Association of the "Jet Phenomenon" with Positive Symptom Outcome Following Surgical Treatment of Cricopharyngeus Muscle Dysfunction.

OBJECTIVES: Cricopharyngeus muscle dysfunction (CPMD) is a common cause for progressive dysphagia and can lead to dietary restriction, reduced nutrition, weight loss, and pneumonia. Controversy exists whether CPMD is best managed with primary surgical treatment of the cricopharyngeus muscle and who represents a good surgical candidate. METHODS: Retrospective review of patients diagnosed with CPMD who underwent surgical treatment were evaluated through prospectively collected pre- and postoperative Eating Assessment Tool-10 (EAT-10) and Functional Oral Intake Scale (FOIS). Videofluoroscopic swallowing studies (VFSS) were reviewed for presence or absence of a high-pressure barium stream through the upper esophageal sphincter, termed the jet phenomenon (JP). RESULTS: We identified 42 patients with CPMD who underwent surgical treatment and had serial Eating Assessment Tool (EAT-10) measures obtained pre- and postoperatively. Mean EAT-10 scores improved by 12.1 points (95%CI = 8.6-15.6), p < 0.0001. There was a significantly greater improvement among patients with JP (|∆EAT-10|= 17.0, 95%CI = 12.5-21.4) compared to those without (|∆EAT-10|= 6.2, 95%CI = 1.6-10.8), p = 0.0013. Patients with JP also showed improved FOIS score (p = 0.0023) while those without JP did not. CONCLUSION: This study provides the initial report on the utility of JP as a VFSS feature that is strongly associated with improved outcomes following surgical treatment of CPMD. Further work determining the physiologic correlates responsible for JP will help clarify its predictive capabilities. LEVEL OF EVIDENCE: Level 3.

Natural History of Cricopharyngeus Muscle Dysfunction Symptomatology.

Cricopharyngeus muscle dysfunction (CPMD) is a common cause for progressive dysphagia and can lead to dietary restriction, reduced nutrition, weight loss, and pneumonia. There is a continuum between small, non-obstructive cricopharyngeus bars representing mild disease and severely obstructive bars or Zenker's diverticulum forming late-stage disease, but the natural history of untreated CPMD and the associated time course for progression is unknown. Retrospective longitudinal cohort study from a tertiary outpatient dysphagia centre. Patients diagnosed with CPMD by fluoroscopy and either awaiting surgical treatment or electing non-operative management were evaluated through prospectively collected Eating Assessment Tool-10 (EAT-10) and Functional Oral Intake Scale (FOIS). Review of available imaging identified degree of CPMD. We identified 174 patients with CPMD diagnosed between July 1, 2016, and June 30, 2020; 52 patients had serial Eating Assessment Tool (EAT-10) measures obtained at time of diagnosis and follow up appointment without operative treatment. Mean EAT-10 scores increased from 17.1 to 20.6 (3.5 ± 8.1 points, p = 0.002) points. This change was related to those with a Zenker's diverticulum rather than an isolated cricopharyngeus bar. Dietary outcomes measured by FOIS were stable. While some patients showed fluoroscopic progression of bar size, no patients developed a Zenker's diverticulum from a pre-existing bar in this population. Our data indicate patients with a cricopharyngeus bar do not decline in subjective dysphagia score or diet tolerance, however those with a Zenker's diverticulum worsen over time. This has implications for treatment timing and counselling patients but also reflects a need to understand the pathophysiology behind CPMD and the subset of patients who show progression.

Correlating Dysphagia Severity with Fluoroscopic Parameters in Patients with Zenker's Diverticulum.

