Therapeutic outcomes of laryngeal closure and laryngostomy in children with recurrent pneumonia.

PURPOSE: Children with medical complexity frequently experience difficulty breathing and swallowing and occasionally develop aspiration pneumonia. Long-term intubation may cause fatal trachea-innominate artery fistula (TIF). In the present study, we retrospectively evaluated the efficacy of laryngeal closure and laryngostomy in children with medical complexity. MATERIALS AND METHODS: Laryngeal closure and laryngostomy were performed in eight children with severe neuromuscular disorders who were incapable of oral ingestion and verbal communication. The laryngostoma was placed at a higher position compared to that in conventional tracheostomies for easier management of the airway and to prevent TIF. RESULTS: Aspiration was successfully prevented postoperatively in all cases. Laryngocutaneous fistula formation was not observed. Two patients successfully achieved oral ingestion capability and tracheal cannulas were removed in two patients. Among the six patients who needed a mechanical ventilator before surgery, two patients were weaned from mechanical ventilation. Five patients were successfully discharged from the hospital. Although two patients died because of their primary condition, pneumonia exacerbation was not observed in any of the patients. CONCLUSION: Compared to the conventional tracheostomy, our procedure improved airway management and function in children with medical complexity and reduced the risk of TIF.

Factors Affecting the Swallowing Dysfunction Following Oral Cancer Surgery.

OBJECTIVE: To investigate the factors affecting the postoperative swallowing dysfunction in patients who underwent oral cancer surgery. METHODS: Retrospective review of clinical records of 70 patients (50 males and 20 females) who underwent oral cancer surgeries from July 2007 to April 2015 were enrolled. Multiple regression analysis was performed using the Food Intake LEVEL Scale (FILS) at discharge as the objective variable and age, tumor size, resection of the tongue base, suprahyoid muscle resection, segmental mandibulectomy, neck dissection and radiation therapy as the explanatory variables in 70 patients. In addition, multiple regression analysis was performed between objective variables, which include maximum hyoid bone movement, laryngeal elevation delay time, pharyngeal constriction ratio (PCR), residue in the vallecular and pear-shaped depression (pyriform sinuses), and Penetration-Aspiration Scale score and one of the main factors representing the characteristics of each case as the explanatory variables, and age was treated as an adjustment factor in 23 patients. RESULTS: The FILS shows significant negative correlation by age and resection of the tongue base. In videofluoroscopic swallowing study, the maximum movement, PCR and residue in the vallecular are significantly correlated with factors demonstrating the characteristic for each case. CONCLUSION: It was suggested that in elderly patients, the presence of more than half of the tongue base resection, suprahyoid muscle resection and neck dissection cause severe dysphagia after surgery.

The effect of a chin-down maneuver after esophagectomy on oropharyngeal swallowing pressure measured using high-resolution manometry.

OBJECTIVE: To elucidate the effects of a chin-down maneuver using high-resolution manometry (HRM) to measure pharyngeal swallowing pressure (SP) after esophagectomy. METHODS: We evaluated 9 of 16 patients who underwent esophagectomy featuring gastric tube reconstruction and three-field lymph node dissection (3FL) in our Department of Gastroenterological Surgery from September 2015 to June 2016. We compared all parameters of the neutral and chin-down positions using HRM to measure the maximum SP at the velopharynx, meso-hypopharynx, and upper esophageal sphincter (UES) and the duration of lowered SP at the UES, the distance from nostrils to the boundary between hypopharynx and UES and to derive SP and SP propagation curves at various distances from the nostrils. RESULTS: Compared to that at the neutral position, the maximum SP at the velopharynx was significantly lower in the chin-down position (p<0.05); however, SP at the meso-hypopharynx and UES did not differ significantly. The duration of lowered SP at the UES was significantly prolonged in the chin-down position and the distance from nostrils to the boundary between hypopharynx and UES was significantly shortened representing the elevation of the larynx, respectively (p<0.05, p<0.01). On the SP propagation curve for males, the times to SP peaks at 13, 16, 17, and 18cm from the nostrils were significantly prolonged (all p<0.05) in the chin-down position. CONCLUSION: Chin-down positioning after esophagectomy/3FL may improve bolus passage by prolonging the duration of lowered SP at the UES, possibly by enhancing laryngeal elevation.

