Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents

The purpose of this study was to determine the efficacy of the uncovered coil stents in patients with malignant dysphagia. Coiled spring-shaped uncovered self-expanding metallic Esophacoil stents (Instent, Eden Prairie, Minnesota) were placed in 11 patients (9 men and 2 women; age range 38-77 years, mean age 60.5 years) with malignant esophageal strictures and dysphagia, under fluoroscopic guidance. Dysphagia was graded on a scale of 0 to 4 (0 = no dysphagia; 1 = dysphagia to normal solids; 2 = dysphagia to soft solids; 3 = dysphagia to solids and liquids; 4 = complete dysphagia, inability to swallow saliva). Two patients had received radiation therapy, 4 had had chemotherapy, and 5 had had a combination of both radiation and chemotherapy before stent palliation. Control clinical examinations and endoscopic or barium swallow studies were performed every 4 weeks until the patient died. The stents were well tolerated by all patients and were effective in 9 of 11 patients with malignant dysphagia. Complications of the procedure included incomplete opening of the stent in 1 case, migration in 1 case, transient pain in 8 cases, reflux in 3 cases and minor gastrointestinal bleeding in 2 cases. Stent migration in 1 case resulted in surgical intervention and incomplete opening of the stent allowed only partial improvement of dysphagia in 1 case. The quality of life significantly improved in all other patients. Mean survival time of the patients was 73 days (range 34-125 days) and no significant tumor ingrowth was detected during the follow-up period. Insertion of an Esophacoil has a good palliative effect on dysphagia in patients with malignant esophageal strictures with few complications. Although the stent is uncovered, tumor ingrowth and overgrowth were not observed in our study, possibly because of previous treatments.

Ultrasound and swallowing

Diagnostic ultrasound plays an important role in logopedics and phoniatrics. In this article the basic principles of ultrasound are introduced along with the various ultrasonic methods used for assessment and intervention: B-mode, TM-mode, spectral Doppler, color Doppler and enhanced color Doppler. The application of each method to the study of swallowing is explored along with recent state-of-the-art advances in three-dimensional ultrasonic imaging of the upper airway.

Simultaneous videofluoroscopic swallow study and modified Evans blue dye procedure: An evaluation of blue dye visualization in cases of known aspiration

The reliability of the modified Evans blue dye (MEBD) test for the detection of aspirated materials in patients with tracheostomy has been questioned. The videofluoroscopic swallow study (VFSS) has been the standard procedure used to detect aspiration, but there are known risks and the VFSS is not always an available evaluation option for aspiration detection. The purpose of the present study was to investigate the visualization of blue tracheal secretions in cases of known aspiration as documented by the VFSS. Twenty consecutive simultaneous MEBD study and VFSS were completed on patients with tracheostomies at an acute rehabilitation hospital. Overall, the MEBD showed a 50% false-negative error rate. The MEBD identified aspiration in 100% of patients who aspirated more than trace amounts but failed to identify aspiration of trace amounts (0%).

Free jejunal grafts of the pharynx: surgical methods, complications, and radiographic evaluation

Free jejunal grafts have been used in the surgical treatment of patients with carcinoma of the pharynx and upper esophagus. Post-operative complications, including swallowing difficulty, are frequent and radiographic assessment may be required. In this pictorial paper, we describe the surgical technique of free jejunal grafting of the pharyngoesophagus, and the radiographic appearances and clinical importance of early and delayed complications following the procedure. Dysphagia after placement of a jejunal graft is a common occurrence which is often multifactorial, and may be related to functional, anatomic, or a combination of factors.

Effects of nasogastric tubes on the young, normal swallowing mechanism

The present study aimed to investigate the effects of different-sized nasogastric tubes on swallowing speed and function in 10 young normal volunteers. Using X-ray visualization, liquid barium swallows were recorded on video (videofluoroscopy) under three experimental conditions: no nasogastric tube, fine-bore nasogastric tube, and wide-bore nasogastric tube. Nasogastric tubes slowed swallowing but did not alter swallowing function, namely bolus transit and clearance, and airway protection. The presence of a wide-bore nasogastric tube caused significant duration changes in several swallowing measures, namely duration of stage transition, duration of pharyngeal response, duration of pharyngeal transit, and duration of upper esophageal sphincter opening. Similar trends were seen for the fine-bore tube. The implications for nonoral feeding of patients with swallowing disorders are discussed.

