HPV vaccination practices and attitudes among primary care physicians since FDA approval to age 45.

PURPOSE: The aim of this study was to examine HPV vaccine administration practices since FDA approval to age 45 and assess knowledge regarding HPV and its association with oropharyngeal cancer. METHODS: A survey was distributed to 86 primary care physicians at Loyola University Medical Center. The survey contained 11 questions designed to capture HPV vaccination practices, knowledge of FDA approval, and barriers to vaccination. RESULTS: 46 (53%) physicians completed the survey and 45 responses were included. Among respondents who treat males ages 9-21 and females ages 9-26, the vaccination is widely recommended with >95% always or almost always recommending the vaccination. Among those treating males >21, and females >26, 52% and 35% of physicians recommend vaccination to these cohorts, respectively. Only 17% and 26% of respondents would recommend the vaccine to men and women respectively up to age 45. 100% of respondents recognize an association between HPV and cervical cancer, and 90% of respondents recognize HPV's association with oropharyngeal cancer. However, respondents also associate HPV with oral cavity and laryngeal cancer. 28% of respondents said parents are barriers to vaccination, while 7% said that insurance is a barrier. CONCLUSIONS: HPV vaccination is widely recommended by physicians at our institution; however, for men older than 21 and women older than 26, vaccination recommendation rates decrease, and relatively few physicians would offer the vaccination up to age 45. Primary care physicians at our institution recognize HPV's close association to oropharyngeal cancer. Barriers to vaccination are primarily negative perception of the vaccine by patients and parents.

Factors associated with skin graft take in fibula and radial forearm free flap donor sites.

LEARNING OBJECTIVES: Identify factors associated with skin graft take in fibula free flaps (FFF) and radial forearm free flaps (RFFF) donor sites. STUDY OBJECTIVES: To determine which factors are associated with decreased skin graft take at the donor site in FFF and RFFF in head and neck patients. DESIGN: Retrospective Chart Review Case Series. SETTING: Multicenter Tertiary Care. METHODS: A multicenter retrospective review was performed at three institutions identifying patients who underwent free tissue transfer, specifically either FFF or RFFF, between 2007 and 2017. Patient demographics, medical history, and social history were examined including age, gender, BMI, smoking status, diabetes and preoperative anticoagulation use. Preoperative, intraoperative data, and postoperative data were also examined including tourniquet use, type of flap, area of skin graft, if the skin graft had a donor site or if it was taken from the flap, wound NPWT use, cast use, use of physical therapy, DVT prophylaxis, limb ischemia, heparin drip, and postoperative aspirin use. Statistical analysis was used to determine which factors were significantly associated with skin graft take. RESULTS: 1415 patients underwent a forearm or fibula flap and 938 patients underwent split-thickness skin graft. Of these, 592 patients had sufficient information and were included in the final analysis. There were 371 males and 220 females. The average age was 55.7. Complete skin graft take was seen in 480 patients (81.1%). On univariate analysis, patients with diabetes (p = .003), type of flap (fibula p < .001), skin graft area (p = .006), tourniquet use (p = .003), DVT prophylaxis (p = .008) and casting (p = .003) were significantly associated with decreased skin graft take rate. In a multivariate analysis, diabetes (OR 2.17 (95%CI 1.16-3.98)), fibula flaps (OR 2.86 (95%CI 1.79-4.76)), an increase in skin graft area (OR 1.01 (95%CI 1.01-1.01)), post-operative aspirin (OR 2.63 (95%CI 1.15-5.88), and casting (OR 2.94 (95%CI 1.22-7.14)) were associated with poor rates of skin graft take. CONCLUSION: Several factors affect skin graft take rate and should be considered when performing a skin graft for a donor site defect.

Tourniquet use and factors associated with hematoma formation in free tissue transfer.

