The Changes in Pharyngeal Constrictor Muscles Related to Head and Neck Radiotherapy: A Systematic Review.

It is well known that radiation damage of the pharyngeal constrictor muscles, the glottic larynx, and the supraglottic larynx may lead to dysphagia, an unwanted effect of head and neck radiotherapy. The reduction of radiotherapy-induced dysphagia might be achieved by adaptive radiotherapy. Although the number of studies concerning adaptive radiotherapy of head and neck cancer is continuously increasing, there are only a few studies concerning changes in dysphagia-related structures during radiotherapy.The goal of this review is to summarize the current knowledge about volumetric, dosimetric, and other changes of the pharyngeal constrictor muscles associated with head and neck radiotherapy. A literature search was performed in the MEDLINE database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The conclusions of 8 studies that passed the criteria indicate a significant increase in the volume and the thickness of the pharyngeal constrictor muscles during radiotherapy. Moreover, the changes in magnetic resonance imaging signal intensity of the pharyngeal constrictor muscles correlate with the absorbed dose (typically higher than 50 Gy) and also with the grade of dysphagia. This systematic review presents 2 variables, which are suitable for estimation of radiotherapy-related pharyngeal constrictor muscles changes-magnetic resonance imaging signal intensity and the thickness. In the case of the thickness, there is no consensus in the level of the measurement-C2 vertebra, C3 vertebra, and the middle of the craniocaudal axis are used. It seems that reference to a position associated with a vertebral body could be more reproducible and beneficial for future research. Although late pharyngeal toxicity remains a challenge in head and neck cancer treatment, better knowledge of radiotherapy-related changes in the pharyngeal constrictor muscles contributes to adaptive radiotherapy development and thus improves the treatment results.

Injury and Apoptosis in the Palatopharyngeal Muscle in Patients with Obstructive Sleep Apnea-Hypopnea Syndrome.

BACKGROUND This study aimed to elucidate the possible activity of the mitochondrial-mediated apoptotic pathway (MMAP) in obstructive sleep apnea-hypopnea syndrome (OSAHS). MATERIAL AND METHODS A control group, a mild OSAHS group, a moderate OSAHS group, and a severe OSAHS group were included. Masson staining, hematoxylin and eosin staining, and terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) assay were performed to assess collagen fiber hyperplasia, pathological morphology, and cell apoptosis, respectively, in muscle samples. RESULTS In the OSAHS groups, the palatopharyngeal muscle fibers were larger, with apparent hypertrophy and increased elastic fiber content. The proportions of type I fibers were markedly higher in the control group than in the moderate and severe OSAHS groups (P<0.05). Moreover, apoptosis was significantly enhanced in the muscle cells of the OSAHS groups. The Bax expression levels gradually increased across the 4 groups (lowest in the control group and highest in the severe OSAHS group) (P<0.05); conversely, the p38 and p62 expression levels did not significantly differ among groups (P>0.05). CONCLUSIONS A decrease in the proportion of the different fiber types can result in collapse of the upper airway. The pathogenesis of OSAHS appears to involve muscle cell apoptosis via MMAP.

Hypopharyngeal Diverticulum: Toward a Unified Understanding of Its Etiopathogenesis.

The etiopathogenesis of Zenker's diverticulum (ZD) remains uncertain. Increased hypopharyngeal pressure due to a hypertonic upper esophageal sphincter results in herniation proximal to the sphincter producing a pulsion diverticulum. Gastroesophageal reflux, which is known to induce shortening of the injured esophagus, likely plays a prominent role in ZD formation by pulling the cricopharyngeus muscle (CPM) away from the anchored inferior constrictor muscle. This creates a "weak zone" encouraging herniation. A bilobed diverticulum may originate from continuation of the fibrous midline raphe inferiorly to developmentally include part of the CPM. We report using laser endoscopy to divide the inter-diverticular septum followed by transmucosal cricopharyngeus myotomy. Presentation of a rare, bilobed diverticulum emphasizes the importance of the midline prevertebral raphe in anchoring the pharyngeal constrictor muscles with respect to the CPM. This lends support to the hypothesis that the etiopathogenesis of ZD is multifactorial while guiding us to a unified understanding of ZD.

