Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry.

OBJECTIVES: The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet.  The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD. METHODS: Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features. RESULTS: We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle. CONCLUSIONS: Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.

BMP signaling to pharyngeal muscle in the C. elegans response to a bacterial pathogen regulates anti-microbial peptide expression and pharyngeal pumping.

Host response to pathogens recruits multiple tissues in part through conserved cell signaling pathways. In Caenorhabditis elegans, the bone morphogenetic protein (BMP) like DBL-1 signaling pathway has a role in the response to infection in addition to other roles in development and postdevelopmental functions. In the regulation of body size, the DBL-1 pathway acts through cell autonomous signal activation in the epidermis (hypodermis). We have now elucidated the tissues that respond to DBL-1 signaling upon exposure to two bacterial pathogens. The receptors and Smad signal transducers for DBL-1 are expressed in pharyngeal muscle, intestine, and epidermis. We demonstrate that expression of receptor-regulated Smad (R-Smad) gene sma-3 in the pharynx is sufficient to improve the impaired survival phenotype of sma-3 mutants and that expression of sma-3 in the intestine has no effect when exposing worms to bacterial infection of the intestine. We also show that two antimicrobial peptide genes - abf-2 and cnc-2 - are regulated by DBL-1 signaling through R-Smad SMA-3 activity in the pharynx. Finally, we show that pharyngeal pumping activity is reduced in sma-3 mutants and that other pharynx-defective mutants also have reduced survival on a bacterial pathogen. Our results identify the pharynx as a tissue that responds to BMP signaling to coordinate a systemic response to bacterial pathogens.

[Help, I can't burp! A brief overview and case discussion of retrograde cricopharyngeal dysfunction]. / Hilfe, ich kann nicht rülpsen: Falldarstellung und Kurzübersicht zur retrograden krikopharyngealen Dysfunktion.

In this short communication, we discuss the recently described syndrome of retrograde cricopharyngeal dysfunction (R-CPD) with its first description in 2019 by the laryngologist Dr. Bastian. Diagnosis is generally based on typical clinical symptoms, e.g., the inability to belch, a bloated abdomen and retrosternal gurgling noises. We also describe high-resolution esophageal manometry as a new tool to further secure the diagnosis of R­CPD, as well as therapeutic options such as botulinum toxin injections in the cricopharyngeal muscle or cricopharyngeal myotomy and the published data thereon.

Tongue, palatal, hyoid and pharyngeal muscle activity during chewing, swallowing, and respiration.

OBJECTIVE: Chewing, swallowing, and respiration are synchronized oropharyngeal functions. This study aimed to analyze the dynamics and coordination during natural chewing and swallowing in relation to respiratory phases. DESIGN: Eight oropharyngeal muscles in minipigs were recorded using electromyography, X-ray fluoroscopy, and nasopharyngeal dynamics. Chewing cycles and swallowing episodes were analyzed for timing and activity amplitude along respiratory cycles. Digastric and middle pharyngeal constrictor were used as zero-points for timing analysis in chewing cycles and swallowing episodes, respectively. The beginning of these cycles and episodes were used as the zero-point for timing analysis in respiration during feeding. RESULTS: The timing of jaw closing (57.8%) was longer than opening (42.2%) during chewing. Muscle activity occurred 20% later than digastric onsets and 15% earlier than jaw closing phase. Duration of muscle activity was shorter in ipsilateral than contralateral sides except for palatal muscles. Pharyngeal, palatal, and hyoid muscles showed longer durations than tongue muscles in jaw opening (p < 0.05). Palatal and hyoid muscles showed 2-phased activity in chewing while hyoid muscles showed higher amplitude in chewing and swallowing than other muscles. About 80% of the chewing cycles and swallowing episodes occurred in expiration. Nasopharyngeal airflow velocity increased from jaw opening to swallowing while airflow pressure decreased. CONCLUSION: These findings indicate key activity of palatal and pharyngeal muscles mostly in chewing. The respiratory cycle changes in chewing and swallowing simultaneously with the activation of the tongue, palatal, and pharyngeal muscles. These findings will be useful for further understanding the mechanisms in swallowing and breathing disorders.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Regional associations between inspiratory tongue dilatory movement and genioglossus activity during wakefulness in people with obstructive sleep apnoea.

