Function in the pharyngoesophageal segment

Examination of the pharyngoesophageal (PE) segment is usually limited to manometry or barium swallow. Manofluorography is a technique which allows simultaneous analysis of both manometry and videofluoroscopy of deglutition on a single video screen. Using manofluorography, the physician can see the cause of the manometric pressure waves. Understanding of the PE segment pathophysiology has been limited. Dysfunction is usually labeled as cricopharyngeal achalasia or incoordination, which may lead to cricopharyngeal myotomy. However, this approach has yielded poor results. This study demonstrates that laryngeal elevation and timing of the swallowing reflex also play an important role in controlling pressures and function in the PE segment during deglutition. These factors must also be examined in assessment of cricopharyngeal dysfunction to guide appropriate management.     

Cineradiography of the pharyngoesophageal segment in postlaryngectomy patients

The use of tracheoesophageal voice prostheses has gained wide acceptance in the field of vocal rehabilitation after total laryngectomy. In a randomized study with 3 arms, alaryngeal speech proficiency was assessed in 60 postlaryngectomy patients: 20 patients underwent primary unilateral pharyngeal myotomy, 21 patients underwent neurectomy of the pharyngeal plexus in addition to pharyngeal myotomy, and 19 patients did not undergo an additional surgical procedure. Pharyngoesophageal (PE) dynamics were examined during esophageal and tracheoesophageal speech. A single vibrating PE segment was seen in good alaryngeal speakers. Hypertonicity, spasm, strictures, and hypotonicity of the PE segment were correlated significantly with poor or moderate alaryngeal speech. Unilateral myotomy with or without unilateral neurectomy prevented hypertonicity or spasm of the PE segment. The acquisition of alaryngeal speech did not differ significantly between the 2 groups who had undergone an additional surgical procedure. Evaluation of anatomic and physiological factors may be helpful in subsequent clinical management to achieve effective alaryngeal speech.     

Morphology and function of the pharyngoesophageal segment

Basing on the review of the foreign and domestic literature the point of view concerning the anatomical structure, innervation and histomorphology of the pharyngoesophageal segment (pes) is being presented. Special attention was paid to the impact of the somatic and autonomic (particularly its sympathetic part) nervous system on the function of the pharynx, as well as the pressure at rest with the pharyngoesophageal sphincter. Histomorphologic investigations suggest that the pes function and tension of the particular pharyngeal constrictors (upper, middle and inferior) is determined by: a) structure, b) distribution of the IX and X nerve fibre ends in pharyngeal sphincters, c) structure of the pharyngeal sphincter, which is also supplied with the nervous fibre ends of the upper cervical sympathetic trunk. The sympathetic trunk is located on both sides of vertebral column from the skull base till the tip of the sacral bone. In case of degenerative process in the neck segment of the vertebral column, irritation of the sympathetic part of the autonomic system is taking place. Experimental investigations revealed that the stimulation of the sympathetic nervous fibres of the autonomic system results in weakening of the upper and middle pharyngeal sphincter's tension and increase of tension in its lower part (cricopharyngeal muscle). This can be an etiopathogenic factor under physiological condition in disturbances of the pharyngeal phase of deglutition act. After total laryngectomy, however, high pressure in the lower part of the pes (in the area of pharyngoesophageal sphincter) renders it difficult or even impossible to introduce the air into the esophagus to master the phonation and esophageal speech. The significance of the knowledge of the pes innervation in clinical practice is important for prognosis in mastering of supplementary, esophageal and shunt phonation.     

Simultaneous manometry and electromyography in the pharyngoesophageal segment

Whether the occlusion between hypopharynx and esophagus is established by anatomical relations and tissue elasticity or by a functional resting tone of the muscle fibers is not quite clear. This study describes simultaneous electromyography (EMG) and electromanometry in the pharyngoesophageal segment to solve this problem and investigate the complex mechanism of deglutition. To register the EMG from the hypopharyngeal constrictor muscle and the upper esophageal sphincter (UES), two copper wire electrode pairs with hooked bare ends were used. These electrodes were introduced into the muscles through a rigid esophagoscope. It is demonstrated that at rest muscle activity is present in the UES. This activity disappears during the relaxation period. Simultaneous manometry and EMG is a valuable supplement to diagnostic procedures in dysphagia patients.     

Fiberoptic examination of the pharyngoesophageal segment in tracheoesophageal speakers

OBJECTIVE: To describe a novel use of flexible fiberoptic endoscopy to examine the pharyngoesophageal segment, upper esophagus, and distal end of the tracheoesophageal prosthesis in patients who have undergone a total laryngectomy and a tracheoesophageal puncture. METHODS: Five patients with poor-quality or no tracheoesophageal voice were evaluated by a speech pathologist and an otolaryngologist. A flexible endoscope interfaced with a video monitoring device was introduced transnasally and passed through the pharyngoesophageal segment. Examination of the anatomical relationship between the prosthesis and the esophageal mucosa was conducted while the subjects attempted to phonate. Treatments were then initiated based on the endoscopic findings. CONCLUSION: Flexible endoscopy is a safe, cost-effective, diagnostic tool for evaluating laryngectomees suffering from poor-quality tracheoesophageal voice.     