Volumetric Changes to the Pharynx in Healthy Aging: Consequence for Pharyngeal Swallow Mechanics and Function.

Pharyngeal lumen volume is prone to increase as a consequence of pharyngeal muscle atrophy in aging. Yet, the impact of this on swallowing mechanics and function is poorly understood. We examined the relationship between pharyngeal volume and pharyngeal swallowing mechanics and function in a sample of healthy community-dwelling seniors. Data were collected from 44 healthy seniors (21 male, mean age = 76.9, SD = 7.1). Each participant swallowed 9 boluses of barium (3 × 5 ml thin, 3 × 20 ml thin, 3 × 5 ml nectar). Pharyngeal shortening, pharyngeal constriction, pyriform sinus and vallecular residue were quantified from lateral view videofluorosopic swallowing studies. Pharyngeal lumen volume was captured during an oral breathing task with acoustic pharyngometry. In addition, within-participant measures of strength and anthropometrics were collected. Four linear mixed effects regression models were run to study the relationship between pharyngeal volume and pharyngeal constriction, pharyngeal shortening, pyriform sinus residue, and vallecular residue while controlling for bolus condition, age, sex, and posterior tongue strength. Increasing pharyngeal lumen volume was significantly related to worse constriction and vallecular residue. In general, larger and thicker boluses resulted in worse pharyngeal constriction and residue. Pharyngeal shortening was only significantly related to posterior tongue strength. Our work establishes the utility of acoustic pharyngometry to monitor pharyngeal lumen volume. Increasing pharyngeal lumen volume appears to impact both pharyngeal swallowing mechanics and function in a sample of healthy, functional seniors.

The Prevalence of Cricopharyngeal Webs in Elderly Cadavers.

OBJECTIVE: Cricopharyngeal webs (CPW) are a frequent cause of solid food dysphagia. They are difficult to diagnose and are often missed on swallowing fluoroscopy. The prevalence of CPWs is uncertain. The purpose of this study was to determine the prevalence of CPWs in elderly cadavers. METHODS: Direct laryngoscopy and cervical esophagoscopy were performed in 19 embalmed cadavers by independent two-clinician consensus. Cadaver demographics and the presence and laterality of a CPW were recorded. The prevalence of CPW was calculated, and the size of the cricopharyngeus muscle (CPM) was quantified. RESULTS: The mean age of the cohort was 83 ( ± 12) years. Fifty-three percent were female, and the mean body mass index was 19.7 ( ± 3). The causes of death were cardiovascular disease (10 of 19), cancer (5 of 19), and respiratory failure (4 of 19). A CPW was present in 68% (13 of 19) of cadavers. Forty-seven percent (9 of 19) had a unilateral web, and 21% (4 of 19) had a bilateral web. There was no laterality predominance (P > 0.05). Forty-two percent (8 of 19) had no CPM prominence; 32% (6 of 19) had a small/moderate CPM prominence; and 26% (5 of 19) had a significant CPM prominence. CONCLUSION: The prevalence of cricopharyngeal webs in elderly cadavers is high (68%). The clinician should maintain a high index of suspicion for CPWs in patients with no other identifiable etiology of solid food dysphagia. LEVEL OF EVIDENCE: 3b Laryngoscope, 129:63-66, 2019.

[Clinical anatomic study on the segment and adjacent of tract of congenital pyriform sinus fistula].

