Videofluoroscopic evaluation of complications after laryngeal resection

Summary In past decades, the surgical techniques for treating laryngeal carcinoma have been vastly improved. For circumscribed tumors, voice-conserving resections are possible and for extensive neoplasms, radical laryngectomy, sometimes combined with chemoradiation, has been developed. Postoperative complications regarding swallowing function are not uncommon. Radiologic examinations, especially pharyngography and videofluoroscopy, are most often used to evaluate patients with complications after laryngeal surgery. An optimized videofluoroscopic technique for evaluation of complications is described. The radiologic appearance of early and late complications, such as fistulas, hematomas, aspiration, strictures, dysfunction of the pharyngoesophageal sphincter, tumor recurrence, and metachronous tumors is demonstrated.      

垂直半喉切除术后双肌蒂瓣残喉修复术

目的探讨喉癌垂直半喉切除的术式和利用正常组织重建修复残喉,恢复喉功能的方法。方法对T1,T2声门型,会厌未侵及,无转移的53例喉癌行喉部分切除术,并用双肌蒂瓣进行残喉修复。结果 53例手术全部成功。51例14～25 d成功拔除气管套管,恢复自体喉呼吸,均能较清晰发音。2例未能拔管。无1例呛咳、误咽、咽漏等。结论 T1N0M0及部分T2N0M0病例,在垂直半喉切除术后,保留甲状软骨,利用患侧甲状软骨表面的胸骨舌骨肌形成双肌蒂瓣翻入喉内进行残喉修复,具有较好的实用价值和效果。     

Defective closure of the laryngeal vestibule: frequency of pulmonary complications

Aspiration and its potential complications, bronchopneumonia and other pulmonary diseases, were studied in 67 fully conscious and mobile patients with cineradiographically verified dysfunction of swallowing. They were compared to a group of 67 patients of similar age with normal swallowing. Bronchopneumonia was found in nine (13%) of the patients with aspiration compared to two (3%) of the patients without (p = 0.05). Chronic pulmonary disease was more frequently observed in patients with aspiration than in those without, seven (10%) and one (1.5%), respectively (p = 0.03). Even though pulmonary complications of defective closure of the laryngeal vestibule are not frequent, swallowing training for fully conscious and relatively mobile patients would seem desirable.     

Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration

OBJECTIVE: This study evaluated the clinical significance of cervical osteophytes impinging on the pharynx in patients with dysphagia and the importance of concurrent disorders that may affect swallowing function. MATERIALS AND METHODS: On videofluoroscopy, anterior cervical osteophytes were found in 55 (32 men, 23 women; mean age, 69 years) of 3318 patients with dysphagia (1.7%). Coexisting diseases that affected swallowing function were found in 28 patients (stroke, n = 7; thyroidectomy, n = 7; tongue base or laryngeal cancer surgery, n = 5; other diseases, n = 9). Swallowing function was assessed with videofluoroscopy evaluating epiglottic tilting, laryngeal closure, impression of the hypopharynx, pharyngeal residue, and aspiration. RESULTS: With advancing age, the probability of aspiration (odds ratio, 1.07; p < 0.05) and of enlarging osteophytes (odds ratio, 1.26; p < 0.01) increased; the probability was higher for osteophytes at more than one vertebrae (odds ratio, 8.00; p < 0.01) and for concurrent diseases (odds ratio, 8.02; p < 0.01). Aspiration was found in 75% of patients with osteophytes larger than 10 mm and in 34% with osteophytes smaller than or equal to 10 mm. In 88% of patients with small osteophytes who aspirated, other diseases affected swallowing function. CONCLUSION: Aspiration is common in patients with dysphagia and cervical osteophytes larger than 10 mm. Aspiration is rare in patients with osteophytes smaller than or equal to 10 mm unless these patients suffer from other disorders that may affect swallowing.     