Determining the Efficacy of the Chin-Down Maneuver Following Esophagectomy With Fiberoptic Endoscopic Evaluation of Swallowing.

OBJECTIVES: To clarify the reliability of fiberoptic endoscopic evaluation of swallowing (FEES) compared to videofluoroscopic swallowing studies (VFSSs). Second, we explored the effect of the chin-down maneuver in the presence or absence of vocal fold paralysis (VFP) using FEES in patients with 3-field lymphadenectomy (3FL) postesophagectomy. DESIGN: Retrospective data collection from FEES and VFSS. SETTING: Dysphagic clinics in the ear, nose, and throat department. PARTICIPANTS: Patients (N=15) underwent esophagectomy with 3FL at the Department of Gastroenterologic Surgery, during a period of 12 months. INTERVENTIONS: The patients underwent FEES and VFSS with neutral and chin-down maneuvers 2 weeks postoperatively. Two raters of speech pathology blindly scored aspiration, penetration, delayed initiation, and pharyngeal clearance in the pyriform sinus and vallecula, respectively, from recorded movie clips of both examinations, using the penetration aspiration scale (PAS) and modified Hyodo FEES rating scale. MAIN OUTCOME MEASURES: The intrarater and interrater correlation coefficients of each parameter examined with FEES. Statistical comparison of each parameter between FEES and VFSS and of each parameter evaluated using FEES between 2 maneuvers with or without VFP. RESULTS: The intrarater and interrater correlation coefficients of the PAS and pyriform sinus examined with FEES were both statistically consistent between the 2 raters. The PAS and pyriform sinus evaluated using FEES were significantly correlated with those evaluated in a VFSS (P<.05). The 2 parameters evaluated using FEES were significantly (P<.05) improved with the chin-down maneuver compared to the neutral maneuver, especially in VFP patients. CONCLUSION: FEES performed postesophagectomy with 3FL for evaluation of aspiration is as reliable statistically as VFSSs. The chin-down maneuver is especially useful for reducing the PAS score and pyriform sinus in VFP patients.

Assessment of oropharyngeal swallowing dysfunction in myasthenia gravis patients presenting with difficulty in swallowing.

OBJECTIVE: To examine the correlation between the results of a clinical neurological evaluation and swallowing dysfunction in myasthenia gravis (MG) patients who presented with difficulty in swallowing and underwent videofluorographic (VF) and fiber-optic endoscopic (FE) evaluation. METHODS: The swallowing studies of 13MG patients with difficulty in swallowing seen at the Department of Neurology from June 2016 to April 2018 were reviewed. The assessment parameters on VF and FE examination were as follows: swallowing initiation, bolus stasis at the pyriform sinus (PS) and vallecula (VC), and the degree of aspiration. They were assessed using a 4 or 5-point scale. Associations between these parameters and the clinical neurological evaluation, which included the Myasthenia Gravis Foundation of America (MGFA) clinical classification, the MG Activities of Daily Living score, and a quantitative MG score, were statistically determined. RESULTS: No patients demonstrated aspiration. However, in patients MGFA IIb/IIIb disease, the Hydo's FEES scale and pharyngeal residue examined using VF were significantly (p<0.05) more severe than in patients classified with MGFA IIa/IIIa disease. None of the parameters evaluated with VF and FE correlated significantly with the clinical neurological evaluation except for the grip assessment. CONCLUSION: While not presenting with aspiration but with swallowing difficulty alone, patients classified with MGFA IIb/IIIb disease, regardless of clinical neurological evaluation, require care addressing the reduced pharyngeal clearance. Controlling the severity of the pharyngeal residue may be the key to preventing silent aspiration, especially in patients with MGFA IIb/IIIb disease.

Surgical treatment of enterovirus D68 brainstem encephalitis-induced dysphagia.

