Circumferential tracheal replacement with silicone stent supported, cryopreserved aortic homograft.

Treatment of long-segment tracheal defects remains a challenge in thoracic surgery with no standard surgical option. Aortic allografts have been used for this purpose with varying degrees of success. In a patient that suffered anastomotic dehiscence after tracheal resection with primary anastomosis, we performed complete tracheal resection and replacement using a stented circumferential aortic allograft. Currently, this patient is able to breathe normally without tracheostomy assistance 22 months postoperatively. Our report is the first in the English literature of long-term survival without tracheostomy dependence and close interval follow-up after circumferential tracheal resection and replacement with a cryopreserved aortic allograft.

Partners of persons with severe swallowing dysfunction have significantly reduced mental health.

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.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients.

OBJECTIVE: To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx. METHODS: Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible. RESULTS: The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus. CONCLUSION: Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

The American Broncho-Esophagological Association Position Statement on Swallowing Fluoroscopy.

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.

Upper Instrumented Vertebrae, Number of Levels Fused, and Plate Morphology Do Not Affect Severity of Chronic Dysphagia After Anterior Cervical Spine Surgery.

BACKGROUND: Disordered swallowing, or dysphagia, is the most common complication after anterior cervical spine (ACS) surgery. Many operative factors are associated with development of dysphagia. The aim of this study was to explore how number of levels instrumented, specific levels fused, and plate morphology affect chronic dysphagia after ACS surgery. METHODS: Consecutive patients referred to a tertiary center for otolaryngology evaluation for chronic dysphagia after ACS surgery between 2012 and 2017 were enrolled. Basic demographic data were obtained. Plain radiographs were reviewed for number of levels fused, upper instrumented vertebrae, and plate morphology. Plate morphology was categorized as a closed, small window, large window, or no profile plate. The 10-item Eating Assessment Tool (EAT-10) was used to assess dysphagia severity. RESULTS: Of 171 patients referred for dysphagia, 126 met inclusion criteria; 54% were female, with a mean age of 63 years (range, 32-88 years). Mean EAT-10 score was 18.5 ± 10.1. Mean time from spine surgery to videofluoroscopic swallow study for dysphagia was 58.3 months. Mean number of levels fused was 2.2 ± 0.9. There were no significant differences in EAT-10 scores in single-level versus multilevel fusion (19.0 vs. 18.4, P = 0.76) as well as with regard to upper instrumented vertebrae or plate morphology. CONCLUSIONS: In this series of patients with chronic dysphagia following ACS surgery, the severity of dysphagia as measured by the EAT-10 was not affected by upper instrumented vertebrae, number of levels fused, or plate morphology.

Best Practices in Treatment of Laryngopharyngeal Reflux Disease: A Multidisciplinary Modified Delphi Study.

BACKGROUND: Laryngopharyngeal reflux (LPR) is a common otolaryngologic diagnosis. Treatment of presumed LPR remains challenging, and limited frameworks exist to guide treatment. METHODS: Using RAND/University of California, Los Angeles (UCLA) Appropriateness Methods, a modified Delphi approach identified consensus statements to guide LPR treatment. Experts independently and blindly scored proposed statements on importance, scientific acceptability, usability, and feasibility in a four-round iterative process. Accepted measures reached scores with ≥ 80% agreement in the 7-9 range (on a 9-point Likert scale) across all four categories. RESULTS: Fifteen experts rated 36 proposed initial statements. In round one, 10 (27.8%) statements were rated as valid. In round two, 8 statements were modified based on panel suggestions, and experts subsequently rated 5 of these statements as valid. Round three's discussion refined statements not yet accepted, and in round four, additional voting identified 2 additional statements as valid. In total, 17 (47.2%) best practice statements reached consensus, touching on topics as varied as role of empiric treatment, medication use, lifestyle modifications, and indications for laryngoscopy. CONCLUSION: Using a well-tested methodology, best practice statements in the treatment of LPR were identified. The statements serve to guide physicians on LPR treatment considerations.

Does Medialization Improve Swallowing Function in Patients with Unilateral Vocal Fold Paralysis? A Systematic Review.