Zenker's diverticulum (ZD) is an uncommon condition characterized by formation of a pseudodiverticulum in the hypopharynx that presents with considerable variability in swallowing symptomatology. Identifying radiographic features of ZD most associated with clinical impact could prove useful in counseling patients and predicting treatment response. This study was a retrospective case series of patients undergoing videofluoroscopic swallowing studies (VFSS) for Zenker's diverticulum at a tertiary dysphagia center. Anatomic parameters identified on VFSS of patients with ZD were correlated with subjective perception of swallowing using Eating Assessment Tool (EAT-10) scores. Upper esophageal sphincter (UES) opening at the point of maximal distention, area of diverticulum on the lateral view, height of the diverticulum, and entrance angle of the esophagus were measured. We identified 40 patients with ZD (52.5% male, mean age = 71.2 years). Narrow UES opening was significantly correlated with dysphagia severity (r = - 0.3445, p = 0.035). Largest area of diverticulum (r = 0.0188, p = 0.87), diverticulum height (r = 0.1435, p = 0.45), and esophageal entrance angle (r = 0.1677, p = 0.42) were not correlated with EAT-10 scores. Maximum UES opening size was predictive of severity of swallowing dysfunction in patients with ZD. Size of ZD and the angle of bolus entry in patients with ZD are not predictive of swallowing dysfunction. Understanding the predictors of swallowing dysfunction will assist in counseling patients on postoperative expectations.

Airway management changes associated with rising radiologic incidence of external laryngotracheal injury.

BACKGROUND: Traumatic laryngeal injuries are uncommon life-threatening injuries that require prompt, rational management of a potentially precarious airway. It is unclear whether the current incidence of laryngotracheal injury is due to enhanced injury detection or increased occurrence. The objective of this study was to evaluate the relations between diagnostic imaging with both initial airway management and surgical treatment in patients with external laryngotracheal injuries (ELTIs) in Alberta. METHODS: In this large-scale population-based analysis, we used regional health databases containing inpatient admissions, emergency department visits and trauma service activations employing International Classification of Diseases diagnostic codes to identify all ELTIs diagnosed from Apr. 1, 1995, to Dec. 31, 2011, in adults (age ≥ 16 yr). We evaluated health records and diagnostic imaging for injury features, airway management, operative interventions and hospital length of stay (LOS). RESULTS: Eighty-nine patients met the inclusion criteria. The incidence of ELTIs increased over time, paralleling a rise in detection during the period incorporating greater computed tomography (CT) use (p = 0.002). Endotracheal tube intubation was performed in 8/30 cases (27%) in the pre-CT era, compared to 38/59 cases (64%) in the post-CT era (p = 0.001); the use of surgical intervention remained consistent. The largest contributors to increased endotracheal tube placements were the emergency department and emergency medical services. No change in survival was detected, but mean LOS among patients admitted for minor, isolated ELTIs increased by 2.3 (95% confidence interval 0.14-4.8) days (p = 0.06), mostly for patients admitted under critical care for mechanical ventilation. CONCLUSION: Management of ELTIs shifted from predominantly conservative airway monitoring to endotracheal tube intubation over the study period in spite of no clinically significant change in injury severity or operative intervention frequency. The location of endotracheal tube placement suggests less comfort with ELTI among first-responder and emergency personnel.

