Simultaneous Radiological and Fiberendoscopic Evaluation of Swallowing ("SIRFES") in Patients After Surgery of Oropharyngeal/Laryngeal Cancer and Postoperative Dysphagia.

To compare the results of a simultaneously performed videofluoroscopic swallowing study and fiberendoscopic evaluation of swallowing in patients with dysphagia after surgery and radiotherapy for oropharyngeal or laryngeal cancer. This prospective study included 31 patients who were examined simultaneously with a standardized protocol. The fiberendoscopic and videofluoroscopic swallowing loops were independently scored by two otorhinolaryngologists/phoniatricians and two radiologists. The presence of penetration/aspiration, the amount of pharyngeal residues and the position of the bolus head when triggering of pharyngeal swallow begins were evaluated. Generalized linear models were used to model the impact of rater, method, bolus and quantities as well as specified moderation effects on scorings. In addition, post hoc Wilcoxon tests were used. Rater agreement was assessed using weighted kappas and their 95% confidence intervals. A total of 202 swallow sequences in 29 patients was evaluated. Interrater agreement was substantial to excellent for both methods (weighted k = 0.979-0.613). Significant differences between both methods were found when assessing the penetration-aspiration scale (p = 0.001, tendency of higher scores by videofluoroscopic (median = 2.59) as opposed to fiberendoscopic (median = 2.14) and the residue severity scores in the valleculae (p = 0.029) and the sinus piriformes (p = 0.002) with larger residues scored by fiberendoscopic evaluation of swallowing. No significant differences were found regarding the time point of triggering (p = 0.273). Simultaneous evaluation of swallowing with FEES and VFSS showed significantly different results in symptomatic patients after tumor operation and radiotherapy.

[Swallowing Disorders]. / Schluckstörungen.

Swallowing disorders are a common disease in all ages. The spectrum of diseases in patients with swallowing disorders has significantly changed in the last decades. Often complexe clinical pictures require a multidisciplinary approach including various different professionals. Videofluoroscopy is the method of choice for evaluation of the entire swallowing tract within one investigation. Functional as well as morphological changes can be diagnosed and as a therapeutic study, it helps guide decisions regarding further swallow therapy based on those findings.

[Radiological media and modern supporting tools in radiology]. / Radiological Media und moderne Tools zur Unterstützung in der Radiologie.

Radiology is a field with a high demand on information. Nowadays, a huge variety of electronic media and tools exists in addition to the classical media. Asynchronous and synchronous e-learning are constantly growing and support radiology with case collections, webinars and online textbooks. Various internet resources, social media and online courses have been established. Dynamic websites show a variety of interactive elements and it is easier and faster to access large amounts of data. Social media have an exponentially growing number of users and enable an efficient collaboration as well as forming professional networks. Massive open online courses (MOOCs) complete the offer of education and increase the opportunity to take part in educational activities. Apart from the existing variety of resources it is essential to focus on a critical selection for using these radiological media. It is reasonable to combine classical and electronic media instead of a one-sided use. As dynamic as the progress in the field of radiological media and its tools may be, the personal contact remains and should be maintained.

Significant symptomatic relief after transoral endoscopic staple-assisted treatment of Zenker's diverticulum.

BACKGROUND: Zenker's diverticulum is associated with characteristic symptoms of progressive dysphagia and regurgitation. As most patients are elderly, the perioperative risk is usually high. We report our clinical experience with the transoral endoscopic staple-assisted method, including a thorough assessment of the symptomatic relief achieved by the procedure. METHODS: 46 consecutive patients (29 m, 17 f) with a median age of 61 years (range, 37-96 years) were treated between 1997 and 2002. The symptoms and their frequency were registered. The follow-up consisted of clinical and radiographic investigations. RESULTS: The median size of the diverticulum was 4 cm (range, 2-12 cm). Transoral treatment was successful in 39 patients; in 7 cases (15.2%) a switch to open surgery was required. The median operating time was 30 min (range, 10-150 min). Mortality rate was nil, while morbidity was 7.7%. The median duration of the postoperative hospital stay was 5 days (range, 1-65 days). After a median follow-up of 11 months (range, 1-40 months), 5 patients had been reoperated on endoscopically due to clinical recurrence. Clinical symptoms were significantly reduced (dysphagia of liquids p

Videofluoroscopy of deglutition in children after repair of esophageal atresia.

