High-Resolution Manometry Contributions to the Physiology of Phonation

High-resolution manometry (HRM) is a motility diagnostic system that measures intraluminal pressure of the gastrointestinal tract using a series of closely spaced pressure sensors. The topographic plot generated by HRM software makes it possible to visualize phonation pressures at the pharynx, UES, and body of the esophagus in real time, indicating pressure intensity by color, which permits easy data interpretation. It has been largely used for swallowing study and dysphagia diagnosis. Due to the proximity of the pharyngoesophageal and laryngeal structures, this technology instigated voice researchers. Despite the few studies published so far, high-resolution manometry has yet proven to be an extremely useful tool in obtaining entire pharyngoesophageal segment pressure measurements during phonation. It also allows natural voice production not interfering with the mouth area. HRM data already brought light to subglottic pressure, vertical laryngeal excursion, cricopharyngeal muscle activation, air flow, muscle tension associated with vocalization and pressure variations associated with different phonatory stimuli.

La manometría de alta resolución (HRM, por sus siglas en inglés) es un sistema de diagnóstico de motilidad que mide la presión intraluminal del tracto gastrointestinal mediante una serie de sensores de presión dispuestos de manera cercana. El gráfico topográfico generado por el software de HRM permite visualizar las presiones de fonación en la faringe, el EEI y el cuerpo del esófago en tiempo real, indicando la intensidad de la presión mediante colores que facilitan la interpretación de los datos. Ha sido ampliamente utilizado para el estudio de la deglución y el diagnóstico de la disfagia. Debido a la proximidad de las estructuras faringoesofágicas y laríngeas, esta tecnología ha despertado el interés de los investigadores en voz. A pesar de los pocos estudios publicados hasta ahora, la manometría de alta resolución ha demostrado ser una herramienta extremadamente útil para obtener mediciones de presión de todo el segmento faringoesofágico durante la fonación. Además, permite la producción natural de la voz sin interferir en el área de la boca. Los datos de HRM ya han arrojado luz sobre la presión subglótica, la excursión laríngea vertical, la activación del músculo cricofaríngeo, el flujo de aire, la tensión muscular asociada con la vocalización y las variaciones de presión asociadas con diferentes estímulos fonatorios.

Anterior cervical release and posterior fixation for the treatment of irreducible atlantoaxial dislocation with retropharyngeal internal carotid artery / 中华骨科杂志

Objective:To investigate the clinical effect of anterior cervical release and posterior fixation in the treatment of irreducible atlantoaxial dislocation with retropharyngeal internal carotid artery.Methods:Thirteen patients with irreducible atlantoaxial dislocation of retropharyngeal internal carotid artery from January 2015 to July 2019 were treated with anterior cervical release and posterior fixation. There were 8 males and 5 females, aged from 34 to 65 years with an average of 46.1±12.6 years. Positive, lateral and dynamic X-ray films, MR and CTA were performed before operation. There were 4 cases with bilateral retropharyngeal internal carotid artery and 9 cases with unilateral retropharyngeal internal pharyngeal artery. The time of operation, the amount of bleeding and intraoperative and postoperative complications were recorded. The main observations were Japanese Orthopaedic Association (JOA) score, atlantodental interval (ADI), Chamberlain line (CL), and changes in the morphology of the retropharyngeal internal carotid artery and implant fusion.Results:All the operations completed successfully. The operation time was 210-260 min, the average was 245±21 min; the blood loss was 350-600 ml, the average blood loss was 490±107 ml. There was no injury of internal carotid artery, vertebral artery, spinal cord or nerve root during the operation. All patients were followed up for 9 to 24 months, with an average of 15.1±6.2 months. Preoperative JOA score was 6.9±2.3 points, 1 month after operation was 13.5±2.5 points, and the last follow-up was 14.3±2.1 points. The difference was statistically significant ( F=30.91, P<0.001). The difference between 1 month after operation and before operation was statistically significant ( P<0.001), and the improvement rate of JOA score was 75.6%±15.2%. There was no significant difference between the last follow-up and 1 month after operation ( P>0.05). The preoperative ADI was 8.9±2.2 mm, 1 month after operation was 1.1±0.8 mm, and the last follow-up was 1.2±0.9 mm. The difference was statistically significant ( F=114.69, P<0.001). The difference between 1 month after operation and before operation was statistically significant ( P<0.001), and ADI had returned to normal level. There was no significant difference between the last follow-up and 1 month after operation ( P>0.05). The preoperative CL was 11.7±4.8 mm, 1 month after operation was 1.6±2.1 mm, and the last follow-up was 1.8±2.3 mm. The difference was statistically significant ( F=34.19, P<0.001). The difference between 1 month after operation and before operation was statistically significant ( P<0.001), and the position of odontoid process returned to normal level. There was no significant difference between the last follow-up and 1 month after operation ( P>0.05). Bone graft fusion was received at 6 to 12 months after operation, with an average of 10.2 months. Conclusion:CTA examination should be performed before anterior release of atlantoaxial dislocation to understand the position and shape of internal carotid artery. Anterior cervical release combined with posterior bone graft fusion is an effective method for the treatment of irreducible atlantoaxial dislocation with retropharyngeal internal carotid artery without increasing the risk of internal carotid artery injury.

