Transoral septotomy with septum traction is an effective treatment for recurrent Zenker diverticulum

Symptoms of Zenker diverticulum can recur whatever the type of primary treatment administered. A modified transoral stapler-assisted septotomy (TS) was introduced in clinical practice a few years ago to improve the results of this mini-invasive technique. The aim of this prospective, controlled study was to assess the outcome of TS in patients with recurrent Zenker diverticulum (RZD), as compared with patients with treatment-naïve Zenker diverticulum (NZD). Patients diagnosed with NZD or RZD, and treated with TS between 2015 and 2021 were compared. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow and endoscopy were performed before and after the TS procedure. In sum, 89 patients were enrolled during the study period: 68 had NZD and 21 had RZD. The patients' demographic and clinical data were similar in the two groups. Three mucosal lesions were detected intra-operatively, and one came to light at post-operative radiological assessment in the NZD group. No mucosal lesions were detected in the RZD group. The median follow-up was 36 months (interquartile range 23-60). The treatment was successful in 97% NZD patients and 95% of RZD patients (P = 0.56). This is the first comparative study based on prospectively collected data to assess the outcome of TS in patients with RZD. Traction on the septum during the procedure proved effective in the treatment of RZD, achieving a success rate that was excellent, and comparable with the outcome in treating NZD.

A rare case of a laryngeal angiomyolipoma

Laryngeal angiomyolipoma is a rare tumor with few reported cases in the literature. The case report explains a 62-year-old man who presents with dyspnea and found to have a laryngeal angiomyolipoma staining CD34 positive, but HMB45 and Melan-A negative.

Assessing the Clinical Utility of the Early Postoperative Pharyngogram in Hypopharyngeal Surgery for Dysphagia

OBJECTIVES/HYPOTHESIS

To evaluate the clinical utility of postoperative contrast x-ray pharyngograms (XRP) for detecting pharyngoesophageal leaks following hypopharyngeal dysphagia surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Medical records were reviewed of patients undergoing endoscopic (E-) or open (O-) Zenker's diverticulectomy (-ZD) with cricopharyngeal myotomy (-CPM) and CPM alone from 2008 to 2020 at one academic institution. Exclusion criteria were patients who were fed enterally or underwent repair of epiphrenic diverticula or O-CPM during laryngectomy. XRP clinical indication, impact on clinical care, and factors associated with use patterns were examined using descriptive statistics and logistic regression (LR).

RESULTS

Of 152 subjects, 52% underwent O-ZD, 30% O-CPM, 15% E-ZD, and 3% E-CPM. An XRP was ordered for 65% of subjects, mostly routinely (94%). Among the four clinically apparent leaks observed in this cohort, early postoperative XRP confirmed one. It did not identify any clinically silent leaks. In univariate LR, undergoing XRP was associated with increasing day of diet advancement (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.5-10.5) and hospital stay duration (OR 3.2, 95% CI 2.1-5.2), as well as surgeon specialty of otolaryngology compared to general surgery (OR 12.8, 95% CI 4.8-40.8) and procedure sub-type (O-CPM: OR 0.03, 95% CI 0.002-0.16). In multivariate LR, the following variables were significantly associated with XRP use: hospital stay (OR 1.7; 95% CI 1.1-3.0), otolaryngology (OR 105; 95% CI 15.4-2193), O-CPM (OR 0.03; 95% CI 0.002-0.16), and E-CPM (OR 0.04, 95% CI 0.002-0.60).

CONCLUSIONS

Prospective, multi-institutional studies are needed to confirm the low clinical utility we observed of early, postoperative XRP following hypopharyngeal surgery for dysphagia.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Transoral Laser-Assisted Diverticulectomy: Swallow Study Results after Complete Endoscopic Pouch Excision for Zenker's Diverticulum

OBJECTIVE

Transoral endoscopic laser-assisted diverticulotomy (TELD) with diverticulectomy and diverticuloplasty (TELD + DD) for the management of Zenker's diverticulum (ZD) has been utilized by our institution since 2016 in attempts to reduce residual pouch size. This technique involves complete endoscopic pouch excision with partial advancement of mucosal flaps. Our study compares the subjective outcomes, objective outcomes, and complication rates between TELD and TELD + DD.