PURPOSE: To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children. MATERIAL AND METHODS: 19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined. RESULTS: The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient. CONCLUSION: Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.

[Malignant and benign diseases of the breast in 41 male patients: mammography, sonography and pathohistological correlations]. / Maligne und benigne Erkrankungen der Brust bei 41 männlichen Patienten: Mammographie und Sonographie mit histopathologischer Korrelation.

AIM: The goal of our study was to evaluate findings in mammography and sonography in male patients with pathohistologically proven diseases of the breast. MATERIAL AND METHODS: Mammographies and sonographies, which were obtained in 41 male patients in a 6-year period, were retrospectively evaluated in accordance with the BI-RADS(R) classification. RESULTS: Histologically 13 carcinomas, 21 gynecomastias, 3 pseudogynecomastias, 2 epithelial inclusion cysts and 2 other benign lesions were diagnosed. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of mammography in differentiation of benign versus malignant disease were 92 %, 89 %, 80 %, 96 % and 90 %, respectively. Additional sonography did not change these results. However, sonography increased diagnostic confidence in 18.2 % (2/11) of suspicious lesions. CONCLUSION: In our study the invasive ductal carcinoma of male patients was a predominantly lobulated, ill-defined lesion in mammography and sonography. The differentiation of carcinoma to pseudogynecomastia and diffuse or dendritic gynecomastia was securely feasible. However, we could not reliably distinguish between carcinoma and some benign mass lesions. In cases of mammographically diagnosed masses or unclear mammography, additional sonography should be performed to increase the diagnostic confidence.

Role of Doppler sonography in the evaluation of accessory spleens after splenectomy.

OBJECTIVE: Splenectomy influences the Doppler blood flow pattern in the splenic artery. Blood flow in this vessel might return to normal if an accessory spleen increases in size after splenectomy. Our objective was to evaluate the resistive index of the splenic artery depending on the presence or absence of a hypertrophic accessory spleen in splenectomized patients. METHODS: The resistive index of the splenic artery was evaluated by duplex Doppler sonography in 19 splenectomized patients (8 with a hypertrophic accessory spleen) and in 8 healthy volunteers. The resistive index was measured within 3 cm of the origin of the splenic artery, and 3 different measurements were averaged. The presence or absence of a hypertrophic accessory spleen was diagnosed on the basis of sonography, computed tomography, magnetic resonance imaging, or scintigraphy, as well as by the presence or absence of Howell-Jolly bodies on a peripheral blood smear. RESULTS: The resistive index of the splenic artery in the splenectomized patients without a hypertrophic accessory spleen (mean +/- SD, 0.82 +/- 0.06; n = 11) was significantly (P < or = .0001) higher than in splenectomized patients with a hypertrophic accessory spleen (0.63 +/- 0.06; n = 8) and in control subjects (0.63 +/- 0.05; n = 8). CONCLUSIONS: In the splenectomized patient, a hypertrophic accessory spleen is associated with a normal resistive index in the splenic artery.

Complications after laryngeal surgery: videofluoroscopic evaluation of 120 patients.