Impacto na deglutição e manejo da mucosite hipofaríngea em pacientes submetidos à quimiorradioterapia na região de cabeça e pescoço: uma revisão integrativa da literatura / Management of hypopharyngeal mucositis in patients undergoing chemoradiotherapy in the head and neck region and its impact on swallowing: an integrative literature review

RESUMO Objetivo Investigar o impacto da mucosite hipofaríngea quimiorradioinduzida na deglutição e o seu manejo, a partir de uma revisão integrativa de literatura. Estratégia de pesquisa A busca e a seleção dos artigos foram realizadas nas seguintes bases de dados: PubMed, Embase, Scopus, ScienceDirect e LILACS. Critérios de seleção Os termos de busca utilizados foram ''Pharyngeal Mucositis", ''Radiotherapy" e ''Esophagitis", com auxílio do operador booleano (AND). A equação de busca utilizada foi: ''Pharyngeal Mucositis" AND "Radiotherapy" AND "Esophagitis". A seguinte questão central orientou o estudo: "Qual a forma de avaliação e manejo da mucosite hipofaríngea induzida pela radiação na região de cabeça e pescoço e seu impacto na deglutição?". Resultados Foram identificados 75 estudos, sendo que 6 foram excluídos devido à duplicidade e 60 foram excluídos por não se encaixarem nos critérios de inclusão; os artigos restantes foram lidos na íntegra e 4 foram selecionados para fazerem parte desta revisão integrativa da literatura. Conclusão Apesar da escassa literatura e das poucas informações sobre os métodos de avaliação da mucosite hipofaríngea, os artigos apontam que, independentemente da dose de radiação, a radioterapia na região cervical causa mucosite hipofaríngea. A mucosite hipofaríngea provoca grande impacto na deglutição, resultando na necessidade de uso de via alternativa de alimentação. Além da ausência de informações quanto à avaliação e graduação da mucosite hipofaríngea, os estudos não discutem o tratamento direto ou a prevenção desse tipo de doença.

ABSTRACT Purpose To investigate the impact of chemoradiation-induced hypopharyngeal mucositis on swallowing and its management, based on an integrative literature review. Research strategy Two researchers were responsible for the search and selection of articles, within the following databases: PubMed, Embase, Scopus, Science Direct, and Lilacs. Selection criteria The search terms used were "Pharyngeal Mucositis", "Radiotherapy" and "Esophagitis", with the aid of the Boolean operator (AND). The search equation used was "Pharyngeal Mucositis" AND Radiotherapy AND Esophagitis. The following central question guided the study: "What is the assessment and management of radiation-induced hypopharyngeal mucositis in the head and neck region and its impact on swallowing?" Results 75 studies were identified, of which 6 were excluded due to duplicity and 60 were excluded for not meeting the inclusion criteria; the remaining articles were read in full and 4 were selected to be part of the integrative literature review. Conclusion Despite the scarce literature and little information on methods for evaluating hypopharyngeal mucositis, the articles point out that, regardless of the radiation dose, radiotherapy in the cervical region causes hypopharyngeal mucositis. Hypopharyngeal mucositis causes a great impact on swallowing, resulting in the need to use an alternative feeding route. In addition to the lack of information regarding the assessment and grading of hypopharyngeal mucositis, the studies do not discussitsdirect treatment or prevention.

Efecto de la expansión ósea maxilar en la vía aérea nasofaríngea: Una revisión bibliográfica / Effect of the maxillary bone expansion on the nasopharyngeal airway. A bibliographic review

Introducción: Uno de los tratamientos indicados para la deficiencia maxilar transversal es la expansión maxilar rápida (REM). El presente artículo trata sobre la terapia REM y muestra, a partir de una revisión bibliográfica, los diversos beneficios que esta puede brindar al paciente y los cambios que puede generar en su anatomía. Objetivos: Abordar el efecto de la terapia REM sobre la vía aérea nasofaríngea. También describir, en base a evidencia científica, los cambios que produce en la morfología y resistencia sobre la vía aérea faríngea. Esto mediante distintos métodos de estudios disponibles actualmente. Materiales y métodos: Se realizó una búsqueda bibliográfica en las bases de datos: PubMed, Clinicalkey y Epistemonikos. Se seleccionaron trabajos publicados en los últimos 8 años en adelante. De un universo total de 77 publicaciones, fueron seleccionados 12 estudios para esta revisión. Se excluyeron estudios en los cuales se realizaban acciones clínicas que escapan al tratamiento ortopédico. También se excluyeron tratamientos realizados para mejorar la vía aérea, basados en el tratamiento ortopédico del crecimiento mandibular. Resultados: En los estudios realizados mediante radiografías cefalométricas se obtuvo un aumento significativo (p <0.05) en el espacio de la vía aérea nasofaríngea, en particular en las medidas AD2 y AD-PtV, después del tratamiento ortodóncico. Por otro lado, AD1 también aumentó, pero no significativamente (p> 0.05). Conclusión: La terapia REM, en pacientes en crecimiento, logra separar la sutura palatina media aumentando el tamaño del piso de las fosas nasales y el volumen en el territorio nasofaríngeo. Se necesitan estudios con un tamaño de muestra mayor y un seguimiento a largo plazo para establecer el éxito de esta terapia.

Introduction: One of the treatments indicated for transverse maxillary deficiency is rapid maxillary expansion (REM). This article deals with REM therapy and shows, based on a bibliographic review, the various benefits that it can generate for the patient and the changes in their anatomy. Objectives: To elucidate the effect of REM therapy on the nasopharyngeal airway. Also expose, based on scientific evidence, the changes that it produces in the morphology and resistance on the pharyngeal airway. This through different study methods currently available. Materials and methods: A bibliographic search was carried out in the databases: PubMed, Clinicalkey and Epistemonikos. From a total universe of 77 publications, 12 studies were selected for this review. Results: In the studies carried out using cephalometric radiographs, a significant increase (p < 0.05) in the nasopharyngeal airway space was obtained, particularly in the AD2 and AD-PtV measurements, after orthodontic treatment. On the other hand, AD1 also increased, but not significantly (p > 0.05). Conclusion: REM therapy, in growing patients, manages to separate the middle palatal suture by increasing the size of the floor of the nostrils and the volume in the nasopharyngeal territory. Studies with a larger sample size and long-term follow-up are needed to establish the success of this therapy.