Glottal incompetence caused by unilateral vocal fold paralysis (UVFP) is a common cause of dysphagia and aspiration. Treatments targeted at reducing glottal incompetence by injection augmentation or medialization thyroplasty are well established at improving voice outcomes, but improvements in swallowing function are less clear. The objective of this systematic review was to determine the impact of vocal fold medialization on dysphagia outcomes. Six electronic bibliographic databases and one clinical trial registry were searched on 3/13/2020. Our patient population were adult patients with verified UVFP that underwent vocal fold medialization. We limited review to prospective studies that had formal dysphagia assessment both before and after medialization. Nine studies met selection criteria (7 prospective case series and 2 prospective cohort studies) totaling 157 patients. The most common etiology of UVFP was iatrogenic (74/157; 47%). The majority of patients underwent injection augmentation (92/157; 59%), and the remaining underwent medialization thyroplasty. A variety of methods were used to assess changes in dysphagia including patient-reported outcome measures, flexible endoscopic evaluation of swallowing, videofluoroscopic swallow study, and high-resolution manometry. 7/9 studies demonstrated clinically significant improvement in swallowing function following medialization; 4/9 studies demonstrated statistically significant improvement, and three studies did not show statistically significant improvement after intervention. Study participants and outcome measures evaluating swallowing function in this review were heterogeneous. Moreover, the reviewed studies are concerning for multiple risks of bias impacting their conclusions. Taken together, this systematic review demonstrates limited evidence that injection augmentation and medialization thyroplasty improve swallowing function and/or safety.

Impact of human immunodeficiency virus status on laryngeal cancer survival and locoregional control.

OBJECTIVES: To compare long-term outcomes of laryngeal cancer (LC) in people living with HIV (PLWH) versus uninfected individuals and determine how clinical and viral factors-such as demographics, cancer stage, HIV viral load, and CD4 nadir-contribute to these outcomes. METHODS: This was a retrospective case-control study of 749 patients seen for LC at a single tertiary care center between 2003 and 2017. Of these, 22 had HIV at the time of LC diagnosis, and they were matched in a 1:4 ratio to uninfected controls based on sex, presence of smoking history, and age at cancer diagnosis. Kaplan-Meier survival curves and Cox proportional hazards models were constructed to identify overall and disease-free survival differences based on HIV status, as well as other clinical and viral factors. RESULTS: Compared to all uninfected individuals, PLWH were diagnosed with LC approximately 6 years younger (p = .013). 1-, 2-, and 5-year overall survival for PLWH were 86.4% (63.4%-95.4%), 77.3% (53.7%-89.9%), and 65.8% (40.8%-82.2%), respectively following LC diagnosis, and HIV was not significantly associated with overall (HR = 3.34 [0.59-18.79]) or disease-free survival (HR = 2.12 [0.71-6.36]). The incidence rate of locoregional recurrence among PLWH was 541 compared to 371 per 10,000 person-years in controls, which were not significantly different (p = .420). Furthermore, among PLWH, peak viral load and CD4 nadir were not associated with overall or disease-free survival. CONCLUSION: While previous work has shown that HIV is associated with elevated risk of LC, survival did not differ significantly between PLWH and uninfected individuals in this study. LEVEL OF EVIDENCE: 3.

Zenker's Diverticulum: Readability and Quality of Online Written Education Materials.

To assess the readability and quality of online materials for Zenker's diverticulum. A Google search of "Zenker's diverticulum" was performed and the first 50 websites were reviewed. Readability was measured by Flesch Reading Ease (FRES), Flesch-Kincaid Grade Level (FKGL) and the Simple Measure of Gobbledygook (SMOG) scores using an online calculator. Understandability and actionability were assessed with the Patient Education Materials Assessment Tool for Printed Materials (PEMAT-P). Websites were categorized as either patient-targeted or physician-targeted and unpaired t tests were used to compare scores between these two groups. A total of 31 websites (23 patient-oriented sites and 8 physician-oriented sites) were analyzed. The average FRES, FKGL, and SMOG scores were 29.96 ± 14.72, 13.75 ± 2.78, and 12.19 ± 2.02, respectively, for the entire cohort. Readability scores for the patient-oriented sites were better than the physician-oriented sites for each measure (FRES 36.21 ± 8.86 vs 11.96 ± 13.54, FKGL 12.68 ± 1.58 vs 16.85 ± 3.25, and SMOG 11.37 ± 1.26 vs 14.53 ± 1.98; p < 0.001 for all comparisons). PEMAT-P understandability and actionability scores for the entire cohort were 68.20% ± 10.19% and 10.75% ± 16.52% respectively, and did not differ between patient-oriented and physician oriented sites. Though patient-oriented sites had better readability than physician-oriented sites for Zenker's Diverticulum, both categories had readability levels more advanced than what is recommended for medical education materials.

Effects of Pyridostigmine on Esophageal and Pharyngeal Motility in Dysphagic Patients Undergoing High-Resolution Manometry.

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.

Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux.

OBJECTIVE: Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD. METHODS: Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction. RESULTS: Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF (P < .001). CONCLUSION: In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF. LEVEL OF EVIDENCE: Level 4.

How to Understand and Treat Laryngopharyngeal Reflux.

Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients' symptoms are refractory to empiric treatment, pH testing with/without impedance should be considered. Additionally, evaluation for non-reflux etiologies of complaints should be performed, including laryngoscopy or videostroboscopy.

Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond.

Growing numbers of SARS-CoV-2 cases coupled with limited understanding of transmissibility and virulence, have challenged the current workflow and clinical care pathways for the dysphagia provider. At the same time, the need for non-COVID-19-related dysphagia care persists. Increased awareness of asymptomatic virus carriers and variable expression of the disease have also focused attention to appropriate patient care in the context of protection for the healthcare workforce. The objective of this review was to create a clinical algorithm and reference for dysphagia clinicians across clinical settings to minimize spread of COVID-19 cases while providing optimal care to patients suffering from swallowing disorders. Every practitioner and healthcare system will likely have different constraints or preferences leading to the utilization of one technique over another. Knowledge about this pandemic increases every day, but the algorithms provided here will help in considering the best options for proceeding with safe and effective dysphagia care in this new era.

Cervical Fibrosis as a Predictor of Dysphagia.

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.

Fluoroscopic Swallowing Abnormalities in Dysphagic Patients Following Anterior Cervical Spine Surgery.

OBJECTIVES: To evaluate the precise objective fluoroscopic abnormalities in persons with dysphagia following anterior cervical spine surgery (ACSS). METHODS: 129 patients with dysphagia after ACSS were age and sex matched to 129 healthy controls. All individuals underwent videofluoroscopic swallow study (VFSS). VFSS parameters abstracted included upper esophageal sphincter (UES) opening, penetration aspiration scale (PAS), and pharyngeal constriction ratio (PCR). Other data collected included patient-reported outcome measures of voice and swallowing, number of levels fused, type of plate, vocal fold immobility, time from surgery to VFSS, and revision surgery status. RESULTS: The mean age of the entire cohort was 63 (SD ± 11) years. The mean number of levels fused was 2.2 (±0.9). 11.6% (15/129) were revision surgeries. The mean time from ACSS to VFSS was 58.3 months (±63.2). The majority of patients (72.9%) had anterior cervical discectomy and fusion (ACDF). For persons with dysphagia after ACSS, 7.8% (10/129) had endoscopic evidence of vocal fold immobility. The mean UES opening was 0.84 (±0.23) cm for patients after ACSS and 0.86 (±0.22) cm for controls (P > .0125). Mean PCR was 0.12 (±0.12) for persons after ACSS and 0.08 (±0.08) for controls, indicating significant post-surgical pharyngeal weakness (P < .0125). The median PAS was 1 (IQR 1) for persons after ACSS as well as for controls. For ACSS patients, PCR had a weak correlation with EAT-10 (P < .0125). CONCLUSION: Chronic swallowing dysfunction after ACSS appears to be secondary to pharyngeal weakness and not diminished UES opening, the presence of aspiration, vocal fold immobility, or ACSS instrumentation factors.Level of Evidence: 3b.

An Otolaryngologist Redeployed to a COVID-19 Intensive Care Unit: Lessons Learned.

The COVID-19 pandemic has placed a significant personnel burden on intensive care units across the globe. Physicians from various specialties, including otolaryngology, have heeded the call and been redeployed to provide support, serving in a capacity outside their usual scope of practice. The author shares personal experience from redeployment and provides a framework for otolaryngologists to maximize their impact while providing high-quality patient care and preserving their personal safety.

Prevalence of profound laryngeal sensory neuropathy in head and neck cancer survivors with feeding tube-dependent oropharyngeal dysphagia.

BACKGROUND: Laryngopharyngeal sensory neuropathy (LSN) has been observed to be a contributing factor to swallowing dysfunction in head and neck cancer (HNC) survivors. METHODS: Retrospective review of 43 tube-dependent HNC survivors was conducted. LSN was assessed with direct palpation of the aryepiglottic fold and by traversing the true vocal folds without eliciting a cough reflex with a flexible laryngoscope. RESULTS: The primary tumor sites were oropharynx (51%), larynx (14%), nasopharynx (4.7%), oral cavity (14%), thyroid (4.7%), unknown primary (9.3%), and esophagus (2.3%). The prevalence of profound LSN was 79.1%. Objective fluoroscopic parameters contributing to swallowing dysfunction were diminished laryngohyoid elevation (100%), pharyngeal weakness (67%), and reduced lateral PES opening (37%). CONCLUSIONS: The prevalence of LSN in HNC survivors with feeding tube-dependent dysphagia is high (79.1%). The data suggest that LSN, in addition to fibrosis, pharyngoesophageal stenosis, and cranial nerve motor deficits contributes to swallowing dysfunction in these patients.

Esophageal A-ring is associated with the severity of gastroesophageal reflux.

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.