Objective: To investigate the anatomic tract of congenital pyriform sinus fistula (CPSF). Methods: A total of 90 patients with CPSF undergoing open surgery between August, 2007 and March, 2017 at the Department of Guangdong General Hospital were retrospectively analyzed. Results: The tracts of all the fistulas actually walked far different from those of theoretical ones. A whole fistula may be divided into 4 segments according to adjacent anatomy of CPSF. The posterior inner segment to the thyroid cartilage was initial part of the fistula. It originated from the apex of pyriform sinus, then piercing out of the inferior constrictor of pharynx inferiorly near the inferior cornu of the thyroid cartilage (ICTC), and descended between the lateral branch of the superior laryngeal nerve and the recurrent laryngeal nerve. The ICTC segment was the second part of the fistula, firstly piercing out of the inferior constrictor of pharynx and/or cricothyroid muscle, and then entering into the upper pole of thyroid. The relationship between fistula and ICTC could be divided into three types: type A (medial inferior to ICTC) accounting for 42.2% (38/90); type B (penetrate ICTC) for 3.3% (3/90); and type C (lateral inferior to ICTC) for 54.5% (49/90). The internal segment in thyroid gland was the third part of fistula, walking into the thyroid gland and terminating at its upper pole (92.2%, 83/90) or deep cervical fascia near the upper pole of thyroid (7.8%, 7/90). The lateral inferior segment to thyroid gland was the last part of the fisula, most of which are iatrogenic pseudo fistula, and started from the lateral margin of thyroid gland. Conclusions: CPSF has a complicated pathway. Recognition of the tract and adjacent anatomy of CPSF will facilitate the dissection and resection of CPSF in open surgery.

Cricopharyngeal achalasia associated with laryngomalacia as a cause of failure to thrive.

OBJECTIVE: To describe a case of concurrent cricopharyngeal achalasia with laryngomalacia as a cause of failure to thrive, and to review the literature and management options of cricopharyngeal achalasia in the paediatric population. METHODS: A chart review was performed on a four-month-old male, referred for failure to thrive, and diagnosed with cricopharyngeal achalasia and laryngomalacia. A PubMed and Embase search for 'cricopharyngeal achalasia' and 'laryngomalacia' was conducted. A review of reported paediatric cricopharyngeal achalasia patients, with emphasis on management options, was undertaken. RESULTS: A flexible laryngoscopic examination confirmed the laryngomalacia diagnosis, and videofluoroscopic evaluation of swallowing demonstrated cricopharyngeal achalasia via a cricopharyngeal bar. Supraglottoplasty was performed, with botulinum toxin injection into the cricopharyngeus muscle, with resultant improvement in oral intake and resolution of failure to thrive. The literature review revealed no reported case of the combined pathologies as a cause of failure to thrive. CONCLUSION: Functional endoscopic evaluation of swallowing and videofluoroscopic evaluation of swallowing are complimentary in the evaluation of paediatric patients with failure to thrive and suspected oropharyngeal dysphagia. Both supraglottoplasty and botulinum toxin injection are effective for definitive management in cases of combined pathology, and can be safely performed in a single surgical setting.

Sudden Death Secondary to an Undiagnosed B-Cell Lymphoma of the Hypopharynx and Infiltration of the Inferior Constrictor Muscle.

The aim of this presentation was to share an uncommon form of sudden death, suffered by a 64-year-old woman, due to a mechanical obstruction of hypopharynx by an undiagnosed B-cell lymphoma, infiltrating the inferior pharyngeal constrictor muscle. A forensic approach by means of scene investigation, circumstantial data collection, autopsy, and histological and toxicological investigations led to conclude that the cause of death was asphyxia, correlated with B-cell lymphoma of the hypopharynx. The autopsy examination highlighted the presence of a wall thickening, infiltrating, and projecting into the hypopharynx lumen. The histological analysis showed the essential finding of a B-cell lymphoma of the hypopharynx, diffusely infiltrating the inferior pharyngeal constrictor muscle. To conclude, this case demonstrates once more that in the absence of specific data, a thorough forensic investigation including autopsy, histological examination, and circumstantial data collection is mandatory to reach a correct cause of death.

Genistein Protects Genioglossus Myoblast Against Hypoxia-induced Injury through PI3K-Akt and ERK MAPK Pathways.