Dysfunction of pharyngeal swallowing. A cineradiographic investigation in 854 dysphagia patients

Cineradiography of pharyngeal swallowing was performed in 854 patients (389 males and 465 females) with dysphagia and analyzed for pharyngeal function. Epiglottic dysmotility was registered in 206 patients (24%), defective closure of the laryngeal vestibule in 318 patients (37%), paresis in pharyngeal constrictors in 130 patients (15%), dysfunction of the cricopharyngeal muscle in 215 patients (25%), webs in 130 patients (15%), Zenker diverticula in 20 patients (2%) and Killian-Jamieson diverticula in 16 patients (2%). The symptom dysphagia was more frequent among young women compared with young men. Over the age of 65 the relation was reversed. Pharyngeal dysfunction was more common among young men than young women and this was due to a high frequency of dysfunction of the laryngeal vestibule in young men. Epiglottic dysfunction and dysfunction of the laryngeal vestibule, pharyngeal paresis, cricopharyngeal incoordination and webs showed an increased frequency with age, while diverticula did not. Pharyngeal constrictor paresis was more common in men. Defective relaxation of the cricopharyngeal muscle and webs were more common among old women compared with old men.     

喉部分切除术在治疗喉癌中的应用

目的　探讨不同术式喉部分切除在治疗喉癌中的应用。方法　对不同术式喉部分切除术后喉功能的恢复及并发症的发生情况进行分析。结果　 1例发生咽瘘 ;3例出现术后间歇性剧烈干咳 ;3例出现术后短期进流食误咽。结论　声门上喉部分切除术的功能恢复最为理想 ;咽瘘的发生与局部感染有重要关系 ;线头残留是干咳的主要原因     

Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration.

OBJECTIVE: This study evaluated the clinical significance of pharyngeal retention to predict aspiration in patients with dysphagia. MATERIALS AND METHODS: At videofluoroscopy, pharyngeal retention was found in 108 (28%; 73 males, 35 females; mean age, 60 years) of 386 patients with a suspected deglutition disorder. Swallowing function was assessed videofluoroscopically. The amount of residual contrast material in the valleculae or piriform sinuses was graded as mild, moderate, or severe. The frequency, type, and grade of aspiration were assessed. RESULTS: Pharyngeal retention was caused by pharyngeal weakness or paresis in 103 (95%) of 108 patients. In 70 patients (65%) with pharyngeal retention, postdeglutitive overflow aspiration was found. Aspiration was more often found in patients who had additional functional abnormalities such as incomplete laryngeal closure or impaired epiglottic tilting (p < 0.05). Postdeglutitive aspiration was diagnosed in 25% patients with mild, in 29% with moderate, and in 89% with severe pharyngeal retention (p < 0.05). CONCLUSION: Postdeglutitive overflow aspiration is a frequent finding in patients with pharyngeal retention, and the risk of aspiration increases markedly with the amount of residue. Functional abnormalities other than pharyngeal weakness, such as impaired laryngeal closure, may contribute to aspiration.     

Digital cineradiography of the pharynx and the oesophagus after total or partial laryngectomy

