were generated through ChatGPT's command to explore diverse aspects of dysphagia. A web-based survey was conducted, 45 dysphagia experts were asked to rank each study on a scale of 1 to 5 according to feasibility, novelty, clinical implications, and relevance to current practice. A total of 26 experts (58%) completed the survey. The mean (± sd) rankings of research ideas were 4.03 (± 0.17) for feasibility, 3.5 (± 0.17) for potential impact on the field, 3.84 (± 0.12) for clinical relevance, and 3.08 (± 0.36) for novelty and innovation. Results of this study suggest that ChatGPT offers a promising approach to generating research ideas in dysphagia. While its current capability to generate innovative ideas appears limited, it can serve as a supplementary resource for researchers.
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Affiliation(s)
- Yuval Nachalon
- Department of Otolaryngology, Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, 6 Weizman Street, 6423906, Tel-Aviv, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Maya Broer
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Nachalon Y, Nativ-Zeltzer N, Dhar SI, Cates DJ, Leon IW, Evangelista LM, Belafsky PC. Partners of persons with severe swallowing dysfunction have significantly reduced mental health. Support Care Cancer 2023; 31:519. [PMID: 37578591 DOI: 10.1007/s00520-023-07991-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 08/09/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Dysphagia can result in malnutrition, dehydration, social isolation, depression, pneumonia, pulmonary abscess, and death. The effect of dysphagia on the health and quality of life (QOL) of the life partners of persons with dysphagia is uncertain. We hypothesize that the partners of individuals with significant dysphagia will experience a significant reduction in quality of life. PURPOSE To evaluate the QOL of the significant others of persons with swallowing dysfunction. METHODOLOGY Persons with significant swallowing dysfunction (defined as EAT10® > 10) and their significant others were prospectively administered the 10-item Eating Assessment Tool (EAT10®) patient-reported outcome measure and the 12-item SF quality of life instrument (SF12). Summary data from the 8 mean health domains were compared between patients and their significant others. Mean scores for each domain are calibrated at 50, and a score below 47 implies significantly diminished QOL for a particular domain. RESULTS Twenty-three couples were evaluated. The mean ± SD EAT10 score for persons with significant dysphagia was 21 ± 7; mean EAT10 for their significant others or for couples in the control group was 0.3 ± 0.8. The mean physical health composite score (PCS) was significantly lower for patients with dysphagia compared to their significant others (39.1 ± 10 and 46.2 ± 11, respectively) (p < 0.05). Both patients and their significant others had comparable mean mental health composite scores (MCS) of 46.6 ± 10 and 46.4 ± 10, respectively (p > 0.05). CONCLUSION Although significant others of persons with swallowing dysfunction have higher physical well-being than their partners, they exhibit the same reduction in mental well-being, which is significantly lower than the general population. The data suggest that clinicians should address the mental well-being of the partners of persons with severe swallowing dysfunction.
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Affiliation(s)
- Yuval Nachalon
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Suite 7200, 2521 Stockton Blvd, Sacramento, CA, 95817, USA.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Nogah Nativ-Zeltzer
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Suite 7200, 2521 Stockton Blvd, Sacramento, CA, 95817, USA
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shumon I Dhar
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Suite 7200, 2521 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Daniel J Cates
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Suite 7200, 2521 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Isabella W Leon
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Suite 7200, 2521 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Lisa M Evangelista
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Suite 7200, 2521 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Suite 7200, 2521 Stockton Blvd, Sacramento, CA, 95817, USA
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Dhar SI, Nativ-Zeltzer N, Starmer H, Morimoto LN, Evangelista L, O'Rourke A, Fritz M, Rameau A, Randall DR, Cates D, Allen J, Postma G, Kuhn M, Belafsky P. The American Broncho-Esophagological Association Position Statement on Swallowing Fluoroscopy. Laryngoscope 2023; 133:255-268. [PMID: 35543231 DOI: 10.1002/lary.30177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/14/2022] [Accepted: 04/24/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To develop an expert consensus statement on the clinical use of swallowing fluoroscopy in adults that reduces practice variation and identifies opportunities for quality improvement in the care of patients suffering from swallowing impairment. METHODOLOGY A search strategist reviewed data sources (PubMed, Embase, Cochrane, Web of Science, Scopus) to use as evidence for an expert development group to compose statements focusing on areas of controversy regarding swallowing fluoroscopy. Candidate statements underwent two iterations of a modified Delphi protocol to reach consensus. RESULTS A total of 2184 publications were identified for title and abstract review with 211 publications meeting the criteria for full text review. Of these, 148 articles were included for review. An additional 116 publications were also included after reviewing the references of the full text publications from the initial search. These 264 references guided the authors to develop 41 candidate statements in various categories. Forty statements encompassing patient selection, fluoroscopic study choice, radiation safety, clinical team dynamics, training requirements, videofluoroscopic swallow study and esophagram techniques, and interpretation of swallowing fluoroscopy met criteria for consensus. One statement on esophagram technique reached near-consensus. CONCLUSIONS These 40 statements pertaining to the comprehensive use of swallowing fluoroscopy in adults can guide the development of best practices, improve quality and safety of care, and influence policy in both the outpatient and inpatient settings. The lack of consensus on some aspects of esophagram technique likely reflects gaps in knowledge and clinical practice variation and should be a target for future research. Laryngoscope, 133:255-268, 2023.
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Affiliation(s)
- Shumon Ian Dhar
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Heather Starmer
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, U.S.A
| | | | - Lisa Evangelista
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Ashli O'Rourke
- Department of Otolaryngology-Head and Neck Surgery, Evelyn Trammell Institute for Voice and Swallowing, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Mark Fritz
- Department of Otolaryngology - Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Anaïs Rameau
- The Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, U.S.A
| | - Derrick R Randall
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel Cates
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Jacqueline Allen
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Gregory Postma
- Department of Otolaryngology-Head & Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Maggie Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Peter Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
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Nativ-Zeltzer N, Kuhn MA, Evangelista L, Anderson JD, Nolta JA, Farwell DG, Canestrari E, Jankowski RJ, Belafsky PC. Autologous Muscle-Derived Cell Therapy for Swallowing Impairment in Patients Following Treatment for Head and Neck Cancer. Laryngoscope 2022; 132:523-527. [PMID: 33988246 PMCID: PMC8909914 DOI: 10.1002/lary.29606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the safety and potential efficacy of autologous muscle-derived cells (AMDCs) for the treatment of swallowing impairment following treatment for oropharynx cancer. STUDY DESIGN Prospective, phase I, open label, clinical trial. METHODS Oropharynx cancer survivors disease free ≥2 years post chemoradiation were recruited. All patients had swallowing impairment but were not feeding tube dependent (Functional Oral Intake Scale [FOIS] ≥ 5). Muscle tissue (50-250 mg) was harvested from the vastus lateralis and 150 × 106 AMDCs were prepared (Cook MyoSite Inc., Pittsburgh, PA). The cells were injected into four sites throughout the intrinsic tongue musculature. Participants were followed for 24 months. The primary outcome measure was safety. Secondary endpoints included objective measures on swallowing fluoroscopy, oral and pharyngeal pressure, and changes in patient-reported outcomes. RESULTS Ten individuals were enrolled. 100% (10/10) were male. The mean age of the cohort was 65 (±8.87) years. No serious adverse event occurred. Mean tongue pressure increased significantly from 26.3 (±11.1) to 31.8 (±9.5) kPa (P = .017). The mean penetration-aspiration scale did not significantly change from 5.6 (±2.1) to 6.8 (±1.8), and the mean FOIS did not significantly change from 5.4 (±0.5) to 4.6 (±0.7). The incidence of pneumonia was 30% (3/10) and only 10% (1/10) experienced deterioration in swallowing function throughout 2 years of follow-up. The mean eating assessment tool (EAT-10) did not significantly change from 24.1 (±5.57) to 21.3 (±6.3) (P = .12). CONCLUSION Results of this phase I clinical trial demonstrate that injection of 150 × 106 AMDCs into the tongue is safe and may improve tongue strength, which is durable at 2 years. A blinded placebo-controlled trial is warranted. LEVEL OF EVIDENCE 3 Laryngoscope, 132:523-527, 2022.