Obstructive sleep apnea and hypopnea syndrome (OSAHS) is a clinical syndrome characterized by recurrent episodes of obstruction of the upper airway during sleep that leads to a hypoxic condition. Genioglossus, an important pharyngeal muscle, plays an important role in maintaining an open upper airway for effective breathing. Our previous study found that genistein (a kind of phytoestrogen) protects genioglossus muscle from hypoxia-induced oxidative injury. However, the underlying mechanism is still unknown. In the present study, we examined the effects of hypoxia on genioglossus myoblast proliferation, viability and apoptosis, and the protective effect of genistein and its relationship with the PI3K/Akt and ERK MAPK pathways. Cell viability and Bcl-2 were reduced under hypoxic condition, while ROS generation, caspase-3, MDA, and DNA damage were increased following a hypoxia exposure. However, the effects of hypoxia were partially reversed by genistein in an Akt- and ERK- (but not estrogen receptor) dependent manner. In conclusion, genistein protects genioglossus myoblasts against hypoxia-induced oxidative injury and apoptosis independent of estrogen receptor. The PI3K-Akt and ERK1/2 MAPK signaling pathways are involved in the antioxidant and anti-apoptosis effect of genistein on genioglossus myoblasts.

Utilidad de la miotomía quirúrgica en la disfagia por distrofia oculofaríngea / Utility of surgical myotomy in the dysphagia due to oculopharyngeal dystrophy

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Treatment of oropharyngeal dysphagia secondary to idiopathic cricopharyngeal bar: Surgical cricopharyngeal muscle myotomy versus dilation.

OBJECTIVE: To compare swallowing outcomes following cricopharyngeal (CP) dilation versus surgical myotomy in patients with dysphagia secondary to idiopathic CP bar. METHODS: All patients had an idiopathic CP bar without a history of Zenker's diverticulum, head and neck cancer, or systemic neurologic disease treated between 2000 and 2013. The Functional Outcome Swallowing Scale (FOSS) was utilized to assess dysphagia symptoms. RESULTS: Twenty-three patients underwent 46 dilations and 20 patients had a myotomy. Nineteen of 23 (83%) patients in the dilation group and all patients in the myotomy group reported improved swallow function. The median difference in pre- versus post-intervention FOSS scores was not statistically significant (p=0.07) between the dilation and myotomy groups with mean reductions of 1.3 and 1.8, respectively. Seventeen of 23 (74%) dilation patients had persistent or recurrent dysphagia with 13 (57%) requiring repeat dilation and 4 (17%) undergoing CP myotomy. The median time to first reintervention in the dilation group was 13.6months. Nineteen of 20 (95%) surgical myotomy patients did not experience recurrent dysphagia. CONCLUSION: Both endoscopic CP dilation and myotomy led to similar initial improvement in swallow function for patients with primary idiopathic CP bar; however, dilation is more likely to provide temporary benefit.

Transoral resection of stylopharyngeus calcification: a unique manifestation of a stylohyoid complex syndrome.

BACKGROUND: Eagle syndrome is often considered in the work-up of odynophagia and neck pain. Classically, this is manifested by ossification or calcification of the stylohyoid ligament or styloid process. There are no reported cases of stylopharyngeal calcification leading to these symptoms. CASE: We describe a patient with a suspected submucosal pharyngeal foreign body who was found to have a calcified stylopharyngeus muscle and tendon during surgery. The patient experienced full resolution of symptoms after transoral robotic resection. This diagnosis was initially missed because the radiology was inconsistent with Eagle syndrome. CONCLUSION: This is the first report of isolated stylopharyngeal calcification, and this unique manifestation of a stylohyoid complex syndrome should be considered in patients with symptoms of Eagle syndrome without styloid elongation.

Imaging evaluation of the suprahyoid neck.