AIM: Videofluoroscopic assessment of the spectrum and incidence of swallowing complications after state-of-the-art laryngeal cancer surgery. MATERIALS AND METHODS: We retrospectively studied videofluoroscopic examinations of 120 patients (94 men, 26 women; mean age, 58 years) with suspected complications after laryngeal resection (partial laryngectomy, 65; total laryngectomy, 55). Swallowing function (i.e., oral bolus control, laryngeal elevation and closure, presence of pharyngeal residue, aspiration) and structural abnormalities such as strictures, fistulas and tumour recurrence were assessed by videofluoroscopy. RESULTS: Abnormalities were found in 110 patients, including strictures in nine, fistulas in six and mass lesions in 13 patients. Aspiration was found in 63 patients overall (partial laryngectomy, 61/65; total laryngectomy, 2/55), occurring before swallowing in five, during swallowing in 34, after swallowing in nine and at more than one phase in 15 patients. Pharyngeal paresis was detected in three and pharyngeal weakness in 19 patients. Pharyngo-oesophageal sphincter dysfunction was observed in 10 cases. CONCLUSION: Aspiration is a very common complication after partial laryngeal resection. It is mainly caused by incomplete laryngeal closure, sphincter dysfunction or pharyngeal pooling. Videofluoroscopy is the only radiological technique able to identify both disordered swallowing function and structural changes after laryngeal resection. Detection of these complications is crucial for appropriate further therapy.Kreuzer, S. H. (2000). Clinical Radiology55, 775-781.

Transfer of interleukin-4 and interleukin-10 in patients with severe inflammatory bowel disease of the rectum.

Inflammatory bowel disease (IBD) comprises the two disorders ulcerative colitis (UC) and Crohn's disease (CD). Although the etiology is still unclear, initiation and aggravation of the inflammatory processes seem to be due to a massive local mucosal immune response. An increased number of greatly activated macrophages seems to contribute to the onset of IBD by expressing upregulated costimulatory molecules (e.g., CD80/CD86) and a cytokine profile favouring a type I proinflammatory response. The release of interleukin 2 (IL-2) and Interferon-gamma (IFN-gamma) by naive T lymphocytes predominantly stimulates cytotoxic T lymphocytes, macrophages, and natural killer (NK) cells and increases the antigen-presenting potential of all these cell types. Opposite this proinflammatory immune reaction a compensatory type II antiinflammatory response has been suggested in the inflamed mucosa, involving mainly interleukin 4 and interleukin 10. Both cytokines are able to down-regulate inflammatory mediators including tumor necrosis factor-alpha (TNF-alpha) and interleukin 1 and favor a humoral immune response. The main goal of this clinical trial is the local liposome-mediated gene transfer of these two antiinflammatory cytokines, interleukin 4 and interleukin 10, in patients with severe IBD of the rectum. This local administration of antiinflammatory cytokines will avoid toxic systemic side effects, prevents blocking of the beneficial effects of proinflammatory cytokines, e.g., TNF-alpha in other tissue compartments and increases the local concentration of interleukin 4 and interleukin 10 over a prolonged period of time. The combined effects of IL-4 and IL-10 have been shown to shift the Th1/Th2 cell activation in favor of a Th2 immune response which seems to be essential for fighting against the inflammation and ultimative healing.

[The pharynx. The imaging of its normal anatomy]. / Pharynx. Bildgebung der Normalanatomie.

BACKGROUND: The pharynx, being part of the digestive as well as the respiratory system, is embedded in the complex spatial anatomy of the neck and, due to its function and location, represents a very sophisticated region. DIAGNOSIS: Cross-sectional imaging with CT and MR imaging plays an indispensable complementary role to clinical work-up, as far as submucosal and deep cervical spaces are concerned. However, as dysphagia is a common symptom in clinical practice, interpretation of double contrast studies and videofluoroscopic investigations are also on frequent demand in the daily routine. CONCLUSION: Close interdisciplinary co-operation and the radiologist's familiarity with the anatomy of the region are required in order to use the diagnostic tools in an optimal fashion.

Videofluoroscopy of swallowing in symptomatic patients who have undergone long-term intubation.

OBJECTIVE: The aim of this study was to evaluate whether specific patterns of swallowing dysfunction occur in symptomatic patients after long-term intubation. SUBJECTS AND METHODS: Twenty-one patients (16 men, five women; mean age, 66 years) who presented with clinical signs of aspiration after long-term intubation (mean duration, 24.6 days) underwent videofluoroscopy. They were analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, and the upper esophageal sphincter. We assessed the presence or absence of aspiration, the type of aspiration (pre-, intra-, and postdeglutitive), and a spectrum of other swallowing abnormalities. RESULTS: There were 18 patients (86%) with radiologically proven aspiration. In another patient only laryngeal penetration occurred. There were 11 combinations of pre-, intra-, and postdeglutitive aspiration. Predeglutitive aspiration was predominant and present in 52% of our patients. We found functional abnormalities of the tongue in 48%, of the soft palate in 10%, of the epiglottis in 48%, of the pharynx in 71%, and of the upper esophageal sphincter in 24%. CONCLUSION: Patients who are symptomatic after undergoing long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration, but show a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy has the ability to reveal complex deglutition disorders and to aid precise planning of individualized functional swallowing therapy.