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Affiliation(s)
- Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Maggie A Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Lisa Evangelista
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Johnathon D Anderson
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | - Jan A Nolta
- Institute for Regenerative Cures, Department of Internal Medicine, University of California, Davis, Sacramento, California, U.S.A
| | - D Gregory Farwell
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
| | | | | | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California, U.S.A
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Evangelista L, Andrews T, Nativ-Zeltzer N, Nachalon Y, Kuhn M, Belafsky P. Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings. JAMA Otolaryngol Head Neck Surg 2021; 147:1065-1070. [PMID: 34529045 DOI: 10.1001/jamaoto.2021.2409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures. Objective To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP. Design, Setting, and Participants This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019. Main Outcomes and Measures Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed. Results Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type. Conclusions and Relevance This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.
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Affiliation(s)
- Lisa Evangelista
- Department of Otolaryngology-Head & Neck Surgery, University of California -Davis, Sacramento
| | - Tess Andrews
- Department of Otolaryngology-Head & Neck Surgery, University of California -Davis, Sacramento
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head & Neck Surgery, University of California -Davis, Sacramento
| | - Yuval Nachalon
- Department of Otolaryngology-Head & Neck Surgery, University of California -Davis, Sacramento
| | - Maggie Kuhn
- Department of Otolaryngology-Head & Neck Surgery, University of California -Davis, Sacramento
| | - Peter Belafsky
- Department of Otolaryngology-Head & Neck Surgery, University of California -Davis, Sacramento
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Nativ-Zeltzer N, Nachalon Y, Kaufman MW, Seeni IC, Bastea S, Aulakh SS, Makkiyah S, Wilson MD, Evangelista L, Kuhn MA, Sahin M, Belafsky PC. Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia. Laryngoscope 2021; 132:1172-1176. [PMID: 34313344 DOI: 10.1002/lary.29770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/20/2021] [Accepted: 07/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To identify risk factors for pneumonia incidence in patients with dysphagia undergoing a videofluoroscopic swallow study (VFSS) in an outpatient tertiary-care center. STUDY DESIGN Historical cohort study. METHODS All individuals undergoing a VFSS between 10/02/13 and 07/30/15 were identified and followed historically for 2 years. Demographic information, medical history, and fluoroscopic data were collected. The 2-year incidence of pneumonia was obtained from the medical records and telephone interview. The incidence of pneumonia and death were calculated and risk factors for pneumonia and mortality were ascertained. RESULTS 689 patients were followed for 2 years. The mean age (±standard deviation) of the cohort was 65 (±15.5) years. 49% (338/689) were female. The most common causes of dysphagia were cricopharyngeus muscle dysfunction (270/689), head and neck cancer (175/689), and neurodegenerative disease (56/689). The incidence of pneumonia was 22% (153/689). The incidence of death was 11%. Multivariable logistic regression revealed that chronic obstructive pulmonary disorder [COPD] (odds ratio [OR] = 2.36, 95% confidence interval [CI]: 1.33-4.19), hypertension (OR = 1.82, 95% CI: 1.23-2.73), tracheotomy status (OR = 2.96, 95% CI: 1.09-7.99), and vallecular residue (OR = 1.88, 95% CI: 1.24-2.85) were all significantly associated with an elevated risk of pneumonia. Kidney disease (OR = 1.27, 95% CI: 1.02-9.9), COPD (OR = 3.27, 95% CI: 1.65-6.49), vallecular residue (OR = 2.35, 95% CI: 1.35-4.1), male gender (OR = 2.21, 95% CI: 1.25-3.92), and low body mass index (OR: 1.12, 95% CI: 1.06-1.19) were independent adjusted risk factors for death. CONCLUSIONS The incidence of aspiration pneumonia (22%) and death (11%) within 2-years of a VFSS was high. The greatest adjusted risk factors for incident pneumonia were tracheotomy (OR = 3.0), COPD (OR = 2.4) and vallecular residue (OR = 1.9). The greatest adjusted risk factors for death were COPD (OR = 3.3), vallecular residue (OR = 2.3), and male gender (OR = 2.2). LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Yuval Nachalon
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Matthew W Kaufman
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Indulaxmi C Seeni
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Silvia Bastea
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Sukhkaran S Aulakh
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Sara Makkiyah
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Machelle D Wilson
- Department of Public Health Sciences, University of California, Davis, Sacramento, California, U.S.A
| | - Lisa Evangelista
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Maggie A Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Mustafa Sahin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
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Evangelista LM, Andrews T, Bayoumi A, Kuhn MA, Nativ-Zeltzer N, Belafsky PC. Endoscopic visualization for tracheoesophageal puncture tract sizing. Acta Otolaryngol 2021; 141:635-639. [PMID: 33825666 DOI: 10.1080/00016489.2021.1907444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Accurate tracheoesophageal prosthesis (TEP) size is essential for optimal functioning. Current sizing techniques do not afford direct visualization. The clinical utility of direct visualization with unsedated transnasal esophagoscopy (TNE) to improve TEP sizing accuracy has not been established. AIMS/OBJECTIVES The purpose of this investigation was to determine if endoscopic visualization with TNE during TEP fitting improves sizing accuracy. MATERIAL AND METHODS Participants undergoing secondary TEP placement had their TEP sized without visualization and with visualization during TNE. The effect of endoscopic visualization on TEP sizing was assessed. RESULTS The mean age (SD) of the cohort (N = 15) was 61.20 (±10.19) years. The percent disagreement between non-visualized and endoscopic-visualized puncture tract measurement was 60%. The mean difference in puncture tract length with visualization compared to without visualization was 1.75 mm (±1.91). Discordance between non-visualized and endoscopic-visualized puncture tract length was worse for persons with a history of radiation (66.7%) than without radiation (33.3%) (p < .05). The overall test agreement between endoscopic and non-endoscopic sizing techniques was moderate (Cohen's kappa coefficient = 0.254; (p < .05). CONCLUSION AND SIGNIFICANCE The percent disagreement between non-visualized and endoscopic-visualized TEP sizing is high (60%). The data suggest that endoscopic visualization with TNE improves sizing accuracy during TEP placement.