Pólipo Nasofaríngeo Primário: Apresentação Incomum / Primary Nasopharyngeal Polyp: Uncommon Presentation

Os pólipos inflamatórios não neoplásicos da nasofaringe são patologias raras e de consistência frágil, que normalmente são confundidos com outras lesões desta região. Entre essas, está o nasoangiofibroma, que possui consistência firme e sangra à manipulação. J.I.R.B., 17 anos, sexo masculino, estudante, com história de dor na faringe, com obstrução nasal noturna há 2 meses, associado à queixa de volume na garganta há 1 mês. À inspeção e oroscopia, encontrou-se uma volumosa lesão de aspecto polipoide, projetando-se da orofaringe. A ressonância magnética (RM) revelou lesão volumosa com componentes císticos, hiperintenso em T1 e hipointenso em T2, de aproximadamente 8,0 cm no seu maior diâmetro no corte sagital, que se estendia da nasofaringe até a orofaringe, chegando à região da epiglote. São descritos na literatura vários estudos relatando pólipos nasofaríngeos em felinos, mas apenas um estudo na literatura médica inglesa fala sobre as propriedades clínicas e histológicas dos pólipos inflamatórios primários da nasofaringe humana. Assim, o presente caso tem grande importância, principalmente pela sua raridade, local de acometimento do pólipo inflamatório benigno, bem como o tamanho da lesão. Na abordagem de massas naso e orofaríngeas em jovens e adultos, os pólipos inflamatórios primários fazem parte dos diagnósticos a serem considerados. Apesar do pequeno número de casos, as características radiológicas e patológicas dessa lesão devem ser lembradas, minimizando o risco de serem diagnosticados incorretamente.

Non-neoplastic inflammatory polyps of the nasopharynx are rare pathologies of fragile consistency, which are usually confused with other lesions of this region. Among these, the nasopharyngeal angiofibroma, which has firm consistency and bleeds to manipulation. J.I.R.B., 17 years old, male, student, with a history of pain pharynx, and nocturnal nasal obstruction for 2 months, associated with the complaint of volume in the throat for 1 month. Inspection and oroscopy, a polypoid lesion was found, protruding from the oropharynx. Magnetic resonance imaging (MRI) revealed a massive lesion with cystic, hyperintense components on T1-weighted images and hypointense at T2, approximately 8.0 cm in its largest diameter in the sagittal section, which was out of the nasopharynx to the oropharynx, reaching the epiglottis region. Several studies reporting nasopharyngeal polyps in felines have been described in the literature, but only one study in the English medical literature talks about the clinical and histological properties of the primary inflammatory polyps of the human nasopharynx. Thus, the present case is of great importance mainly, due to its rarity, site of involvement of benign inflammatory polyp, as well as the size of the lesion. In the approach of nasopharynx and oropharyngeal masses in young and adult, the primary inflammatory polyps are part of the diagnoses to be considered. Despite the small number of cases, the radiological and pathological characteristics of this lesion should be remembered, minimizing the risk of being misdiagnosed.

Cuerpo extraño faríngeo migratriz. A propósito de un caso

RESUMEN Introducción: la faringe es el sitio más común de alojamiento de cuerpos extraños dentro del área otorrinolaringológica. Usualmente su diagnóstico y extracción resultan fáciles. Sin embargo, y afortunadamente, unos pocos se encarnan profundamente y causan infecciones en el cuello, o más raro aún, logran migrar y se sitúan inmediatamente por debajo de la piel. Presentación del caso: presentamos el caso de un paciente masculino de 27 años que fue atendido durante nuestra misión en Namibia en el 2018, quien se tragó una espina de pescado, la cual se alojó inicialmente en el espacio retrofaríngeo para luego migrar hasta el tejido celular subcutáneo del cuello. Discusión: el mecanismo por el cual un cuerpo extraño migra puede estar dado por la combinación del peristaltismo del esófago y los movimientos del cuello u otros factores como la configuración lineal y afilada del cuerpo extraño, la deglución forzada de alimentos de consistencia dura inmediatamente a la impactación del cuerpo extraño y la asistencia tardía del paciente a los servicios de salud. Conclusiones: la migración de un cuerpo extraño ingerido es una rara forma de evolución. Su tratamiento depende fundamentalmente de potenciales complicaciones que podrían poner en riesgo la vida del paciente.

ABSTRACT Introduction: the pharynx is the most common site of lodging of foreign bodies within the otorhinolaryngological area. Diagnosis and removal are usually easy. Fortunately, however, a few become deeply ingrown and cause neck infections, or more rarely, manage to migrate and lie just under the skin. Case presentation: we present the case of a 27-year-old male patient who was treated during our mission in Namibia in 2018, who swallowed a fish bone, which initially lodged in the retropharyngeal space and then migrated to the cellular tissue. subcutaneous neck. Discussion: the mechanism by which a foreign body migrates may be due to the combination of peristalsis of the esophagus and movements of the neck or other factors such as the linear and sharp configuration of the foreign body, the forced swallowing of food with a hard consistency immediately after impaction of the foreign body and late attendance of the patient to health services. Conclusions: the migration of an ingested foreign body is a rare form of evolution. Its treatment fundamentally depends on potential complications that could put the patient's life at risk.

RESUMO Introdução: a faringe é o local mais comum de alojamento de corpos estranhos na área otorrinolaringológica. O diagnóstico e a remoção geralmente são fáceis. Felizmente, no entanto, alguns ficam profundamente encravados e causam infecções no pescoço ou, mais raramente, conseguem migrar e ficam logo abaixo da pele. Apresentação do caso: apresentamos o caso de um paciente do sexo masculino de 27 anos que foi atendido durante nossa missão na Namíbia em 2018, que engoliu uma espinha de peixe, que inicialmente se alojou no espaço retrofaríngeo e depois migrou para o tecido celular. Discussão: o mecanismo pelo qual um corpo estranho migra pode ser devido à combinação de peristaltismo do esôfago e movimentos do pescoço ou outros fatores como a configuração linear e aguda do corpo estranho, a deglutição forçada de alimentos de consistência dura imediatamente após a impactação do corpo estranho e comparecimento tardio do paciente aos serviços de saúde. Conclusões: a migração de um corpo estranho ingerido é uma forma rara de evolução. Seu tratamento depende fundamentalmente de potenciais complicações que podem colocar em risco a vida do paciente.