PURPOSE: Our objective was to understand which variables are associated with hematoma formation at both the donor and recipient sites in head and neck free tissue transfer and if hematoma rates are affected by tourniquet use. METHODS: Patients were identified who underwent free tissue transfer at three institutions, specifically either a radial forearm free flap (RFFF) or a fibula free flap (FFF), between 2007 and 2017. Variables including use of tourniquet, anticoagulation, treatment factors, demographics, and post-operative factors were examined to see if they influenced hematoma formation at either the free tissue donor or recipient site. RESULTS: 1410 patients at three institutions were included in the analysis. There were 692 (49.1%) RFFF and 718 (50.9%) FFF. Tourniquets were used in 764 (54.1%) cases. There were 121 (8.5%) hematomas. Heparin drips (p < .001) and DVT prophylaxis (p = .03) were significantly associated with hematoma formation (OR 95% CI 12.23 (4.98-30.07), 3.46 (1.15-10.44) respectively) on multivariable analysis. CONCLUSIONS: Heparin Drips and DVT prophylaxis significantly increased hematoma rates in free flap patients while tourniquets did not affect rates of hematoma.

p16 Immunohistochemistry Is a Useful Diagnostic Adjunct in Cases of Metastatic Cervical Carcinoma of Unknown Origin.

PURPOSE: Metastatic cervical carcinoma of unknown primary (MCCUP) is increasing in frequency owing in part to rising human papillomavirus (HPV)-driven oropharyngeal carcinoma. Identifying the primary site is valuable, because it is associated with increased survival and decreased morbidity. HPV-positive cervical nodal disease focuses attention on the oropharynx for directed biopsy examinations, including tonsillectomy. When the primary is small, carcinoma might not be apparent by traditional hematoxylin and eosin (H&E) staining alone. MATERIALS AND METHODS: This report describes 2 cases of p16-positive MCCUP in which a small primary carcinoma was not readily identified in surgical specimens using H&E staining. RESULTS: Additional evaluation of the specimens with p16 immunohistochemistry (IHC) showed carcinoma in these 2 cases. CONCLUSIONS: When H&E staining does not show carcinoma in cases of MCCUP, p16 IHC should be considered given the high prevalence of HPV-positive MCCUP and the potential for identification of a small primary tumor that might otherwise be missed with H&E staining.

Patient and tumor characteristics predictive of primary parotid gland malignancy: A 20-year experience at the University of Wisconsin.

PURPOSE: To identify patient and tumor characteristics predictive of primary parotid malignancy. MATERIALS AND METHODS: Records were reviewed for patients who underwent parotidectomy at the University of Wisconsin from 1994 to 2013. Patients with primary parotid neoplasms were separated into benign or malignant subgroups. A multivariate logistic regression model was employed to compare categorical (gender, lesion side, nature of presentation, recurrence) and numerical variables (age, tumor size) between the benign and malignant groups. Mean BMI was compared between the groups by univariate analysis. RESULTS: 771 patients underwent parotidectomy from 1994 to 2013, and 474 had a primary parotid neoplasm. No relationship existed between malignancy and gender (p=0.610), lesion side (p=0.110), or BMI (p=0.196). Mean age (p=0.015) and tumor size (p=0.011) were significantly different between the benign and malignant groups. Patient presentation was classified into three categories: symptomatic (n=109), palpable and asymptomatic (n=303), and incidentally noted on imaging (n=57). From all patients with symptomatic, asymptomatic or incidentally noted masses, 41.3%, 10.6% and 5.3%, respectively, were diagnosed with malignant disease. There was a significant relationship between the patient's initial presentation and malignancy (p<0.001), and patients with facial nerve dysfunction or skin involvement had the greatest likelihood of malignancy. Finally, there was a significant association between malignancy and recurrence (p=0.001). CONCLUSIONS: In this study, age, tumor size, and nature of presentation were all associated with primary parotid malignancy. Understanding the impact of these features on the probability of malignancy is valuable in decision making and counseling of patients presenting with a newly diagnosed parotid neoplasm.

Deep Lobe Parotid Tumors: A Systematic Review and Meta-analysis.