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Affiliation(s)
- Lisa M. Evangelista
- Center for Voice and Swallowing, Department of Otolaryngology – Head and Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Tess Andrews
- Center for Voice and Swallowing, Department of Otolaryngology – Head and Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Ahmed Bayoumi
- Center for Voice and Swallowing, Department of Otolaryngology – Head and Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Maggie A. Kuhn
- Center for Voice and Swallowing, Department of Otolaryngology – Head and Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Nogah Nativ-Zeltzer
- Center for Voice and Swallowing, Department of Otolaryngology – Head and Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Peter C. Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology – Head and Neck Surgery, University of California Davis, Sacramento, CA, USA
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9
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Dhar SI, Nativ-Zeltzer N, Mehdizadeh OB, Ramaswamy AT, Nachalon Y, Belafsky PC. Effects of Pyridostigmine on Esophageal and Pharyngeal Motility in Dysphagic Patients Undergoing High-Resolution Manometry. Dysphagia 2021; 37:4-10. [PMID: 33452552 DOI: 10.1007/s00455-020-10243-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/30/2020] [Indexed: 02/07/2023]
Abstract
Weak or absent peristalsis of the esophageal musculature is a common finding in ambulatory patients suffering from dysphagia and frequently associated with gastroesophageal reflux. There is currently no pharmacologic intervention that reliably improves esophageal contractility in patients suffering from various esophageal motility disorders. Our objective was to evaluate the acute effects of pyridostigmine on high-resolution manometry parameters in patients suffering from dysphagia with evidence of esophageal dysmotility. Pyridostigmine is an acetylcholinesterase inhibitor which increases effective concentrations of acetylcholine at the neuromuscular junction of both striated and smooth muscle cells. We conducted a prospective crossover study of five patients with dysphagia and proven esophageal dysmotility. Three patients had baseline ineffective esophageal motility and two had achalasia. Patients underwent pharyngeal and esophageal manometry before and after pyridostigmine administration. The median distal contractile integral (DCI), a marker of esophageal contractile vigor, was significantly higher post pyridostigmine administration 3001 (1950.3-3703.2) mmHg × s × cm compared to pre-pyridostigmine DCI of 1229.9 (956.2-2100) mmHg × s × cm; P < 0.001. Pre-pyridostigmine 18/25 (72%) of the patient's swallows was peristaltic compared to 25/25 (100%) post-pyridostigmine; P < 0.005. No other pharyngeal or esophageal high-resolution manometry parameter differed significantly after pyridostigmine administration. The results of this pilot study demonstrate that pyridostigmine acutely improves esophageal contractile vigor in patients suffering from dysphagia with esophageal dysmotility. Further investigation with larger sample size, longer follow-up, side effect profile, and patient-reported outcome measures is still needed to determine the clinical usefulness of pyridostigmine in specific disorders of esophageal motility.
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Affiliation(s)
- Shumon I Dhar
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD, 21287, USA.
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
| | - Omid B Mehdizadeh
- Pacific Eye, Ear, and Skull Base Center, Pacific Neuroscience Institute, 11645 Wilshire Blvd., 6th Floor, Los Angeles, CA, 90025, USA
| | - Apoorva T Ramaswamy
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
| | - Yuval Nachalon
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
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10
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Nativ-Zeltzer N, Ueha R, Nachalon Y, Ma B, Pastenkos G, Swackhamer C, Bornhorst GM, Lefton-Greif MA, Anderson JD, Belafsky PC. Inflammatory Effects of Thickened Water on the Lungs in a Murine Model of Recurrent Aspiration. Laryngoscope 2020; 131:1223-1228. [PMID: 32770795 DOI: 10.1002/lary.28948] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/03/2020] [Accepted: 06/28/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Liquid thickeners are commonly recommended in individuals with dysphagia and recurrent aspiration as a strategy for pneumonia prevention. The goal of this study was to examine the effects of small amounts of aspirated liquid thickener on the lungs. STUDY DESIGN Animal model. Prospective small animal clinical trial. METHODS Adult Sprague Dawley rats (n = 19) were divided into two groups and underwent three intratracheal instillations of either xanthan gum-based nectar-thick water (0.1-0.25 mL/kg) or water-only control over the course of 8 days. Blood was collected from a peripheral vein on days 1 and 8 and submitted for complete blood count (CBC) analysis. Rats were euthanized 10 days after the last instillation, and the lungs were harvested. Histopathology was conducted on lung specimens by a blinded licensed veterinary pathologist and scored for evidence of lung injury and pneumonia. RESULTS Fifteen animals (8 nectar-thickener group, 7 control group) survived until the endpoint of the study (day 18). Serum CBC did not show abnormalities at any timepoint in either group. Histological evidence of lung inflammation and edema were significantly greater in the nectar-thick group compared to controls (P < .05). Signs of inflammation included aggregates of foamy macrophages, expansion of bronchiolar lymphoid tissue, and large numbers of eosinophilic intraalveolar crystals. Histiocytic and neutrophilic pneumonia was noted in one animal that received thickened liquids. CONCLUSION Recurrent aspiration of small amounts of thickened water resulted in significant pulmonary inflammation in a murine model of aspiration. Results of this study support the need for further investigation of liquid thickener safety and its efficacy in reducing the pulmonary complications of swallowing disorders. LEVEL OF EVIDENCE NA Laryngoscope, 131:1223-1228, 2021.
