Longitudinal Analysis of Dysphagia and Factors Related to Postoperative Pneumonia in Patients Undergoing Esophagectomy for Esophageal Cancer.

Few studies have quantified longitudinal changes in swallowing in patients undergoing esophagectomy for esophageal cancer. This study longitudinally analyzed the changes in the Modified Barium Swallow Study Impairment Profile (MBSImP™) scores, swallowing kinematic measurements, and swallowing-related symptoms in patients undergoing esophagectomy. We also examined the association between identified swallowing impairment and aspiration pneumonia after surgery. We included consecutive patients who underwent esophagectomy and completed laryngoscopy and videofluoroscopy before, two weeks, and three months after surgery. We analyzed physiological impairments using the MBSImP. We also assessed the swallowing kinematics on a 5 mL thickened liquid bolus at three time points. Vocal fold mobility was assessed using a laryngoscope. Repeated measures were statistically examined for longitudinal changes in swallowing function. The association between the significant changes identified after esophagectomy and aspiration pneumonia was tested. Twenty-nine patients were included in this study. Preoperative swallowing function was intact in all participants. The timing of swallowing initiation and opening of the pharyngoesophageal segment remained unchanged after surgery. Tongue base retraction and pharyngeal constriction ratio worsened two weeks after surgery but returned to baseline levels three months after surgery. Three months after surgery, hyoid displacement and vocal fold immobility did not fully recover. Aspiration pneumonia occurred in nine patients after surgery and was associated with postoperative MBSImP pharyngeal residue scores. Decreased hyoid displacement and vocal fold immobility were observed postoperatively and persisted for a long time. The postoperative pharyngeal residue was associated with pneumonia and thus should be appropriately managed after surgery.

Aspiration Prevention Surgery: Clinical Factors Associated With Improvements in Oral Status Intake and Suction Frequency.

OBJECTIVE: In recent years, the use of aspiration prevention surgery (APS) for the treatment of severe dysphagia has been on the rise. However, relevant clinical studies have included small samples, and the frequency of, and risk factors for postoperative complications have not been clarified. We investigated the clinical features of patients undergoing APS and whether oral-intake status and suction frequency could be reduced. STUDY DESIGN: A case series. SETTING: Single-institution academic center. METHODS: We retrospectively evaluated medical charts generated from 2010 to 2021. The clinical characteristics of patients undergoing APS, changes in the oral-intake status (Functional Oral Intake Scale, FOIS), suction frequency before and after surgery, risk factors for postoperative complications, and factors contributing to improvements in postoperative oral-intake status were retrieved. RESULTS: We included the data of 100 patients (median age: 65 years, 72 men). Amyotrophic lateral sclerosis was the most common primary disease (28%), and glottis closure was the most common APS (69%). Postoperatively, 78% of patients showed improvements in the FOIS score, and suction frequency decreased in 85% of cases. Postoperative complications were observed in 10 patients (10%), wound infection in 6, and bleeding in 4; all improved. Higher preoperative FOIS scores were significantly associated with postoperative complications (p = 0.02). CONCLUSION: APS contributed to improving the FOIS score and helped reduce the suction frequency in most cases. APS can be performed safely with proper perioperative management, even in patients with poor preoperative general conditions and nutritional status.

Sex-and Age-Based Etiological Analysis of 2901 Patients With Dysphonia in a Japanese Tertiary Medical Institute.

OBJECTIVES: Societal aging is a grave concern in Japan, and its impact on voice clinics has not been investigated. This study aimed to clarify recent demographic features of geriatric dysphonia at a tertiary medical institute in Japan. STUDY DESIGN: Retrospective study. METHODS: The medical records of 2901 patients newly referred to the Voice Outpatient Clinic of the University of Tokyo Hospital between 2003 and 2020 were analyzed for age, sex, and etiology. RESULTS: The mean ± standard deviation age of all patients was 53.2 ± 20.7 (median, 58; range, 0-95) years. The aging rate (ratio of patients aged ≥65 years) increased continuously during the study period, and the recent aging rate was the highest in the world (43%). However, its rate of increase has slowed over the past 10 years. The etiologies of dysphonia associated with the largest number of older patients were vocal fold immobility (32%), vocal fold atrophy (23%), and benign vocal fold lesions (11%). The highest aging rate was detected in patients with laryngeal cancer/leukoplakia, vocal tremor, vocal fold atrophy, sulcus vocalis, and vocal fold immobility. CONCLUSIONS: Societal aging substantially increased the aging rate of patients with dysphonia in a Japanese voice clinic. The incidence of vocal fold immobility and atrophy is expected to continue to increase, whereas that of benign vocal fold lesions is expected to decrease.