Estenosis nasofaríngea: a propósito de la leishmania mucocutánea / Nasopharyngeal stenosis: about mucocutaneous leishmania

La leishmaniasis es una enfermedad protozoaria intracelular. Una de sus formas de presentación es la mucocutánea, que es secuela de la leishmania cutánea y solo se presenta en el 1 % al 5 % de quienes la padecen. Afecta la mucosa nasal, faríngea y laríngea, lo que ocasiona disnea y disfagia. Se presenta el caso de una paciente de 76 años con síntomas obstructivos nasales, en quien se evidenciaron múltiples sinequias nasales y faringolaríngeas. Ante la sospecha clínica de la enfermedad, es importante recordar que el diagnóstico se realiza a través de la intradermorreacción de Montenegro o títulos de inmunofluorescencia indirecta superiores a 1:16, y su tratamiento incluye el antimonio pentavalente, uno de los más utilizados; sin embargo, este tiene alto grado de recurrencias y efectos secundarios, por lo que la anfotericina B se convierte en el tratamiento de elección. En algunos casos, el manejo quirúrgico puede ser de gran utilidad para la mejoría de síntomas y secuelas de la enfermedad. Entonces, la leishmania mucocutánea se convierte en una enfermedad de interés para los otorrinolaringólogos, quienes con el conocimiento de la historia natural de la misma pueden realizar un manejo temprano y la adecuada corrección de secuelas para mejorar la calidad de vida de los pacientes.

Leishmaniasis is an intracellular protozoan disease. One of its forms of presentation is mucocutaneous, which is sequela of cutaneous leishmania and only occurs in 1% to 5% of those who suffer it. It affects the nasal, pharyngeal and laryngeal mucosa, causing dyspnea and dysphagia. We presented a case of a 76-year-old patient with obstructive nasal symptoms, who evidenced multiple nasal and pharyngolaryngeal synechiae. Given the clinical suspicion of the disease, it is important to remember that the diagnosis is made through the Montenegro intradermal reaction and or indirect immunofluorescence titers greater than 1:16, and the treatment includes pentavalent antimonial, one of the most used; however, it has a high degree of recurrence and side effects, so amphotericin B becomes the treatment of choice. In some cases, surgical management can be very useful for the improvement of symptoms caused by the disease. Thus, mucocutaneous leishmania becomes a disease of interest for otorhinolaryngologists, who, with knowledge of its natural history, can carry out early management and adequate correction of sequelae to improve the patients' quality of life.

Apneia Obstrutiva do Sono: caracterização do sítio obstrutivo e tipo de colapso / Obstructive Sleep Apnea: characterization of the obstructive site and type of collapse

RESUMO A Apneia Obstrutiva do Sono caracteriza-se por episódios recorrentes de colapso parcial ou completo da faringe, seguidos de diminuição da saturação de oxihemoglobina e despertares frequentes. É considerada problema de saúde pública com importantes sintomas noturnos e diurnos, impactando qualidade de vida. Seus efeitos associam-se as áreas de competência da Fonoaudiologia. Para estabelecer diagnóstico e métodos de tratamento eficientes, profissionais devem conhecer a patogênese da obstrução da via aérea superior durante o sono. Visando contribuir para a compreensão da fisiopatologia da apneia obstrutiva do sono, elegibilidade de procedimentos terapêuticos individualizados e direcionamento para terapêutica miofuncional orofacial, o presente estudo tem como objetivo descrever e ilustrar os locais e tipos de colapso da via aérea superior durante o sono. Após processos éticos, foram analisados registros originais das sonoendoscopias de uma série de casos com diagnóstico polissonográfico de apneia obstrutiva do sono. As imagens das gravações dos exames foram analisadas por cinco profissionais com expertise na área do sono. Os locais obstrutivos e tipos de colapso foram apresentados conforme classificação vigente. Os vídeos foram divididos em capturas de tela, originando figuras de cada sítio anatômico: sem colapso e com colapso. Os resultados foram apresentados por imagens dos casos, que ilustram cada colapso, predominando colapso velofaríngeo: anteroposterior, lateral ou concêntrico; seguido por colapso orofaríngeo lateral; colapso anteroposterior na hipofaringe e colapso anteroposterior da epiglote. O entendimento dos locais de obstrução e tipos de colapso ilustrados nesse estudo pode ser um preditor de respostas terapêuticas, auxiliando a compreensão das limitações ou direcionando propostas para cada paciente.

ABSTRACT Obstructive Sleep Apnea is characterized by recurrent episodes of partial or complete collapse of the pharynx, followed by decreased oxyhemoglobin saturation and frequent arousals. It is regarded as a public health issue with important night and day symptoms that impact life quality. Its effects are associated with the areas of competence of Speech and Language Pathologists. To establish efficient diagnosis and treatment methods, professionals must know the pathogenesis of upper airway obstruction during sleep. This study seeks to enlarge the understanding of obstructive sleep apnea pathophysiology, eligibility of individualized therapeutic procedures and guidance for orofacial myofunctional therapy by describing and illustrating the locations and types of upper airway collapse during sleep. We analyzed original records of Drug Induced Sleep Endoscopy exams of a series of cases with polysomnographic diagnosis of obstructive sleep apnea following the proper ethical processes. The images of the exam recordings were analyzed by five professionals with expertise in the sleep area. Obstructive sites and types of collapse were presented according to the current classification. The videos were divided into screenshots, originating figures from each anatomical site: without collapse and collapsed. The results are visualized in the images of the cases showing a predominance of velopharyngeal collapse: anteroposterior, lateral, or concentric; oropharyngeal lateral collapse; tongue anteroposterior collapse and anteroposterior collapse of the epiglottis. Understanding the obstruction sites and types of collapse illustrated in this study may help to predict therapeutic responses and learn the limitations or direct individual proposals patient.

