Outcome of radiotherapy for the treatment of laryngeal squamous cell carcinoma in the very elderly population.

BACKGROUND: Treatment selection for squamous cell carcinoma patients aged over 84 years is controversial. This retrospective chart review examined and compared characteristics of laryngeal squamous cell carcinoma in very elderly (over 84 years) and younger patients (approximately 65 years). The secondary objective was to further evaluate the outcome of radiotherapy as a treatment modality in this patient population. METHODS: Of all 23 very elderly patients with laryngeal squamous cell carcinoma treated with radiotherapy, with or without surgery, in the Davidoff Cancer Center, from 1992 to 2012, 19 had sufficient data for analysis, and comprised the study group. RESULTS: Median age at diagnosis was 86 years. Disease stage at diagnosis was I, II, III and IVA in 53 per cent, 21 per cent, 21 per cent and 5 per cent, respectively. Median radiotherapy dose was 60 Gy given in 25 fractions. Three patients had recurrence. No patient discontinued treatment because of toxicity. Median overall survival was 3.6 years (range, 0-10 years). CONCLUSION: Very elderly laryngeal squamous cell carcinoma patients may derive a similar survival advantage as younger counterparts. Modern radiotherapy is effective and safe for treating laryngeal squamous cell carcinoma in this study population. Further, large-scale studies are needed.

Using ChatGPT to Generate Research Ideas in Dysphagia: A Pilot Study.

Current research in dysphagia faces challenges due to the rapid growth of scientific literature and the interdisciplinary nature of the field. To address this, the study evaluates ChatGPT, an AI language model, as a supplementary resource to assist clinicians and researchers in generating research ideas for dysphagia, utilizing recent advancements in natural language processing and machine learning. The research ideas were generated through ChatGPT's command to explore diverse aspects of dysphagia. A web-based survey was conducted, 45 dysphagia experts were asked to rank each study on a scale of 1 to 5 according to feasibility, novelty, clinical implications, and relevance to current practice. A total of 26 experts (58%) completed the survey. The mean (± sd) rankings of research ideas were 4.03 (± 0.17) for feasibility, 3.5 (± 0.17) for potential impact on the field, 3.84 (± 0.12) for clinical relevance, and 3.08 (± 0.36) for novelty and innovation. Results of this study suggest that ChatGPT offers a promising approach to generating research ideas in dysphagia. While its current capability to generate innovative ideas appears limited, it can serve as a supplementary resource for researchers.

Use of a Novel Hypercrosslinked Carbohydrate Scaffold for Vocal Fold Medialization in an Ovine Model.

Objectives: Vocal fold medialization is commonly performed for glottic insufficiency and vocal fold immobility. Currently available materials are temporary injectables or synthetic implants. Acellular scaffolds may allow vocal fold augmentation with autologous tissue via host cell migration. The purpose of this investigation was to evaluate the use of a novel carbohydrate scaffold as a medialization implant. Study Design: Animal model. Setting: Academic medical center. Methods: Unilateral type I medialization thyroplasty was performed in 3 Dorper cross ewes using a hypercrosslinked carbohydrate polymer (HCCP) scaffold. Animals were monitored for 4 weeks for general well-being, dyspnea, and weight loss. The animals were euthanized at 4 weeks and the larynges harvested. Histologic evaluation was performed to assess for adverse tissue reaction, migration, degradation, and biocompatibility. Results: No adverse events were reported. No animals lost weight or displayed evidence of dyspnea. Histology demonstrated ingrowth of host cells and neovascularization with minimal peri-implant inflammatory reaction. Cellular ingrowth into the scaffold was predominately made up of fibroblasts and early inflammatory cells. Scaffold shape was grossly maintained as it underwent degradation and replacement with host tissue. Migration of the implant material was not observed. Conclusion: Vocal fold medialization in an ovine model with an HCCP scaffold resulted in the ingrowth of host cells with minimal peri-implant inflammation. Scaffold shape was maintained without evidence of migration as it underwent replacement with host tissue. Further research is required to assess long-term efficacy in comparison to currently available implants.