Risk Factors for Aspiration Pneumonia After Receiving Liquid-Thickening Recommendations.

OBJECTIVE: We examined the influence of liquid thickness levels on the frequency of liquid penetration-aspiration in patients with dysphagia and evaluated the clinical risk factors for penetration-aspiration and aspiration pneumonia development. STUDY DESIGN: A case series. SETTING: Single-institution academic center. METHODS: We reviewed medical charts from 2018 to 2019. First, we evaluated whether liquid thickness levels influence the frequency of liquid penetration-aspiration in patients with dysphagia. Penetration-aspiration occurrence in a videofluoroscopic swallowing study was defined as Penetration-Aspiration Scale (PAS) scores ≥3. Second, the association between liquid thickness level and penetration-aspiration was analyzed, and clinical risk factors were identified. Moreover, clinical risk factors for aspiration pneumonia development within 6 months were investigated. RESULTS: Of 483 patients, 159 showed penetration-aspiration. The thickening of liquids significantly decreased the incidence of penetration-aspiration (P < .001). Clinical risk factors for penetration-aspiration were vocal fold paralysis (odds ratio [OR], 1.99), impaired laryngeal sensation (OR, 5.01), and a history of pneumonia (OR, 2.90). Twenty-three patients developed aspiration pneumonia while undertaking advised dietary changes, including liquid thickening. Significant risk factors for aspiration pneumonia development were poor performance status (OR, 1.85), PAS score ≥3 (OR, 4.03), and a history of aspiration pneumonia (OR, 7.00). CONCLUSION: Thickening of liquids can reduce the incidence of penetration-aspiration. Vocal fold paralysis, impaired laryngeal sensation, and history of aspiration pneumonia are significant risk factors of penetration-aspiration. Poor performance status, PAS score ≥3, and history of aspiration pneumonia are significantly associated with aspiration pneumonia development following recommendations on thickening liquids. LEVEL OF EVIDENCE: 3.

Safety of surgical tracheostomy under continued antithrombotic therapy: A retrospective cohort study.

OBJECTIVE: Although various guidelines have been established for the management of antithrombotic therapy during surgical treatments, surgical tracheostomy (ST) under continued antithrombotic therapy (CAT) remains challenging. Here, we investigated the risk factors for complications after ST by focusing on the application of CAT during ST. DESIGN: A retrospective cohort study with medical records from 2009 to 2020. SETTING: A single-center study. PARTICIPANTS: This study included patients who had undergone ST at the Department of Otolaryngology of our hospital MAIN OUTCOME MEASURES: The primary outcomes were the incidence of complications and blood test results. Secondary outcomes were risk factors for postoperative complications. RESULTS: We identified 288 patients (median age: 64 years; 184 men [64%]), among whom 40 (median age: 67 years; 29 men [73%]) underwent CAT. Although the patients undergoing CAT had significantly longer activated partial thromboplastin time (p=0.002) and a higher prothrombin time-international normalized ratio (p=0.006) compared to antithrombotic naïve patients, no statistically significant intergroup differences were observed for the risk of bleeding, infection, or subcutaneous emphysema. Instead, ST under local anesthesia (p=0.01) and ST for airway emergency (p=0.02) significantly increased the risk of early postoperative complications. CONCLUSION: These results suggest that ST under CAT can be safely performed without any increased risk of postoperative complications. Nevertheless, surgeons should be extra cautious about early complications after ST under local anesthesia without intubation or ST for airway emergencies.

Effects of Aspiration Prevention Surgery on the Dynamics of the Pharynx and Upper Esophageal Sphincter.