Preescolar con divertículo de Zenker y hallazgo intraoperatorio de cuerpo extraño esofágico / Preschool-age child with Zenker's diverticulum and intraoperative finding of an esophageal foreign body

Introducción. El divertículo de Zenker es una evaginación sacular ciega que puede presentarse a nivel faringoesofágico. No se conoce exactamente su incidencia en la edad pediátrica, constituyendo una patología muy infrecuente. La sintomatología es inespecífica, lo que dificulta el diagnóstico precoz y determina un mayor riesgo de complicaciones asociadas. Caso clínico. Paciente preescolar femenina con cuadro recurrente de emesis con deshidratación, posteriormente asociado a disfagia, a quien se le diagnosticó un divertículo de Zenker. Se realizó tratamiento quirúrgico con hallazgo intraoperatorio de dilatación esofágica, un área de estenosis secundaria al hallazgo incidental de un cuerpo extraño y divertículo de Zenker en la región lateral del esófago dilatado. Discusión. Esta patología es extremadamente rara, pero se debe tener en cuenta dentro de los diagnósticos diferenciales en pacientes con sintomatología faringo-esofágica. Conclusión. Se presenta una preescolar sin antecedente de procedimientos esofágicos o malformaciones congénitas asociadas con diagnóstico de un divertículo de Zenker y dilatación esofágica por un cuerpo extraño, tratada quirúrgicamente de forma exitosa.

Introduction. Zenker's diverticulum is a blind saccular evagination that can present at the pharyngoesophageal level. Its incidence in pediatric age is not exactly known, constituting a very infrequent pathology. The symptoms are nonspecific, which makes early diagnosis difficult and determines a higher risk of associated complications.Clinical case. Female preschool patient with recurrent dehydration due to emesis, later associated with dysphagia, who was diagnosed with Zenker's diverticulum. Surgical treatment was performed with intraoperative finding of esophageal dilation, an area of stenosis secondary to the incidental finding of a foreign body, and a Zenker's diverticulum in the lateral region of the dilated esophagus. Discussion. This pathology is extremely rare, but it should be taken into account within the differential diagnoses in patients with pharyngo-esophageal symptoms. Conclusion: We present a preschool female patient with no history of esophageal procedures or congenital malformations associated with a diagnosis of Zenker's diverticulum and esophageal dilation due to a foreign body, successfully treated surgically.

Respostas pressóricas faringeana, esofágica e do esfíncter esofagiano a tarefas vocais à luz da manometria de alta resolução / Pharyngeal, upper esophageal sphincteric and esophageal pressures responses related to vocal tasks at the light of high resolution manometry

ABSTRACT BACKGROUND: High-resolution manometry (HRM) represents a potential tool for measuring pharyngoesophageal phonation pressures. OBJECTIVE: This study aims to evaluate pharyngeal, esophageal upper sphincteric and esophageal pressures during different phonation tasks. METHODS: 12 (six males, mean age 27 years) professional singers underwent HRM and produced four different vocal tasks at low, medium and high vocal loudness: vowel /ae/, ascending five note scale, word /hey/ and word /go/. Pressures were measured at pharynx, upper esophageal sphincter (UES) and esophagus. Visual analysis of the HRM topographic plots were performed. RESULTS: Esophageal pressures are higher during vocalization than at rest. Pharyngeal and UES phonation pressures does not differ significantly from rest pressures. Visual analysis of the topographic plots showed an important UES pressure increasement during phonation. CONCLUSION: HRM is a valuable tool for measuring pharyngoesophageal pressures during phonation. Esophageal pressures are higher during phonation than at rest and tend to increase with vocal loudness increment. The topographic plot provides additional data about phonatory mechanism physiology, especially at the UES region.

RESUMO CONTEXTO: A manometria de alta resolução (MAR) é uma ferramenta de grande potencial para mensuração das pressões faringoesofágicas durante a fonação. OBJETIVO: O estudo visa avaliar pressões faringianas, do esfíncter esofagiano superior e do esôfago durante manobras fonatórias. MÉTODOS: Doze (seis homens, idade média 27 anos) cantores profissionais foram submetidos à MAR e produziram quatro tarefas vocais em intensidade baixa, média e alta: vogal / ae /, escala ascendente de cinco notas, palavras /hey/ e /go/. Pressões aos níveis da faringe, esfíncter esofagiano superior e esôfago foram aferidas além de análise visual dos traçados. RESULTADOS: Pressões esofágicas foram maiores na vocalização que no repouso. Pressões da faringe e esfíncter esofagiano superior durante a fonação não foram diferentes que no repouso. Análise visual dos traçados mostrou importante incremento da pressão do esfíncter durante a fonação. CONCLUSÃO: MAR é uma ferramenta valiosa para mensurar as pressões faringoesofágicas durante a fonação. Pressões esofágicas são maiores durante a fonação que no repouso e tendem a aumentar com maior intensidade sonora. Análise visual dos traçados mostram dados adicionais sobre a fisiologia do mecanismo da fonação, especialmente na região do esfíncter esofagiano superior.

Horse choanae are directionally asymmetric / Las coanas de los caballos son direccionalmente asimétricas

SUMMARY: Studies related to the upper respiratory pathway asymmetries are still scarce in the veterinary literature. We present here a study of choanae asymmetries of a pure horses belonging to "Cavall Pirinenc Català" (Pyrenean Horse Breed). For this goal, the palates of 23 dry skulls with no apparent pathologies were photographed and evaluated using geometric morphometrics. On each photo, we identified and digitized a total of 26 points (subset of 2 mid-sagittal, 4 paired landmarks (discrete homologous points) and 10 semilandmarks (points on an outline determined by extrinsic criteria) per side on the choana. Both fluctuating and directional asymmetries appeared statistically significant, the latter accounting more than half of the total variation. The lateral bend observed in horse choanae may be due to the asymmetrically positioned nasal passages. So detected equine choana asymmetry must rather be considered functional, with no clinical implication and presents an important consideration when equine choanae shape.