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.

The effect of gastric fundus radiation dose on postoperative anastomotic leakage in esophageal cancer.

Introduction: Standard-of-care treatment for locally advanced esophageal carcinoma (LAEC) includes neoadjuvant chemoradiotherapy followed by esophagectomy. A potentially catastrophic surgical complication is the development of a postoperative anastomotic leak. To date, the association with radiation dose exposure had been inconclusive. We examined the correlation between radiation exposure to the gastric fundus and risk of postoperative leakage using contemporary radiation doses and fractionation. Methods: A total of 69 consecutive patients with LAEC who underwent neoadjuvant chemoradiotherapy followed by esophagectomy in our tertiary center were prospectively followed (median, 27 months). Neoadjuvant regimen included 50.4 Gy in 28 fractions with 5-fluorouracil and cisplatin and 41.4 Gy in 23 fractions with carboplatin and paclitaxel. The gastric fundus was contoured and dosimetric and radiation technique parameters were retrospectively evaluated. Results: Of the total number of patients, 71% and 29% had esophageal and gastroesophageal junction (GEJ) tumors, respectively. Fourteen patients (20.3%) experienced anastomotic leaks within a median of 2 days postoperatively, 78.6% of whom had lower third esophagus or GEJ primaries. Mean and minimum fundus dose did not significantly differ between those with and those without leakage (p = 0.42, p = 0.51). Mean fundus V25, V30, and V35 doses were numerically but not statistically higher in those with anastomotic leak (p = 0.58, p = 0.39, and p = 0.30, respectively). No correlation with incidence of leakage was seen between 3D and IMRT treatment modalities. Conclusions: In our comparatively large prospectively collected series of patients treated for LAEC, radiation dose to the gastric fundus during neoadjuvant combination therapy prior to surgery did not correlate with the risk of postoperative anastomotic leak.

Diagnostic efficacy of positron emission computerized tomography scans in suspicious laryngeal findings postorgan preservation treatment.

BACKGROUND: Larynx preservation protocols (LPP) for glottic primary squamous cell carcinoma has gained popularity worldwide. Direct laryngoscopy (DL) with biopsy is mandated when recurrence is suspected. The efficacy of 18Fluoro-deoxy-glucose positron emission computerized tomography (PET-CT) as alternative first-line diagnostic investigation in suspected recurrence was evaluated. METHODS: A retrospective study of patients with suspicious fiber-optic findings at more than 12 weeks after LPP. Sensitivity, specificity, and the negative predictive value (NPV) of DL and PET-CT were compared. RESULTS: Seventy-two patients presenting 105 cases of suspicious events were included in this study. Fifty-two events were initially investigated by DL and 53 events by PET-CT. The sensitivity of DL and PET-CT was 56.25% and 100%, respectively. The NPV was 84% for DL and 100% for PET-CT (p = 0.015). CONCLUSION: Negative PET scans after LPP are highly accurate in ruling out recurrent/persistent disease and may spare the patient from negative biopsies.

Anterior cervical spine surgery and dysphagia.

PURPOSE OF REVIEW: The purpose of this review is to summarize current evidence regarding dysphagia in anterior cervical spine surgeries (ACSS) and to present recent advances in evaluation and surgical technique. RECENT FINDINGS: Various risk factors for dysphagia have been identified, and they include female sex, smoking history, prior surgery and cervical lordotic angle. EAT-10 is a validated tool for the assessment of individuals with dysphagia post-ACSS. Local intraoperative corticosteroid application significantly reduced the incidence and magnitude of dysphagia in four out of five studies that were reviewed. Individuals who had undergone cervical disc replacement (CDR) and revision surgery by a zero-profile anchored spacer (ROI-C) device experienced less dysphagia than those who had anterior cervical discectomy with fusion (ACDF). Videofluoroscopic swallow study (VFSS) after ACSS demonstrated pharyngeal weakness and increased posterior pharyngeal wall thickness, while no other abnormality was found. SUMMARY: Different technique variations can reduce dysphagia severity in individuals undergoing ACSS. Surgeons are encouraged to continue performing randomized control studies to assist in choosing the most favourable technique for the patient.