Cluster of acute flaccid paralysis and cranial nerve dysfunction was associated with a 2014 outbreak of enterovirus D68 (EV-D68) respiratory illness in US. We describe a 33 year-old male patient of refractory dysphagia due to EV-D68-induced brainstem encephalitis successfully treated by surgery. Following acute upper respiratory tract infection, he developed dysphagia and bilateral facial paralysis. A coughing reflex was readily produced when the laryngopharyngeal fiberscope touched the epiglottis, however, water infusion induced only very weak and slow swallowing reflex, suggesting that only motor component was impaired but sensory function was preserved during swallowing. Despite eight months-conservative rehabilitations, Food Intake Level Scale (FILS) remained level 4. Therefore, corrective surgeries including cricopharyngeal myotomy, laryngeal suspension, and pharyngeal flap were performed. Thirty-six days after surgery, FILS rapidly and dramatically improved to level 8. This is the first report describing a successful surgical intervention for EV-D68-induced refractory dysphagia. Surgical treatment was suitable for EV-D68-induced dysphagia, perhaps because sensory function was preserved and only motor disturbance was present during the pharyngeal stage of swallowing.

Videofluoroscopic evaluation of pharyngeal swallowing dysfunction after esophagectomy with three-field lymph node dissection.

To determine the factors inducing aspiration following esophagectomy with three-field lymph node dissection (3FL) and the effect of the chin-down maneuver combined with supraglottic swallow (CDSS). Retrospective analysis of a consecutive case series. Videofluoroscopic (VF) evaluations of 25 patients who consulted with our out-patient clinic from 2006 to 2012 for swallowing dysfunction following esophagectomy with 3FL without tracheostomy were reviewed. The penetration aspiration scale (PAS) was used for evaluation. The assessment parameters of VF examination were set as follows: laryngeal elevation, peristaltic wave of the pharynx, upper esophageal sphincter opening, and bolus residue in the pyriform sinus and vallecula after swallowing. Associations of the degree of aspiration with these parameters and the effect of CDSS maneuver on PAS were statistically examined. Fourteen patients had swallowing dysfunction with PAS score (1-3). Disturbance of laryngeal elevation was significantly correlated with the degree of aspiration (p = 0.021). Multivariate logistic regression analysis demonstrated that reduced laryngeal elevation significantly enhanced aspiration (p = 0.0026). Sixteen patients had already acquired compensated chin-down swallowing at the time of VF (Group I). Among the remaining nine patients (Group II), the PAS score was significantly (p < 0.05) improved after training in chin-down swallowing. The mean PAS score of the Group I patients was not significantly different from that of the Group II patients after the training in CDSS. Laryngeal aspiration following esophagectomy with 3FL is significantly correlated with reduced laryngeal elevation and can be ameliorated after training in CDSS. Level of evidence IV.

Effects of Chin-Down Maneuver on the Parameters of Swallowing Function After Esophagectomy With 3-Field Lymphadenectomy Examined by Videofluoroscopy.

OBJECTIVES: To determine the effect of the chin-down maneuver after esophagectomy with 3-field lymphadenectomy (3FL) on pharyngeal residue, upper esophageal sphincter (UES) opening, and laryngeal closure. DESIGN: Prospective data were collected from a pharyngeal videofluoroscopic swallowing study. SETTING: Dysphagia clinics. PARTICIPANTS: Patients selected according to the inclusion criteria (N=14; mean age, 65.9y) from a total of 43 patients who underwent esophagectomy with 3FL from May to December 2014 were enrolled. INTERVENTIONS: Videofluoroscopy was conducted in head-neutral and chin-down positions to measure the pharyngeal constriction ratio (PCR), amount of residue in the vallecula and pyriform sinus after the first swallow, UES opening diameter, duration of UES opening, and duration of laryngeal vestibule closure. MAIN OUTCOME MEASURES: The aforementioned parameters were compared statistically between the head-neutral and chin-down positions. RESULTS: In comparison with the neutral group, the PCR and residue in the pyriform sinus were significantly smaller in the chin-down group (P<.01). However, the residue in the vallecula did not differ significantly from that of the neutral group (P=.44). The UES opening diameter, duration of UES opening, and duration of laryngeal vestibule closure were all significantly larger in the chin-down group than in the neutral group (P<.05). CONCLUSIONS: This study demonstrates that use of the chin-down maneuver after esophagectomy with 3FL can help expedite swallowing by strengthening pharyngeal constriction, widening the UES, and enhancing laryngeal closure.