RESUMEN: Los estudios relacionados con las asimetrías de las vías respiratorias superiores aún son escasos en la literatura veterinaria. Presentamos un estudio de coanas asimetrías de un caballo puro perteneciente al "Cavall Pirinenc Català" (Raza del Caballo de los Pirineos). Para ello, se fotografiaron y evaluaron los paladares de 23 cráneos secos sin patologías aparentes mediante morfometría geométrica. En cada foto, identificamos y digitalizamos un total de 26 puntos (subconjunto de 2 puntos medio sagitales, 4 puntos de referencia emparejados (puntos homólogos discretos) y 10 puntos semillanos (puntos en un contorno determinado por criterios extrínsecos) por lado de la coana. Ambos fluctúan Las asimetrías direccionales aparecieron estadísticamente significativas, representando estas últimas más de la mitad de la variación total. La curvatura lateral observada en las coanas de caballo puede deberse a los conductos nasales asimétricamente posicionados. Por lo tanto, la asimetría de coanas equinas detectada debería considerarse funcional, sin implicación clínica y presenta una importante consideración cuando se forman coanas equinas.

Adequate Number of Swallows for Pharyngeal Pressure Measurement of a Subject using High-resolution Manometry

Abstract Introduction The number of pressure measurements that need to be recorded using high-resolution manometry (HRM) for the accurate evaluation of pharyngeal function is not well established. Objective The purpose of this study is to clarify the number of swallows required to obtain an accurate pharyngeal manometric profile of a person. Methods Forty healthy adults performed a dry swallow and bolus swallows using 3-, 5-, or 10 ml of water and underwent measurements using the Starlet HRM system. Each subject underwent 10 swallows for each of the four bolus volume conditions. Results The mean of up to seven measurements of maximum pre-swallow upper esophageal sphincter pressure with 10 ml of swallow was close to the mean of up to eight measurements in 95% of the subjects. Similarly, the rate of change of the average for the eighth and ninth measurements and the rate of change for the average of the ninth and tenth measurements were less than 5 %. When the other parameters were similarly measured up to the sixth measurement, no major change in the average value was observed even if more measurements were taken. Conclusion A minimum of six measurements are required, and seven swallows are sufficient for evaluating the pharyngeal manometric profile of a single person. This number of measurements can be a useful criterion when performing HRM measurements on individual subjects.

Head and neck injuries after leopard attack: Presentation and management / 中华创伤杂志(英文版)

Leopard attacks on humans are reported most often from the Indian subcontinent. The bite wounds are complex injuries infected with polymicrobial inoculum and may present as punctures, abrasions, lacerations or avulsions. The presentation and acceptable treatment of these injuries vary according to the wound. We hereby describe the clinical presentation and treatment of a male victim with leopard bite injuries on the head and neck region. As bite injuries are commonly found on and around the face, maxillofacial surgeons should be familiar with the therapy. Through thorough clinical and radiological examination, it is essential to prevent missing any hidden injuries, which can easily turn lethal. To benefit the rural population, more health facilities need to be established in remote areas.

Brazilian manuscripts published in the Dysphagia journal / Trabalhos brasileiros publicados na revista Dysphagia

ABSTRACT Objective: to survey the Brazilian participation in original and review articles published in the Dysphagia journal. Methods: original and review articles in volumes 1 to 35, quantifying all those developed in Brazil, the diseases researched, the places where the investigations were conducted, and the number of citations they received, were analyzed. The categorical variables are presented in relative and absolute frequencies. Literature Review: a total of 35 Brazilian manuscripts were published. The most researched disease was Parkinson's, followed by Chagas disease, stroke, and the physiology of swallowing. The highest number of publications was carried out at the Universidade de São Paulo, campus at Ribeirão Preto, SP, and the Universidade Federal de São Paulo, capital city. Between 2001 and 2010, 14 manuscripts were published (3.7% of the journal), and between 2011 and 2020, 20 were published (2.9% of the journal). By 2019, the manuscripts had received 481 citations - 17 citations per article between 1998 and 2009, and 14, between 2010 and 2019. Conclusion: Brazilian manuscripts are regularly published in the Dysphagia journal and have a scientific impact. However, there has not been a progressive increase in the number of published articles.

RESUMO Objetivo: avaliar a participação brasileira em publicações de artigos originais e de revisão na revista Dysphagia. Métodos: foram analisados artigos originais e de revisão do volume 1 ao 35, com quantificação do total de artigos provenientes do Brasil, as doenças pesquisadas, o local onde a pesquisa foi realizada e o número de citações. As variáveis categóricas foram descritas como frequências relativas ou absolutas. Revisão da Literatura: foram publicados 35 trabalhos provenientes do Brasil. Doença de Parkinson foi a doença mais pesquisada, seguida da doença de Chagas, acidente vascular cerebral e fisiologia da deglutição. Universidade de São Paulo, campus de Ribeirão Preto (SP) e a Universidade Federal de São Paulo (SP) foram os locais com maior número de publicações. Entre 2001 e 2010, foram publicados 14 trabalhos (3,7% dos publicados na revista), e de 2011 a 2020 foram 20 (2,9% dos publicados na revista). Até 2019 os trabalhos tiveram 481 citações, sendo 17 citações por artigo entre 1998 e 2009, e 14 citações por artigo entre 2010 e 2019. Conclusão: as publicações de trabalhos brasileiros na revista Dysphagia têm regularidade e impacto, entretanto não houve aumento progressivo no número de artigos publicados.