Laryngectomy-free survival after salvage partial laryngectomy: a systematic review and meta-analysis.

PURPOSE: Radiotherapy (RT) is widely used for early glottic cancer. Patients failing this treatment are referred to surgical management of their disease. Salvage partial laryngectomy (SPL) has the advantage of preserving laryngeal function with total laryngectomy (TL) remaining as a last resort. The purpose of this study was to determine the efficacy of SPL in preventing total laryngectomy, following failed RT, for early glottic cancer. METHODS: A meta-analysis of all published English literature was performed. All publications that included patients undergoing SPL were reviewed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) reporting guidelines. The search strategy identified 154 relevant articles. A total of 15 retrospective studies that included 323 suitable patients were subsequently analyzed in this meta-analysis. The main outcome measure was the rate of laryngectomy-free survival (LFS) following SPL. The indications for salvage TL (i.e., disease recurrence and poorly functional larynxes) as well as subgroup analyses for open and trans-oral SPLs were also calculated. RESULTS: The overall rate of LFS following SPL was 81.2% (fixed effects model range: 75.7-86.8%). Salvage TL following SPL were performed in 96.8% due to disease recurrence and in 3.2% to poorly functional larynxes. A subgroup analysis showed a 90.4% LFS after open SPL and 78.6% following trans-oral SPL. CONCLUSION: A high rate of successful salvage partial laryngectomies, regardless of surgical technique, is to be anticipated in well-selected patients after RT failure.

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.

Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia.

OBJECTIVES/HYPOTHESIS: To identify risk factors for pneumonia incidence in patients with dysphagia undergoing a videofluoroscopic swallow study (VFSS) in an outpatient tertiary-care center. STUDY DESIGN: Historical cohort study. METHODS: All individuals undergoing a VFSS between 10/02/13 and 07/30/15 were identified and followed historically for 2 years. Demographic information, medical history, and fluoroscopic data were collected. The 2-year incidence of pneumonia was obtained from the medical records and telephone interview. The incidence of pneumonia and death were calculated and risk factors for pneumonia and mortality were ascertained. RESULTS: 689 patients were followed for 2 years. The mean age (±standard deviation) of the cohort was 65 (±15.5) years. 49% (338/689) were female. The most common causes of dysphagia were cricopharyngeus muscle dysfunction (270/689), head and neck cancer (175/689), and neurodegenerative disease (56/689). The incidence of pneumonia was 22% (153/689). The incidence of death was 11%. Multivariable logistic regression revealed that chronic obstructive pulmonary disorder [COPD] (odds ratio [OR] = 2.36, 95% confidence interval [CI]: 1.33-4.19), hypertension (OR = 1.82, 95% CI: 1.23-2.73), tracheotomy status (OR = 2.96, 95% CI: 1.09-7.99), and vallecular residue (OR = 1.88, 95% CI: 1.24-2.85) were all significantly associated with an elevated risk of pneumonia. Kidney disease (OR = 1.27, 95% CI: 1.02-9.9), COPD (OR = 3.27, 95% CI: 1.65-6.49), vallecular residue (OR = 2.35, 95% CI: 1.35-4.1), male gender (OR = 2.21, 95% CI: 1.25-3.92), and low body mass index (OR: 1.12, 95% CI: 1.06-1.19) were independent adjusted risk factors for death. CONCLUSIONS: The incidence of aspiration pneumonia (22%) and death (11%) within 2-years of a VFSS was high. The greatest adjusted risk factors for incident pneumonia were tracheotomy (OR = 3.0), COPD (OR = 2.4) and vallecular residue (OR = 1.9). The greatest adjusted risk factors for death were COPD (OR = 3.3), vallecular residue (OR = 2.3), and male gender (OR = 2.2). LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1172-1176, 2022.