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Affiliation(s)
- Nogah Nativ-Zeltzer
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California, Davis, California, U.S.A
| | - Rumi Ueha
- Department of Otorhinolaryngology, Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Yuval Nachalon
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California, Davis, California, U.S.A
| | - Betty Ma
- Office of Research: Campus Veterinary Services, University of California, Davis, California, U.S.A
| | - Gabrielle Pastenkos
- Comparative Pathology Laboratory, University of California, Davis School of Veterinary Medicine, Davis, California, U.S.A
| | - Clay Swackhamer
- Department of Biological and Agricultural Engineering, University of California Davis, Davis, California, U.S.A
| | - Gail M Bornhorst
- Department of Biological and Agricultural Engineering, University of California Davis, Davis, California, U.S.A
| | - Maureen A Lefton-Greif
- Department of Pediatrics, Otolaryngology, Head & Neck Surgery, and Physical Medicine & Rehabilitation, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Johnathon D Anderson
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California, Davis, California, U.S.A
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California, Davis, California, U.S.A
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11
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Nachalon Y, Nativ-Zeltzer N, Evangelista LM, Dhar SI, Lin SJ, Shen SC, Belafsky PC. Cervical Fibrosis as a Predictor of Dysphagia. Laryngoscope 2020; 131:548-552. [PMID: 32628787 DOI: 10.1002/lary.28880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Radiotherapy of head and neck cancer (HNCA) causes dysfunction through radiation-induced fibrosis (RIF). We hypothesize that the degree of cervical fibrosis is associated with swallowing dysfunction. This study evaluated the association between cervical fibrosis and swallowing dysfunction in patients after radiation therapy for HNCA. STUDY DESIGN Cross sectional study. METHODOLOGY A convenience sample of patients with dysphagia who were at least 1 year post radiation therapy for HNCA underwent simultaneous cervical ultrasound (US) and video-fluroscopic swallow study (VFSS). US determinants of fibrosis were measurements of sternocleidomastoid fascia (SCMF) thickness bilaterally at the level of the cricoid. Primary and secondary outcome variables on VFSS were pharyngeal constriction ratio, a validated measure of pharyngeal contractility, and penetration aspiration scale (PAS). A qualitative assessment of lateral neck rotation was performed as a functional measure of neck fibrosis. RESULTS Simultaneous cervical US and VFSS examinations were performed on 18 patients with a history of radiotherapy for HNCA and on eight controls. The mean (±SD) age of the entire cohort (N = 26) was 66 (±10) years. Individuals with a history of radiation had significantly thinner mean SCMF (0.26 [±0.04 mm]) compared to controls (0.48 [±0.06 mm]; P < .05). Individuals with thinner SCMF were more likely to have moderate to severe restriction in lateral neck rotation, a higher PCR, and a higher PAS (P < .05). CONCLUSION Thinner sternocleidomastoid fascia on ultrasound in patients having undergone radiotherapy for head and neck cancer was associated with reduced lateral neck movement, poorer pharyngeal constriction and greater penetration/aspiration scale. The data suggest that cervical fibrosis is associated with swallowing dysfunction in head and neck cancer survivors and support the notion that, "As the neck goes, so does the swallow." LEVEL OF EVIDENCE 3. Laryngoscope, 131:548-552, 2021.
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Affiliation(s)
- Yuval Nachalon
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Lisa M Evangelista
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Shumon I Dhar
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Sharon J Lin
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Shih C Shen
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
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12
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Ueha R, Sato T, Goto T, Yamauchi A, Nativ-Zeltzer N, Mitsui J, Belafsky PC, Yamasoba T. Esophageal Dysmotility is Common in Patients With Multiple System Atrophy. Laryngoscope 2020; 131:832-838. [PMID: 32621533 DOI: 10.1002/lary.28852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/28/2020] [Accepted: 05/22/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Esophageal dysmotility (ED) in patients with multiple system atrophy (MSA) are poorly understood. This study aimed to investigate the prevalence of ED in patients with MSA and to assess the relationship of esophageal abnormalities with other clinical findings and characteristics in these patients. METHODS A retrospective chart review was conducted to identify patients with MSA and to compare them to the elderly controls without MSA (65+ years) who underwent a videofluorographic esophagram from 2014 to 2019. Disease type, disease severity, vocal fold mobility impairment, abnormal deglutitive proximal esophageal contraction (ADPEC), and intra-esophageal stasis (IES) were reviewed and compared between groups. RESULTS Thirty-seven patients with MSA were identified. The median age was 63 and 26 (70%) were male. These patients were matched to 22 elderly adults with presbylarynx but not MSA (median age 77, 68% male). In MSA patients, cerebellar variant type was predominant (59%), and ADPEC was recognized in 18 patients (49%). Disease severity level (P = 0.028) and existence of IES (P = 0.046) were associated with higher risks of developing ADPEC. The prevalence of IES was significantly higher in patients with MSA (95%) compared to controls without MSA (46%) (P < 0.001). Disease severity level and the existence of IES were significantly associated with the presence of ADPEC (p < 0.05). CONCLUSION ADPEC and IES were significantly more common in MSA than in elderly subjects without MSA. MSA severity is associated with the development of ADPEC. The data suggest that esophageal motility is predominantly affected in MSA. LEVEL OF EVIDENCE 3 Laryngoscope, 131:832-838, 2021.
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Affiliation(s)
- Rumi Ueha
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taku Sato
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takao Goto
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akihito Yamauchi
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology, The University of California, Davis, California, U.S.A
| | - Jun Mitsui
- Department of Neurology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Peter C Belafsky
- Department of Otolaryngology, The University of California, Davis, California, U.S.A
| | - Tatsuya Yamasoba
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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13
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Ian Dhar S, Wegner AM, Rodnoi P, Wuellner JC, Mehdizadeh OB, Shen SC, Nachalon Y, Nativ-Zeltzer N, Belafsky PC, Klineberg EO. Fluoroscopic Swallowing Abnormalities in Dysphagic Patients Following Anterior Cervical Spine Surgery. Ann Otol Rhinol Laryngol 2020; 129:1101-1109. [DOI: 10.1177/0003489420929046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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
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Affiliation(s)