Inspiratory tongue dilatory movement is believed to be mediated via changes in neural drive to genioglossus. However, this has not been studied during quiet breathing in humans. Therefore, this study investigated this relationship and its potential role in obstructive sleep apnoea (OSA). During awake supine quiet nasal breathing, inspiratory tongue dilatory movement, quantified with tagged magnetic resonance imaging, and inspiratory phasic genioglossus EMG normalised to maximum EMG were measured in nine controls [apnoea-hypopnea index (AHI) ≤5 events/h] and 37 people with untreated OSA (AHI >5 events/h). Measurements were obtained for 156 neuromuscular compartments (85%). Analysis was adjusted for nadir epiglottic pressure during inspiration. Only for 106 compartments (68%) was a larger anterior (dilatory) movement associated with a higher phasic EMG [mixed linear regression, beta = 0.089, 95% CI [0.000, 0.178], t(99) = 1.995, P = 0.049, hereafter EMG↗/mvt↗]. For the remaining 50 (32%) compartments, a larger dilatory movement was associated with a lower phasic EMG [mixed linear regression, beta = -0.123, 95% CI [-0.224, -0.022], t(43) = -2.458, P = 0.018, hereafter EMG↘/mvt↗]. OSA participants had a higher odds of having at least one decoupled EMG↘/mvt↗ compartment (binary logistic regression, odds ratio [95% CI]: 7.53 [1.19, 47.47] (P = 0.032). Dilatory tongue movement was minimal (>1 mm) in nearly all participants with only EMG↗/mvt↗ compartments (86%, 18/21). These results demonstrate that upper airway dilatory mechanics cannot be predicted from genioglossus EMG, particularly in people with OSA. Tongue movement associated with minimal genioglossus activity suggests co-activation of other airway dilator muscles. KEY POINTS: Inspiratory tongue movement is thought to be mediated through changes in genioglossus activity. However, it is unknown if this relationship is altered by obstructive sleep apnoea (OSA). During awake supine quiet nasal breathing, inspiratory tongue movement, quantified with tagged magnetic resonance imaging (MRI), and inspiratory phasic genioglossus EMG normalised to maximum EMG were measured in four tongue compartments of people with and without OSA. Larger tongue anterior (dilatory) movement was associated with higher phasic genioglossus EMG for 68% of compartments. OSA participants had an ∼7-times higher odds of having at least one compartment for which a larger anterior tongue movement was not associated with a higher phasic EMG than controls. Therefore, higher genioglossus phasic EMG does not consistently translate into tongue dilatory movement, particularly in people with OSA. Large dilatory tongue movements can occur despite minimal genioglossus inspiratory activity, suggesting co-activation of other pharyngeal muscles.

Combined laryngeal framework surgery and cricopharyngeal muscle-origin transection: a novel effective surgery for dysphagia with pharyngolaryngeal palsy and cricopharyngeal dysfunction under local anesthesia.

BACKGROUND: Cricopharyngeal myotomy and laryngeal framework surgery can improve swallowing function in patients with severe dysphagia. We developed a novel surgical technique for severe dysphagia associated with pharyngolaryngeal paralysis and cricopharyngeal dysfunction, performed under local anesthesia, and investigated its effectiveness. METHODS: We included nine patients who underwent cricopharyngeal muscle-origin transection with laryngeal framework surgery through a horizontal skin incision under local anesthesia. CONCLUSIONS: All patients demonstrated significant improvement in the Food Intake LEVEL Scale without complications. Thus, this surgical technique may serve as a useful and less invasive treatment option for patients with severe dysphagia.

Drive versus Pressure Contributions to Genioglossus Activity in Obstructive Sleep Apnea.