METHODS

A retrospective cohort study was performed on patients who underwent TELD or TELD + DD by a single surgeon at a tertiary academic center (2013-2019). Videofluoroscopic swallow studies (VFSS) with esophagram, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and 3 month follow-up visits. A single blinded reviewer recorded height, width, and depth of pre and postoperative pouches with volumetric analysis performed assuming an ellipsoid shape. Comorbidities, complications, postoperative course, and recurrence were recorded.

RESULTS

Of the 75 patients that met criteria, 27 underwent TELD + DD and 48 underwent TELD. Eighteen TELD + DD and 37 TELD had both pre and post-operative VFSS. TELD + DD and TELD had a 96 ± 7% and 87 ± 16% reduction in pouch volume, respectively (t-test; P = .01). Complications (TELD + DD 7%, TELD 17%, fisher's exact; P = .31) and final subjective outcomes after adjusting for initial were not significantly different between methods (EAT-10 with TELD + DD ∆ + 1.3, P = .18; RSI ∆ + 1.4, P = .29; FOSS ∆-0.02, P = .91). One short-term recurrence was reported with TELD.

CONCLUSION

Use of TELD + DD is associated with a statistically significantly decreased residual pouch size with no significant difference in short-term subjective outcomes. Complication rates and short-term recurrence rates are comparable. Long-term recurrence rates will require further studies to characterize.

LEVEL OF EVIDENCE

Level 3.

A Novel Presentation of the Acute Airway: Anti-IgLON5 Disease

Anti-IgLON5 disease is a newly discovered novel sleep disorder at the crossroads of neurology and immunology. In addition to the underlying sleep disorder, anti-IgLON5 manifests with progressive aerodigestive symptoms such as dysphagia, stridor, and vocal cord paresis in 90% cases and may present to the otolaryngologist. Herein we present a case of a patient with anti-IgLON5 disease who presented to the hospital with an acute airway including marked stridor and respiratory failure requiring intubation and subsequently a tracheostomy. Laryngoscope, 131:E724-E726, 2021.

Operative Management of Vocal Fold Avulsion Following Pediatric Laryngotracheal Separation

Laryngotracheal disruption in children is rare but life-threatening, and endolaryngeal injuries may go overlooked. We present the case of a 10-year-old boy who sustained near-complete laryngotracheal separation, multiple laryngeal fractures, and arytenoid and vocal fold avulsion following blunt cervical trauma. These injuries were not identified radiographically and only became apparent intraoperatively. Following surgical repair, the patient was successfully decannulated, eating a normal diet, and had a serviceable speaking voice within 2 months. In children, the diagnosis of severe endolaryngeal injuries may be elusive and therefore require high degree of clinical suspicion. Surgical success requires accurate diagnosis and prompt intervention.

Association Between Age and Patient-Reported Changes in Voice and Swallowing After Thyroidectomy

OBJECTIVES

Despite intact recurrent laryngeal nerves, patient-reported voice and swallowing changes are common after thyroidectomy. The association between patient age or frailty status and these changes is unknown. The aim of this study was to evaluate the impact of age and frailty on the incidence of voice and swallowing alterations after thyroidectomy.

METHODS

We performed an institutional review board (IRB)-approved retrospective review of consecutive patients who underwent total thyroidectomy with intraoperative recurrent laryngeal nerve (RLN) monitoring at a single institution between January 2014 and September 2016. Patients with RLN injury were excluded. After data extraction, a modified frailty index (mFI) was calculated for each patient. The association among risk factors, including age, mFI, prior history of neck surgery, frequent voice use, presence of malignancy or gastroesophageal reflux disease, and smoking status and reported voice and/or swallowing changes was examined.

RESULTS

Of 924 patients undergoing thyroidectomy, 148 (16.0%) reported only changes in voice; 52 (5.6%) reported only difficulty in swallowing; and 26 (2.8%) reported changes with both voice and swallowing. On multivariate analysis, we found a significant increase in voice or swallowing alterations up to the age of 50 years (5% increased odds per year), after which these changes plateaued. We found that mFI was not associated with voice or swallowing changes.

