Endoscopic dilatation improves long-term dysphagia following head and neck cancer therapies: a randomized control trial

Swallowing improvement surgeries

PURPOSE

To discuss the different swallowing improvement surgeries that address one or more dysfunctional pharyngolaryngeal structures causing dysphagia. These surgeries reduce the risk of aspiration without sacrificing vocal function.

METHODS

We searched the PubMed database and used Google Scholar search engine to find studies discussing the different swallowing improvement surgeries. A manual search of references in selected articles and reviews was done as well. No chronologic limitation was set for the studies; however, only articles written in English and Japanese were considered. Due to the nature of this article, no particular inclusion or exclusion criteria were set when searching for studies to be used as references; however, all relevant studies were reviewed and agreed upon by the authors for inclusion in this review article.

RESULTS/DISCUSSION

Surgeries to improve swallowing function can be categorized into those that reinforce nasopharyngeal closure or pharyngeal contraction, improve laryngeal elevation or pharyngoesophageal segment opening, and those that improve vocal fold closure to protect the airway during swallowing. They are an effective alternative treatment that may significantly improve these patients' quality of life. Swallowing rehabilitation with the altered pharyngolaryngeal structures is required post-operatively to significantly improve patients' dysphagia.

CONCLUSIONS

Surgeries to improve swallowing function address specific dysfunctional sites involved in the swallowing mechanism. Choosing the most appropriate surgery for each patient requires knowledge of the pathophysiology for their dysphagia and detailed pre-operative work-up.

Swallowing after total laryngectomy surgery: where are we after 150 years?

Purpose of review

Recent findings

Dysphagia is a common sequela following total laryngectomy surgery; however, there is significant variability in its assessment and management. Manometry enables an accurate understanding of the underlying mechanism of dysphagia and precise assessment of any oesophageal dysfunction. EndoFLIP is a useful tool to better understand dysfunction of the upper oesophageal sphincter particularly to detect stricture.

Summary

Following total laryngectomy surgery, dysphagia is common; clinicians need to be alert to early indicators of dysfunction and understand the tools to comprehensively characterize swallow function. Accurate diagnosis of a stricture is important, as this aspect of dysfunction can be modified, and may alleviate surrogate problems such as a leaking voice prosthesis. Clinicians should have a low threshold to examine patients for oesophageal dysfunction due to the high prevalence of dysmotility following a laryngectomy.

Neopharyngeal Stricture following Laryngectomy

Stricture formation is a serious complication following pharyngeal reconstruction. These strictures can be life-threatening and can severely impact quality of life. In this article, the existing literature on surgical risk factors linked to neopharyngeal stricture formation is reviewed. Intraoperative preventative measures reconstructive surgeons should consider are also discussed. Finally, this article will describe the evaluation and management of pharyngoesophageal strictures, including the challenges and options when dealing with refractory strictures.

Pharyngeal tongue base augmentation for dysphagia therapy: A prospective case series in patients post head and neck cancer treatment

BACKGROUND

Dysphagia post head and neck cancer (HNC) multimodality treatment is attributed to reduced pharyngeal strength. We hypothesized that pharyngeal tongue base augmentation for dysphagia (PAD therapy) would increase pharyngeal pressures during swallowing thereby improving swallow symptoms.

METHODS

Adults with moderate-severe dysphagia post-HNC treatment had PAD therapy using a temporary filler (hyaluronic acid [HA]), with follow-up long-lasting lipofilling. Swallowing preprocedure and postprocedure was assessed with the Sydney Swallow Questionnaire (SSQ), High-Resolution Pharyngeal Manometry (HRPM), and Videofluoroscopic Swallowing Study (VFSS). Statistical comparison utilized paired tests.

RESULTS

Six participants (all male; median age 64 years [IQR 56, 71]) underwent PAD therapy at a median of 47 [IQR 8, 95] months post-treatment. SSQ scores reduced from baseline (mean 1069 [95%CI 703, 1434]) to post-HA (mean 579 [76, 1081], p > 0.05), and post-lipofilling (491 [95%CI 913, 789], p = 0.003, n = 4). Individual participants demonstrated reduced Swallow Risk Index, Bolus Presence Time, and increased Upper Esophageal Sphincter opening, but mesopharyngeal contractile pressures were unchanged. VFSS measures of aspiration, residue, and severity were unchanged.

CONCLUSIONS

Novel PAD therapy is safe and improves dysphagia symptoms. Biomechanical swallowing changes are suggestive of more efficacious bolus propulsion with conservative filler volume, but this was unable to resolve residue or aspiration measures.

A Novel Balloon Catheter-based Dilation Intervention for Patients with Cricopharyngeus Achalasia After Stroke: A Randomized Study

This study aimed to investigate the efficacy and safety of a novel balloon catheter in dilation intervention for patients with cricopharyngeus achalasia after stroke. Thirty-four patients with cricopharyngeus achalasia after stroke received routine swallowing rehabilitation training and were randomly assigned to an experimental group (Exp, n = 17) that received dilation therapy using the novel balloon catheter once daily for 5 days per week or a control group (Con, n = 17) that received dilation therapy with a 14-Fr ordinary urinary catheter once daily for 5 days per week. The intervention duration, Eating Assessment Tool (EAT)-10 scores, and Functional Oral Intake Scale (FOIS) scores were recorded at baseline and each day during intervention. The time for a patient's FOIS score to be ≥ 3 as well as the recovery time for oral intake of water, liquid food, mushy food, and solid food were recorded or estimated. Complications were also recorded during intervention. The intervention duration was shorter in the Exp group than in the Con group (p = 0.005). The Exp group patients improved faster than the Con group patients, with a shorter recovery time for oral intake of liquid food (p = 0.002), mushy food (p = 0.001), and solid food (p = 0.001). At the time of intervention termination, EAT-10 scores were lower in the Exp group than in the Con group (p = 0.005). The Exp group had a similar incidence of complications as the Con group but with better tolerability (p = 0.028). Compared with the urinary catheter, the novel balloon catheter for dilation in patients with cricopharyngeus achalasia after stroke may lead to a better and more rapid recovery.