CONTEXTE: Les lésions traumatiques du larynx sont des blessures rares qui peuvent être mortelles et nécessitent une prise en charge rapide et efficiente, en raison de l'état potentiellement précaire des voies respiratoires. On ignore si l'incidence actuelle des lésions laryngo-trachéales est attribuable à une amélioration de la détection ou à une augmentation de la fréquence réelle. Cette étude avait pour but d'évaluer le lien entre l'imagerie diagnostique, et la prise en charge initiale des voies respiratoires ainsi que le traitement chirurgical chez des patients ayant subi des lésions laryngo-trachéales externes (LLTE) en Alberta. MÉTHODES: Dans le cadre de cette analyse de grande envergure basée sur une population, nous avons interrogé des bases de données régionales sur les hospitalisations, les consultations aux services d'urgence et la prestation de services de traumatologie. Nous nous sommes servis des codes diagnostiques de la Classification statistique internationale des maladies pour repérer tous les cas de LLTE diagnostiqués entre le 1er avril 1995 et le 31 décembre 2011 chez des adultes (16 ans et plus). Nous avons examiné les dossiers de santé et les résultats d'imagerie diagnostique pour en extraire des données sur les caractéristiques des lésions, la prise en charge des voies respiratoires, les interventions chirurgicales et la durée de séjour à l'hôpital. RÉSULTATS: Au total, 89 patients répondaient aux critères d'inclusion. L'incidence des LLTE a augmenté au fil du temps; en parallèle, l'utilisation répandue de la tomographie par ordinateur a entraîné une augmentation de la détection de ces lésions (p = 0,002). Une intubation trachéale a été réalisée chez 8/30 patients (27 %) pendant la période prétomographie, et chez 38/59 patients (64 %) pendant la période post-tomographie (p = 0,001); le recours à la chirurgie est demeuré constant. L'augmentation du nombre d'intubations est principalement attribuable aux interventions effectuées par le personnel ambulancier et par les services d'urgence. Aucun changement du taux de survie n'a été enregistré; toutefois, la durée de séjour moyenne des patients hospitalisés en raison de LLTE mineures et isolées a augmenté de 2,3 jours (intervalle de confiance à 95 % : 0,14-4,8; p = 0,06), surtout pour les patients admis aux soins intensifs pour recevoir une ventilation mécanique. CONCLUSION: Durant la période à l'étude, la prise en charge des LLTE est passée d'un suivi essentiellement conservateur des voies respiratoires à la prépondérance de l'intubation trachéale, bien qu'aucun changement significatif n'ait été observé quant à la gravité des lésions ou à la fréquence des interventions chirurgicales. Le contexte où ont lieu les intubations laisse croire que le personnel ambulanciers et les premiers intervenants sont moins à l'aise de prendre en charge les LLTE.

The Relationship between Upper Esophageal Sphincter Manometry Function and Esophageal Motility Disorders.

OBJECTIVE: High-resolution manometry (HRM) provides measures of esophageal function which are used to classify esophageal motility disorders based on the Chicago Classification system. Upper esophageal sphincter (UES) measures are obtained from HRM, but are not included in the classification system, rendering the relationship between UES measures and esophageal motility disorders unclear. Furthermore, changes in the acceptable amount of esophageal dysfunction between versions of this classification system has created controversy. The objective of this study was to determine the relationship between UES measures and esophageal function. STUDY DESIGN: Cross-sectional study. SETTING: Referral centre. METHODS: HRM studies from the Calgary Gut Motility Center were reviewed for UES mean basal pressure, mean residual pressure, relaxation time-to-nadir, relaxation duration, and recovery time. Patients were grouped by number of failed swallows according to different iterations of the Chicago Classification: 0 to 4 (Group 1), 5 to 7 (Group 2), and 8 to 10 (Group 3). RESULTS: 2114 patients (65.1% female, median age 56 y) were included. There were significant increases in UES mean basal pressure (P < .001), mean residual pressure (P < .001), relaxation duration (P < .001), and recovery time (P < .001) between groups. Positive correlations existed between number of failed swallows and UES mean basal pressure (r = 0.143; P < .001), mean residual pressure (r = 0.201; P < .001), relaxation duration (r = 0.145; P < .001), and recovery time (r = 0.168; P < .001). CONCLUSIONS: Differences in UES measures exist among patients with failed swallows, with a positive correlation between UES dysfunction and increasing dysmotility. Our findings illustrate that UES measures are closely related to esophageal function, and that even minor esophageal dysfunction is related to UES dysfunction.

Functional Outcomes of Swallowing Following Surgery for Obstructive Sleep Apnea.

