Normative High-Resolution Pharyngeal Manometry: Impact of Age, Size of System, and Sex on Primary Metrics and Pressure Stability.

There have been many reports of normative pharyngeal swallowing pressures using high-resolution pharyngeal manometry, but there is a fair amount of between-subject variance in reported pressure parameters. The purpose of this study was to put forward normative pharyngeal high-resolution manometry measures across the lifespan and investigate the effects of age, size of system, and sex. High-resolution pharyngeal manometry was performed on 98 healthy adults (43 males) between the ages 21 and 89. Pressure duration, maxima, integral, and within-individual variability metrics were averaged over 10 swallows of 10-ml thin liquid. Multiple linear and logistic regressions with model fitting were used to examine how pharyngeal pressures relate to age, pharyngeal size, and sex. Age was associated with tongue base maximum pressure, tongue base maximum variability, and upper esophageal sphincter-integrated relaxation pressure (F3,92 = 6.69; p < 0.001; adjusted R2 = 0.15). Pharyngeal area during bolus hold was associated with velopharynx integral (F1,89 = 5.362; p = 0.02; adjusted R2 = 0.05), and there was no significant model relating pharyngeal pressures to C2-C4 length (p < 0.05). Sex differences were best described by tongue base integral and hypopharynx maximum variability (χ2 = 10.27; p = 0.006; pseudo R2 = 0.14). Normative data reveal the distribution of swallow pressure metrics which need to be accounted for when addressing dysphagia patients, the importance of pressure interactions in normal swallow, and address the relative stability of swallow metrics with normal aging.

The Manometric Representation of the Upper Esophageal Sphincter During the Resting State: A Descriptive Study.

The upper esophageal sphincter (UES) is the high-pressure zone marking the transition between the hypopharynx and esophagus. There is limited research surrounding the resting UES using pharyngeal high-resolution manometry (HRM) and existing normative data varies widely. This study describes the manometric representation of the resting UES using a clinically accessible method of measurement. Data were obtained from 87 subjects in a normative database of pharyngeal HRM with simultaneous videofluoroscopy. The resting UES manometric region was identified and ten measurement segments of this region were taken throughout the duration of the study using the Smart Mouse function within the manometry software. Intraclass correlation coefficients (ICC) were used to analyze within-subject reliability across measurements. Linear mixed-effects regression models were used to analyze how subject characteristics and manometric conditions influence resting UES pressure. There was excellent within-subject reliability between resting UES mean pressures (ICC = 0.96). In bivariate analysis, there were significant effects of age, number of sensors contained within the resting UES, and preceding swallow volume on mean resting UES pressure. For every 1 unit increase in age, there was a 0.19 unit decrease in resting UES pressure (p = 0.008). For every 1 unit increase in number of sensors contained within the resting UES, there was a 3.71 unit increase in resting UES pressure (p < 0.001). This study presents normative data for the resting UES, using a comprehensive and clinically accessible protocol that can provide standard comparison for the study of populations with swallowing disorders, particularly UES dysfunction, and provides support for UES-directed interventions.

Enhancing Surgical Teaching Effectiveness: A Needs Assessment Study Using a Modified Delphi Process.

INTRODUCTION: As methods of measuring surgical resident competency become more defined, how can faculty know that they are effectively guiding residents toward increasing entrustment? The goal of this study was to use a systematic process to identify effective teaching behaviors, understand discrepancies between learner and teacher perception of behaviors, and provide an insight into areas for improvement in surgical teaching. MATERIALS AND METHODS: A modified Delphi process was used to create a list of critical teaching behaviors for surgical resident education in four domains: Operating Room, Clinic, Inpatient Rounds, and Didactics. Round One surveyed residents and faculty to identify critical teaching behaviors. In Rounds Two and Three, stakeholders narrowed the list to five behaviors in each domain. A needs assessment survey was created and used to identify (1) areas for improvement in residency education and (2) differences in perception of teaching behavior use between faculty and residents. RESULTS: Eighty one faculty and 56 residents in the Department of Surgery completed the survey. All teaching behaviors in the Operating Room, Clinic, and Rounds domains had a significant difference in response distribution between residents and faculty. Except in Didactics, residents perceived that teaching behaviors were performed less often by attending surgeons than was reported by the faculty members. CONCLUSIONS: A modified Delphi process is an effective way to create a needs assessment survey relating to how surgical education is delivered. Future steps will involve directed interventions aimed at improving the use of certain surgical teaching behaviors in our department.