OBJECTIVE: Oral intake after aspiration prevention surgery (APS) is influenced by postoperative pharyngeal pressure and the dynamics of the upper esophageal sphincter (UES). We examined the effects of less invasive APS combined with UES relaxation techniques (laryngeal closure with cricopharyngeal myotomy [LC-CPM] and central-part laryngectomy [CPL]) on pharyngeal pressure and UES dynamics. STUDY DESIGN: Retrospective, observational study. SETTING: Single center. METHODS: We assessed the high-resolution pharyngeal manometric parameters of patients who underwent APS from 2018 to 2020. Then, we compared the effects of bilateral cricopharyngeal myotomy (combined with LC: LC-CPM group) and total cricoidectomy (CPL group) on both pharyngeal pressure and UES dynamics pre- and postoperatively. RESULTS: Eighteen patients (median age, 68 years; 17 men [94%]) were enrolled. Primary diseases associated with severe aspiration were neuromuscular disorders in 13, stroke in 3, and others in 2 patients. Pharyngeal swallowing pressure did not significantly change before and after APS. UES resting pressure and UES relaxation duration were significantly reduced (P < .001) and prolonged (P < .001), respectively, after APS. Only the CPL group (8 patients: median 62 years, all men) showed an increase in the velopharyngeal closure integral after APS (P < .05). More prolonged UES relaxation duration was recognized postoperatively in the CPL group (P < .01) than in the LC-CPM group. CONCLUSION: Less invasive APS minimally affects pharyngeal swallowing pressure, decreases UES resting pressure, and prolongs UES relaxation duration. CPL may be more effective for postoperative UES relaxation in patients with a short UES relaxation time.

The effects of barium concentration levels on the pulmonary inflammatory response in a rat model of aspiration.

PURPOSE: Barium sulfate (Ba) suspension is the most widely used contrast agent for upper gastrointestinal and videofluoroscopic swallow studies (VFSS). The effect of Ba concentration on lung injury is uncertain. The aims of this study were to explore the effects of different barium concentrations on the respiratory organs and elucidate the underlying mechanisms of these effects in an established animal model of aspiration. METHODS: Animal model study. Eight-week-old male Sprague-Dawley rats were allocated into three groups (n = 12, each group). Two groups underwent tracheal instillation of low (30% w/v) and high (60% w/v) concentration Ba (low-Ba, high-Ba). A control group was instilled with saline. Half of the animals were euthanized on day 2 and the remaining half were euthanized on day 30. Histological and gene analyses were performed. RESULTS: Both low-Ba and high-Ba aspiration caused inflammatory cell infiltration in the lung at 2 days post aspiration with an increase in the expression of inflammatory cytokines. At 30 days post aspiration, small quantities of barium particles remained in the lung of the low-Ba group without any inflammatory reaction. Chronic inflammation was recognized in the high-Ba group up to 30 days post aspiration. CONCLUSION: A small amount of high concentration Ba (60% w/v) caused sustained inflammation in the rat lung at least 30 days after aspiration. Even with a small amount of low concentration Ba aspiration (30% w/v), Ba particles can remain in the lung over a month, causing sustained late effects.

Choice of Aspiration Prevention Surgery for Patients With Neuromuscular Disorders: Report of Three Cases.

Dysphagia, one of the major complications of neuromuscular diseases such as Parkinson's disease and amyotrophic lateral sclerosis (ALS), decreases quality of life and may lead to malnutrition or aspiration pneumonia. Although recent reports have suggested that surgical aspiration prevention improves quality of life and enables oral intake, the selection of appropriate aspiration prevention techniques has rarely been discussed. In this report, we present the cases of three patients with neuromuscular diseases who underwent surgical aspiration prevention; we selected the surgical techniques based on analysis of the dysphagia mechanisms, disease progression, and general condition in each case. Case 1 was a 55-year-old man with multiple system atrophy (MSA) and presented with dysphagia associated with insufficient upper esophageal sphincter (UES) relaxation. We performed central-part laryngectomy, which was able to improve UES relaxation. Case 2 was a 79-year-old man with progressive supranuclear palsy who presented with respiratory disorder and dysphagia. Glottic closure under local anesthesia was selected because he also had acute hepatobiliary dysfunction and methicillin-resistant Staphylococcus aureus pneumonia with pleural effusion. Case 3 was a 75-year-old man with ALS and presented with respiratory disorder and mild dysphagia. Subglottic closure with total cricoidectomy was selected because his dysphagia was expected to worsen due to tracheostomy and disease progression. We also summarize the characteristics of the aspiration prevention surgical techniques based on our cases and on literature review. The causes of dysphagia, including insufficient UES opening during swallowing, weak pharyngeal constriction, velopharyngeal insufficiency, and inadequate laryngeal elevation, should be assessed by detailed examination before surgery, and the type of aspiration prevention surgery should be selected based on patient swallowing function and general condition.