Postdeglutitive residue in vagus nerve paralysis and its association with feeding style.

The objective of this study is to compare the postdeglutitive pharyngeal residues between Xth cranial nerve paralysis (XNP) and isolated recurrent laryngeal nerve paralysis (RLNP) to elucidate the association with feeding style. This study enrolled 15 XNP patients with injuries at the brainstem level (Group I) and 26 patients with RLNP (Group II). All subjects underwent videofluoroscopic swallowing studies (VFSS). The pyriform sinus (PS) and vallecula residues were quantified. The symmetry of the affected versus non-affected sides was compared in both groups. Feeding style at the time of VFSS was also examined. The intra-rater correlation coefficients for all of the data, including the areas of both the vallecula and pyriform sinus on the affected and non-affected sides, were 0.88-0.92 (p < 0.001), reflecting high consistency of the evaluation. In Group I, there was significantly (p < 0.01) more residue in the PS, but not vallecula, compared to the respective non-affected sides, while in Group II there were no significant differences in residue between the affected and non-affected sides for either the vallecula or PS. Comparing Groups I and II, there was significant (p < 0.01) residue on the affected side in the PS but not the vallecula. There was a significant correlation between dependency on a feeding tube and XNP (p < 0.01, Chi-square test). XNP at the brainstem level may cause significantly increased residue in the PS compared to RLNP. This might increase the dependency on a feeding tube with XNP.

Effect of three different chin-down maneuvers on swallowing pressure in healthy young adults.

OBJECTIVES/HYPOTHESIS: To determine the effects of three different chin-down maneuvers on swallowing pressure (SP) in healthy young adults using high-resolution manometry (HRM). STUDY DESIGN: Repeated measures with subjects serving as their own controls. METHODS: Twenty-six healthy subjects (average age 26.4 [range 21-35] years) swallowed 5 mL of cold water to examine the maximum swallowing pressure (MSP) at the velopharynx, meso-hypopharynx, and upper esophageal sphincter (UES), and to determine the duration of lowered SP at the UES using HRM. The subjects swallowed in the neutral position as a control and in the following three chin-down positions: 1) head flexion (HF); 2) neck flexion (NF); and 3) combined head and neck flexion (HFNF). RESULTS: The MSP at the velopharynx and meso-hypopharynx did not significantly differ among the three chin-down positions. Upon swallowing in the NF posture, the MSP was significantly lower (P < 0.0001) at the UES, and the duration of the lowered SP at the UES was significantly prolonged (P = 0.0010) compared to the neutral position. In comparison, the duration of lowered SP at the UES was significantly (P = 0.0001) shorter in the HF position than in the neutral position. Moreover, the HFNF position significantly (P = 0.0276) lowered the MSP at the UES compared to the control position. CONCLUSION: In young healthy adults, NF maneuver resulted in significantly lower MSP and longer duration of the lowered swallowing pressure at the UES, which might assist bolus passage through the UES. LEVEL OF EVIDENCE: 3b.

Propagation Curve and Velocity of Swallowing Pressure in Healthy Young Adults.

The objective of this study is to construct a propagation curve and determine propagation velocities in young healthy adults examined using a 2.64-mm-diameter high-resolution manometry catheter with 36 circumferential sensors; to explore data reproducibility; and to determine whether the swallowing pressure (SP) propagation velocity correlated with bolus volume. Repeated measures with subjects serving as their own controls. Thirty healthy subjects (average age 25.3 years) swallowed saliva and 2, 5, and 10 mL of cold water to determine the maximum SP from the soft palate to the cervical esophagus. The SP propagation curve was obtained by plotting the duration to reach each SP peak. The SP propagation velocity was calculated for each region. These parameters were examined according to bolus size and gender. The intra-class correlation coefficient for estimating the SP propagation curves was >0.61 (i.e., highly consistent). The propagation velocity was maximal at the meso-hypopharynx and minimal at the UES and cervical esophagus. The SP propagation curve was very reproducible within any subject. Neither the water volume (with the exception of 2 and 5 mL) nor gender exerted any apparent effect on velocity in any region. However, the velocity was quite variable at the cervical esophagus.

Event-related potentials for better speech perception in noise by cochlear implant users.