The effects of pharyngeal pressure feedback training on pharynx constriction caused by brainstem lesions / 中华物理医学与康复杂志

Objective:To explore the effect of the pharyngeal pressure feedback training on pharyngeal constriction in persons with swallowing disorders caused by brainstem lesions.Methods:Twenty patients with disordered swallowing caused by a brainstem lesion were randomly divided into a control group and an intervention group, each of 10. Both groups received routine swallowing training including oral sensorimotor training, neuromuscular stimulation and balloon catheter dilation, while the intervention group was additionally provided with two weeks of pharyngeal pressure feedback training. Before and after the treatment, both groups were evaluated in terms of the peak pressure of superior and inferior pharyngeal constriction, endoscopically and also using the functional oral intake scale.Results:There was no significant difference between the two groups in any measure before the intervention. Afterward, both groups had improved significantly by all of the measurements, but the average peak upper pharyngeal pressure, the average intake scale score and the endoscopy results of the intervention group were all significantly better than the control group′s averages.Conclusions:Pharyngeal pressure feedback training can significantly relieve swallowing disorders caused by brainstem lesions.

Pharyngeal tuberculosis. Concerning a case in Peru / Tuberculosis faríngea. A propósito de un caso en Perú

Abstract Pharyngeal tuberculosis is an extrapulmonary form of this disease which makes up less than 1% of cases, most of which are secondary. In Peru, there are no case reports of this form of extra-pulmonary tuberculosis. We present the case of a 42-year-old man who consulted due to a two-month history of sore throat and a pharyngeal lump, with no epidemiological or medical history. A biopsy of the lesion and Ziehl-Neelsen staining yielded results compatible with pharyngeal tuberculosis. A chest x-ray showed bilateral miliary lesions, confirming a secondary form of disseminated tuberculosis. This highlights the importance of ruling out tuberculosis in all cases of chronic pharyngitis which are unresponsive to conventional treatment.

Resumen La tuberculosis faríngea es una forma extrapulmonar de esta enfermedad que corresponde a menos de 1% de casos, mayormente de carácter secundario. En Perú, no hay datos de reportes de casos en esta forma de tuberculosis extrapulmonar. Presentamos el caso de un varón de cuarenta y dos años que consultó por dolor de garganta y tumoración en faringe de dos meses de evolución, sin antecedentes epidemiológico o patológico. Se realiza biopsia de la lesión y coloración Ziehl Neelsen dando compatible a tuberculosis faríngea. En la radiografía de tórax se encontró lesiones pulmonares diseminadas bilaterales de tipo miliar, confirmando forma secundaria a tuberculosis diseminada. Por ello, se resalta la importancia de descartar tuberculosis ante toda faringitis crónica sin respuesta al tratamiento convencional.

Avaliação do volume das vias aéreas superiores conforme o padrão facial / Upperairway volume assessment accordingto facial pattern

Objetivo: analisar o volume da via aérea superior (VAS) em pacientes adultos saudáveis, a partir de exames de tomografia computadorizada de feixe cônico, comparando os padrões faciais esqueléticos I, II e III, considerando a idade e o sexo. Método: um estudo retrospectivo de análise do banco de dados de uma clínica radiológica, com uma amostra de 129 exames de face total em formato DICOM, datados de 2015 a 2018. Após a divisão da amostra em três grupos, conforme o padrão esquelético, as medidas volumétricas foram obtidas através do aplicativo ITK-SNAP versão 3.6.0, um processador gratuito de segmentação anatômica 3D. Resultados: a amostra foi separada em padrão I com 60 exames, padrão II com 48 exames e padrão III com 21 exames. O sexo feminino foi o mais frequente, com 69,8% (n = 90), e a média de idade foi definida em 35 anos. O volume médio geral foi de 22.774,2 mm³ e a média entre os padrões esqueléticos não apresentou diferença significante (p = 0,251), segundo o teste não paramétrico de Kruskal-Wallis (p < 0,05). Na análise do dimorfismo sexual, os homens apresentaram maior volume, com diferença estatística (p = 0,033) através do teste de Mann-Whitney. Conclusão: o volume médio da VAS entre indivíduos saudáveis com padrões faciais I, II e III não apresentou diferença significativa, apenas uma discreta variação, sendo o padrão III maior em 14,8% do que o padrão I. O sexo masculino se destacou com maior volume, e a variação da idade não teve correlação com o volume do espaço aéreo faríngeo.(AU)

Aims: Analyze upper airway volume in healthy adult patients from CBCT examinations, comparing skeletal facial patterns I, II and III, considering age and gender. Methods: A retrospective study of a radiological clinic database analysis, with a sample of 129 full-face DICOM exams, dated between 2015 and 2018. After dividing the sample into three groups, according to skeletal pattern, volumetric measurements were obtained through the application ITK-SNAP version 3.6.0, a free 3D anatomical segmentation process. Results: The sample was separated into pattern I with 60 exams, pattern II with 48 and pattern III with 21 exams. Females were the most frequent with 69.8% (n = 90) and the mean age was defined as 35 years. The overall mean volume was 22,774.2 mm³ and the mean between skeletal patterns showed no significant difference (p = 0,251), according to the nonparametric Kruskal-Wallis test (p < 0,05). In the analysis of sexual dimorphism, men presented higher volume, with statistical difference (p = 0,033) through the Mann-Whitney test. Conclusion: The mean upper airway volume among healthy individuals with facial patterns I, II and III showed no significant difference, only a slight variation, pattern III being 14.8% higher than pattern I. The male gender stood out with greater volume and the age variation had no correlation with the pharyngeal space volume.(AU)

Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome

Abstract Introduction Obstructive sleep apnea syndrome (OSAS) is a multifactorial disease characterized by episodes of partial or complete collapse during sleep of different regions of the upper airway. Surgery for OSAS evolved with the introduction of different techniques, considering new surgical concept of reconstruction of the upper airway. Objective To retrospectively evaluate the effectiveness of a new approach aimed at reducing pharyngeal collapse by combining two surgical techniques: lateral and expansion pharyngoplasty. Methods We reviewed the medical records of 38 patients with OSAS undergoing lateral/expansion pharyngoplasty from January 2012 to December 2016. The following data were collected: patient age, gender, and pre- and postoperative body mass index (BMI), Epworth sleepiness scale (ESS) scores, snoring visual analogue scale (VAS) scores, and polysomnography (PSG) results. Results The PSG results showed a significant reduction in the apnea/hypopnea index (AHI) from 22.4 ± 27.3 events/h preoperatively to 13.6 ± 17.9 events/h postoperatively (p = 0.009), with postoperative AHI reduction greater than 50% in 63.2% of the patients. There was also a significant reduction in the microarousal index (19.5 ± 22.6 vs 11.0 ± 13.4 events/h; p = 0.001) and in the minimum oxygen saturation (82.6 ± 10.3 vs 86.9 ± 11.1; p = 0.007). Conclusions Lateral-expansion pharyngoplasty represents a new surgical strategy for the treatment of OSAS in patients with palatal collapse by combining two different techniques: lateral and expansion pharyngoplasty. The two techniques, performed as a one-stage procedure, led to improvements in excessive daytime sleepiness, snoring, and PSG respiratory parameters by acting on lateral and retropalatal collapse, produc- ing favorable results with good applicability in otolaryngology clinical practice.

Effect of laryngeal mask and endotracheal tube ventilation on gastric insufflation during general anesthesia with ultrasound evaluation / 上海交通大学学报（医学版）

Objective • To observe the correlation between streamlined liner of pharynx airway (SLIPA) and gastric insufflation. Methods • Seventy patients who underwent elective general anesthesia in Jiading District Central Hospital Affiliated to Shanghai University of Medicine & Health Sciences from September 2017 to May 2018 were included. They were randomly divided into SLIPA group (S group, n=35) and endotracheal tube group (T group, n=35). The gastric antrum ultrasonography was performed at four time points before induction, immediately after intubation (insertion of laryngeal mask), before extubation (laryngeal mask), and immediately after extubation (laryngeal mask), to measure the cross sectional area (CSA) of gastric insufflation. Gastric intake was assessed by ultrasonic measurement of CSA and "comet tail sign" in ultrasound imaging. Pulse oxygen saturation (SpO2), end-tidal pressure of carbon dioxide (PETCO2), peak inspiratory pressure (PIP) and CSA were recorded and compared at the corresponding time points. Results • There was no significant difference in gastric insufflation rate between the two groups during anesthesia (P=0.894). There was no significant difference in SpO2 at each time point between the two groups (all P>0.05). At the end of surgery, PETCO2 in group S was significantly higher than that in group T (P=0.000). Conclusion • Compared with endotracheal tube, the SLIPA does not increase gastric insufflation during general anesthesia.

Analysis of the middle region of the pharynx in adolescents with different anteroposterior craniofacial skeletal patterns

ABSTRACT Objective: To assess the volume and morphology of the middle region of the pharynx (MRP) in adolescents with different anteroposterior craniofacial skeletal patterns. Methods: One hundred twenty-six patients (56 male and 70 female), who had cone-beam computed tomography (CBCT) within their records, were selected for this cross-sectional study. Participants were classified, according to their ANB angle value, in Class I (1o ≤ ANB ≤ 3o), Class II (ANB > 3o) and Class III (ANB < 1o). The total volume (tV), minimum axial area (AxMin) and morphology of the MRP and its subdivisions - velopharynx (VP) and oropharynx (OP) - were characterized by CBCT and 3-dimensional image reconstruction software. Intergroup comparisons were performed by ANOVA and Tukey post-hoc tests. Correlations between tV and Axmin with the ANB angle values were tested using linear regression analysis, considering sex as covariable. Results: Statistically significant difference between groups were observed in tV only for the VP region; Class II individuals presented significantly lower tV (6863.75 ± 2627.20 mm3) than Class III subjects (9011.62 ± 3442.56 mm3) (p< 0.05). No significant differences were observed between groups for any other variable assessed, neither in MRP nor in the OP region (p> 0.05). A significant negative correlation was evidenced between tV and Axmin and the ANB angle values; sexual dimorphism was observed for some variables. Conclusions: Class II subjects have smaller tV in the VP region. tV and Axmin tend to decrease in all evaluated regions when the ANB angle values increase.

RESUMO Objetivo: avaliar o volume e a morfologia da porção média da faringe (PMF) em adolescentes com diferentes padrões esqueléticos no sentido anteroposterior. Método: para esse estudo transversal, foram selecionados cento e vinte e seis pacientes (56 homens e 70 mulheres) que tinham tomografia computadorizada de feixe cônico (TCFC) em seus registros. Os participantes foram classificados de acordo com o valor do ângulo ANB, em Classe I (1o ≥ ANB ≤ 3o), Classe II (ANB > 3o) e Classe III (ANB < 1o). O volume total (Vt), a área axial mínima (AxMin) e a morfologia da PMF e de suas subdivisões - velofaringe (VF) e orofaringe (OF) - foram avaliados na TCFC e em software de reconstrução tridimensional (3D) de imagens. As comparações intergrupos foram realizadas por meio dos testes ANOVA e post-hoc de Tukey. As correlações entre os valores de Vt e Axmin das vias aéreas com os valores do ângulo ANB foram testadas por meio de análise de regressão linear, considerando-se o sexo como uma covariável. Resultados: diferença estatisticamente significativa entre os grupos foi observada apenas no Vt da VF; indivíduos Classe II apresentaram Vt significativamente menor (6.863,75 ± 2.627,20 mm3) do que indivíduos Classe III (9.011,62 ± 3.442,56 mm3) (p< 0,05). Não foram observadas diferenças significativas entre os grupos em nenhuma outra variável avaliada, nem na PMF, nem na OF (p> 0,05). Foi evidenciada uma correlação negativa significativa entre Vt e Axmin e os valores do ângulo ANB; dimorfismo sexual foi observado para algumas variáveis. Conclusões: indivíduos Classe II apresentam o menor Vt da VF. O Vt e a Axmin tenderam a diminuir quando os valores do ângulo ANB aumentaram, em todas as regiões avaliadas.