The Dysphagia Outcome and Severity Scale

The Dysphagia Outcome and Severity Scale (DOSS) is a simple, easy-to-use, 7-point scale developed to systematically rate the functional severity of dysphagia based on objective assessment and make recommendations for diet level, independence level, and type of nutrition. Intra- and interjudge reliabilities of the DOSS was established by four clinicians on 135 consecutive patients who underwent a modified barium swallow procedure at a large teaching hospital. Patients were assigned a severity level, independence level, and nutritional level based on three areas most associated with final recommendations: oral stage bolus transfer, pharyngeal stage retention, and airway protection. Results indicate high interrater (90%) and intrarater (93%) agreement with this scale. Implications are suggested for use of the DOSS in documenting functional outcomes of swallowing and diet status based on objective assessment.

Cervical osteoarthropathy: an unusual cause of dysphagia

PRESENTATION

A 72-year-old man complained of progressive dysphagia for solids associated with a sensation of foreign body in his throat for 2 years. A barium swallow showed a bridging osteophyte between C4 and C5 vertebrae indenting the oesophagus posteriorly and displacing it anteriorly.

OUTCOME

He refused surgical intervention and was given dietary advice. After 6 months, his weight was steady and he was able to swallow semi-solid food without difficulty.

Transpharyngeal approach for the treatment of dysphagia due to Forestier's disease

Forestier's disease (diffuse idiopathic skeletal hyperostosis) is characterized by extensive spinal osteophyte formation and endo-chondral ossification of paravertebral ligaments and muscles. Dysphagia in the setting of Forestier's disease is a rare and hence often unrecognized entity. The dysphagia is due to mechanical obstruction in the initial stages and later due to inflammation and fibrosis. Most of these patients are treated conservatively in the initial stages and later by excision of osteophytes through a lateral cervical approach. We present a case of dysphagia due to cervical osteophytes in the setting of Forestier's disease causing narrowing of the pharynx. The patient was treated surgically via a peroral-transpharyngeal route with excellent results.

Swallowing function after stroke: prognosis and prognostic factors at 6 months

BACKGROUND AND PURPOSE

Swallowing dysfunction (dysphagia) is common and disabling after acute stroke, but its impact on long-term prognosis for potential complications and the recovery from swallowing dysfunction remain uncertain. We aimed to prospectively study the prognosis of swallowing function over the first 6 months after acute stroke and to identify the important independent clinical and videofluoroscopic prognostic factors at baseline that are associated with an increased risk of swallowing dysfunction and complications.

METHODS

We prospectively assembled an inception cohort of 128 hospital-referred patients with acute first stroke. We assessed swallowing function clinically and videofluoroscopically, within a median of 3 and 10 days, respectively, of stroke onset, using standardized methods and diagnostic criteria. All patients were followed up prospectively for 6 months for the occurrence of death, recurrent stroke, chest infection, recovery of swallowing function, and return to normal diet.

RESULTS

At presentation, a swallowing abnormality was detected clinically in 65 patients (51%; 95% CI, 42% to 60%) and videofluoroscopically in 82 patients (64%; 95% CI, 55% to 72%). During the subsequent 6 months, 26 patients (20%; 95% CI, 14% to 28%) suffered a chest infection. At 6 months after stroke, 97 of the 112 survivors (87%; 95% CI, 79% to 92%) had returned to their prestroke diet. Clinical evidence of a swallowing abnormality was present in 56 patients (50%; 95% CI, 40% to 60%). Videofluoroscopy was performed at 6 months in 67 patients who had a swallowing abnormality at baseline; it showed penetration of the false cords in 34 patients and aspiration in another 17. The single independent baseline predictor of chest infection during the 6-month follow-up period was a delayed or absent swallowing reflex (detected by videofluoroscopy). The single independent predictor of failure to return to normal diet was delayed oral transit (detected by videofluoroscopy). Independent predictors of the combined outcome event of swallowing impairment, chest infection, or aspiration at 6 months were videofluoroscopic evidence of delayed oral transit and penetration of contrast into the laryngeal vestibule, age >70 years, and male sex.