Unilateral vocal fold adductor paralysis after tracheal intubation.

Vocal fold immobility is a relatively rare complication that can occur after tracheal intubation. Differential diagnoses include a rare clinical entity called unilateral vocal fold adductor paralysis in which only branches entering the thyroarytenoid and lateral cricoarytenoid muscles of the recurrent laryngeal nerve become paralyzed. Computed tomography and laryngeal electromyography are required to distinguish this condition from others such as cricoarytenoid dislocation/subluxation. Here, we describe two patients who developed vocal fold adductor paralysis after intubation. Patient 1 was a 56-year-old man who underwent living-donor liver transplantation and was extubated on day 7 after surgery. Patient 2 was a 52-year-old man who received life support measures including intubation due to ventricular fibrillation, and was extubated two days later. Both were hoarse soon after extubation. Endoscopic laryngeal examination revealed normal abduction and insufficient adduction of paralyzed vocal folds. Computed tomography ruled out cricoarytenoid dislocation/subluxation and laryngeal electromyography confirmed unilateral vocal fold adductor paralysis. Laryngologists should consider this rare pathogenesis.

High-speed Videolaryngoscopy: Quantitative Parameters of Glottal Area Waveforms and High-speed Kymography in Healthy Individuals.

OBJECTIVES: We conducted a study to obtain quantitative parameters of the vocal dynamic using high-speed videolaryngoscopy and to characterize the vocal fold vibration pattern of healthy individuals by analyzing glottal area waveforms and high-speed kymography. METHODS: Laryngeal images of 45 healthy individuals were captured using high-speed videolaryngoscopy. The open and speed quotients of the glottal area waveforms and high-speed kymography were obtained and statistically analyzed according to the gender of each individual. RESULTS: Glottal area waveforms revealed average values of 0.85 and 1.16 for open and speed quotients, respectively, for women, and 0.70 and 1.19 for men. Using high-speed kymography, quantitative parameters of open and speed quotients for women were 0.62 and 1.02, respectively, and for men were 0.57 and 1.12. By gender, a significant statistical difference emerged for open quotients obtained from both glottal area waveforms (P = 0.004) and high-speed kymography (P = 0.013). CONCLUSION: Obtained by using computational tools specifically for analyzing laryngeal images from high-speed videolaryngoscopy, quantitative parameters of glottal area waveforms and high-speed kymography in healthy individuals provide reference data and normality for future studies.

Visualization and Estimation of Vibratory Disturbance in Vocal Fold Scar Using High-Speed Digital Imaging.

OBJECTIVE: To explore the method to visualize and quantify the abnormality of vocal fold vibration in vocal fold scar (VFS) using high-speed digital imaging (HSDI). METHODS: HSDI was performed on 12 patients (2 men and 10 women) with VFS and 46 vocally healthy subjects (17 men and 29 women), and the obtained data were quantitatively evaluated by frame-by-frame analysis, laryngotopography (LTG), single-line and multiline kymography, and glottal area waveform. RESULTS: Visualization of a scarred area was feasible in 75% of VFS in the present study using LTG. Quantitative HSDI analysis revealed that VFS had poorer glottal closure (eg, larger open quotients, larger minimal glottal area), reduced vibration in a scarred area (eg, smaller mucosal wave magnitude, mucosal wave persistence, lateral peak index), and greater asymmetry (eg, amplitude difference, mucosal wave magnitude difference, lateral phase difference) than the control group. Correlation study revealed moderate correlations between HSDI-derived parameters and conventional acoustic or aerodynamic parameters (eg, period perturbation quotient). CONCLUSIONS: HSDI is considered to be useful in the diagnosis of VFS, visualization of a scarred area, and quantification of vibratory abnormality.