OBJECTIVE: We performed a systematic review and meta-analysis of deep lobe parotid tumors to evaluate their unique characteristics. DATA SOURCES: PubMed/Medline, Embase, Web of Sciences, and Cochrane Library databases were queried for relevant literature. REVIEW METHODS: Studies were individually assessed by 2 independent reviewers. Risk of bias was assessed with the Cochrane bias tool, GRADE criteria, and MINORS criteria. Results were reported according to the PRISMA guidelines. Statistical analysis was performed by comparing rates of malignancy between deep and superficial lobe tumors. RESULTS: In total, 8 studies including 379 deep lobe parotid tumors met inclusion criteria. Mean age at diagnosis was 44.9 years. Computed tomography scan was the most common imaging modality. Preoperative diagnostic fine-needle aspiration was utilized in 39.4% of patients and demonstrated high sensitivity for malignant disease. The most common approach was subtotal parotidectomy with facial nerve preservation (58.9%). The rate of malignancy was 26.6%, which was significantly higher than that of the superficial lobe tumors in this study (risk ratio, 1.25; 95% CI, 1.01-1.56). The rate of temporary postoperative facial nerve weakness between deep and superficial lobe tumors was 32.5% and 11.7%, respectively. CONCLUSION: Deep lobe parotid tumors had a 26.6% rate of malignancy. On meta-analysis, deep lobe tumors appeared to have higher rates of malignancy than superficial lobe tumors. Surgical excision of deep lobe tumors showed increased rates of temporary facial nerve paresis as compared with superficial lobe tumors. Computed tomography scan was the most common imaging modality. There were limited data regarding the utility of fine-needle aspiration.

Tyrosine Kinase Inhibitor Use and Wound Healing in Tracheoesophageal Punctures.

Tyrosine kinase inhibitors (TKIs) aid in prolonging life in patients with advanced locoregional thyroid malignancy. Such patients may undergo total laryngectomy for local disease control and tracheoesophageal puncture (TEP) for speech rehabilitation. Enlargement of TEP fistulas is usually attributed to wound healing issues and leads to major complications. Four laryngectomies with TEP were performed between 2015 and 2016 and subsequently placed on a TKI. Three patients developed a complication after TKI treatment, and 2 patients had a tracheoesophageal fistula. Patients should be counseled about possible wound healing risks associated with TKIs.

A Review of and Algorithmic Approach to Soft Palate Reconstruction.

IMPORTANCE: The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity. OBJECTIVE: To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review. EVIDENCE REVIEW: A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded. FINDINGS: The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases. CONCLUSIONS AND RELEVANCE: Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

Incidental Findings on FDG PET/CT in Head and Neck Cancer.

Objective 18F-fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG PET/CT) imaging is common in head and neck cancer and often identifies incidental findings that necessitate additional patient evaluations. Our goal was to assess the frequency and nature of these incidental imaging findings on FDG-PET/CT. Study Design Retrospective cohort study. Setting Tertiary medical center. Subjects and Methods All patients with head and neck cancer who had undergone FDG-PET/CT imaging between January 2014 and June 2015 at our institution were evaluated for incidental findings. Results A total of 293 patients met criteria; more than one-third (n = 103) had at least 1 finding unrelated to their head and neck cancer, for a total of 134 incidental findings. Incidental findings within the head and neck (33.5% of all) excluding the thyroid were most common: 35% incidental findings were concerning for malignancy; of these, 25.5% were malignant with further workup. Recommendations were given by the head and neck radiologist on 72 (53.7%) findings: 74.5% of potentially malignant findings and 42.5% of benign findings had recommendations for follow-up. Significantly more patients with findings described as malignant were given recommendations for follow-up ( P = .0004). Conclusion Incidental findings on FDG-PET/CT are present in more than one-third of patients with head and neck cancer. More than one-third of incidental findings were concerning for malignancy. This study illustrates how the incidental findings discovered on FDG PET/CT frequently necessitate additional evaluations unrelated to the index head and neck cancer. The impact of these additional assessments on the cost and quality of health care warrants future evaluation.

Assessment of a Statistical Algorithm for the Prediction of Benign Paroxysmal Positional Vertigo.