Speech perception in noise is still difficult for cochlear implant (CI) users even with many years of CI use. This study aimed to investigate neurophysiological and behavioral foundations for CI-dependent speech perception in noise. Seventeen post-lingual CI users and twelve age-matched normal hearing adults participated in two experiments. In Experiment 1, CI users' auditory-only word perception in noise (white noise, two-talker babble; at 10 dB SNR) degraded by about 15%, compared to that in quiet (48% accuracy). CI users' auditory-visual word perception was generally better than auditory-only perception. Auditory-visual word perception was degraded under information masking by the two-talker noise (69% accuracy), compared to that in quiet (77%). Such degradation was not observed for white noise (77%), suggesting that the overcoming of information masking is an important issue for CI users' speech perception improvement. In Experiment 2, event-related cortical potentials were recorded in an auditory oddball task in quiet and noise (white noise only). Similarly to the normal hearing participants, the CI users showed the mismatch negative response (MNR) to deviant speech in quiet, indicating automatic speech detection. In noise, the MNR disappeared in the CI users, and only the good CI performers (above 66% accuracy) showed P300 (P3) like the normal hearing participants. P3 amplitude in the CI users was positively correlated with speech perception scores. These results suggest that CI users' difficulty in speech perception in noise is associated with the lack of automatic speech detection indicated by the MNR. Successful performance in noise may begin with attended auditory processing indicated by P3.

Swallowing pressure and pressure profiles in young healthy adults.

OBJECTIVES/HYPOTHESIS: To measure the swallowing pressure (SP) of normal subjects using a 2.64-mm-diameter high-resolution manometry (HRM) catheter with 36 circumferential sensors. STUDY DESIGN: Repeated measures with subjects serving as controls. METHODS: Thirty healthy subjects swallowed water at different temperatures and volumes to examine the maximum SP at the velopharynx, meso-hypopharynx, upper esophageal sphincter (UES), and cervical esophagus, and the duration of lowered pressure at the UES. RESULTS: The maximum SP at any location was unaffected by the volume of water, whereas the maximum SP at the UES and cervical esophagus was affected by the temperature. The duration of lowered SP at the UES was significantly prolonged with 10 versus 2 mL of cold water. The pressure curve in males had two peaks (at the velopharynx and UES), whereas that of females had a single peak at the UES. CONCLUSIONS: Our data obtained with 2.64-mm HRM demonstrated that as the bolus volume is increased, the duration of lowered SP at the UES is prolonged. The higher maximum SP at the velopharynx in males versus females suggests that there may be a gender difference in pressure at the velopharynx that has not been described previously. This implies that it is necessary to take gender differences into consideration when evaluating the etiology of swallowing dysfunction by examining the SP and SP curve. Moreover, the thinner catheter is less invasive and may contribute to obtaining more physiological measurements.

Postdeglutitive residue in idiopathic unilateral vocal fold paralysis: a quantitative videofluoroscopic study.

OBJECTIVES/HYPOTHESIS: To quantitate postdeglutitive residue and determine its association with paralysis duration (≤6 vs. ≥6 months) in patients with idiopathic unilateral vocal fold paralysis (UVFP). STUDY DESIGN: Primary institutional retrospective review. METHODS: Twenty patients (mean age, 72 years) with idiopathic UVFP and 13 patients (mean age, 66 years) with isolated recurrent laryngeal nerve paralysis (RLNP) who underwent videofluoroscopic swallow studies (VFSSs) were included. Vallecular and pyriform sinus (PS) residues in the anteroposterior view were analyzed quantitatively. In both regions, the symmetry of the affected versus nonaffected sides between patients with idiopathic UVFP and RLNP were compared. Residual differences between short- versus long-term paralysis duration in idiopathic UVFP patients alone were also evaluated. RESULTS: The affected PS of the idiopathic group demonstrated significantly increased residue (P = .007) as compared with the nonaffected PS, but with no significant difference with respect to the vallecula (P = .183). There was no significant difference in the RLNP group. When compared with RLNP patients, the idiopathic group showed significantly increased residue on the affected PS (P = .002), but differences in the vallecular residue were nonsignificant. Pharyngeal residue and the duration of paralysis in idiopathic UVFP patients were not significantly different. CONCLUSIONS: Idiopathic UVFP patients were more likely to demonstrate increased residue and asymmetry toward the involved region as compared with RLNP patients, suggesting that nerve involvement in idiopathic UVFP may not be exclusive to the RLN.