Factors influencing morphology and function of the pharynx and pharyngoesophageal sphincter after total laryngectomy. Part II. The impact of degenerative changes in the neck segment of the vertebral column on the rest pressure within pharyngoesophageal sphincter after laryngectomy

Radiological examinations of the vertebral column neck segment were done in 41 patients after total laryngectomy (n = 29) and laryngopharyngectomy (n = 12). Degeneration changes of different degree (from I degree to IV degree) were stated in 37 cases. Criteria of assessment were as follows: a) the width of the intervertebral space b) appearance and degree of the exostoses c) the length of the degenerative process in vertebral segment of the neck. The advanced degenerative changes in the vertebral column (IV degree) included all neck segment and were characterized by significant narrowing of the intervertebral spaces and exostoses longer than 0.5 cm. These changes were seen statistically more often in the patients after 50. The pharyngoesophageal sphincter's (p.e.s.) rest pressure was statistically rising significantly with the degree of the degeneration changes in the vertebral column. The high pressure in p.e.s. (5.7 + 2.85 kPa--43 + 21 mm Hg) was seen only in the cases of the IV degree degree. In the patients with the IV degree degree of degenerative changes in 67% retention of saliva in the hypopharynx was seen. Probably it was due to irritation of the sympathetic part of the autonomic system. The statistically significant correlation between the degree of the degenerative changes and the complains like pain during the head movement and limitation of the neck motion was also observed. In IV degree degree these complains were noted in 57% cases. The results of the investigations prove the hypothesis of influence of the sympathetic part of the autonomic system on the pharyngoesopghageal sphincter rest pressure.     

Free vascularized jejunum interposition for pharyngoesophageal reconstruction after total laryngopharyngectomy

The records of 28 patients who underwent free jejunal graft reconstruction after resection for cancer involving the pharynx were analysed. Seven patients had a T₃ carcinoma, 15 patients T₄ and six patients recurrence after laryngectomy. Ten patients had received radiotherapy in the past. Post-operatively, 15 patients (54%) had complications and two patients (7%) died. No significant difference was observed in the complication rate between the group that received radiotherapy in the past and those who did not. Nineteen patients received post-operative radiotherapy. Nine patients had no radiotherapy on the basis of complete resection or because of serious complications. For the whole group the 2-year recurrence free period and survival were 42% and 51% respectively. The postoperative radiotherapy group had a significantly better survival (73%) and recurrence free period (63%) than the group without post-operative radiotherapy (0%). Thus, post-operative radiotherapy seems indicated irrespective of resection margins.     

Inhaled foreign bodies in laryngectomees

As a consequences of laryngectomy, patients possess a tracheostoma presenting on the neck skin which is an intrinsic component of their airway and which provides a portal through which potentially dangerous foreign bodies can enter the tracheobronchial tree. In addition, new methods of speech rehabilitation require the placement of a valve within the stoma which needs regular cleaning and manipulation. We report 3 cases of aspiration, each of a different piece of equipment that is commonly associated with laryngectomees, illustrating potential unique risks to the airway in such individuals.     

Speech acceptability and olfaction in laryngectomees

A number of hypotheses concerning the causal relationships and interrelationships between esophageal speech acceptability, olfactory abilities, and airflow volume in laryngectomees were tested. To assess the hypotheses, data were collected from 25 laryngectomees and comprised the following: (1) A measure of speech acceptability using a standard passage of prose; (2) odor identification test results in which 14 common odorants were used; (3) odor threshold test results in which an 11-step aqueous dilution series of l-butanol was used and: (4) a measure of nasal airflow volume in liters per minute. The null hypotheses linking speech acceptability, olfaction, and airflow volume were all tested and none of the path coefficients was significant. The results are discussed in relation to observations made by Gilchrist [Acta Otolaryngol. (Stockh.) 75:511-518 (1973)], who noted that those esophageal speakers who attained good speech maintained a greater sensitivity to smell. The findings in the present study do not support Gilchrist's observations.     

Olfactory mucosa histological findings in laryngectomees

After total laryngectomy, the patients often report immediate and marked olfactory deficit. The aim of this study was to determine whether hyposmia in laryngectomees reflects olfactory epithelial damage. Ten laryngectomized patients and ten rhinologically normal subjects were subjected to olfactory testing, after which histological examination of biopsied olfactory mucosa was performed. Olfactory testing in laryngectomees revealed a marked reduction in odor perception. Histological examination of olfactory mucosa specimens showed that in laryngectomees some neuroepithelial structural features were comparable with those found in normal subjects. However, additional signs of damage were also observed, consisting mainly of various degrees of epithelial degeneration, above and beyond those that are characteristic of physiological epithelium turnover. These different degenerative features consisted of severe damage to the neuroepithelium, culminating in complete topical loss. Bowman's glands were also observed to be involved in the degenerative process. Laryngectomy-induced hyposmia seems to be correlated with the almost complete loss of nasal airflow due to the disconnection between the upper and lower airways, which prevents odor molecules from reaching the olfactory area, together with degenerative phenomena, which affect the neuroepithelium, and consequent failure in neurosensorial performance.     