- Shumon Ian Dhar
- Johns Hopkins University, Department of Otolaryngology-Head and Neck Surgery, Baltimore, MD
| | - Adam M. Wegner
- Washington University in Saint Louis, Department of Orthopedic Surgery, Saint Louis, MO, USA
| | - Pope Rodnoi
- University of California Davis, Department of Orthopaedic Surgery, Sacramento, CA, USA
| | - John C. Wuellner
- University of California Davis, Department of Orthopaedic Surgery, Sacramento, CA, USA
| | - Omid Benjamin Mehdizadeh
- University of California Davis, Department of Otolaryngology-Head and Neck Surgery, Sacramento, CA
| | - Shih C. Shen
- University of California Davis, Department of Otolaryngology-Head and Neck Surgery, Sacramento, CA
- Chang Gung Memorial Hospital Department of Otolaryngology-Head and Neck Surgery, Linkou
| | - Yuval Nachalon
- University of California Davis, Department of Otolaryngology-Head and Neck Surgery, Sacramento, CA
| | - Nogah Nativ-Zeltzer
- University of California Davis, Department of Otolaryngology-Head and Neck Surgery, Sacramento, CA
| | - Peter C. Belafsky
- University of California Davis, Department of Otolaryngology-Head and Neck Surgery, Sacramento, CA
| | - Eric O. Klineberg
- University of California Davis, Department of Orthopaedic Surgery, Sacramento, CA, USA
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14
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Dhar SI, Wegner AM, Rodnoi P, Wuellner JC, Mehdizadeh OB, Shen SC, Nachalon Y, Nativ-Zeltzer N, Klineberg EO, Belafsky PC. Swallowing Characteristics in Zenker's-like Diverticulum After Anterior Cervical Spine Surgery. Laryngoscope 2019; 130:1383-1387. [PMID: 31461167 DOI: 10.1002/lary.28266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 07/12/2019] [Accepted: 08/12/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES A Zenker's diverticulum (ZD) is a hypopharyngeal pulsion diverticula caused by dysfunction of the cricopharyngeus muscle with herniation of hypopharyngeal mucosa through Killian's dehiscence. Anterior cervical spine surgery (ACSS) can cause a Zenker's-like traction diverticulum (ZTD) with a similar presentation but different pathophysiology. The purpose of this investigation was to compare the fluoroscopic parameters and surgical outcomes of ZTD after ACSS to those of typical ZD. STUDY DESIGN Case-control study. METHODS The charts of patients undergoing a videofluoroscopic swallow study after ACSS between January 1, 2014, and January 1, 2018, were evaluated for evidence of ZTD. Patients with ZTD were age and gender matched to persons with ZD. Fluoroscopic parameters and patient-reported outcomes were compared between groups. RESULTS Eleven patients with ZTD were identified. The mean pharyngeal constriction ratio (PCR) was significantly higher for persons with ZTD (0.87 [±0.07] vs. 0.17 [±0.08]; P < 0.05). Mean hyolaryngeal elevation was significantly less (2.5 [±0.9] cm vs. 3.5 [±0.7] cm) and mean diverticulum size significantly smaller (1.3 [±1.0] cm vs. 2.3 [±2.0] cm) for persons with ZTD (P < 0.05). Five ZTD patients had exposed hardware necessitating open approach for removal. CONCLUSION We report the largest cohort of ZTD after ACSS. ZTD are smaller than traditional Zenker's and associated with more pharyngeal weakness, poorer laryngeal elevation, and worse treatment outcomes. Although these diverticula can be managed endoscopically, the high percentage of exposed cervical hardware necessitates a thorough preoperative assessment and frequent need for open management and pharyngeal repair. LEVEL OF EVIDENCE 3b Laryngoscope, 130:1383-1387, 2020.
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Affiliation(s)
- Shumon I Dhar
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California Davis, Sacramento, California
| | - Adam M Wegner
- Department of Orthopedic Surgery, Washington University in Saint Louis, Saint Louis, Missouri, U.S.A
| | - Pope Rodnoi
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
| | - John C Wuellner
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
| | - Omid B Mehdizadeh
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California Davis, Sacramento, California
| | - Shih C Shen
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California Davis, Sacramento, California
| | - Yuval Nachalon
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California Davis, Sacramento, California
| | - Nogah Nativ-Zeltzer
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California Davis, Sacramento, California
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California Davis, Sacramento, California
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15
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Nativ-Zeltzer N, Bayoumi A, Mandin VP, Kaufman M, Seeni I, Kuhn MA, Belafsky PC. Validation of the PILL-5: A 5-Item Patient Reported Outcome Measure for Pill Dysphagia. Front Surg 2019; 6:43. [PMID: 31396520 PMCID: PMC6667828 DOI: 10.3389/fsurg.2019.00043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Objectives: Pill dysphagia is common and costly with a significant risk of pill retention, caustic injury, and poor medication compliance. The purpose of this investigation was to determine the validity and reliability of the PILL-5, a self-administered patient reported outcome measure (PROM) to quantify the degree of pill (tablet and capsule) dysphagia. The PILL-5 is a 5-item questionnaire with a maximum symptom score of 20. Methods: The PILL-5 was administered to 190 patients with dysphagia referred for videofluoroscopic esophagography (VFE). Construct validity was assessed by comparing PILL-5 composite scores to delayed barium tablet transit on VFE. Normative data was obtained by administering the instrument to a cohort of healthy community based volunteers. Internal consistency was assessed with the Cronbach alpha. Test/retest reliability was determined by administering the instrument to the same cohort of patients at two time points. Results: The mean PILL-5 was 5.6 (±4.9) for persons with dysphagia and 1.6 (±2.7) for healthy volunteers (p < 0.001). The internal consistency of the instrument was high (Cronbach alpha = 0.85). The mean PILL-5 was 4.3 (±4.1) for patients with normal transit and 7.6 (±5.3) for patients with delayed barium tablet transit on esophagography, indicating excellent criterion based validity (p < 0.001). Reproducibility was high with an intraclass correlation coefficient of 0.83 (p < 0.001). Conclusions: Healthy individuals report some degree of swallowing difficulty with pills. Normative data suggest that a PILL-5 > 6 is abnormal (mean + 2 SD). The instrument demonstrated excellent criterion based validity and reliability. The PILL-5 is the first validated patient reported outcome measure for pill dysphagia.
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Affiliation(s)
- Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice and Swallowing, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Ahmed Bayoumi
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice and Swallowing, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Van Pierre Mandin
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice and Swallowing, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Matthew Kaufman
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice and Swallowing, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Indulaxmi Seeni
