Investigation of pharyngeal swallowing function using high-resolution manometry

Objectives/Hypothesis: This study aimed to demonstrate the feasibility of a novel high‐resolution manometry system, and to establish normal values of swallowing pressures along the velopharynx and upper esophagus. Study Design: Prospective study. Methods: Thirty‐three asymptomatic adult Japanese controls were studied. A solid‐state high‐resolution manometry assembly with 36 circumferential sensors spaced 1 cm apart was positioned to record pressures during swallowing from the velopharynx to the upper esophagus. The maximum values of the swallowing (dry and 5 mL of water) pressures at velopharynx, meso‐hypopharynx, and at the upper esophageal sphincter (UES) were measured. The resting UES pressure, the length of the part in the cervical esophagus showing the resting UES pressure, and the distances from the nostril to the above‐mentioned points of pressure measurement were also measured. Results: The maximum value of dry and water swallowing pressures at the velopharynx, meso‐hypopharynx and UES, and the distances from the nasal vestibulum to each point in men were 141.1 ± 73.5 (mm Hg, mean ± standard deviation) and 162.7 ± 94.9, 175.3 ± 59.7 and 182.9 ± 83.6, 172.7 ± 73.8 and 236.1 ± 78.9, and 10.0 ± 1.3 (cm) and 10.1 ± 1.4, 14.1 ± 1.5 and 14.4 ± 1.3, 17.9 ± 1.7 and 18.0 ± 1.4, respectively. Those in women were 118.9 ± 38.0 (mm Hg) and 124.7 ± 43.4, 165.9 ± 41.5 and 167.3 ± 65.0, 149.2 ± 68.7 and 243.7 ± 87.4, and 9.5 ± 1.2 (cm) and 9.4 ± 1.2, 13.0 ± 1.5 and 12.8 ± 1.4, 15.8 ± 1.5 and 16.0 ± 1.3, respectively. The maximum value of resting UES pressure, the length of the part in the cervical esophagus showing the resting UES pressure and the distance from the nostril to the mid‐point of the width of the resting UES pressure in men and in women were 70.2 ± 30.0 mm Hg, 4.0 ± 0.7 cm, 19.1 ± 1.3 cm, and 61.8 ± 26.7 mm Hg, 3.6 ± 0.6 cm, 17.0 ± 1.2 cm, respectively. Conclusion: The present study provides anatomical and physiological information about normal swallowing along the velopharynx and upper esophagus, which will be an aid to the future clinical and investigative studies.     

影响口腔口咽癌广泛切除后吞咽功能恢复的因素

目的探讨影响口腔、口咽癌广泛切除后吞咽功能恢复的诸多因素。方法自2002年12月N2008年1月,共102例口腔或口咽癌患者经广泛切除手术治疗,其中男性77例,女性25例,年龄32N76岁,平均56．2岁。按照AJCC（2002）癌症患者分期标准,I期7例、II期39例、Ⅲ期44例、Ⅳ期12例。按照年龄大于或小于60岁、临床T分级、有否颈清扫、舌及舌根切除范围、下颌骨切除范围以及重建方法等因素进行多因素分析。结果102例患者术后7～47天去掉鼻饲管恢复经口进食功能。对于术后经口吞咽功能恢复期限的影响,年龄大于或小于60岁、T分级和临床分期、有否颈清扫、舌切除及下颌骨切除与否及其范围等均无统计学意义（P〉O．05）。而舌根切除或未切除（P=O．0164）,不同的重建方法（P=O．0011）,则有统计学意义。结论有否舌根切除及不同的重建方法是影响口腔及口咽癌切除术后恢复独立经口进食功能的主要因素。     

The effect of a chin-down maneuver after esophagectomy on oropharyngeal swallowing pressure measured using high-resolution manometry

ObjectiveTo elucidate the effects of a chin-down maneuver using high-resolution manometry (HRM) to measure pharyngeal swallowing pressure (SP) after esophagectomy.MethodsWe evaluated 9 of 16 patients who underwent esophagectomy featuring gastric tube reconstruction and three-field lymph node dissection (3FL) in our Department of Gastroenterological Surgery from September 2015 to June 2016. We compared all parameters of the neutral and chin-down positions using HRM to measure the maximum SP at the velopharynx, meso-hypopharynx, and upper esophageal sphincter (UES) and the duration of lowered SP at the UES, the distance from nostrils to the boundary between hypopharynx and UES and to derive SP and SP propagation curves at various distances from the nostrils.ResultsCompared to that at the neutral position, the maximum SP at the velopharynx was significantly lower in the chin-down position (p < 0.05); however, SP at the meso-hypopharynx and UES did not differ significantly. The duration of lowered SP at the UES was significantly prolonged in the chin-down position and the distance from nostrils to the boundary between hypopharynx and UES was significantly shortened representing the elevation of the larynx, respectively (p < 0.05, p < 0.01). On the SP propagation curve for males, the times to SP peaks at 13, 16, 17, and 18 cm from the nostrils were significantly prolonged (all p < 0.05) in the chin-down position.ConclusionChin-down positioning after esophagectomy/3FL may improve bolus passage by prolonging the duration of lowered SP at the UES, possibly by enhancing laryngeal elevation.     