Safety of Endoscopic Sinus Surgery in the Elderly-Are Octogenarian Patients at a Higher Risk?

BACKGROUND: Surgeons are often faced with concerns regarding the risks versus benefits of endoscopic sinus surgery (ESS) in elderly patients. OBJECTIVE: To analyze the risk for complications of ESS in the elderly (age ≥70 years) compared to younger patients, with emphasis on octogenarians. METHODS: Retrospective review of medical charts of adult patients who underwent ESS at a tertiary referral center during the years 2014 to 2018. RESULTS: We compared 128 elderly patients with 276 matched younger patients. In the elderly group mean age was 76 years (range, 70-91 years ). Thirty-one elderly patients were 80 years or older. Surgical complications in the elderly patients were 3.9%. Minor complications were 2.3% and major complications were 1.7%. The surgical complications rate was similar in the younger group (8%, P value: .127). Medical complications were observed in 2.3% comparing to 0.7% in younger patients. Interestingly, age, revision surgery, extent and duration of surgery, and modality of anesthesia were not identified as risk factors. Only ischemic heart disease (IHD) was identified as a risk factor for complications in a multivariate analysis in elderly patients. Comparison of elderly patients younger than 80 years with octogenarians revealed no difference in complication rate between these groups. CONCLUSIONS: Overall, ESS was found to be a safe procedure in elderly patients compared to younger patients. Octogenarian patients should not be denied upfront surgery. IHD is a risk factor for complications in elderly patients.

Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings.

Importance: Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures. Objective: To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP. Design, Setting, and Participants: This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019. Main Outcomes and Measures: Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed. Results: Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type. Conclusions and Relevance: This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.

Effects of surgery for obstructive sleep apnea on cognitive function and driving performance.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with a significantly increased risk of motor vehicle accidents in addition to such cognitive impairments as attention and memory deficits. The aim of the study was to examine the effect of upper airway surgery for OSA on driving and cognitive function. METHODS: Adult patients who underwent surgery for OSA at a tertiary medical center in 2016-2019 were prospectively recruited. Patients were assessed before and 3-6 months after surgery with a self-report and neurocognitive battery and a driving simulation platform. RESULTS: The cohort included 32 patients of average age 46.9 ± 11.6 years. During the 3 years before treatment, 9 patients had been involved in road accidents and 18 were detained by police for traffic violations. After surgery, there was a significant decrease in the Epworth Sleepiness Scale (13.7 vs. 8.1, p 0.043) and a significant reduction in time to completion of the Color Trail Test (part 1: 21.4 vs 18.7 s, p = 0.049; part 2: 46.8 vs 40.5 s, p = 0.038). Improvements in divided attention and selective attention response times were noted on the advanced stages of the Useful Field of Vision Scale (p = 0.013, p = 0.054). Before surgery, patients showed a high tendency to drive over the speed limit and to cross the dividing line to the opposite lane on the simulation test. Nevertheless, all considered themselves good drivers. These tendencies decreased after treatment. CONCLUSIONS: Surgery for OSA can significantly improve driving performance and cognitive function.

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.

Inflammatory Effects of Thickened Water on the Lungs in a Murine Model of Recurrent Aspiration.