Mitomycin C for the treatment of pharyngoesophageal stricture after total laryngopharyngectomy and microvascular free tissue reconstruction

OBJECTIVES: To assess the role of mitomycin C (MMC) in the management of pharyngoesophageal stricture after total laryngopharyngectomy and free flap reconstruction. STUDY DESIGN: Five patients since 1998 underwent evaluation and treatment for pharyngoesophageal stricture after total laryngopharyngectomy and free flap reconstruction. The method of reconstruction included four tubed radial forearm free flaps and one jejunal free flap. All patients underwent barium swallow, computed tomography, and endoscopic examination and were proven to be free of recurrent disease. METHODS: The patients were taken to the operating room. After dilation, the stenotic segment was exposed, and 1 mL of 0.4 mg/mL mitomycin-C was applied for 4 minutes using a cotton pledget. The patients were then followed clinically and with barium swallows for a minimum follow-up period of 18 months. RESULTS: All five patients experienced improved swallowing ability. The need for further dilatations was either eliminated or lessened. All patients were happy with the treatment results. No complications occurred. CONCLUSIONS: This small case series suggests that MMC is a safe and effective adjunctive treatment for pharyngoesophageal stricture after total laryngopharyngectomy and free flap reconstruction.     

Factors influencing pharynx' and pharyngoesophageal sphincter's morphology and their function after total laryngectomy

The usefulness of the videolaryngoscopy in patients after total laryngectomy/laryngopharyngectomy was discussed. They serve for: a) evaluation of the pharynx and of the pharyngoesophageal sphincter (pes) morphology, b) prognosis of the esophageal speech developing. In the study videolaryngoscopy was done in 82 patients (7 female and 75 male). In 62 of them total laryngectomy was done (among them in 50/62--with standard pharynx suture, in 9/62--with the pes plasty, and 3/62--with simple pes myotomy). In 20 case of laryngopharyngectomies--4/20 standard pharynx suture was done, 12/20 were reconstructed with tongue flap, 3/20--with pes plasty, and in 1/20 simple myotomy was performed. The investigations were carried out between 1 to 36 months after total laryngectomy and 24 month after laryngopharyngectomy. The analysis of the videolaryngoscopy imagings revealed that the pharynx and pes morphology after laryngectomy/laryngopharyngectomy (shape, thickness of the mucose, weakened wall peristalsis, secretion retention, lack or presence of the pes relaxation at the time of examination) correlates with the rest pressure in the pes area, measured by Seeman's method and with the occurrence of the esophageal speech mastering. The most significant changes in morphology and function of the pharynx (irregular shape, weakened wall peristalsis, retention of secretion) as well as the highest pressure in the area (5.1 +/- 3.33 kPa-38 +/- 25 mm Hg) was found after pharyngolaryngectomy. The shape of the pharynx in all the patients after laryngectomy with plasty or simple myotomy of the pes was regular, with thin and smooth mucosa while the rest pressure was low (3.0 +/- 1.18 kPa(-)+/- 22.5 +/- 8.8 mm Hg). In the analyzed material at the rest pressure in the sphincter area from 0.7 to 4kPa (from 5 to 30 mm Hg), 93% (41/44) of the patients have mastered the esophageal speech. It was stressed that videolaryngoscopy is entirely sufficient for the approximate assessment of the rest pressure in the pes area and prognosis of the esophageal speech development process.     

Videostroboscopy of human vocal fold paralysis.

Previous stroboscopic studies of human vocal cord paralysis have been infrequent and have lacked documentation of the site of lesion. In order to study human laryngeal paralysis, the recurrent and superior laryngeal nerves were infiltrated unilaterally with lidocaine hydrochloride in three human volunteers. Vagal paralysis was simulated by combined (superior and recurrent) infiltration in one volunteer. Additionally, 20 patients with untreated laryngeal paralysis were studied from the voice laboratory at UCLA. In addition to videostroboscopic analysis, photoglottography and electroglottography were performed and synchronized with the stroboscopic images. The most significant finding in stroboscopy of the paralyzed larynx was the asymmetry of traveling wave motion. The traveling wave on the normal vocal fold had a faster wave velocity that created a phase difference in the vibration of the two folds. The wave also traversed a greater distance along the vocal fold mucosa on the normal side. No patient or volunteer with untreated laryngeal paralysis had a symmetric traveling wave, either in superior or recurrent laryngeal nerve paralysis. Synchronization with glottography indicated that the differentiated electroglottographic waveform provides useful information about the timing of glottic opening and closure in states of asymmetric laryngeal vibration. Implications for future studies and for the diagnosis of laryngeal paralysis are discussed.