Cine MRI of swallowing in patients with advanced oral or oropharyngeal carcinoma: a feasibility study

Treatment of oral and oropharyngeal cancer may cause dysphagia. Purpose is to examine whether cine magnetic resonance imaging (MRI) yields additional information compared to standard examination in the evaluation of posttreatment dysphagia and mobility of oral and oropharyngeal structures. Thirty-four cine MRIs were made in 23 patients with advanced oral and oropharyngeal cancer, consisting of an MR image every 800 ms during swallowing which is compared to videofluoroscopy and quality of life questionnaires. A scoring system was applied to assess mobility on cine MR and videofluoroscopy leading to a score ranging from 9 to 17. Cine MRI of the swallowing in a midsagittal plane visualized the tumor (if located in the same plane), important anatomic structures and surgical reconstructions. Posttreatment mobility on cine MRI and videofluoroscopy was significantly diminished compared to pretreatment, mean pretreatment cine MRI score was 10.8 and posttreatment 12.4 (p = 0.017). Impaired mobility on cine MRI was significantly correlated to more swallowing problems (Spearman’s correlation coefficient 0.73, p = 0.04), on videofluoroscopy not. Cine MRI is a promising new technique as an adjunct to standard examinations for evaluation of swallowing in patients with oral and oropharyngeal cancer. Cine MRI directly visualizes the dynamics of swallowing and allows evaluation of pre- and posttreatment differences. Abnormal findings are significantly correlated with subjective swallowing complaints of patients.     

Comparison of psychosocial factors over time among HPV+ oropharyngeal cancer and tobacco-related oral cavity cancer patients

Introduction

The role of human papilloma virus (HPV) in the pathogenesis of oropharyngeal squamous cell carcinoma (OPSCC) is well documented, as is the excellent prognosis of patients with HPV-associated disease; in contrast, oral cavity squamous cell carcinoma (OCSCC) is associated with tobacco and alcohol use and has a worse prognosis. While causative factors, staging, and treatment guidelines differ between these cancer subsets, few studies have compared psychosocial factors in these groups.

Assessment of oropharyngeal swallowing dysfunction in myasthenia gravis patients presenting with difficulty in swallowing

Objective

To examine the correlation between the results of a clinical neurological evaluation and swallowing dysfunction in myasthenia gravis (MG) patients who presented with difficulty in swallowing and underwent videofluorographic (VF) and fiber-optic endoscopic (FE) evaluation.

Swallowing dysfunction in myasthenia gravis patients examined with high-resolution manometry

ObjectiveTo prospectively compare oropharyngeal swallowing dysfunction in myasthenia gravis (MG) patients presenting with difficulty in swallowing between the neutral and chin-down positions, based on the results of high-resolution manometry (HRM) examination.MethodsWe prospectively compared the HRM results of swallowing studies of seven MG patients showing difficulty in swallowing (neutral and chin-down positions) at the Department of Neurology of our institution during the period February–December 2018. The HRM assessment parameters were as follows: maximum swallowing pressure (SP) at the soft palate, meso‑hypopharynx, and upper esophageal sphincter (UES), and the duration of relaxation pressure at the UES. These parameters were compared between the two positions and their correlations with the results of neurological evaluations, such as the Quantitative Myasthenia Gravis (QMG) score (total and neck muscles alone), and grip strength, were also analyzed.ResultsIn comparison with the neutral position, in the chin-down position the maximum SP at the meso‑hypopharynx was significantly increased (p < 0.05), the maximum SP at the UES was significantly decreased (p < 0.05), and the duration of relaxing SP at the UES was significantly increased (p < 0.05). Interestingly, there were no correlations between the SP at any location and the results of the neurological evaluations.ConclusionsThe chin-down position appears useful for improving pharyngeal clearance in MG patients, by promoting increased SP at the meso‑hypopharynx, relaxing SP at the UES, and increasing the duration of relaxation pressure at the UES.     