CONCLUSION

Age ≥ 50 years is independently associated with the development of voice or swallowing changes after thyroidectomy, despite intact RLN. Additional prospective studies are needed to validate these findings, further define this association, and identify risk factors for developing these changes.

LEVEL OF EVIDENCE

2b Laryngoscope, 129:519-524, 2019.

The Incidence and Characterization of Globus Sensation, Dysphagia, and Odynophagia Following Surgery for Obstructive Sleep Apnea

STUDY OBJECTIVES

To determine the incidence, duration, and predictors of swallowing-related symptoms following upper airway surgery for obstructive sleep apnea.

METHODS

Adults (age 18 years or older) who underwent surgery for obstructive sleep apnea at a tertiary care institution from January 2012 to December 2015 were retrospectively reviewed. The incidence, duration, and associated factors of postoperative swallowing complaints were evaluated.

RESULTS

A total of 130 patients (135 surgical encounters) met criteria for inclusion. There were 91 men (70.0%) and 39 women (30.0%) with a median age of 60 years (range: 19-79). Presurgical diagnosis of gastroesophageal reflux disease was present in 57 patients (43.8%). An average of 2.1 procedures (± 0.8) were conducted at each encounter. Uvulopalatopharyngoplasty (54.8%) was the most common followed by radiofrequency ablation of the soft palate (34.8%) and tongue base (29.6%). Postoperatively, 25 patients (19.8%) complained of dysphagia, 14 (10.9%) of globus, and 9 (6.7%) of odynophagia. Preoperative gastroesophageal reflux (odds ratio [OR] 4.09, 95% confidence interval [CI] 1.41-11.91) and hyoid myotomy with suspension (OR 4.88, 95% CI 1.34-17.77) were significant predictors for dysphagia. Radiofrequency ablation of the tongue base (OR 5.00, 95% CI 1.28-19.50) was a predictor for globus sensation. Median symptom durations, in months, were 4.0 for dysphagia, 7.3 for globus, and 3.0 for odynophagia.

CONCLUSIONS

Preoperative gastroesophageal reflux and hyoid myotomy with suspension procedure were associated with postoperative dysphagia whereas radiofrequency ablation of the tongue base was associated with globus. These findings can assist surgeons in providing preoperative counseling and postoperative supportive measures regarding dysphagic symptoms following sleep surgery.

Residue influences quality of life independently of penetration and aspiration in head and neck cancer survivors

OBJECTIVES/HYPOTHESIS

Dysphagia is one of the most significant side effects of the treatment of head and neck cancer. Residue and aspiration are two indicators of dysphagia, but aspiration is historically the only indicator of interest, because it may impact health outcomes. Clinicians have anecdotally used residue as another marker of swallowing dysfunction, but it is understudied. This project investigated the impact of aspiration versus residue on function and quality of life (QoL) in these patients.

STUDY DESIGN

Observational study.

METHODS

A total of 168 head and neck cancer survivors with moderate to severe dysphagia were enrolled in a randomized clinical trial comparing two swallow therapy interventions. Data at time of entry were used for the current study. A modified barium swallow study was done to compute Penetration-Aspiration Scale (PAS) scores, percentage oral residue, and percentage pharyngeal residue with three bolus consistencies (5 mL thin, nectar, and pudding). The Performance Status Scale (PSS) and the Head Neck Cancer Inventory (HNCI) questionnaires were administered. Data were analyzed to determine associations between aspiration and residue estimates with function and QoL scores.

RESULTS

Worsening aspiration and residue estimates were all correlated with decreased scores on the PSS functional scales (r = -0.190 to -0.324, P ≤ .031). However, only increasing residue estimates were significantly related to decreased patient-perceived QoL on the HNCI (r = -.178 to -.194, P < .046). This effect was more pronounced with oral versus pharyngeal residue.

CONCLUSIONS

In this group of head and neck cancer survivors, penetration/aspiration and residue show independent effects. PAS affects functional status only, but residue affects both functional status and QoL. This study supports that residue should be considered a primary measurement of swallowing function and be a target for identification, treatment, and evaluation of swallowing.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:1615-1621, 2017.