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice and Swallowing, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Maggie A Kuhn
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice and Swallowing, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice and Swallowing, University of California Davis School of Medicine, Sacramento, CA, United States
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16
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Ueha R, Nativ-Zeltzer N, Sato T, Goto T, Nito T, Tsunoda K, Belafsky PC, Yamasoba T. Chronic inflammatory response in the rat lung to commonly used contrast agents for videofluoroscopy. Laryngoscope Investig Otolaryngol 2019; 4:335-340. [PMID: 31236468 PMCID: PMC6580069 DOI: 10.1002/lio2.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 11/10/2022] Open
Abstract
Objectives Contrast agents (CAs) are essential for upper gastrointestinal and videofluoroscopic swallow studies (VFSSs). Recently, we reported that small amounts of Ba aspiration caused severe acute lung inflammation in a rodent model. However, the underlying molecular biological mechanisms of chronic response to CA aspiration remain unclear. The aims of this study were to explore the underlying molecular biological mechanisms of the chronic response to three kinds of CA aspiration on the lung. Study Design Animal model. Methods Eight‐week‐old male Sprague Dawley rats were divided into five groups (n = 6, each group). Three groups underwent tracheal instillation of one of three CAs: barium sulfate (Ba), ionic iodinated contrast agent (ICA), and nonionic iodinated contrast agent (NICA). A sham group was instilled with air and a control group was instilled with saline. All animals were euthanized 30 days after treatment and histological and gene analyses were performed. Results No animal died after CA or sham/control aspiration. Ba particles remained after 30 days and caused histopathologic changes and inflammatory cell infiltration. Iodinated ICA and NICA did not result in perceptible histologic change. Expression of Tnf, an inflammatory cytokine was increased in only Ba aspirated rats (P = .0076). Other inflammatory cytokines and fibrosis‐related genes did not alter between groups. Conclusion Aspirated Ba particles did not clear from the lung within a month and caused mild chronic pulmonary inflammation. ICA and NICA did not cause any inflammatory responses in the lungs, suggesting that ICA and NICA may be safer CAs for VFSS than Ba. Level of Evidence NA
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Affiliation(s)
- Rumi Ueha
- Department of Otolaryngology The University of Tokyo Tokyo Japan
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology The University of California Davis California U.S.A
| | - Taku Sato
- Department of Otolaryngology The University of Tokyo Tokyo Japan
| | - Takao Goto
- Department of Otolaryngology The University of Tokyo Tokyo Japan
| | - Takaharu Nito
- Department of Otolaryngology The University of Tokyo Tokyo Japan
| | - Koichi Tsunoda
- Department of Artificial Organs and Otolaryngology National Institute of Sensory Organs Tokyo Japan
| | - Peter C Belafsky
- Department of Otolaryngology The University of California Davis California U.S.A
| | - Tatsuya Yamasoba
- Department of Otolaryngology The University of Tokyo Tokyo Japan
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Nachalon Y, Nativ-Zeltzer N, Dhar SI, Mehdizadeh OB, Cassady AT, Belafsky PC. Esophageal A-ring is associated with the severity of gastroesophageal reflux. Laryngoscope 2019; 130:951-954. [PMID: 31199518 DOI: 10.1002/lary.28143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/15/2019] [Accepted: 05/29/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND The esophageal A-ring (EAR) is an anatomic finding appreciated on videofluoroscopic esophagram (VFE) at the junction of the tubular esophagus and esophageal vestibule. EARs are appreciated on a small subset (5%) of VFEs. We hypothesize that EARs represent a compensatory mechanism to protect against gastroesophageal reflux (GER). OBJECTIVE To evaluate the association between EAR and GER. STUDY DESIGN Case control study. METHODS All persons having undergone ambulatory pH testing with an EAR identified on VFE between November 1, 2014 and June 30, 2014 were identified. All cases were matched to controls by age, gender, and the presence/absence of hiatal hernia. Subjective dysphagia severity was assessed with the EAT10 and the presence of erosive esophagitis and intestinal metaplasia on esophagoscopy was abstracted. RESULTS The mean (±SD) age of the entire cohort (N = 20) was 63 (±7.7) years. 60% was female. The mean composite DeMeester pH score for persons with and without an EAR was 48.9 (±39.6) and 15.4 (±12.3), respectively (P = .033). The mean total % time of pH < 4 for persons with and without an EAR was 26.4 (±21.9) and 7.7 (±6.8), respectively (P = .034). The prevalence of erosive esophagitis among persons with and without an EAR was 70% and 10%, respectively (P = .019). CONCLUSION There is a significant association between the presence of esophageal A-rings on esophagography and the severity of acid reflux on endoscopy and ambulatory pH testing. The data suggest that the presence of an esophageal A-ring may be either a compensatory mechanism to protect against gastroesophageal reflux and/or an inflammatory consequence of peptic esophagitis. LEVEL OF EVIDENCE 3b Laryngoscope, 130:951-954, 2020.
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Affiliation(s)
- Yuval Nachalon
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Shumon I Dhar
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Omid B Mehdizadeh
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Antonio T Cassady
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
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Shen SC, Nachalon Y, Randall DR, Nativ-Zeltzer N, Belafsky PC. High elevation training mask as a respiratory muscle strength training tool for dysphagia. Acta Otolaryngol 2019; 139:536-540. [PMID: 31035838 DOI: 10.1080/00016489.2019.1605196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Expiratory muscle strength training (EMST) is a treatment for swallowing dysfunction due to its activation of the suprahyoid muscles. Current EMST devices have numerous limitations. OBJECTIVE The purpose was to evaluate the utility of elevation training mask as an alternative respiratory muscle strength training (RMST) device. METHODS A closed system, simulating expiration was designed. Air was delivered through a pressure gauge with a measurement range of 0-15 psi. The EMST150TM and the Elevation Training Mask 2.0® (ETM) maximal resistance levels were measured and compared. RESULTS EMST150 produced increasing expiratory resistance pressures of 0.3, 0.6, 1.2, 1.9 and 2.1 psi, which correspond to its indicator of 30, 60, 90, 120 and 150 cmH2O. The ETM resistance pressure produced expiratory resistance pressures of 0.1 and 0.2 psi at simulated altitudes of 3000 and 6000 feet, respectively. A stable expiratory resistance pressure of 0.25 psi was measured at simulated altitudes of 9000, 12,000, 15,000 and 18,000 feet. CONCLUSION ETM provides adjustable expiratory muscle strength resistance pressures. Further investigation is necessary to evaluate safety, compliance and clinical efficacy in patients with swallowing dysfunction. SIGNIFICANCE ETM can serve as an effective treatment modality for pulmonary dysfunction and swallowing disorders through RMST.
