The Upper Esophageal Sphincter Distensibility Index Measured Using Functional Lumen Imaging Probe Identifies Defective Barrier Function of the Upper Esophageal Sphincter.

Background/Aims: The mechanism via which supra-esophageal symptoms are generated is unclear. We assessed upper esophageal sphincter (UES) function in novel fashion using functional lumen imaging probe (FLIP) topography. We hypothesize that symptoms related to aspiration of esophageal contents may be associated with a more distensible UES. Methods: FLIP and reflux symptom index score data from patients undergoing diagnostic evaluation for an esophageal complaint over a 10-month period were analyzed retrospectively. UES distensibility on FLIP was studied at 40-70 mL volumes with in-depth analysis at 50 and 60 mL. Symptoms were compared between patients with low, middle, and high UES-distensibility index (UES-DI). Receiver-operating characteristic analysis was performed to determine associations between the UES-DI and individual reflux symptom index symptom item scores. Results: One hundred and eleven subjects were included. Overall, the associations between UES-DI and symptoms that could be related to supra-esophageal aspiration were strongest at the 50 mL FLIP volume. Choking item score was highest in the high UES-DI group (2.8) vs 1.4 (P < 0.001) in the middle UES-DI and 1.1 (P = 0.004) in the low UES-DI groups. Similarly, the cough item score was highest in the high UES-DI group (2.7) vs 1.5 (P = 0.009) and 0.9 (P = 0.002) groups. Conclusion: A higher UES-DI measures defective barrier function which could may be the main pathophysiology that generates supra-esophageal symptoms.

Characterizing postoperative physiologic swallow function following transoral robotic surgery for early stage tonsil, base of tongue, and unknown primary human papillomavirus-associated squamous cell carcinoma.

BACKGROUND: Data objectively evaluating acute post-transoral robotic surgery (TORS) swallow function are limited. Our goal was to characterize and identify clinical variables that may impact swallow function components 3 weeks post-TORS. METHODS: Retrospective cohort study. Pre/postoperative use of the Modified Barium Swallow Impairment Profile (MBSImP) and Penetration-Aspiration Scale (PAS) was completed on 125 of 139 TORS patients (2016-2019) with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma. Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scores were retrospectively calculated. Uni/multivariate analysis was performed. RESULTS: Dysfunctional pre-TORS DIGEST scores were predictive of post-TORS dysphagia (p = 0.015). Pre-TORS MBSImP deficits in pharyngeal stripping wave, swallow initiation, and clearing pharyngeal residue correlated with airway invasion post-TORS based on PAS scores (p = 0.012, 0.027, 0.048, respectively). Multivariate analysis of DIGEST safety scores declined with older age (p = 0.044). Odds ratios (ORs) for objective swallow function components after TORS were better for unknown primary and tonsil primaries compared to base of tongue (BOT) (OR 0.35-0.91). CONCLUSIONS: Preoperative impairments in specific MBSImP components, older patients, and BOT primaries may predict more extensive recovery in swallow function after TORS.

Upper Esophageal Sphincter Dilation for Recalcitrant Dysphagia Secondary to Dermatomyositis.

Dermatomyositis is a rare multisystem autoimmune disorder occasionally accompanied by dysphagia. It is typically treated with immune modulating agents; however, dysphagia is often unresponsive to these. Previous reports have demonstrated the utility of videoflouroscopy and manometry in understanding the etiologies of dysphagia to inform a procedural target, historically the cricopharyngeus muscle. We present a case of dermatomyositis and dysphagia resistant to medical management in a patient found by videoflouroscopy and manometry to have severe oropharyngeal dysphagia, esophageal dysmotility and a cricopharyngeal web. We demonstrate the utility and safety of upper esophageal sphincter dilation by transnasal esophagoscopy even in the setting of multifactorial dysphagia.

Pretreatment swallowing exercises improve swallow function after chemoradiation.

OBJECTIVES/HYPOTHESIS: Swallowing dysfunction is a devastating complication of chemoradiation therapy (CRT) for head and neck squamous cell carcinoma. We have previously demonstrated that pretreatment swallowing exercises improve posttreatment swallowing-related quality of life. This study evaluates the effect of pretreatment swallowing exercises on posttreatment swallow function as measured by videofluoroscopy. STUDY DESIGN: Retrospective case control. METHODS: Eighteen patients with advanced squamous cell carcinoma of the oropharynx, hypopharynx, and larynx treated at University of Alabama at Birmingham with CRT were included in the study. Nine patients received pretreatment swallowing exercises prior to CRT, and nine patients received swallowing exercises during routine posttreatment management. Approximately 3 months after completing treatment, standard videofluoroscopy examinations were conducted. Outcomes measured by the videofluoroscopy examinations included hyoid elevation, epiglottis inversion, tongue base movement, cricopharyngeal opening, and Rosenbeck aspiration score. Percutaneous endoscopic gastrostomy (PEG) tube use was assessed at 12 months after treatment. RESULTS: Epiglottis inversion was better maintained (P = .05) in patients receiving pretreatment swallowing therapy. The position of the tongue base during swallowing was also significantly closer to the posterior pharyngeal wall (P = .025) for patients receiving pretreatment exercises. PEG tube removal rates did not significantly differ between groups. CONCLUSIONS: Performing pretreatment swallowing exercises produces measurable improvements in posttreatment swallowing function in patients who undergo organ-preservation CRT for head and neck cancer. This study provides an initial foundation for the development of noninvasive, cost-effective, evidence-based interventions in this group of vulnerable patients.

Pretreatment, preoperative swallowing exercises may improve dysphagia quality of life.