Free Flap microvascular pharyngeal closure results in improved dysphagia-specific quality of life following total laryngectomy

Background

Total laryngectomy (TL) as either a primary or salvage treatment strategy remains an effective oncologic operation in the management of laryngeal cancer. Dysphagia is the most common complication following TL and this has a significant impact on patients’ quality of life (QOL). Following removal of the larynx, a number of pharyngeal closure techniques exist. We aimed to evaluate the effect pharyngeal closure techniques have on dysphagia-specific QOL postoperatively.

Methods

We retrospectively reviewed patients who had undergone TL at our institution (2014–2019). Patients alive at the time of study were invited to complete the MD Anderson Dysphagia Inventory (MDADI). Outcomes were compared among Primary Closure (PC), Pedicled Pectoralis Major Myocutaneous Flap (PMMF) and Free Flap (FF) closure groups.

Results

There were 27 patients identified for inclusion. Eight patients (30%) underwent PC, 10 patients (37%) had PMMF-assisted closure and 9 patients (33%) underwent FF-assisted closure. Patients within the FF group scored consistently higher MDADI scores across all subscales (emotional, functional, physical, global) as well as composite MDADI score in comparison to the PC and PMMF groups. FF closure was associated with a reduced inpatient length of stay (LOS). Additionally, no significant differences in postoperative morbidity including rates of pharyngo-cutaneous fistula (PCF) were observed between groups.

Conclusions

We now advocate FF closure for our patients following salvage TL due to the improved dysphagia-specific QOL, reduced inpatient LOS and lack of additional surgical morbidity.

Level of evidence, Level III, therapeutic/prognostic study.

Montgomery Salivary Bypass Tube in Head and Neck Cancer: The Experience of Our Otolaryngology Clinic

INTRODUCTION

One of the most common complications in the immediate and late postoperative period following total laryngectomy or pharyngolaryngectomy is pharyngocutaneous fistulae (PCF) formation and pharyngoesophageal stenosis (PES), causing significant mortality and morbidity. Since 1978, Montgomery salivary bypass tube (MSBT) has been used to reduce the incidence of PCF and PES. The aim of this retrospective study was to analyze the outcomes of using MSBT both as a tool to prevent PCF and PES and to treat these complications in the postoperative period.

METHODS

Between January 2013 and December 2019, we inserted 109 MSBT in 87 patients with laryngeal/hypopharyngeal cancer treated in the Unit of Otolaryngology of our University Hospital.

RESULTS

Sixty (86.9%) patients healed from complications with primary and secondary placement of MSBT. Seven patients presented a persistence of PCF and 2 presented a recurrence of PES. Secondary placement of MSBT allowed treating successfully 15 (83%) of 18 patients. Only 3 of them presented a PCF at the end of the follow-up period.

CONCLUSION

According to our experience, the MSBT is an affordable, easy to apply and well-tolerated tool. Although it is generally used for PCF treatment, it can also be used intraoperatively for PCF and PES prevention.

Reconstruction technique following total laryngectomy affects swallowing outcomes

OBJECTIVES

How reconstruction affects function following total laryngectomy is unclear. This study seeks to determine whether reconstruction method is associated with differences in swallowing outcomes.

METHODS

Retrospective review of reconstruction technique in patients undergoing TL was compared by pharyngeal transit time (PTT), patient-reported dysphagia (EAT-10), and diet-tolerated (FOIS).

RESULTS

Ninety-five patients met inclusion criteria, with 40 patients (42.1%) undergoing primary closure and 55 patients (57.9%) undergoing tissue transfer. There was no difference in EAT-10 scores between the groups (P = .09). There was a significantly higher proportion of patients achieving oral diet (FOIS >3) with primary closure (P = .003). Patients undergoing PMC vs free flap had similar rates of g-tube dependency. Primary closure had the shortest PTT (1.89 seconds) compared to free flap (3.47-4.65 seconds) or PMC (5.1 seconds; P = .035).

CONCLUSIONS

When primary closure is achievable, these results suggest improved swallowing outcomes with better tolerance of oral diet and shorter pharyngeal transit times.

LEVEL OF EVIDENCE

IV.

Novel Therapeutic Strategy for Pharyngoesophageal Stricture following Total Laryngectomy

Current therapeutic strategies for pharyngoesophageal stricture, while effective in the short term, are protracted and costly in the longer term. Conceptually, if a stricture can be dilated with minimal tissue injuries, the rate of fibrosis and the resultant stricture recurrence could be reduced. We evaluated a prototype computer-controlled syringe pump device programmed to distend a commercially available balloon dilator at variable rate, asserting incremental lumen distension pressures tailored to the resistive force encountered within the stricture. We completed 17 graded dilatation procedures among 4 total laryngectomy patients. All patients had a short-term response (1 month), with a mean decrement (improvement) in Sydney Swallow Questionnaire score of 448 (total score range, 0-1700; normal <234). The overall procedural tolerability and safety were encouraging; the only complication was the displacement of the voice prosthesis during 1 dilatation. From a technical viewpoint, the main challenge was to maintain the balloon in position during dilatation.