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Affiliation(s)
- Shih Chieh Shen
- Department of Otolaryngology – Head & Neck Surgery, University of California – Davis, Center for Voice and Swallowing, Sacramento, CA, USA
- Department of Otolaryngology – Head & Neck Surgery, Chang Gung Memorial Hospital Linkou Branch, Taipei, Taiwan
| | - Yuval Nachalon
- Department of Otolaryngology – Head & Neck Surgery, University of California – Davis, Center for Voice and Swallowing, Sacramento, CA, USA
| | - Derrick R Randall
- Section of Otolaryngology – Head & Neck Surgery, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology – Head & Neck Surgery, University of California – Davis, Center for Voice and Swallowing, Sacramento, CA, USA
| | - Peter C. Belafsky
- Department of Otolaryngology – Head & Neck Surgery, University of California – Davis, Center for Voice and Swallowing, Sacramento, CA, USA
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Nativ-Zeltzer N, Belafsky PC, Bayoumi A, Kuhn MA. Volitional control of the upper esophageal sphincter with high-resolution manometry driven biofeedback. Laryngoscope Investig Otolaryngol 2019; 4:264-268. [PMID: 31024999 PMCID: PMC6476264 DOI: 10.1002/lio2.255] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/13/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Dysfunction of the upper esophageal sphincter (UES) is associated with swallow dysfunction and globus pharyngeus. Although volitional augmentation of the UES has been previously documented, the ability of individuals to control UES pressure with high‐resolution manometry (HRM) driven biofeedback has not been assessed. Purpose To evaluate the ability of patient driven HRM biofeedback to control UES basal pressure. Methods HRM data was collected from 10 patients undergoing esophageal manometry. Participants were trained on real‐time HRM‐driven biofeedback to both elevate and reduce UES pressure. Measures of baseline UES minimum, mean and maximum pressures (mmHg) were compared to biofeedback‐driven volitional increases and decreases in UES pressures. Pre‐ and post‐biofeedback data were compared with paired sample T‐tests. Results The mean age (± standard deviation) of the cohort was 68 (±12.7) years. Sixty percent (6/10) were female. The mean UES baseline pressure increased from 30.1 (±15.3) mmHg to 44.8 (±25.03) mmHg (P = .02) with biofeedback‐driven UES augmentation (P < .05). Maximum UES pressures were also increased from 63.84 (±24.1) mmHg to 152.4 (±123.7) (P = .04). Although some individuals were able to successfully decrease basal UES tone with the HRM biofeedback, no statistically significant group differences were observed (P > .05). Conclusion Volitional control of UES pressure is possible with HRM‐driven biofeedback. Patients vary in their ability to intentionally control UES pressure and some may require further training aimed at lowering UES pressure with HRM‐guided biofeedback. These data may have significant implications for the future treatment of UES disorders and warrant further investigation. Level of Evidence 4
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Affiliation(s)
- Nogah Nativ-Zeltzer
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
| | - Ahmed Bayoumi
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
| | - Maggie A Kuhn
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
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Ueha R, Nativ-Zeltzer N, Sato T, Goto T, Nito T, Belafsky PC, Yamasoba T. Acute inflammatory response to contrast agent aspiration and its mechanisms in the rat lung. Laryngoscope 2018; 129:1533-1538. [PMID: 30467858 PMCID: PMC6618150 DOI: 10.1002/lary.27663] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
Objectives/Hypothesis Contrast agent (CA) aspiration is an established complication of upper gastrointestinal and videofluoroscopic swallow studies. The underlying molecular biological mechanisms of acute response to CA aspiration in the respiratory organs remain unclear. The aims of this study were to elucidate the histological and biological influences of three kinds of CAs on the lung and to clarify the differences in acute responses. Study Design Animal model. Methods Eight‐week‐old male Sprague Dawley rats were divided into five groups (n = 6 in each group). Three groups underwent tracheal instillation of one of three different CAs: barium (Ba) sulfate, nonionic contrast agents (NICAs), and ionic contrast agents (ICAs). A control group was instilled with saline and a sham group was instilled with air. All animals were euthanized on day 2 after treatment and histological and gene analysis was performed. Results No animal died after CA or control/sham aspiration. Ba caused severe histopathologic changes and more prominent inflammatory cell infiltration in the lungs compared with the two other iodinated contrast agents. Increases in expressions of inflammatory cytokines (tumor necrosis factor [Tnf], interleukin‐1β [Il1b], and interferon‐γ [Ifng]) were observed in Ba aspiration rats, and upregulation of Il1b was seen in ICA aspiration rats. NICA did not cause obvious histologic changes or expressions of inflammatory cytokines and fibrosis‐related genes in the lungs. Conclusions Ba caused significantly more acute lung inflammation in a rodent model than did ioinic and nonionic iodinated CAs. Nonionic contrast did not cause any discernible inflammatory response in the lungs, suggesting that it may be the safest contrast for videofluoroscopic swallow studies. Level of Evidence NA Laryngoscope, 129:1533–1538, 2019
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Affiliation(s)
- Rumi Ueha
- Department of Otolaryngology, University of Tokyo, Tokyo, Japan
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology, University of California Davis, Sacramento, California, U.S.A
| | - Taku Sato
- Department of Otolaryngology, University of Tokyo, Tokyo, Japan
| | - Takao Goto
- Department of Otolaryngology, University of Tokyo, Tokyo, Japan
| | - Takaharu Nito
- Department of Otolaryngology, University of Tokyo, Tokyo, Japan
| | - Peter C Belafsky
- Department of Otolaryngology, University of California Davis, Sacramento, California, U.S.A
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Nativ-Zeltzer N, Rameau A, Kuhn MA, Kaufman M, Belafsky PC. The Relationship Between Hiatal Hernia and Cricopharyngeus Muscle Dysfunction. Dysphagia 2018; 34:391-396. [DOI: 10.1007/s00455-018-9950-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 10/06/2018] [Indexed: 01/11/2023]
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Ueha R, Goto T, Sato T, Nativ-Zeltzer N, Shen SC, Nito T, Belafsky PC, Yamasoba T. High Resolution Manofluorographic Study in Patients With Multiple System Atrophy: Possible Early Detection of Upper Esophageal Sphincter and Proximal Esophageal Abnormality. Front Med (Lausanne) 2018; 5:286. [PMID: 30345277 PMCID: PMC6182049 DOI: 10.3389/fmed.2018.00286] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/17/2018] [Indexed: 12/31/2022] Open
Abstract
Introduction: Multiple system atrophy (MSA) has detrimental effects on swallowing function. The swallowing function of patients with MSA has not been systematically characterized and the underlying pathophysiological mechanisms of dysphagia remain poorly understood. Objectives: To investigate the characteristics of swallow function in MSA using high-resolution manofluorography (HRMF). Methods: We conducted a retrospective review of twenty-five MSA patients who underwent HRMF from 2016 to 2017. HRMF was utilized on patients with only oral diet (Functional Oral Intake Scale (FOIS) >3). Pharyngoesophageal and proximal esophageal pressure profiles were evaluated and compared to established normative data. The frequency and characteristics of upper esophageal sphincter (UES) and proximal esophageal abnormalities during rest and swallow were calculated. Results: The ages of patient cohort in our study ranged from 48–81 years (median 65 years) with male predominance (68%). We observed a distinct abnormal deglutitive proximal esophageal contraction (ADPEC) in 14 (56% of patients), which appears to reflect a discoordinated response of the striated muscle esophagus. Deficient UES relaxation duration, impaired UES relaxation, hypertensive resting UES pressure and hypotensive resting UES pressure were detected in 8 patients (32%), 3 patients (12%), 1 patient (4%), and 11 patients (44%) respectively. Conclusions: In patients with MSA, abnormal UES resting pressure is common. A discoordinated proximal esophageal pressure response was identified and may be a pathognomonic manometry finding for MSA. These findings may serve as indications of early stage swallowing dysfunction in patients with MSA.