CONCLUSIONS

Swallowing function should be assessed in all acute stroke patients because swallowing dysfunction is common, it persists in many patients, and complications frequently arise. The assessment of swallowing function should be both clinical and videofluoroscopic. The clinical and videofluoroscopic features at presentation that are important predictors of subsequent swallowing abnormalities and complications are videofluoroscopic evidence of delayed oral transit, a delayed or absent swallow reflex, and penetration. These findings require validation in other studies.

Aspiration: cause and implications

The purpose of this investigation was to determine the overall prevalence of aspiration in dysphagic individuals referred for a modified barium swallow and the underlying anatomic and/or physiologic causes. A total of 166 patients were seen during a 1-month period at 5 participating institutions. Aspiration was detected in 51.2% of the patients. The most common causes were decreased laryngeal elevation and delayed triggering of the pharyngeal motor response. A history of aspiration pneumonia was significantly associated with the presence of aspiration on modified barium swallow study. The presence of a protective cough was present in only 53% of patients who aspirated, reinforcing the need for appropriate radiologic assessment in patients with suspected dysphagia.

Frequency of videofluoroscopic modified barium swallow studies and pneumonia in stroke rehabilitation patients: a comparative study

OBJECTIVE

To study the association between the frequency of videofluoroscopic modified barium swallow (VMBS) studies and the incidence of pneumonia in stroke rehabilitation patients.

DESIGN

Retrospective comparative study.

SUBJECTS AND SETTING

Five hundred sixty-three consecutive stroke patients admitted to one hospital rehabilitation unit in London, Ontario, Canada were compared with 461 consecutive stroke patients admitted to another hospital rehabilitation unit in the same city.

INTERVENTIONS

The number of initial and total VMBS studies and the timing from stroke onset to initial VMBS studies.

MAIN OUTCOME MEASURE

Incidence of pneumonia.

RESULTS

At the first hospital, 146 patients (25.9%) had 232 total VMBS studies performed, whereas at the second hospital 57 patients (12.4%) had 73 total studies (p<.001). For the first 15 days there was no significant difference in the number of initial VMBS studies performed (8.2% vs. 9.2%). There was a marked difference in the number of initial VMBS studies performed after 15 days (17.2% vs. 2.0%, p<.0001). The difference between the hospitals in the number of VMBS studies in patients with brain stem strokes was not statistically significant, but for patients with hemispheric stroke, the difference was statistically significant. Pneumonia developed in 12 patients at the first hospital (2.1%) and 10 patients at the second hospital (2.2%), a difference that was not significant.

CONCLUSIONS

The more frequent use of VMBS beyond 15 days after stroke was not associated with a change in the incidence of pneumonia among hemispheric stroke rehabilitation patients, assuming the two units were otherwise similar.

Radioisotope evaluation of the esophageal remnant and the gastric conduit after gastric pull-up esophagectomy

BACKGROUND

The act of swallowing after gastric pull-up esophagectomy has not been thoroughly investigated. The aim of this study was to evaluate deglutition in the esophageal remnant and in the gastric conduit in patients who have undergone this operation.

METHODS

The residual radionuclide activity was measured 15 seconds after a swallow in the esophageal remnant and at intervals up to a maximum of 120 minutes after a swallow in the gastric conduit. The scintigraphic rate of transit of a bolus in both areas was compared in patients who had anastomosis in the neck (n = 15) versus patients who had anastomosis in the chest (n = 19). Comparisons were also made between patients with and without symptoms of dysphagia. The scintigraphic measurements were also correlated with anastomotic diameters, measured with use of a volumetric balloon insufflation method, at 3, 6, and 12 months after operation.

RESULTS

There were no significant differences in esophageal residual radionuclide activity at 15 seconds after a swallow in the groups with anastomosis in the neck versus anastomosis in the chest, with 30% residual activity up to 12 months after operation in both groups (P = .24). In the patients as a whole the 50% gastric conduit emptying time of 44 to 61 minutes did not change during the first postoperative year (P = .12). There was no association between anastomotic diameter and residual activity in the remaining esophagus (P < .126). Moderate and severe dysphagia was reported in only a few patients, and there was no correlation between dysphagic symptoms and retention in the residual esophagus or slower emptying in the gastric conduit.

CONCLUSIONS

The amount of peristaltic activity in the remaining esophagus after esophagectomy with gastric replacement is unaffected by the level of the anastomosis. The gastric conduit empties slowly in all patients, and there is no correlation between the rate of emptying and either anastomotic diameter or symptoms of dysphagia.