PURPOSE: The aim of the present study is to report our experience using digital cineradiography to assess morphological and functional disorders of the pharynx in patients with prior partial or total laryngectomy. MATERIALS AND METHODS: From March 2000 to October 2002, 21 patients (18 males and 3 females) with prior total laryngectomy (12 patients), total laryngopharyngectomy (2 patients) and partial laryngectomy (7 patients) were examined. A digital cineradiography with 12 frames/second acquisition was performed in all patients. In four patients the procedure was interrupted for massive barium aspiration, without cough (silent aspiration). In 17 patients standing in the left posterior oblique position and prone in the right posterior oblique position the oesophagus and oesophagogastric junction were also examined. The water siphon test was performed at the end of the procedure. Small boluses (10 ml) of liquid (60% w/v) and high-density (250% w/v) barium, barium paste (110% w/v), and solid meal (obtained spreading a dry biscuit with barium paste) were used. RESULTS: All patients with prior total laryngectomy and total laryngopharyngectomy showed morphological and functional disorders of the neopharynx: parapharyngeal diverticulum (2 cases), submandibular pouch (6 cases), fistulas (2 cases), lumen narrowing and post-surgical stenoses (2 cases), tumour recurrence (1 case), prominent cricopharynx (5 cases) and rhinopharyngeal reflux (4 cases). All patients with prior partial laryngectomy (7 cases) presented silent aspiration. Eleven patients had an oesophageal motility disorder, which was very serious in three of them with decrease in oesophageal clearing and barium retention in the oesophagus. Oesophagogastric junction evaluation showed hiatus hernia in six cases, two of them with associated gastro-oesophageal reflux. CONCLUSIONS: Digital cineradiography appears able to identify the organic and functional postoperative complications of patient treated with partial or total laryngectomy. A special swallowing study can suggest to the speech therapist the best compensatory mechanism for improving patient swallowing and therefore quality of life.     

Radiological evaluation of covered self-expandable metallic stents used for palliation in patients with malignant esophageal strictures

Purpose: To study the role of self-expandable metallic stents in malignant esophageal strictures in terms of patency, improved dysphagia score, and possible associated complications.

Material and Methods: Twenty-two patients with inoperable carcinoma of the esophagus underwent stent placement. Four different varieties of covered stents were used. Stenting was performed under fluoroscopic guidance and local pharyngeal anesthesia. During follow-up, patients were examined clinically and radiologically to assess the effectiveness of stents in relieving dysphagia, to check the stent position, patency, and possible complications.

Results: Fluoroscopic placement of the stent was successful and well tolerated in all patients without any serious complications. Accurate stent placement was possible in 95% of cases. The mean dysphagia score prior to stenting was 3.5 and poststent 1.2, with an improvement of 2.3 degrees. In two patients with associated fistulas, complete closure was seen after stent insertion. There was poor stent expansion in three patients. Significant tumor overgrowth occurred in two patients, and a second overlapping stent was deployed in one case. Three patients developed food impaction, which needed endoscopic removal of impacted food in two cases.

Conclusion: Fluoroscopic placement of self-expandable metallic stents is a safe and effective method of palliating severe dysphagia and fistulas in patients with inoperable esophageal carcinoma. However, complications such as tumor overgrowth and food impaction may require reintervention after stent placement.     

Videofluoroscopy of swallowing in symptomatic patients who have undergone long-term intubation

OBJECTIVE: The aim of this study was to evaluate whether specific patterns of swallowing dysfunction occur in symptomatic patients after long-term intubation. SUBJECTS AND METHODS: Twenty-one patients (16 men, five women; mean age, 66 years) who presented with clinical signs of aspiration after long-term intubation (mean duration, 24.6 days) underwent videofluoroscopy. They were analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, and the upper esophageal sphincter. We assessed the presence or absence of aspiration, the type of aspiration (pre-, intra-, and postdeglutitive), and a spectrum of other swallowing abnormalities. RESULTS: There were 18 patients (86%) with radiologically proven aspiration. In another patient only laryngeal penetration occurred. There were 11 combinations of pre-, intra-, and postdeglutitive aspiration. Predeglutitive aspiration was predominant and present in 52% of our patients. We found functional abnormalities of the tongue in 48%, of the soft palate in 10%, of the epiglottis in 48%, of the pharynx in 71%, and of the upper esophageal sphincter in 24%. CONCLUSION: Patients who are symptomatic after undergoing long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration, but show a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy has the ability to reveal complex deglutition disorders and to aid precise planning of individualized functional swallowing therapy.     