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Affiliation(s)
- Rumi Ueha
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
| | - Takao Goto
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
| | - Taku Sato
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology, The University of California, Davis, Davis, CA, United States
| | - Shih Chieh Shen
- Department of Otolaryngology, The University of California, Davis, Davis, CA, United States
| | - Takaharu Nito
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
| | - Peter C Belafsky
- Department of Otolaryngology, The University of California, Davis, Davis, CA, United States
| | - Tatsuya Yamasoba
- Department of Otolaryngology, The University of Tokyo, Tokyo, Japan
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Randall DR, Nativ-Zeltzer N, Cates DJ, Tinling SP, Belafsky PC. Decreased intramuscular calcium hydroxyapatite implant resorption in a murine model of osteoporosis. Laryngoscope 2018; 128:2576-2580. [PMID: 30194683 DOI: 10.1002/lary.27348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/21/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Calcium hydroxyapatite (CaHA) is a common material for vocal fold injection augmentation. Durability is variable, and factors involved in implant longevity are not understood. Animal models of osteoporosis show decreased bone density and increased mineral liberation, suggesting CaHA retention may be altered in these conditions. STUDY DESIGN Prospective murine investigation. METHODS Fourteen skeletally mature, 10-month-old female Sprague-Dewley rats were treated by one of three interventions: oophorectomy, laparotomy without oophorectomy (sham), or monthly risedronate injection (90 μg/kg, subcutaneous). CaHA was implanted into the right lateral thigh muscle in all animals at the time of procedure or first risedronate injection. After 17 weeks, all rats were sacrificed, and the residual CaHA isolated from excised lateral thigh muscle through incubation in a 900 °C calcinator for 9 hours. RESULTS Mean CaHA mass remaining in the oophorectomy group was 65.9 (standard deviation ± 16.1) mg, compared to 44.4 ± 10.0 mg CaHA in the risedronate group and 48.6 ± 7.5 mg in the sham group. One-way analysis of variance found a statistically significant difference between the oophorectomy and risedronate groups but not between the sham and other groups, F(2,11) = 4.404, P = 0.039. CONCLUSION Persistent estrogen deficiency in a murine model of osteoporosis demonstrated decreased rate of CaHA resorption. This suggests that hormone alterations associated with osteoporosis may alter the longevity of CaHA implant resorption through an uncertain mechanism. LEVEL OF EVIDENCE NA. Laryngoscope, 2576-2580, 2018.
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Affiliation(s)
- Derrick R Randall
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, CA, U.S.A
- the Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, CA, U.S.A
| | - Daniel J Cates
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, CA, U.S.A
| | - Steve P Tinling
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, CA, U.S.A
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, CA, U.S.A
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Nativ-Zeltzer N, Kuhn MA, Imai DM, Traslavina RP, Domer AS, Litts JK, Adams B, Belafsky PC. The effects of aspirated thickened water on survival and pulmonary injury in a rabbit model. Laryngoscope 2017; 128:327-331. [DOI: 10.1002/lary.26698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/09/2017] [Accepted: 04/26/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Nogah Nativ-Zeltzer
- Center for Voice and Swallowing; Department of Otolaryngology-Head and Neck Surgery, University of California, Davis School of Medicine; Sacramento California
| | - Maggie A. Kuhn
- Center for Voice and Swallowing; Department of Otolaryngology-Head and Neck Surgery, University of California, Davis School of Medicine; Sacramento California
| | - Denise M. Imai
- Comparative Pathology Laboratory; University of California, Davis School of Veterinary Medicine; Sacramento California
| | - Ryan P. Traslavina
- Comparative Pathology Laboratory; University of California, Davis School of Veterinary Medicine; Sacramento California
- United States Army Institute of Chemical Defense; Aberdeen Proving Grounds; Maryland U.S.A
| | | | - Juliana K. Litts
- Department of Otolaryngology-Head and Neck Surgery; University of Colorado; Denver Colorado
| | | | - Peter C. Belafsky
- Center for Voice and Swallowing; Department of Otolaryngology-Head and Neck Surgery, University of California, Davis School of Medicine; Sacramento California
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Siddiqui MT, Litts JK, Cheney DM, Kuhn MA, Nativ-Zeltzer N, Belafsky PC. The effect of aspirated barium sulfate, iodixanol, and diatrizoic acid on survival and lung injury in a lagomorph model. Laryngoscope 2017; 127:E148-E152. [PMID: 28233902 DOI: 10.1002/lary.26494] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/30/2016] [Accepted: 12/20/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Contrast agents are an integral component of the video fluoroscopic swallow study. Agents commonly used include barium sulfate (E-Z Paque), iodixanol (Visipaque), and diatrizoic acid (Gastrografin). Barium is water insoluble, whereas iodixanol and diatrizoic acid are water-soluble iodine-based agents. The detrimental effect of these agents on the lungs has not been systematically evaluated. Our aim was to evaluate and compare the effects of aspirated barium, iodixanol, and diatrizoic acid on pulmonary injury in a lagomorph model. STUDY DESIGN Animal model. METHODS Twenty adult male New Zealand White rabbits were divided into four groups (n = 5). Group 1 received 3 mL of barium sulfate injected into the trachea for 3 consecutive days. Group 2 received 3 mL of iodixanol injected into the trachea for 3 consecutive days. Group 3 received 3 mL of diatrizoic acid injected into the trachea for 3 consecutive days. A control group received 3 mL of air injected into the trachea under an identical protocol. All animals were euthanized on day 4, and the lung and trachea were harvested for blinded histopathologic analysis. The primary outcome measure was survival. The secondary endpoint was a blinded, histologic grading system of lung injury. RESULTS Two animals in the barium group, one in the diatrizoic acid group, and 0 animals in the iodixanol and control groups died. The overall lung injury score for the barium (60.60 ± 6.34) and iodixanol groups (52.30 ± 3.11) were significantly higher (worse) than the diatrizoic acid (49.60 ± 7.64) and control groups (37.80 ± 3.56) (P < .05). Diatrizoic acid produced the least amount of lung injury. CONCLUSIONS The data suggest that 3 mL of aspirated barium sulfate (E-Z Paque) over 3 consecutive days causes more severe lung injury in a lagomorph model than 3 mL of aspirated iodixanol (Visipaque) and diatrizoic acid (Gastrografin). Diatrizoic acid caused the least histologic evidence of lung injury. LEVEL OF EVIDENCE NA Laryngoscope, 127:E148-E152, 2017.
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Affiliation(s)
- M Tausif Siddiqui
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Juliana K Litts
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Diane M Cheney
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Maggie A Kuhn
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Peter C Belafsky
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
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Nativ-Zeltzer N, Logemann JA, Zecker SG, Kahrilas PJ. Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults. Neurogastroenterol Motil 2016; 28:721-31. [PMID: 26822009 PMCID: PMC4892368 DOI: 10.1111/nmo.12769] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/11/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined. METHODS Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter. KEY RESULTS Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus. CONCLUSIONS & INFERENCES Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies.
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Affiliation(s)
| | - Jeri A. Logemann
- Department of Communication Sciences and Disorders, Evanston, Illinois
| | - Steven G. Zecker
- Department of Communication Sciences and Disorders, Evanston, Illinois
| | - Peter J. Kahrilas
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, U.S.A
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Nativ-Zeltzer N, Logemann JA, Kahrilas PJ. Comparison of timing abnormalities leading to penetration versus aspiration during the oropharyngeal swallow. Laryngoscope 2013. [DOI: 10.1002/lary.24408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Jeri A. Logemann
- Department of Communication Sciences and Disorders; Evanston Illinois
| | - Peter J. Kahrilas
- Department of Medicine; Northwestern University; Feinberg School of Medicine; Chicago Illinois U.S.A
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