Quantification of Vocal Fold Vibration in Various Laryngeal Disorders Using High-Speed Digital Imaging.

OBJECTIVE: To quantify vibratory characteristics of various laryngeal disorders seen by high-speed digital imaging (HSDI). METHODS: HSDI was performed on 78 patients with various laryngeal disorders (20 with polyp, 16 with carcinoma, 13 with leukoplakia, 6 with vocal fold nodule, and 33 with others) and 29 vocally healthy subjects. Obtained data were quantitatively evaluated by frame-by-frame analysis, laryngotopography, digital kymography, and glottal area waveform. RESULTS: Overall, patients with laryngeal pathologies showed greater asymmetry in amplitude, mucosal wave and phase, smaller mucosal wave, and poorer glottal closure than vocally healthy subjects. Furthermore, disease-specific vibratory disturbances that generally agreed with the findings in the literature were quantified: comparing polyp with nodule, differences were noted in longitudinal phase difference, amplitude, and mucosal wave. In comparison with leukoplakia and cancer, nonvibrating area was more frequently noted in cancer. CONCLUSIONS: The HSDI analysis of various voice disorders using multiple methods can help phonosurgeons to properly diagnose various laryngeal pathologies and to estimate the degree of their vocal disturbances.

Quantitative Analysis of Vocal Fold Vibration in Vocal Fold Paralysis With the Use of High-speed Digital Imaging.

INTRODUCTION: The goal of this work was to objectively elucidate the vibratory characteristics of vocal fold paralysis (VFP) using high-speed digital imaging (HSDI). METHODS: HSDI was performed in 29 vocally healthy subjects (12 women and 17 men) and in 107 patients with VFP (40 women and 67 men). Then, the HSDI data were evaluated by visual-perceptual rating, single-line kymography, multiline kymography, laryngotopography, and glottal area waveform analysis. RESULTS: Patients with VFP compared with vocally healthy subjects revealed more frequent incomplete glottal closure, greater asymmetry in amplitude, mucosal wave, frequency, and phase, as well as larger open quotient, smaller speed index, larger maximal and minimal glottal area, and smaller glottal area difference. Paralyzed vocal folds in VFP revealed reduced mucosal wave than nonparalyzed vocal folds in VFP or in intact vocal folds in vocally healthy subjects. CONCLUSIONS: HSDI was effective in documenting the characteristics of vocal fold vibrations in patients with VFP and in exploring the vibratory disturbance for estimating the severity of dysphonia.

Supra-thyroid alar cartilage approach for the complete resection of laryngeal submucosal tumors and postoperative voice quality.

Various surgical approaches for the treatment of laryngeal submucosal tumors have been reported. Endoscopic excision is indicated for small lesions, while external approaches are recommended for larger tumors. This report introduces a supra-thyroid alar cartilage approach (STACA), which has strong advantages for the preservation of the laryngeal framework and voice recovery after surgery. Case series with chart review. Four patients with laryngeal submucosal tumors in the paraglottic space underwent complete tumor removal through STACA. Medical charts were reviewed to evaluate patient background, major complaints, tumor type, tumor size, the time period from operation to tracheostomy closure, tumor recurrence, and the difference between pre- and postoperative voice quality. Voice quality was assessed using the GRBAS score, maximum phonation time (MPT) and Voice Handicap Index-10 (VHI-10) 6 months after surgery. All patients were females between 43 and 67 years of age. Two patients had schwannoma, one laryngocele, and one lipoma. Mean tumor size was 3.4 cm. The main complaints were hoarseness in all patients, and dyspnea in one. The periods of time from surgery to oral intake and tracheostomy closure were 3.5 and 7 days, respectively. No patient developed recurrence during a minimum follow-up period of 2 years. The postoperative GRBAS scores, MPT and VHI-10 improved in all patients. STACA has advantages including minimal trauma, no deformity to the laryngeal framework, and good voice qualities after the resection of laryngeal submucosal tumors.