The Natural Swallow: Factors Affecting Subject Choice of Bolus Volume and Pharyngeal Swallow Parameters in a Self-selected Swallow.

Predetermined volumes are used extensively throughout clinical assessment of swallowing physiology, but bolus volumes selected by an individual in their natural swallow can vary greatly from those used in structured assessment. This study aims to identify factors influencing self-selected volume and how the mechanics of self-selected volume swallows differ from predetermined volume swallows. We used pharyngeal high-resolution manometry (HRM) with simultaneous videofluoroscopy to measure swallowing pressures in the velopharynx, hypopharynx, and upper esophageal sphincter (UES). Data were collected from 95 healthy adults during thin liquid swallows of 10 mL and a self-selected comfortable volume. An intraclass correlation coefficient (ICC) was calculated to analyze within-subject self-selected volume reliability. Linear mixed effects regression models were used to examine the association of subject characteristics with self-selected swallow volume and of self-selected volumes on pharyngeal swallowing pressures and timing events. Mean self-selected volume was 16.66 ± 7.70 mL. Increased age (p = 0.002), male sex (p = 0.021), and increased pharyngeal hold area (p = 0.007) were significantly associated with increase in self-selected bolus volume. There was good reliability between subjects' individual swallow volumes (ICC = 0.80). Velopharyngeal maximum pressure and pressure integral, tongue base duration and maximum pressure, UES pre- and post-swallow maximum pressure, and overall pharyngeal contractile integral decreased significantly with self-selected boluses. Understanding a patient's natural swallow volume, and how their natural swallow functions, will be important for designing clinical evaluations that place stress on the patient's natural swallowing mechanics in order to assess for areas of dysfunction.

Functional Outcomes After Transoral Plus Lateral Pharyngotomy Approach for Advanced Oral and Oropharyngeal Tumors.

Objective: The aim of this study was to evaluate our institutional experience with the combined transoral plus lateral pharyngotomy (TO+LP) approach in a subset of patients with advanced or recurrent oral and oropharyngeal malignancy. Study Design: A retrospective study of procedures utilizing TO+LP for cancer resection between January 2007 and July 2019. Setting: Tertiary academic medical center. Methods: Thirty-one patients underwent a TO+LP approach for the resection of oral and oropharyngeal tumors. Functional and oncologic outcomes were analyzed. Results: Eighteen (58.1%) patients were treated with TO+LP for recurrent disease. Twenty-nine required free tissue transfer and 2 (6.5%) had positive margins. The median time to decannulation was 22 days (range 6-100 days). Thirteen (41.9%) patients still required enteral feeding at their most recent follow-up. Patients without a history of prior radiation were decannulated sooner (p = .009) and were less likely to require enteral feeding at the first postoperative follow-up (p = .034) than those who had prior head and neck radiotherapy. Conclusion: A TO+LP approach can be used to achieve good functional and oncologic results for selected patients with advanced or recurrent oral and oropharyngeal cancer when minimally invasive options such as transoral robotic surgery, transoral laser microsurgery, or radiotherapy are not possible.

Granulomatous Inflammation Causing Severe Supraglottic Edema and Airway Obstruction in a Pediatric Patient.

A 12-year-old male with a family history of inflammatory bowel disease presented with sleep-disordered breathing and was found to have chronic, granulomatous swelling of the supraglottic larynx. His airway was managed with tracheostomy, regular interval laryngeal steroid injections, supraglottoplasty, and "pepper pot" CO2 laser resurfacing leading to eventual decannulation. Due to the non-necrotic nature of the granulomatous inflammation, as well as the patient's family history of inflammatory bowel disease, the leading diagnosis was Crohn disease, but isolated laryngeal sarcoidosis could not be ruled out. There are only 13 reported cases of laryngeal manifestations of Crohn disease in the literature, with only 2 cases occurring in pediatric patients. This case report adds to this body of literature and discusses strategies for managing granulomatous supraglottic edema when definitive diagnosis is not fully clear.