Rationale: Loss of pharyngeal dilator muscle activity is a key determinant of respiratory events in obstructive sleep apnea (OSA). After the withdrawal of wakefulness stimuli to the genioglossus at sleep onset, mechanoreceptor negative pressure and chemoreceptor ventilatory drive feedback govern genioglossus activation during sleep, but the relative contributions of drive and pressure stimuli to genioglossus activity across progressive obstructive events remain unclear. We recently showed that drive typically falls during events, whereas negative pressures increase, providing a means to assess their individual contributions to the time course of genioglossus activity. Objectives: For the first time, we critically test whether the loss of drive could explain the loss of genioglossus activity observed within events in OSA. Methods: We examined the time course of genioglossus activity (EMGgg; intramuscular electromyography), ventilatory drive (intraesophageal diaphragm electromyography), and esophageal pressure during spontaneous respiratory events (using the ensemble-average method) in 42 patients with OSA (apnea-hypopnea index 5-91 events/h). Results: Multivariable regression demonstrated that the falling-then-rising time course of EMGgg may be well explained by falling-then-rising drive and rising negative pressure stimuli (model R = 0.91 [0.88-0.98] [95% confidence interval]). Overall, EMGgg was 2.9-fold (0.47-∞) more closely associated with drive than pressure stimuli (ratio of standardized coefficients, ßdrive:ßpressure; ∞ denotes absent pressure contribution). However, individual patient results were heterogeneous: approximately one-half (n = 22 of 42) exhibited drive-dominant responses (i.e., ßdrive:ßpressure > 2:1), and one-quarter (n = 11 of 42) exhibited pressure-dominant EMGgg responses (i.e., ßdrive:ßpressure < 1:2). Patients exhibiting more drive-dominant EMGgg responses experienced greater event-related EMGgg declines (12.9 [4.8-21.0] %baseline/standard deviation of ßdrive:ßpressure; P = 0.004, adjusted analysis). Conclusions: Loss of genioglossus activity precipitating events in patients with OSA is strongly associated with a contemporaneous loss of drive and is greatest in those whose activity tracks drive rather than pressure stimuli. These findings were upheld for events without prior arousal. Responding to falling drive rather than rising negative pressure during events may be deleterious; future therapeutic strategies whose aim is to sustain genioglossus activity by preferentially enhancing responses to rising pressure rather than falling drive are of interest.

Cricopharyngeal and thyropharyngeal myectomy for management of cricopharyngeal achalasia in a 6-month-old coton de Tulear dog.

A 6-week-old intact female coton de Tulear dog presented to a veterinary teaching hospital (VTH) internal medicine service for dysphagia that was persistent since birth. The patient was diagnosed with cricopharyngeal achalasia based on a fluoroscopic swallow study. To facilitate surgical intervention, a percutaneous endoscopic gastrostomy (PEG) tube was placed to bypass the upper esophageal sphincter and provide nutritional support until the dog was larger. At 6 mo of age, the dog underwent unilateral cricopharyngeal and thyropharyngeal myectomy. Marked improvement in dysphagia was noted immediately postoperatively. Improvement in dysphagia persisted in this dog, with continued marked improvement in clinical signs noted 1 y postoperatively. Key clinical message: Cricopharyngeal achalasia can be successfully managed with surgical intervention with a good long-term prognosis. Before surgical intervention, nutritional support is of critical importance. A combined procedure of cricopharyngeal and thyropharyngeal myectomy may be associated with outcomes superior to those of alternative procedures.

Myectomie cricopharyngée et thyropharyngée pour prise en charge de l'achalasie cricopharyngée chez un chien coton de Tuléar âgé de 6 mois. Une chienne coton de Tuléar femelle intacte âgée de 6 semaines a été présentée au service de médecine interne d'un CHU vétérinaire pour une dysphagie persistante depuis la naissance. Le patient a reçu un diagnostic d'achalasie cricopharyngée sur la base d'une étude fluoroscopique de la déglutition. Pour faciliter l'intervention chirurgicale, un tube de gastrostomie endoscopique percutanée (PEG) a été placé pour contourner le sphincter supérieur de l'oesophage et fournir un soutien nutritionnel jusqu'à ce que le chien soit plus gros. À l'âge de 6 mois, le chien a subi une myectomie cricopharyngée et thyropharyngée unilatérale. Une nette amélioration de la dysphagie a été notée immédiatement après l'opération. L'amélioration de la dysphagie a persisté chez ce chien, avec une amélioration continue et marquée des signes cliniques notée 1 an après l'opération.Message clinique clé :L'achalasie cricopharyngée peut être gérée avec succès par une intervention chirurgicale avec un bon pronostic à long terme. Avant l'intervention chirurgicale, le soutien nutritionnel est d'une importance cruciale. Une procédure combinée de myectomie cricopharyngée et thyropharyngée peut être associée à des résultats supérieurs à ceux des procédures alternatives.(Traduit par Dr Serge Messier).