Importance: Benign paroxysmal positional vertigo (BPPV) is an otologic pathologic condition defined as a sensation of spinning triggered by changes in head position relative to gravity and caused by an entrapment of fragmented endolymph debris most commonly in the posterior semicircular canal. Confirmation of diagnosis requires experience with procedures that are poorly known by those other than practitioners with advanced otologic training. The complexity in the diagnosis of BPPV inspired the design of a questionnaire-based algorithm that would be useful for determining a vestibular diagnosis and treatment options. Objective: To assess a statistical algorithm for the diagnosis of BPPV in a busy tertiary care setting, with the long-term goal of implementing a clinical pathway to efficiently diagnose and treat patients with dizziness. Design, Setting, and Participants: In this retrospective case series, 200 patients who visited the Department of Otolaryngology-Head and Neck Surgery at Johns Hopkins University School of Medicine for their initial vertigo symptoms from September 1, 2016, to December 31, 2016, were assessed. Interventions: Use of a validated patient questionnaire as a tool to differentiate patients with dizziness in an electronic medical record review. Main Outcomes and Measures: Linear predictor (LP) value based on the questionnaire for the diagnosis of BPPV. Results: Of the 200 patient visits reviewed (132 [66%] female), 106 (53.0%; 68 [64%] female) had the information necessary to calculate the LP value and had a confirmed final diagnosis. On the basis of an LP value of 0.2 or greater, the sensitivity for a diagnosis of BPPV was 0.75 and the specificity was 1.0. The positive predictive value was 1.0, whereas the negative predictive value was 0.96. Patients with BPPV had a statistically significantly different LP value (odds ratio, 5.92; 95% CI, 2.73-12.83) than did patients without BPPV. Conclusions and Relevance: The findings of this study suggest that the algorithm is efficient for the diagnosis of BPPV in a clinical care setting.

Contemporary management of advanced laryngeal cancer.

The treatment of advanced laryngeal cancer has undergone a paradigm shift in recent years, with an increase in chemoradiation for organ preservation and a decrease in primary surgery. This review will summarize the contemporary management of advanced laryngeal cancer and discuss treatment-related toxicity and strategies to improve outcomes. LEVEL OF EVIDENCE: NA.

Energy-Based Facial Rejuvenation: Advances in Diagnosis and Treatment.

IMPORTANCE: The market for nonsurgical, energy-based facial rejuvenation techniques has increased exponentially since lasers were first used for skin rejuvenation in 1983. Advances in this area have led to a wide range of products that require the modern facial plastic surgeon to have a large repertoire of knowledge. OBJECTIVE: To serve as a guide for current trends in the development of technology, applications, and outcomes of laser and laser-related technology over the past 5 years. EVIDENCE REVIEW: We performed a review of PubMed from January 1, 2011, to March 1, 2016, and focused on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines including case control, case studies and case reports when necessary, and included 14 articles we deemed landmark articles before 2011. FINDINGS: Three broad categories of technology are leading non-energy-based rejuvenation technology: lasers, light therapy, and non-laser-based thermal tightening devices. Laser light therapy has continued to diversify with the use of ablative and nonablative resurfacing technologies, fractionated lasers, and their combined use. Light therapy has developed for use in combination with other technologies or stand alone. Finally, thermally based nonlaser skin-tightening devices, such as radiofrequency (RF) and intense focused ultrasonography (IFUS), are evolving technologies that have changed rapidly over the past 5 years. CONCLUSIONS AND RELEVANCE: Improvements in safety and efficacy for energy-based treatment have expanded the patient base considering these therapies viable options. With a wide variety of options, the modern facial plastic surgeon can have a frank discussion with the patient regarding nonsurgical techniques that were never before available. Many of these patients can now derive benefit from treatments requiring significantly less downtime than before while the clinician can augment the treatment to maximize benefit to fit the patient's time schedule.

Use of sialendoscopy as an aid to identify a large retained foreign body.

We describe the novel use of sialendoscopy in a 51-year-old man to identify a large and long-standing foreign body (wood) within the facial soft tissues that had eluded detection on previous imaging and surgical exploration. The identification of this foreign body was elusive on both computed tomography and magnetic resonance imaging, illustrating the limitations of imaging in identifying vegetable matter within soft tissues.