Evaluating the complex anatomy of the suprahyoid neck on imaging studies can be a daunting task without a sound understanding of anatomy and a systematic approach. In this article, the suprahyoid neck is divided into characteristic anatomic spaces, which allow for the accurate localization of both normal structures and abnormal pathology in the neck. Once a lesion is localized to a specific suprahyoid space, imaging characteristics and clinical data can be used in a logical fashion to provide a clinically useful imaging differential diagnosis.

Successful treatment of cricopharyngeal dysphagia with bilateral myectomy in a dog.

An 8-month-old golden retriever/standard poodle mixed breed dog was diagnosed with cricopharyngeal dysphagia and possibly asynchrony. After failing standard unilateral cricopharyngeal myectomy, the dog underwent a second surgery to completely resect the contralateral musculature resulting in immediate and complete resolution of clinical signs. Bilateral myectomy can be considered for dogs with cricopharyngeal dysphagia that fail unilateral myectomy.

Traitement réussi de la dysphagie cricopharyngienne avec une myectomie bilatérale chez un chien. Un chien de race croisée Golden retriever/Caniche standard âgé de 8 mois a été diagnostiqué avec de la dysphagie cricopharyngienne et une asynchronie possible. Après un échec de la myectomie cricophryngienne unilatérale standard, le chien a subi une deuxième chirurgie pour réséquer complètement la musculature controlatérale, ce qui a produit une résolution immédiate et complète des signes cliniques. La myectomie bilatérale peut être considérée pour les chiens atteint de dysphagie cricopharyngienne pour lesquels la myectomie unilatérale est un échec.(Traduit par Isabelle Vallières).

Targeted use of endoscopic CO2 laser cricopharyngeal myotomy for improving swallowing function following head and neck cancer treatment.

BACKGROUND: Cricopharyngeal dysfunction following head and neck cancer treatment may lead to a significant reduction in oral intake. Carbon dioxide laser is an established procedure for the treatment of non-malignant cricopharyngeal disorders. We report our experience of laser cricopharyngeal myotomy with objective swallowing outcome measures, before and after treatment. METHODS: We identified 11 patients who had undergone carbon dioxide laser cricopharyngeal myotomy for dysphagia following radiotherapy, with or without chemotheraphy between January 2006 and July 2011. We analysed the swallowing outcomes following carbon dioxide laser cricopharyngeal myotomy by retrospective grading of pre- and post-procedure videofluoroscopic swallowing study of liquids, using the validated Modified Barium Swallow Impairment Profile. RESULTS: The median Modified Barium Swallow Impairment Profile score was 13 pre-myotomy and 10 post-myotomy. This difference between scores was non-significant (p = 0.41). The median, cricopharyngeal-specific Modified Barium Swallow Impairment Profile variables (14 and 17) improved from 3 to 2, but were similarly non-significant (p = 0.16). We observed the improved Modified Barium Swallow Impairment Profile scores post-procedure in the majority of patients. CONCLUSION: Endoscopic carbon dioxide laser cricopharyngeal myotomy remains a viable option in treatment-related cricopharyngeal dysfunction; its targeted role requires further prospective study. Objective analysis of the technique can be reported using the validated Modified Barium Swallow Impairment Profile.

Sound-producing voice prostheses: 150 years of research.

Advanced laryngeal cancer sometimes necessitates the removal of the complete larynx. This procedure involves suturing the trachea to an opening in the neck, the most disturbing consequence of which is the loss of voice. Since 1859, several devices have been developed for voice restoration, based mainly on a vibrating reed element. However, the resulting sound is very monotonous and thus unpleasant. Presently the most successful way of voice restoration is the placement of a one-way shunt valve in the tracheo-esophageal wall, thus preventing aspiration and allowing air to flow from the lungs to the esophagus, where soft tissues start to vibrate for substitute voicing. However, the quality of this voice is often poor. New artificial vocal folds to be placed within the shunt valve have been developed, and a membrane-principle concept appears very promising, owing to the self-cleaning construction and the high voice quality. Future developments will include electronic voice sources. Hopefully these developments will result in a high-quality voice, after 150 years of research.