Estimation of inferior-superior vocal fold kinematics from high-speed stereo endoscopic data in vivo.

Despite being an indispensable tool for both researchers and clinicians, traditional endoscopic imaging of the human vocal folds is limited in that it cannot capture their inferior-superior motion. A three-dimensional reconstruction technique using high-speed video imaging of the vocal folds in stereo is explored in an effort to estimate the inferior-superior motion of the medial-most edge of the vocal folds under normal muscle activation in vivo. Traditional stereo-matching algorithms from the field of computer vision are considered and modified to suit the specific challenges of the in vivo application. Inferior-superior motion of the medial vocal fold surface of three healthy speakers is reconstructed over one glottal cycle. The inferior-superior amplitude of the mucosal wave is found to be approximately 13 mm for normal modal voice, reducing to approximately 3 mm for strained falsetto voice, with uncertainty estimated at σ ≈ 2 mm and σ ≈ 1 mm, respectively. Sources of error, and their relative effects on the estimation of the inferior-superior motion, are considered and recommendations are made to improve the technique.

Vocal fold atrophy in a Japanese tertiary medical institute: status quo of the most aged country.

OBJECTIVE: Voice problems in the geriatric population are increasing worldwide. Since the demographic research of geriatric voice patients in Japan, the country of the most advanced Aging Society, is missing, the authors assessed the current trend of geriatric voice patients, especially patients with presbylarynx at a tertiary medical institute of Japan. STUDY DESIGN: Retrospective study. METHODS: From a review of the medical records of newly referred patients, patients aged 65 years and older and patients with vocal fold atrophy were selected, and demographic data, questionnaires, and parameters of aerodynamic and acoustic study, and videostroboscopy were analyzed in terms of age and gender. Subsequently, the difference between patients with presbylarynx and 20 vocally healthy elderly subjects were assessed with multivariate analysis. RESULTS: Of 1157 newly referred patients seen at the Voice Outpatient Clinic between 2006 and 2012, patients aged 65 years and older accounted for 37% (428 patients): there was 7% increase during the past 7 years and the prevalence was considerably higher than any other previous reports. Vocal fold atrophy accounted for 11% (128 patients) of all patients: dysphonia in patients with vocal fold atrophy aggravated as age advanced; there was a gender difference; and multivariate analysis revealed that reflux laryngitis, chronic medical condition, and vocal abuse were risk factors of presbylarynx. CONCLUSION: In Japan, elderly dysphonic patients were prevalent and rapidly increasing in recent years. Age- and gender-related differences should receive attention. Preventive approach on risk factors such as reflux laryngitis, chronic medical condition, and vocal abuse should be considered in the management of presbylarynx.

Evaluation of vocal fold vibration with an assessment form for high-speed digital imaging: comparative study between healthy young and elderly subjects.

OBJECTIVES/STUDY DESIGN: We conducted a prospective study with a subjective assessment form for high-speed digital imaging (HSDI) to elucidate the features of vocal fold vibrations in vocally healthy subjects and to clarify gender- and age-related differences. METHODS: Healthy adult volunteers participated in this study. They were divided into young (aged 35 and younger) and elderly (aged 65 and older) groups, and the scores of an assessment form for HSDI characteristics elaborated at our institution were statistically analyzed. RESULTS: Twenty-six young subjects (males: 9, females: 17; mean age: 27 years) and 20 elderly subjects (males: 8, females: 12; mean age: 72 years) were assigned to our study. Posterior gap and posterior-to-anterior longitudinal phase difference were characteristic to young females, whereas in young males, mucosal wave, anterior-to-posterior longitudinal phase difference, and supraglottic hyperactivity were frequent. In elderly males, axis shift, asymmetry, supraglottic hyperactivity, increased mucosal wave, lateral phase difference, and anterior-to-posterior longitudinal phase difference were frequent; and in elderly females, high incidence of lateral phase difference, atrophic change, anterior gap, and asymmetry were observed. CONCLUSIONS: The results show that the behaviors of vocal fold vibrations were diverse even in healthy subjects with no vocal complaints or history of laryngeal diseases, and hence, the diversity of vocal fold vibrations in normal subjects must be taken into account in evaluating vocal fold vibrations.