OBJECTIVES: Dysphagia is commonly associated with head and neck cancer treatment. Traditional dysphagia management strategies focus on post-treatment therapy. This study evaluated the utility of pretreatment swallowing exercises in improving post-treatment swallowing quality of life (QOL). STUDY DESIGN: Prospective cohort study and cross-sectional QOL analysis. METHODS: This study includes 37 patients who underwent primary radiation or combined chemoradiation treatment for newly diagnosed hypopharyngeal, laryngeal, or oropharyngeal primary tumors at the University of Alabama at Birmingham. Of the 37, 25 patients underwent swallowing exercises beginning 2 weeks prior to the start of radiation. The M.D. Anderson Dysphagia Inventory (MDADI) was administered an average of 14 months after treatment to assess the success of the protocol. Analysis of QOL scores related to gender, primary site, stage, and race were obtained. RESULTS: Patients who performed pretreatment swallowing exercises (n = 25) showed improvement in the overall MDADI score (P = .0002) compared to the control population (n = 12) who underwent post-treatment therapy. Furthermore, a separate analysis of individual domains of the MDADI (global, emotional, functional, and physical) demonstrated improved quality of life. CONCLUSIONS: Implementation of pretreatment swallowing education and exercise may improve dysphagia-specific QOL in head and neck cancer patients undergoing radiation and/or chemoradiation therapy.

Dynasplint for the management of trismus after treatment of upper aerodigestive tract cancer: a retrospective study.

In order to evaluate the Dynasplint Trismus System (DTS) for the relief of trismus secondary to the treatment of head and neck cancer, we conducted a retrospective chart review of patients who had undergone DTS therapy during a 1-year period. Our inclusion criteria were cancer of the upper aerodigestive tract; treatment with radiation, chemotherapy, and/or surgery; and a maximal incisal opening (MIO) of less than 30 mm. MIO and the rate of improvement of trismus ("gain") were measured at selected intervals. Twenty-six patients met our study criteria; their pretherapy mean MIO was 19.3 mm. At the time of their most recent measurement, the mean MIO had increased to 25.5 mm-a measured gain of 32%. Although the initial rate of gain was 0.36 mm/day during the first 6 weeks, improvement leveled off over time, and the overall rate of gain was 0.16 mm/day. We conclude that the DTS is effective in increasing the mandibular range of motion at a rate of change that is maximized during initial treatment.

Patient-perceived and objective functional outcomes following transoral robotic surgery for early oropharyngeal carcinoma.

OBJECTIVE: To evaluate changes in patient-perceived swallowing function over time following transoral robotic surgery (TORS) for primary T1 and T2 oropharyngeal squamous cell carcinomas. DESIGN: Prospective case series. SETTING: Academic tertiary referral center. PATIENTS: Forty-two patients with T1 or T2 oropharyngeal squamous cell carcinomas. INTERVENTION: TORS-assisted resection of indicated tumors. MAIN OUTCOME MEASURES: Changes in patient-perceived swallowing function over time (using the M. D. Anderson Dysphagia Inventory) and gastrostomy tube dependence. RESULTS: Between March 19, 2007, and April 21, 2010, forty-two patients with primary T1 or T2 oropharyngeal squamous cell carcinomas underwent TORS-assisted resection. Most (76% [32 of 42]) patients had stage III disease; 93% (39 of 42) of patients underwent staged neck dissection. The median postoperative follow-up time was 17 months (range, 4-40 months). There were no complications or tumor recurrences. Postoperative chemotherapy use predicted gastrostomy tube retention for longer than 3 months (P = .01). Immediate mean postoperative M. D. Anderson Dysphagia Inventory scores in each assessed domain (global, emotional, physical, and functional) decreased compared with preoperative baseline scores; however, ongoing improvement in all domains was observed over time. Nodal status (P = .049), follow-up time of less than 12 months (P = .03), and preoperative physical scores of less than 100 (P = .01) predicted poorer physical M. D. Anderson Dysphagia Inventory outcomes. Positive pathological margins predicted poorer functional scores (P = .03). CONCLUSIONS: After TORS-assisted resection of T1 and T2 oropharyngeal squamous cell carcinomas, approximately one-third of patients will experience a sustained decrease in perceived swallowing function. However, ongoing improvement of swallowing function over time is likely even after 12 months. Patients receiving adjuvant chemotherapy after TORS should be counseled about the possibility of prolonged gastrostomy tube dependence.

Primary versus delayed tracheoesophageal puncture for laryngopharyngectomy with free flap reconstruction.

OBJECTIVES: To determine whether postoperative complication rates and speech outcomes differ between patients undergoing primary versus secondary tracheoesophageal puncture following total laryngectomy with free flap reconstruction. STUDY DESIGN: Retrospective clinical study in a tertiary academic center. METHODS: Between November 2004 and June 2010, 137 patients underwent total laryngectomy or laryngopharyngectomy with pharyngeal free flap reconstruction for malignant disease. Data was collected on patient and operative demographics, early postoperative complications, speech outcomes, and predictive factors for tracheoesophageal puncture failure. RESULTS: Thirty patients (22%) had a primary tracheoesophageal puncture performed at the time of laryngectomy, 27 patients (20%) received secondary punctures (>3 months postlaryngectomy), and 80 patients (58%) never received a puncture. Patient and operative demographics were similar between groups (P < .05), apart from proportionately more hypopharyngeal tumors in the "no puncture" group (P < .002). Similar numbers of patients in primary and secondary puncture groups achieved intelligible speech (67% vs. 71%, P = .82) and both groups reported good patient-perceived voice-related quality of life. Salvage surgery and nonpatch radial forearm free flap reconstruction both trended toward increased early postoperative complication rates (P = .09). CONCLUSIONS: There is no difference in the early postoperative complication rate for primary versus secondary tracheoesophageal puncture following total laryngectomy with concurrent free flap reconstruction. Radial forearm patch free flap reconstruction achieves good speech outcomes.