[Pathological deglutition pattern after tumor surgery of the oro- and hypopharynx. Analysis by differentiated deglutition]

Dysphagia is a common complaint following surgical intervention in the oral cavity and hypopharynx, often leading to prolonged postoperative recovery. Videofluoroscopy allows detailed visualization of deglutition, demonstrating the morphology as well as the functional aspects. Therefore, videofluoroscopy provides the basis for further therapeutic management. We discuss the pathology of deglutition in 19 patients recovering from tumor surgery of the oro- and hypopharynx. In most cases the results demonstrated severe impairment of both the oral and pharyngeal phase of deglutition. Our data emphasize the importance of the oral phase of deglutition for preparation and initiation of the following phases.

[Nutritional status and clinical score of 95 patients examined by radiovideoscopy for deglutition]

Ninety five consecutive patients were examined. One performed swallowing videoradioscopy, swallowing clinical score calculation and nutritional assessment with four different methods: Body Mass Index (BMI), arm muscle circumference, dual frequency bioelectrical impedance analysis and serum albumin level. The easiest and the most reliable method for nutritional assessment, comparing to the others, was BMI, where only weight ant height were necessary to measure. So, the prevalence of protein-energy malnutrition was 24.2%, unlinked neither with the presence of videoradioscopy swallowing disorders nor with clinical swallowing score level. The score level was inversely correlated with the presence of videoradioscopy swallowing disorders, and correlated with feeding types: the highest for per os normal feeding, the lowest for patients with parenteral nutrition. The presence of videoradioscopy swallowing disorders was inversely correlated with feeding types. Swallowing clinical score was validated.

Myasthenia gravis presenting with dysphagia and postoperative ventilatory failure

We report a case of myasthenia gravis presenting to the department of otolaryngology with acute dysphagia on two separate occasions over a one-year period. Diagnosis of myasthenia gravis was made when the patient developed ventilatory failure after his second general anaesthetic for rigid oesophagoscopy. Our patient required emergency transfer to the intensive therapy unit for ventilation. He improved after treatment with corticosteroids, anticholinesterase and immunosuppressive medications. Our case was unusual in that cricopharyngeal spasm causing dysphagia and significant aspiration was demonstrated by a barium swallow and this was completely resolved after treatment of the myasthenia gravis.

Incidence and patient characteristics associated with silent aspiration in the acute care setting

Coughing is a physiologic response to aspiration in normal healthy individuals. However, there are published records that report no cough in response to aspiration (i.e., silent aspiration) in dysphagic patients. In this retrospective study, for more than 2 years in two acute care hospitals we examined frequency of the cough response in patients identified as aspirators by using videofluoroscopy. One thousand one hundred one patients underwent videofluorographic evaluation of their swallowing during this 2-year period; 469 aspirated; 276 were silently aspirating. Two hundred twenty-four of these silent aspirators aspirated once during a swallow and 52 silently aspirated more than once during a swallow. These two groups of patients were analyzed separately. Univariate (chi-square and Fisher's exact tests) and multivariate (logistic regression) analyses were conducted to assess the relationship of silent aspiration to age, gender, medical diagnosis, timing of aspiration, and etiology of aspiration. In univariate analysis, age (p < 0.001), gender (p < 0.004), and medical diagnosis (p = 0.05) were significantly associated with silent aspiration in the group who aspirated once during a swallow. No significant associations were seen in the group of patients who aspirated more than once during a swallow.

An unusual complication of Cloward's procedure presenting to the otolaryngologist

We present the case of a 51-year-old lady who developed a CSF leak following a Cloward's procedure (anterior cervical surgery with fusion), which settled with conservative management. Two months following the surgery she was assessed by an otolaryngologist for persistent dysphagia and a swelling in the anterior triangle of her neck. A computed tomography (CT) scan identified a fluid-filled mass displacing the trachea and communicating with the anterior cervical vertebrae, thus confirming the persistence of a CSF leak.

Dysphagia secondary to invasive candidiasis of a jejunal free flap

The presence of a mass in a jejunal free flap that causes dysphagia less than two years after a pharyngolaryngectomy for carcinoma usually indicates tumour recurrence. We present a case of invasive candidiasis of a jejunal free flap presenting with dysphagia and a mass. To our knowledge this is previously unreported. Such a cause should always be considered in the differential diagnosis, as early recognition and treatment are likely to result in a favourable outcome.