EAT-2 attenuates C. elegans development via metabolic remodeling in a chemically defined food environment.

Dietary intake and nutrient composition regulate animal growth and development; however, the underlying mechanisms remain elusive. Our previous study has shown that either the mammalian deafness homolog gene tmc-1 or its downstream acetylcholine receptor gene eat-2 attenuates Caenorhabditis elegans development in a chemically defined food CeMM (C. elegans maintenance medium) environment, but the underpinning mechanisms are not well-understood. Here, we found that, in CeMM food environment, for both eat-2 and tmc-1 fast-growing mutants, several fatty acid synthesis and elongation genes were highly expressed, while many fatty acid ß-oxidation genes were repressed. Accordingly, dietary supplementation of individual fatty acids, such as monomethyl branch chain fatty acid C17ISO, palmitic acid and stearic acid significantly promoted wild-type animal development on CeMM, and mutations in either C17ISO synthesis gene elo-5 or elo-6 slowed the rapid growth of eat-2 mutant. Tissue-specific rescue experiments showed that elo-6 promoted animal development mainly in the intestine. Furthermore, transcriptome and metabolome analyses revealed that elo-6/C17ISO regulation of C. elegans development may be correlated with up-regulating expression of cuticle synthetic and hedgehog signaling genes, as well as promoting biosynthesis of amino acids, amino acid derivatives and vitamins. Correspondingly, we found that amino acid derivative S-adenosylmethionine and its upstream metabolite methionine sulfoxide significantly promoted C. elegans development on CeMM. This study demonstrated that C17ISO, palmitic acid, stearic acid, S-adenosylmethionine and methionine sulfoxide inhibited or bypassed the TMC-1 and EAT-2-mediated attenuation of development via metabolic remodeling, and allowed the animals to adapt to the new nutritional niche.

Ring Finger 149-Related Is an FGF/MAPK-Independent Regulator of Pharyngeal Muscle Fate Specification.

During embryonic development, cell-fate specification gives rise to dedicated lineages that underlie tissue formation. In olfactores, which comprise tunicates and vertebrates, the cardiopharyngeal field is formed by multipotent progenitors of both cardiac and branchiomeric muscles. The ascidian Ciona is a powerful model to study cardiopharyngeal fate specification with cellular resolution, as only two bilateral pairs of multipotent cardiopharyngeal progenitors give rise to the heart and to the pharyngeal muscles (also known as atrial siphon muscles, ASM). These progenitors are multilineage primed, in as much as they express a combination of early ASM- and heart-specific transcripts that become restricted to their corresponding precursors, following oriented and asymmetric divisions. Here, we identify the primed gene ring finger 149 related (Rnf149-r), which later becomes restricted to the heart progenitors, but appears to regulate pharyngeal muscle fate specification in the cardiopharyngeal lineage. CRISPR/Cas9-mediated loss of Rnf149-r function impairs atrial siphon muscle morphogenesis, and downregulates Tbx1/10 and Ebf, two key determinants of pharyngeal muscle fate, while upregulating heart-specific gene expression. These phenotypes are reminiscent of the loss of FGF/MAPK signaling in the cardiopharyngeal lineage, and an integrated analysis of lineage-specific bulk RNA-seq profiling of loss-of-function perturbations has identified a significant overlap between candidate FGF/MAPK and Rnf149-r target genes. However, functional interaction assays suggest that Rnf149-r does not directly modulate the activity of the FGF/MAPK/Ets1/2 pathway. Instead, we propose that Rnf149-r acts both in parallel to the FGF/MAPK signaling on shared targets, as well as on FGF/MAPK-independent targets through (a) separate pathway(s).