OBJECTIVE: Identification and evaluation of swallowing dysfunction in patients undergoing upper airway surgery for obstructive sleep apnea (OSA) is limited. This study evaluated subjective swallowing function pre and postoperatively in patients undergoing multi-level reconstructive pharyngeal sleep surgery. METHODS: A retrospective analysis of prospectively-administered Eating Assessment Tool (EAT-10) scores was conducted among adult patients undergoing surgery for OSA at a tertiary sleep surgery center. Preoperative and 1, 3, and 6-month postoperative time points were assessed. Patients were subdivided into two groups based on the degree of upper airway reconstruction performed. All patients underwent uvulopalatopharyngoplasty +/-tonsillectomy and tongue-base reduction. Patients undergoing Phase 1 reconstructive surgery additionally underwent tongue-base advancement procedures. RESULTS: A total 100 patients underwent airway reconstructive surgery. Forty-one patients underwent Phase 1 surgery; 59 patients underwent Mini-Phase 1 surgery. Neither group demonstrated preoperative dysphagia. Both groups experienced significant subjective dysphagia at 1-month postoperatively, which was greater among Phase 1 patients (mean EAT-10 14.8; SD 10.4) versus Mini-Phase 1 patients (mean EAT-10 6.7; SD 7.5) (p < 0.001). Swallowing function among both groups normalized by 3 and 6 months postoperatively. Phase 1 patients with pre-operative dysphagia (mean EAT-10 9.6; SD 5) demonstrated initial worsening of their swallowing postoperatively; however, reported improved swallowing versus pre-operative levels by 6 months postoperatively (mean EAT-10 3.6; SD 4.3) (p = 0.03). CONCLUSION: Pharyngeal surgery resulted in no significant, persistent adverse change in swallowing function. Among both groups, significant subjective dysphagia was reported at 1 month postoperatively, yet returned to preoperative levels by 6 months postoperatively. OSA patients with pre-existing dysphagia undergoing Phase 1 surgery trended towards improved swallowing function postoperatively. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:199-204, 2023.

Developing an Artificial Intelligence Tool to Predict Vocal Cord Pathology in Primary Care Settings.

OBJECTIVES: Diagnostic tools for voice disorders are lacking for primary care physicians. Artificial intelligence (AI) tools may add to the armamentarium for physicians, decreasing the time to diagnosis and limiting the burden of dysphonia. METHODS: Voice recordings of patients were collected from 2019 to 2021 using smartphones. The Saarbruecken dataset was included for comparison. Audio files were converted to mel-spectrograms using TensorFlow. Diagnostic categories were created to group pathology, including neurological and muscular disorders, inflammatory, mass lesions, and normal. The samples were further separated into sustained/a/and the rainbow passage. RESULTS: Two hundred three prospective samples and 1131 samples were used from the Saarbruecken database. The AI detected abnormal pathology with an F1-score of 98%. The artificial neural network (ANN) differentiated key pathologies, including unilateral paralysis, laryngitis, adductor spasmodic dysphonia (ADSD), mass lesions, and normal samples with 39%-87% F-1 scores. The Calgary database models had higher F-1 scores in a head-to-head comparison to the Saarbruecken and combined datasets (87% vs. 58% and 50%). The AI outperformed otolaryngologists using a standardized test set of recordings (83% compared to 55% ± 15%). CONCLUSION: An AI tool was created to differentiate pathology by individual or categorical diagnosis with high evaluation metrics. Prospective data should be collected in a controlled fashion to reduce intrinsic variability between recordings. Multi-center data collaborations are imperative to increase the prediction capability of AI tools for detecting vocal cord pathology. We provide proof-of-concept for an AI tool to assist primary care physicians in managing dysphonic patients. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1952-1960, 2023.

Developing an Objective Structured Assessment of Technical Skills (OSATS) for Microlaryngoscopy.

BACKGROUND: Microlaryngoscopy is a basic technical skill in Oto-HNS. It is essential for residency programs to have a competency-based assessment tool to evaluate residents' performance of this procedure. An Objective Structured Assessment of Technical Skills (OSATS) is a procedure-specific assessment, which consists of the following: (a) Operation-Specific Checklist and (b) Global Rating Scale (GRS). OBJECTIVE: The objective of this study was to create an OSATS for adult microlaryngoscopy. METHODS: This was a prospective study, with an initial qualitative phase for OSATS development (Phase I), and a clinical pilot phase (Phase II). In Phase I, interviews were conducted with three laryngologists to establish a stepwise description of adult microlaryngoscopy and review a previously validated GRS for relevance to microlaryngoscopy. Responses were used to create a framework for the OSATS. The OSATS was then presented to Oto-HNS residents and laryngologists in an alternating fashion, for review of clarity and relevance. A pilot study was then performed to evaluate the resident performance of adult microlaryngoscopy. Multiple regression analysis was carried out to investigate whether training level, case complexity, and previous OSATS exposure could predict participant scores. RESULTS: Phase I of this study led to the creation of a 34-item OSATS. The pilot study (N = 28 procedures) revealed that training level was significantly correlated with increased OSATS scores. There was no statistically significant correlation between case complexity and resident scores. Assessors reported the perceived utility of the OSATS and intent for use in residency training. CONCLUSION: Application of the proposed OSATS will allow for competency-based assessment of the resident performance of microlaryngoscopy. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2719-2724, 2023.