Esophageal regurgitation as a cause of inspiratory distress after thyroplasty.

OBJECTIVES: Edema of the arytenoid and wound hematoma are principal causes of inspiratory distress after arytenoid adduction and type I thyroplasty. The purpose of the present study was demonstrate esophageal regurgitation one of the causes of inspiratory distress after thyroplastic surgeries. STUDY DESIGN: Two case reports. METHODS: We encountered 2 patients with unilateral vocal fold immobility who required emergent tracheostomy owing to sudden inspiratory distress 1 to 2 days after completion of arytenoid adduction combined with type I thyroplasty. RESULTS: Their dyspneic attacks occurred just after taking a meal. Both had a history of esophagectomy with reconstruction of the food passage using a gastric tube. They had a sufficiently wide glottis as indicated by laryngeal fiberscopy. Videofluorography showed a stricture at the junction between the duodenum and the gastric tube and barium pooling above the stricture. Regurgitation of barium was also seen. CONCLUSION: Based on these clinical courses and findings, laryngeal closure reflex triggered by esophageal regurgitation was considered to be the most possible cause of their dyspneic attacks. Phonosurgeons considering thyroplastic surgeries for postesophagectomy patients should be aware that esophageal regurgitation possibly causes laryngeal closure reflex resulting in inspiratory distress during the postoperative period.

A case of migratory fish bone in the thyroid gland.

Fish-bone foreign bodies represent a common condition readily identified in the pharynx. We encountered a case of fish bone in the thyroid gland. Only three other such cases have been reported in the English-language literature. This foreign body was identified by computed tomography and ultrasonography 16 days after onset, and removed through a cervical skin incision. The diagnosis and treatment of extrapharyngeal foreign bodies are discussed.

[The improvement of quality of life of patients with aspiration pneumonia after surgical therapy for intractable aspiration].

Sixteen patients with recurrent aspiration pneumonia that could not be controlled by appropriate medical therapies. These patients had no hope of recovering laryngeal function. Eight underwent laryngectomy, six underwent laryngotracheal separation and four underwent tracheoesophageal anastomosis. After surgery, we evaluated the efficacy of the therapy and the patients' satisfaction with therapy. Before and after surgery, the following clinical markers were examined to evaluate the efficacy of surgery: scores of aspiration pneumonia, WBC count, C-reactive protein, erythrocyte sedimentation rate, hematocrit, body mass index, total protein, albumin, and the Barthel index, an indicator of daily activity. Furthermore, the grade of Depression and mood, and satisfaction of patients and their carers among family members were scored using the Zung self-rating depression scale, a 20-picture face scale, the visual analog scale, and feeding status. After surgical therapy, we confirmed that aspiration was prevented in fourteen patients of sixteen, and the state of inflammation and nutrition, the state of depression and mood were improved. Thirteen patients from sixteen were able to ingest a meal orally. The quality of life of patients with intractable aspiration was improved.

[Videofluorography of the pharynx in patients suffering from aspiration pneumonia].

We evaluated videofluorographic recordings of the pharynx (VF) in patients suffering from aspiration pneumonia. The patients consisted of 55 men and 6 women who consulted the ENT Department at Kumamoto University Hospital between May 1994 and February 2002. Surgery for an upper alimentary tract malignancy (16 patients) was the most frequent background feature. The number of patients with cerebrovasucular disease and neuronal/neuromuscular diseases were 11 and 12, respectively. VF enabled the misswallowing of barium into the trachea to be visualized in 38 patients. Of these 38 patients, 20 exhibited misswallowing during or after the pharyngeal stage of swallowing. Among the 23 patients in whom misswallowing was not detected, 13 had upper alimentary tract diseases. The VF findings suggested the presence of gastroesophageal clearance after swallowing. Gastro-esophageal regurgitation may be a significant factor, in addition to the silent aspiration of oral and pharyngeal secretions during the night as a trigger of recurrent aspiration pneumonia.