Diagnosing and managing dysphagia in inclusion body myositis: a systematic review.

OBJECTIVES: Dysphagia is a common debilitating clinical feature of IBM. However, the impact of dysphagia in IBM has been historically overlooked. This study aimed to identify, evaluate and summarize the evidence regarding the assessment and management of dysphagia in persons with IBM undergoing treatment. METHODS: A systematic review was conducted using a multiengine search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Eligible studies had to employ an intervention for persons with IBM, report a swallowing outcome and be published in English. Quality assessments of the eligible studies were performed. RESULTS: Of 239 studies found, 19 met the inclusion criteria. One study was rated as 'fair' and the rest as 'poor' quality, particularly due to the lack of published and validated swallowing assessment procedures and outcome measures. Cricopharyngeal (CP) dysfunction (12/19) was the most commonly reported swallowing abnormality. Interventions for disease management included pharmacological agents (10/19), followed by surgical (3/19), behavioral (1/19) and combined approaches (5/19). Interventions with immunosuppressants, botulinum toxin injection, balloon dilation and/or CP myotomy led to mixed and transient benefits. Few studies examining statins or behavioral therapies (primarily focused on respiratory function) showed no effects for dysphagia. CONCLUSION: Various interventions have been reported to temporarily improve dysphagia in persons with IBM. However, these findings are based on limited and overall low-quality evidence. This study cautions against the generalization of these findings and emphasizes the need for further systematic research to improve the diagnosis and management of dysphagia in IBM.

Evaluation of morphological features of palatopharyngeus insertion into the thyroid cartilage.

The attachment of the palatopharyngeus extended from the posterior end of the thyroid cartilage to the posterior margin of the inferior constrictor attachment that might contribute to successive swallowing movements. Laryngeal elevation is essential for proper swallowing and breathing. Recently, clinical research has demonstrated that the palatopharyngeus, a longitudinal muscle of the pharynx, is involved in the elevation of the larynx. However, the morphological relationship between the larynx and palatopharyngeus remains unclear. In the present study, we analyzed the attachment site and characteristics of the palatopharyngeus in the thyroid cartilage. We evaluated 14 halves of seven heads from Japanese cadavers (average age: 76.4 years); 12 halves, anatomically and two halves histologically. A part of the palatopharyngeus, which originated from the inferior aspect of the palatine aponeurosis, was attached to the inner and outer surfaces of the thyroid cartilage through collagen fibers. The attachment area extends from the posterior end of the thyroid cartilage to the posterior margin of the attachment site of the inferior constrictor. The palatopharyngeus may elevate the larynx with the suprahyoid muscles and contribute to successive movements of swallowing with surrounding muscles. Based on our findings and previous studies, palatopharyngeus with various muscle bundle directions may be essential for the coordination of continuous swallowing events.

Surface electromyographic activity of submental muscles during different types of swallow-specific tasks: A comparative study.

BACKGROUND: Repetitive performance of a motor task has been proposed to increase the ability to perform that motor task. Therefore, exercise training including swallow-specific task may be an optimal training to improve swallowing function. OBJECTIVES: To determine the submental muscles activity during different types of swallow-specific tasks (effortful swallow, ES; tongue-hold swallow, THS; swallow with Kinesio taping, SwKT; and head extension swallowing exercise, HESE) compared to normal swallow (NS), and also compare these tasks within themselves. METHODS: Thirty-five healthy adults participated in this prospective experimental study with one participant group. The surface electromyography (sEMG) was used to evaluate submental muscles activity while performing swallow-specific tasks. RESULTS: While the greatest submental muscles activity was revealed during the ES, HESE, NS and THS tasks, respectively, the lowest was obtained during SwKT. When compared to NS, ES caused a statistically greater submental muscles activity (p1  = .000 and p2  = .000), although SwKT revealed a lower submental muscles activity (p1  = .002 and p2  = .000). When swallow-specific tasks were compared within themselves, ES caused the highest muscles activity (p < .005) than all other tasks, and HESE caused higher muscles activity than THS and SwKT (p < .005). CONCLUSION: Different swallow-specific tasks can cause increased or decreased submental muscles activity compared to NS task. Since ES and HESE are superior in selective submental muscles, they appear to be more promising in terms of submental muscles gains in long-term exercise training.