Lymph node ratio as a predictor of outcome in patients with oropharyngeal cancer

To evaluate the utility of lymph node ratio (LNR) as a potential prognostic predictor and to test whether LNR may be useful as a potential selection criterion for adjuvant treatment in patients with oropharyngeal squamous cell carcinoma (OPSSC). This retrospective study included 384 patients with regionally metastasized OPSCC who underwent primary surgery with or without adjuvant therapy from 1980 to 2010. LNR was calculated as the ratio of positive lymph nodes to the total number of lymph nodes removed during neck dissection. Statistical analysis using a Cox regression model was carried out. The 5-year disease-specific survival (DSS) was 73 %. An individual LNR peak at 0.1 was closest to the median of 0.0909, and both were set as cut-off values. Patients in the group greater than median had a hazard ratio (HR) of 2.472 for a DSS event; this was close to an HR of 2.513 for LNR >0.1. In multivariate analysis, LNR showed a markedly stronger HR with regard to survival in comparison with the grouped pN classification. The covariate treatment modality did not meet the assumption of the Cox regression, and it was therefore not possible to comment reasonably on the issue of whether LNR could be a potential selection criterion for adjuvant treatment. Lymph node ratio is in itself a valuable additional prognostic factor for risk stratification. According to the current results, the most valuable LNR for OPSSC is expected to be located in the range from 0.09 to 0.1. Further investigations in large prospective trials will be required to allow evidence-based recommendations for treatment decisions based on the LNR.     

Swallowing and tongue function following treatment for oral and oropharyngeal cancer.

This study examined tongue function and its relation to swallowing in 13 subjects with oral or oropharyngeal cancer treated with primary radiotherapy +/- chemotherapy and 13 age- and sex-matched control subjects. Measures of swallowing and tongue function were obtained using videofluoroscopy, pretreatment and 2 months posttreatment. Maximum isometric strength and endurance at 50% of maximum strength were obtained with the Iowa Oral Performance Instrument (IOPI). Control subjects were tested once. All subjects with head and neck cancer were evaluated pretreatment and 2 months posttreatment. No significant differences were found for the tongue function measures pre- and 2 months posttreatment in the group with head and neck cancer. Significantly higher tongue strength was observed in the control than in the group with head and neck cancer both pre- and posttreatment. No significant differences were found for the 2 groups for tongue endurance measures. Significant correlations of tongue strength and endurance and some swallow measures were found pre- and posttreatment for the group with head and neck cancer and for the control group. These correlations included oral and pharyngeal temporal swallow measures and oropharyngeal swallow efficiency. Pretreatment differences between the 2 groups in tongue strength were likely related to tumor bulk, pain, and soreness. Two-month posttreatment differences were likely related to radiation +/- chemotherapy changes to the oral and pharyngeal mucosa. This study provides support for the hypothesis that tongue strength plays a role in oropharyngeal swallowing, particularly related to the oral phase of the swallow.     

Functional outcomes and survival of patients with oral and oropharyngeal cancer after total glossectomy

IntroductionCancer of the oral cavity and oropharynx presents aggressive behavior and its diagnosis is, in most cases, performed in advanced stages. Total glossectomy is a therapeutic option in locally advanced cancer, and the only one in the recurrent or residual disease, after chemoradiotherapy.ObjectiveTo evaluate the clinical-epidemiological profile, postoperative complications, survival rates and functional aspects of patients with oral cavity and oropharynx cancer after total glossectomy.MethodsIt was a retrospective study where 22 patients were included with oral cavity and oropharyngeal cancer after total glossectomy at the Hospital Regional do Vale do Paraíba, em Taubaté, São Paulo.ResultsAll patients were male, with a median age of 57 years, most of tumors are located in the tongue and floor of the mouth and classified as stage IVa. Total glossectomy as initial treatment was performed in 18 and as salvage in four patients. The major pectoralis myocutaneous flap was used for reconstruction in all cases. The main postoperative complication was wound infection and salivary fistula.ConclusionOverall survival was 19% and cancer-specific survival was 30.8% in five years. Eight patients were rehabilitated for exclusive oral feeding without the dependence tracheostomy and enteral tube, all with an overall survival greater than 15 months.     

Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy

OBJECTIVE: To investigate factors that influence postoperative swallowing function in patients who underwent tongue and oropharynx resection. METHODS: Sixty-two subjects who had undergone extensive resection of oral or oropharyngeal cancer between 1993 and 2005 participated in this study. All surgical procedures involved excision of the bilateral suprahyoid muscles or of >or=50% of the tongue base. Laryngeal suspension and cricopharyngeal myotomy were performed on all subjects. A multivariate analysis of the effects of extensive tongue and oropharynx resection on swallowing function was performed. RESULTS: A total of 53 (85.5%) of the 62 subjects achieved independent oral intake and no longer required tube feeding. Six months after surgery, better eating capabilities had been attained by younger patients as compared with older patients; patients with less extensive tongue base resections; patients who had not undergone radiotherapy; and patients reconstructed with free flaps rather than pedicled flaps. CONCLUSIONS: Age was found to be the most important factor in determining whether a patient could achieve independent oral intake after extensive oral or oropharyngeal resection. The main factors in determining the quality of diet attained by the patient were found to be age, the percentage of tongue base resection, and the method of postoperative reconstruction.     