Traumatic pharyngo-oesophageal perforation in the newborn: a condition mimicking oesophageal atresia.

Two newborn infants with traumatic perforation of the pharyngo-oesophageal region are presented. This injury was induced by pharyngeal suction catheters and/or vigorous attempts at nasogastric or tracheal intubation during resuscitation of the newborn. The true nature of this condition remained unrecognized and the babies were thus referred with a tentative diagnosis of oesophageal atresia. The perforation itself could be treated successfully without surgery, despite a severe complication in one infant resulting from inadvertent use of barium sulphate contrast medium. Raising awareness of the possibility of this injury should help in avoiding this complication by gentle and skilful action during newborn resuscitation, particularly in the premature infant.

Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration.

OBJECTIVE: This study evaluated the clinical significance of cervical osteophytes impinging on the pharynx in patients with dysphagia and the importance of concurrent disorders that may affect swallowing function. MATERIALS AND METHODS: On videofluoroscopy, anterior cervical osteophytes were found in 55 (32 men, 23 women; mean age, 69 years) of 3318 patients with dysphagia (1.7%). Coexisting diseases that affected swallowing function were found in 28 patients (stroke, n = 7; thyroidectomy, n = 7; tongue base or laryngeal cancer surgery, n = 5; other diseases, n = 9). Swallowing function was assessed with videofluoroscopy evaluating epiglottic tilting, laryngeal closure, impression of the hypopharynx, pharyngeal residue, and aspiration. RESULTS: With advancing age, the probability of aspiration (odds ratio, 1.07; p < 0.05) and of enlarging osteophytes (odds ratio, 1.26; p < 0.01) increased; the probability was higher for osteophytes at more than one vertebrae (odds ratio, 8.00; p < 0.01) and for concurrent diseases (odds ratio, 8.02; p < 0.01). Aspiration was found in 75% of patients with osteophytes larger than 10 mm and in 34% with osteophytes smaller than or equal to 10 mm. In 88% of patients with small osteophytes who aspirated, other diseases affected swallowing function. CONCLUSION: Aspiration is common in patients with dysphagia and cervical osteophytes larger than 10 mm. Aspiration is rare in patients with osteophytes smaller than or equal to 10 mm unless these patients suffer from other disorders that may affect swallowing.

Radiological findings in acute adult epiglottitis.

Acute epiglottitis is a rare but life-threatening disease that commonly occurs in children, and also rarely in adults. The symptoms may be mild and non-specific before a rapid onset of airway obstruction occurs. Early diagnosis is essential, as delayed treatment is associated with a high rate of complications including death. We present the clinical and radiological findings of this unusual condition in an adult.

[Staging of carcinomas of the upper gastrointestinal tract. The current status of diagnostic imaging]. / Staging von Karzinomen des oberen Gastrointestinaltraktes. Standortbestimmung der Bildgebung.

Esophageal carcinoma: CT and endosonography are complementary and the most important imaging modalities at present for staging. After endoscopic and histological diagnosis, CT of the thorax and the abdomen is used. With the proof of local infiltration of a neighbouring organ or in the presence of distant metastasis, palliative therapy can be started. If CT is not conclusive or no local infiltration or distant metastasis is proven, endosonography should be performed. Gastric carcinoma: At present endosonography shows the highest accuracy for diagnosis of the T stage. For differentiation between T3 and T4 tumors the accuracy of CT is not sufficient to predict resectability. The N stage can be determined at present by no modality with sufficient accuracy. Distant metastasis can be diagnosed by CT with high sensitivity and specificity. Small bowel carcinoma: These rare tumors are diagnosed with high accuracy by enteroclysis, whereby the diagnosis takes place at a late stage due to the nonspecific clinical findings.