Subjective and Objective Evaluation of Speech in Adult Patients With Repaired Cleft Palate.

OBJECTIVE: To explore the speech outcomes of adult patients with repaired cleft palate through subjective perception evaluation and objective acoustic analysis, and to compare the differences in pronunciation characteristics between speakers with complete velopharyngeal closure (VPC) and velopharyngeal insufficiency (VPI) patients. PARTICIPANTS AND INTERVENTION: Subjective evaluation indicators included speech intelligibility, nasality and consonant missing rate, for objective acoustic analysis, we used speech sample normalization and objective acoustic parameters included normalized vowel formants, voice onset time and the analysis of 3-dimensional spectrogram and spectrum, were carried out on speech samples produced by 3 groups of speakers: (a) speakers with velopharyngeal competence after palatorrhaphy (n=38); (b) speakers with velopharyngeal incompetence after palatorrhaphy (n=70), (c) adult patients with cleft palate (n=65) and (d) typical speakers (n=30). RESULTS: There was a highly negative correlation between VPC grade and speech intelligibility (ρ=-0.933), and a highly positive correlation between VPC and nasality (ρ=0.813). In subjective evaluation, the speech level of VPI patients was significantly lower than that of VPC patients and normal adults. Although the nasality and consonant loss rate of VPC patients were significantly higher than that of normal adults, the speech intelligibility of VPC patients was not significantly different from that of normal adults. In acoustic analysis, patients with VPI still performed poorly compared with patients with VPC. CONCLUSIONS: The speech function of adult cleft palate patients is affected by abnormal palatal structure and bad pronunciation habits. In subjective evaluation, there was no significant difference in speech level between VPC patients and normal adults, whereas there was significant difference between VPI patients and normal adults. The acoustic parameters were different between the 2 groups after cleft palate repair. The condition of palatopharyngeal closure after cleft palate can affect the patient's speech.

Suspension-expansion pharyngoplasty: a modified technique for oropharyngeal collapse in obstructive sleep apnea.

BACKGROUND AND PURPOSE: Lateral pharyngeal wall (LPW) collapse plays a fundamental role in the pathogenesis of obstructive sleep apnea (OSA) and might determine the severity of the disease. This study presents the suspension/expansion pharyngoplasty (SEP) for the treatment of selected cases of OSA. The procedure aimed to splint LPW collapse via supporting and lateralization of both superior constrictor muscle (SCM) and palatopharyngeal muscle (PPM) individually and in two different planes. METHODS: Twenty-one adult patients with single-level OSA who showed a lateral pattern of collapse at the oropharyngeal region had the modified procedure (SEP). The basic steps are the individual dissection of the muscular components of the lateral pharyngeal wall: SCM which was sutured anteriorly to the anterior tonsillar pillar and the PPM which was suspended to the pterygomandibular raphe. The supra-tonsillar fat was preserved. RESULTS: At 9-12 months, highly significant improvement was reported as regards the mean Apnea hypopnea index and the mean lowest oxygen saturation (p < 0.000). The Epworth Sleepiness Scale and VAS-snoring showed a significant (p < 0.05) reduction. The oxygen desaturation index showed significant improvement. Non-significant improvements were reported as regards the percentage of total sleep time with oxygen saturation below 90%. According to Sher criteria, successful outcomes were reported in 17 patients. CONCLUSION: SEP could widen the pharyngeal airway and could support the collapsible lateral pharyngeal wall guarding against soft tissue collapse. In selected subjects, SEP had reported subjective and objective favorable outcomes with no significant comorbidities. The procedure could be combined with other procedures in multilevel surgery.