Evaluation of swallowing pressure in a patient with amyotrophic lateral sclerosis before and after cricopharyngeal myotomy using high-resolution manometry system

Background

This study aimed to evaluate the pharyngeal pressure of a patient with, amyotrophic lateral sclerosis (ALS) before and after cricopharyngeal myotomy by high-resolution manometry (HRM) system.

Methods

A 60-year-old man with ALS underwent cricopharyngeal myotomy for his intractable, aspiration. The swallowing pressure along the velopharynx and upper esophagus was measured using, the HRM 1 month before and 3 months after the surgery.

Results

Before cricopharyngeal myotomy, the maximum values of the resting UES pressure, the dry swallowing, pressures in the velopharyngeal muscle zone and in the UES zone were 89, 95, and 171 mmHg, respectively. After surgery, the maximum values of both the resting pressure and dry swallowing, pressure in the UES zone remarkably decreased to 21 and 75 mmHg, respectively.

Conclusions

This is the first report showing the effect of cricopharyngeal myotomy by demonstrating, the difference in the swallowing pressure along the velopharynx and upper esophagus before and after, the surgery in an ALS patient using this HRM system.     

Clinical outcome and health-related quality-of-life following microsurgical reconstruction in patients with oral and oropharyngeal cancer

Conclusion: Radial forearm free flap (RFFF) and fibula free flap (FFF) provide high safety and reliability with low incidence of free flap failure and an acceptable level of complications and health-related quality-of-life (HRQoL).

Objectives: To determine the clinical outcomes and long-term HRQoL in patients with oral or oropharyngeal cancer following free flap reconstruction.

Methods: A retrospective review of medical records and self-administered HRQoL questionnaires, EORTC QLQ-C30, and -H&N35. All patients who underwent surgery for oral or oropharyngeal cancer followed by primary reconstruction by RFFF or FFF at Rigshospitalet between September 2001 and November 2011 were included.

Results: The study comprised 19 patients still alive out of 61 patients. The free flap success rate was 94.7%. Early post-operative complications occurred in 11 patients (57.9%); however, only three cases (15.8%) required re-surgery. Nine patients (47.4%) developed late complications, including mandibular osteoradionecrosis in six cases (31.6%). Most patients obtained acceptable values of global quality-of-life and relatively high scores on the functional scales.     

Role of videoendoscopy in assessment of pharyngeal function in oropharyngeal dysphagia: Comparison with videofluoroscopy and manometry

Objective: The purpose of the current report is to evaluate the ability of videoendoscopic swallowing study in assessing pharyngeal propulsion and aspiration episodes when compared with videofluoroscopy and manometry. Study Design: Prospective study. Methods: Thirty-four patients with oropharyngeal dysphagia underwent videoendoscopy of swallowing to assess pharyngeal propulsion as pathologic or non-pathologic, and aspiration. These features were compared with those found on manometry and videofluoroscopy, which were considered as the reference examinations. Sensitivity, specificity, and positive and negative predictive values of videoendoscopy were estimated, with their 95% confidence intervals. Results: A total agreement between videoendoscopy and videofluoroscopy was found in 76.4% of cases for pharyngeal propulsion and in 82.3% for aspiration. This rate for pharyngeal propulsion reached 82.3% between videoendoscopy and manometry. Moreover, in 24 cases (70.5%) in which videofluoroscopy and manometry agreed for pharyngeal propulsion, 22 were assessed similarly through fiberoscopy. When using fluoroscopy and manometry as reference examinations, videoendoscopy detected nearly 90% (95% confidence interval [CI] = 0.80, 1.0) of impaired pharyngeal propulsion. Concerning aspiration, 70% (95% CI = 0.54, 0.85) of events detected by videoendoscopy were also observed on videofluoroscopy. Sensitivity, specificity, and positive and negative predictive values of videoendoscopy reached a higher rate (90% to 92.8%) when agreement was found between fluoroscopy and manometry. Conclusions: Videoendoscopy is an examination that can be used to detect inexpensively pharyngeal propulsion disorders and aspiration episodes. Laryngoscope, 108:1712–1716, 1998     

Rehabilitation needs of patients with oropharyngeal cancer

Swallowing and swallowing-related impairments present important posttreatment challenges in individuals undergoing organ preservation therapy for head and neck cancer. Literature pertinent to this topic is reviewed. A protocol for treatment of speech and swallowing deficits related to oropharyngeal cancer and treatment performed at Johns Hopkins Hospital is described. Data collected from a sample of oropharyngeal patients with cancer, with and without human papillomavirus-related disease, are summarized. Future directions for further study of this population are discussed.