Factors influencing sialocele or salivary fistula formation postparotidectomy.

BACKGROUND: Does the extent of parotidectomy or other patient or tumor characteristics influence the rate of sialocele/salivary fistula formation? METHODS: All patients who underwent parotidectomy at the University of Wisconsin from 1994 to 2013 were considered. Patients who developed a sialocele/salivary fistula were identified. Extent of dissection, age, sex, body mass index (BMI), volume of specimen, and rate of malignancy were examined. RESULTS: Seventy of 771 patients (9.1%) developed a sialocele/salivary fistula. Sixty-seven fistulae (96%) developed within 1 month and all resolved by 6 months. Age, sex, pathology, and BMI were not increased in the sialocele group. Inferior and middle superficial parotidectomy had a significantly higher rate of sialocele than other extents of dissection. Volume of tissue removed was not significantly different between dissection groups. CONCLUSION: Sialocele/salivary fistula is common postparotidectomy and is more likely with inferior and middle superficial parotidectomy. © 2016 Wiley Periodicals, Inc. Head Neck 39: 387-391, 2017.

Chondroradionecrosis of the larynx: 24-year University of Wisconsin experience.

BACKGROUND: Chondroradionecrosis (CRN) is an uncommon but significant complication of laryngeal radiotherapy that presents a diagnostic challenge to clinicians through its similarity in presentation to cancer recurrence. METHODS: Two hundred ninety-four patients underwent primary, adjuvant, or salvage radiation for laryngeal cancer from 1991 to 2015 at the University of Wisconsin. Medical records were reviewed to identify and characterize patients with a diagnosis of CRN. RESULTS: Of the 294 patients, 7 cases (2.4%) of CRN were identified. Development of CRN was associated with the presence of cartilage invasion by tumor (p = .038) and ongoing alcohol use postradiotherapy (p = .036). Additionally, a trend between development of CRN and ongoing smoking postradiotherapy was observed (p = .067). CONCLUSION: The diagnosis of CRN is challenging, and the likelihood of successful resolution is modest. A high premium should be placed on efforts directed at prevention, such as tobacco and alcohol cessation. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1189-1194, 2017.

Quality indicators of laryngeal cancer care in commercially insured patients.

OBJECTIVE: To examine associations between quality, complications, and costs in commercially insured patients treated for laryngeal cancer. STUDY DESIGN: Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data (Truven Health Analytics, Ann Arbor, Michigan, U.S.A.). METHODS: We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression. Using quality indicators derived from guidelines for recommended care, summary measures of quality were calculated for diagnosis, initial treatment, surveillance, treatment for recurrence, performance, and an overall summary measure of quality. RESULTS: Higher-quality care in the initial treatment period was associated with lower odds of 30-day mortality (odds ratio [OR] = 0.21, 95% confidence interval [CI] [0.04-0.98]), surgical complications (OR = 0.39 [0.17-0.88]), and medical complications (OR = 0.68 [0.49-0.96]). Mean incremental 1-year costs were higher for higher-quality diagnosis ($20,126 [$14,785-$25,466]), initial treatment ($17,918 [$10,481-$25,355]), and surveillance ($25,424 [$20,014-$30,834]) quality indicators, whereas costs were lower for higher-quality performance measures (-$45,723 [-$56,246--$35,199]) after controlling for all other variables. Higher-quality care was associated with significant differences in mean incremental costs for initial treatment in surgical patients ($-37,303 [-$68,832--$5,775]), and for the overall summary measure of quality in patients treated nonoperatively ($10,473 [$1,121-$19,825]). After controlling for the overall summary measure of quality, costs were significantly lower for patients receiving high-volume surgical care (mean -$18,953 [-$28,381--$9,426]). CONCLUSION: Higher-quality larynx cancer care in commercially insured patients was associated with lower 30-day mortality and morbidity. High-volume surgical care was associated with lower 1-year costs, even after controlling for quality. These data have implications for discussions of value and quality in an era of healthcare reform. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:2805-2812, 2017.

Tracheal exposure: Anticipatory management of the difficult airway.