OBJECTIVE: Liquid thickeners are commonly recommended in individuals with dysphagia and recurrent aspiration as a strategy for pneumonia prevention. The goal of this study was to examine the effects of small amounts of aspirated liquid thickener on the lungs. STUDY DESIGN: Animal model. Prospective small animal clinical trial. METHODS: Adult Sprague Dawley rats (n = 19) were divided into two groups and underwent three intratracheal instillations of either xanthan gum-based nectar-thick water (0.1-0.25 mL/kg) or water-only control over the course of 8 days. Blood was collected from a peripheral vein on days 1 and 8 and submitted for complete blood count (CBC) analysis. Rats were euthanized 10 days after the last instillation, and the lungs were harvested. Histopathology was conducted on lung specimens by a blinded licensed veterinary pathologist and scored for evidence of lung injury and pneumonia. RESULTS: Fifteen animals (8 nectar-thickener group, 7 control group) survived until the endpoint of the study (day 18). Serum CBC did not show abnormalities at any timepoint in either group. Histological evidence of lung inflammation and edema were significantly greater in the nectar-thick group compared to controls (P < .05). Signs of inflammation included aggregates of foamy macrophages, expansion of bronchiolar lymphoid tissue, and large numbers of eosinophilic intraalveolar crystals. Histiocytic and neutrophilic pneumonia was noted in one animal that received thickened liquids. CONCLUSION: Recurrent aspiration of small amounts of thickened water resulted in significant pulmonary inflammation in a murine model of aspiration. Results of this study support the need for further investigation of liquid thickener safety and its efficacy in reducing the pulmonary complications of swallowing disorders. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1223-1228, 2021.

Induction chemotherapy for locally advanced laryngeal and hypopharyngeal cancer: Single institution experience.

BACKGROUND: The role of induction chemotherapy (IC) in locally-advanced head and neck squamous cell carcinoma (LAHNSCC) is unclear. METHODS: A retrospective study of 104 patients with LAHNSCC of the larynx and hypopharynx, treated with IC or up-front chemoradiotherapy (CRT). RESULTS: Eighty patients received CRT and 24 IC followed by CRT; median follow up was 51.33 months. IC significantly improved median overall survival (OS) in the hypopharyngeal cancer group (64.7 vs 21 months, P = .003); with significant difference in the proportion of complete response at first imaging assessment post definitive CRT; no significant difference in disease free survival (DFS), loco-regional or distant failure in the hypopharyngeal cancer group; or OS and DFS in the laryngeal cancer group. Patients with laryngeal cancer had significantly better median OS than those with hypopharyngeal cancer. CONCLUSIONS: IC significantly improved complete response rates after CRT, and improved outcomes for patients with locally advanced hypopharyngeal, not laryngeal, cancers.

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.

Validation of a computerized scoring system for foreign body aspiration: An observational study.

OBJECTIVE: The diagnosis of foreign body aspiration (FBA) is challenging. In a previous study, we developed a computerized scoring system (CSS) to support decision-making. In the present study, we aimed to validate it on a further cohort. STUDY DESIGN: In this observational study, 100 children referred to the emergency department of a tertiary pediatric hospital for suspected FBA and treated according to standard protocol, were assigned a probability score using the CSS, between 0 and 1 (0, very low probability; 1, very high). The diagnosis of FBA was based on bronchoscopy, and if discharged without bronchoscopy, determined via telephone questionnaire, 4 to 6 months after discharge, supplemented by clinical re-evaluation and bronchoscopy, if respiratory symptoms persisted. RESULTS: Thirty-five out of 100 children (35%) underwent bronchoscopy with 12 of 35 (34%) positive for FBA. Sixty-five patients were discharged without bronchoscopy and completed a telephone questionnaire. Seven patients required clinical re-evaluation for persistent respiratory symptoms, in two out of them, additional bronchoscopies were performed and were negative. The CSS median probability score was 0.94 in patients with FBA, as compared to 0.73 in patients without FBA (P = .007). The CSS area under the receiver operating curve was 0.74. At a probability score threshold of 0.6, the sensitivity and specificity were 100% and 41%, respectively. CONCLUSION: The present validation study suggests a high sensitivity of the CSS for the identification of FBA in children. We suggest that it might aid decision-making with regard to the need for bronchoscopy in children presenting to the emergency room.

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.