The American Broncho-Esophagological Association Position Statement on Swallowing Fluoroscopy.

OBJECTIVES: To develop an expert consensus statement on the clinical use of swallowing fluoroscopy in adults that reduces practice variation and identifies opportunities for quality improvement in the care of patients suffering from swallowing impairment. METHODOLOGY: A search strategist reviewed data sources (PubMed, Embase, Cochrane, Web of Science, Scopus) to use as evidence for an expert development group to compose statements focusing on areas of controversy regarding swallowing fluoroscopy. Candidate statements underwent two iterations of a modified Delphi protocol to reach consensus. RESULTS: A total of 2184 publications were identified for title and abstract review with 211 publications meeting the criteria for full text review. Of these, 148 articles were included for review. An additional 116 publications were also included after reviewing the references of the full text publications from the initial search. These 264 references guided the authors to develop 41 candidate statements in various categories. Forty statements encompassing patient selection, fluoroscopic study choice, radiation safety, clinical team dynamics, training requirements, videofluoroscopic swallow study and esophagram techniques, and interpretation of swallowing fluoroscopy met criteria for consensus. One statement on esophagram technique reached near-consensus. CONCLUSIONS: These 40 statements pertaining to the comprehensive use of swallowing fluoroscopy in adults can guide the development of best practices, improve quality and safety of care, and influence policy in both the outpatient and inpatient settings. The lack of consensus on some aspects of esophagram technique likely reflects gaps in knowledge and clinical practice variation and should be a target for future research. Laryngoscope, 133:255-268, 2023.

Treatment of Essential Vocal Tremor: A Scoping Review of Evidence-Based Therapeutic Modalities.

OBJECTIVES/HYPOTHESIS: Essential vocal tremor (EVT) is an uncommon but challenging condition to manage. Several medical and interventional treatment options have been reported but efficacy remains unclear. We performed a scoping review of high-quality clinical trials to identify effective evidence-based treatments for EVT. STUDY DESIGN: Scoping review. METHODS: Relevant studies were identified using the databases MedLine, Cochrane Central Register of Controlled Trials, and Embase. Subjective and objective outcomes for each modality were analyzed and the effect sizes were quantified using Hedges' g measure to allow comparison between studies. RESULTS: We identified 421 studies eligible for screening with 11 included in the final analysis. Evidence supporting effective EVT treatments was found for bilateral versus unilateral deep brain stimulation (DBS) (Hedges' g 0.65, 95% CI = 0.10-1.20) and octanoic acid (Hedges' g 1.15, 95% CI = 0.40-1.90). Evidence to support the use of methazolamide was not sufficient (Hedges' g 0.51, 95% CI = -0.64 to 1.66). Botulinum toxin (BT) injections were equivalent when comparing unilateral versus bilateral (Hedges' g -0.18, 95% CI = -1.06 to 0.70); BT did not display any advantage over propranolol (Hedges' g -0.47, 95% CI = -1.73 to 0.78) or injection augmentation (Hedges' g 0.068, 95% CI = -0.98 to 1.12). CONCLUSIONS: Our review finds very little high-quality evidence supporting any treatment for EVT. Octanoic acid reduced fluctuations in EVT but did not affect the perception of the tremor. In refractory cases, bilateral DBS was superior to unilateral DBS in improving subjective voice outcomes. Unilateral and bilateral BT injections were equivalent, and BT injection was not more effective than injection augmentation. Further direct comparison in well-designed prospective studies may help clarify optimal treatment for EVT patients.