BACKGROUND: When a patient cannot be intubated or ventilated, cricothyrotomy is indicated. Risks associated with emergent cricothyrotomy are significant, and this procedure typically requires revision. Additional options for establishing an emergent airway are limited. Thus, elective tracheotomy to ensure a safe airway after procedures involving the upper aerodigestive tract is common. Although safe and effective overall, this procedure is not without additional risks, added resources, complex cares, and extended hospitalizations. METHODS: We present a case in which exposure of the anterior trachea was performed without tracheotomy in a patient with a high-risk airway undergoing an open partial laryngectomy. RESULTS: The patient did not develop respiratory distress postoperatively and was able to avoid a tracheostomy and its associated cares. CONCLUSION: Pretracheotomy with tracheal exposure simplifies emergent surgical access to the airway. We believe tracheal exposure in the appropriately selected patient is a safe and cost-effective alternative to elective tracheotomy. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2446-E2448, 2016.

Bone-anchored hearing aid and skin graft removal with subsequent cochlear implantation.

We describe a novel technique of scalp flap rearrangement for cochlear implant (CI) candidates who have previously undergone ipsilateral bone-anchored hearing aid (BAHA) placement. One patient with single-sided deafness (SSD) underwent removal of a BAHA with subsequent scalp rearrangement for coverage of the implant site. After adequate healing of the scalp rotational flap, he underwent uncomplicated cochlear implantation without soft tissue complications. With increasing utilization of CIs in SSD, there will be more patients undergoing cochlear implantation who have previously had a BAHA. We present a novel method for accomplishing this goal while minimizing the risk of soft tissue complications. Laryngoscope, 126:2601-2604, 2016.

Metastatic synovial sarcoma of the scalp: Case report.

BACKGROUND: Synovial sarcoma is a malignant tumor of soft tissue that is rarely found in the head and neck. Even less common are metastasis within the head and neck. METHODS: We describe a case of a delayed metastatic synovial sarcoma to the scalp. A man who had been diagnosed and treated 16 years previously for monophasic synovial sarcoma of the groin, presented with a new scalp lesion confirmed to be metastatic monophasic synovial sarcoma. Wide local excision and sentinel lymph node biopsy (SLNB) were performed and adjuvant radiation therapy was deferred. RESULTS: A positron emission tomography (PET)/CT was obtained 3 months after surgery and showed no evidence of local recurrence or metastatic disease. CONCLUSION: This case report describes a rare case of synovial sarcoma metastasizing to the scalp. The genetic, histopathologic, and clinical features of synovial sarcoma are reviewed with a focus on their manifestation and management within the head and neck.

Preliminary Evaluation of Functional Swallow After Total Laryngectomy Using High-Resolution Manometry.

INTRODUCTION: Understanding of swallowing pressures after total laryngectomy (TL) and what constitutes a "functional" swallow are limited. Mobile structures are altered or removed after TL, with consequent effects on pressure profiles. High-resolution manometry (HRM) can characterize these pressures. METHODS: Six TL subjects without dysphagia and 6 controls underwent pharyngeal HRM. Timing and pressure variables for the velopharynx, mesopharynx, and upper esophageal sphincter (UES) were compared. Changes in variables due to bolus volume were evaluated in TL subjects. RESULTS: The TL subjects had increased duration of velopharyngeal pressure (P = .012). Maximum mesopharyngeal pressure was lower versus controls (P = .003). Maximal and total pre-opening (P = .002, P = .002) and post-closure (P = .001, P = .002) UES pressures were lower. Maximum mesopharyngeal pressure (P = .032) decreased with increasing bolus volume. CONCLUSIONS: Increased velopharyngeal pressure duration and total swallow duration reflect separation of the pharynx into distinct conduits for air and food, thus ensuring successful bolus passage without the need for respiration. Decreased UES pressure highlights the effects of disrupting the cricopharyngeal and rostral esophageal muscle fibers from their attachments to the larynx and performing a cricopharyngeal myotomy. Additional studies including subjects with dysphagia could further characterize the functional TL swallow and identify aspects susceptible to dysfunction.