Radiographic detection of achalasia: diagnostic accuracy of videofluoroscopy.

AIMS: To retrospectively evaluate the accuracy of videofluoroscopy in the diagnosis of achalasia. MATERIALS AND METHODS: Videofluoroscopic studies of the oesophagus of 53 patients (25 males, 28 females; mean age, 49 years) with manometrically revealed diagnosis of achalasia were retrospectively evaluated. The videofluoroscopic examinations had been carried out with one swallow of low-density barium suspension in the erect and up to three swallows in the prone oblique position. Videofluoroscopically, a diagnosis of achalasia was made in 31 of the patients (58%) with manometrically proven achalasia, of whom only nine had oesophageal dilatation. Non-specific oesophageal motor abnormalities were diagnosed radiographically in 18 patients (34%) and a normal motility in four patients (8%). CONCLUSION: Videofluoroscopy is a valuable and sensitive technique for the detection of disordered oesophageal motility in achalasia.

Globus sensation: pharyngoesophageal function, psychometric and psychiatric findings, and follow-up in 88 patients.

BACKGROUND: The globus sensation has been widely regarded as psychogenic, but organic disorders were found to be etiologically significant. OBJECTIVE: To investigate the structural, functional, psychological, and psychiatric factors possibly eliciting the globus sensation and influencing its course. METHODS: Eighty-eight patients, 67 women and 21 men (aged 22-71 years), referred to 2 tertiary care centers underwent history taking, otolaryngological examination, pharyngoesophageal videofluoroscopy and manometry, psychosocial evaluation, psychometric tests, psychiatric interview, and when indicated, esophagogastroduodenoscopy, esophageal bolus transport, gastroesophageal reflux, and gastric emptying studies. According to revealed disorders, therapy was initiated, and the outcome was studied. RESULTS: Only 15 patients had normal pharyngoesophageal function; of these 15, 6 had chronic tonsillitis or pharyngitis, 3 had thyroid adenomata, 4 had cervical spondylosis, and 1 each had dry oropharyngeal mucosa and chronic bronchitis. Of the other 73 patients, 2 had pharyngeal dysfunction, 24 had achalasia, 1 had diffuse esophageal spasms, 3 had "nutcracker esophagus," 30 had nonspecific esophageal motor disorders, and 13 had gastroesophageal reflux. Psychometry revealed no more anxiety and depression than in general medical outpatients. Of 58 patients interviewed, 37 met criteria for psychiatric disorders. Psychometric scores and psychiatric characteristics were unrelated to the sensation's course. Therapy was recommended, but only 26 patients were treated accordingly; 22 received nonspecific treatment. Follow-up 3 to 59 months later revealed that the sensation had vanished in 13 patients who had received specific treatment, 5 who had received nonspecific treatment, and 6 who had received no treatment; it was alleviated in 10 who had received specific treatment, 13 who had received nonspecific treatment, and 9 who had received no treatment; and it was unchanged in 3 who had received specific treatment, 5 who had received nonspecific treatment, and 23 patients who had received no treatment. CONCLUSIONS: Pharyngoesophageal disorders may be sensed only vaguely, inducing the globus sensation. Psychological and psychiatric characteristics could be relevant to the discomfort experienced but are unlikely to be etiologically significant.

[Diagnostic imaging of the larynx. Normal anatomy of the regional spread of pathologic changes]. / Bildgebende Diagnostik des Larynx. Normale Anatomie und Ausbreitungswege pathologischer Veränderungen.

The primary goal of diagnostic imaging of the larynx is analysis of submucosal structures that are not visible by clinical or endoscopic means. Therefore, image analysis of the larynx should only be performed under knowledge of the results of clinical diagnosis. The anatomic relationships of the laryngeal skeleton, the intrinsic structures, and the surrounding soft tissue are presented synoptically.