Cineradiography in closed and open pharyngeal swallow

The pattern of swallowing by which the oral bolus reaches an air-containing oropharynx is called an 'open swallow' whereas the sequence in which the oropharynx is collapsed on the arrival of the bolus is called a 'closed swallow'. The significance of this distinction was further analyzed by a correlation with other laryngeal and pharyngeal functions during swallowing in a cineradiologic study in 75 dysphagic patients and 50 asymptomatic volunteers. The relative incidence of open and closed type swallows was similar in the two groups. The maximum elevation of the pharynx and larynx was the same in open and closed swallow, although in individuals with an open swallow the elevation occurred later than in individuals with a closed swallow. Epiglottic movement disturbances, defective closure of the laryngeal vestibule, pharyngeal constrictor muscle paresis, cricopharyngeal incoordination, cervical esophageal webs and Zenker diverticula were significantly more common in individuals with an open pharyngeal swallow than in those with closed swallowing.     

Pharyngeal swallowing in patients with paresis of the recurrent nerve

Pharyngolaryngeal function during swallowing was investigated cineradiographically in 22 patients with paresis of the recurrent nerve. Nineteen of these patients (86%) had defective closure of the laryngeal vestibule: 10 patients had defective apposition of the corniculate cartilages, (paresis of the oblique cricoarytenoid muscle), 9 patients had defective apposition of the arytenoid cartilages, (paresis of the interarytenoid muscle), 13 patients had defective movement of the epiglottis (paresis of, i.a. the thyrohyoid muscle), 1 patient had defective closure of the subepiglottic portion of the vestibule (paresis of the thyroepiglottic muscle), 2 patients had defective closure of the supraglottic portion of the vestibule (paresis of the superior ventricular segment of the thyroarytenoid muscle). Five patients with immobility of the epiglottis also had paresis of the pharyngeal constrictor musculature indicating paresis of the superior laryngeal nerve. Our investigation has shown that patients with paresis of the recurrent nerve who present with dysphagia with or without aspiration should be examined cineradiographically for pharyngolaryngeal function during swallowing.     

The effect of high- vs low-density barium preparations on the quantitative features of swallowing

We compared the effect of high-density and low-density barium preparations on the quantitative features of swallowing. The two barium preparations differed primarily in density but also differed somewhat in viscosity. Concurrent videofluoroscopic and manometric studies were done in nine healthy control subjects. Videofluoroscopy was recorded in the lateral projection at 30 frames/sec while concurrent manometry was done with five intraluminal transducers that straddled the pharynx and upper esophageal sphincter. Swallows of 5 and 10 ml of high- and low-density barium preparations were recorded. Analysis indicated that, compared with the low-density barium (1.4 g/cm3), the high-density barium (2.5 g/cm3) preparation had a slower oral and pharyngeal bolus transit time and caused significant quantitative differences in the function of the upper esophageal sphincter. Compared with low-density barium boluses, the high-density barium boluses were associated with later sphincter opening and closure, longer duration of sphincter opening and flow, lower flow rate, greater maximal anterior hyoid movement, greater sagittal sphincter diameter, and higher intrabolus pressure upstream of and within the sphincter. We conclude that the density as well as the viscosity of the barium preparation used in radiologic examination of the oral-pharyngeal phases of swallowing has an influence on bolus transit time through the mouth and pharynx, and on the quantitative features of upper esophageal sphincter opening. Although these quantitative differences cannot generally be recognized visually at fluoroscopy, they become important for the quantitative assessment of swallowing in patients with suspected disorders of oral-pharyngeal swallowing. Therefore, the basic barium preparations used to examine such patients should be either standardized or at least specified.     

Posture of the head and pharyngeal swallowing

Closure of the laryngeal vestibule during swallowing is important for protection of the airways. The present investigation included 53 patients with dysphagia examined cineradiographically with the head held in resting posture, flexion and extension. The ability to protect the airways by the downward movement of the epiglottis and by obliteration of the laryngeal vestibule was studied in different postures of the head. Of 35 patients with normal laryngeal obliteration with the head in resting position 10 showed a defective closure at swallowing in extension. In 18 patients with defective closure of the laryngeal vestibule in resting position 9 were improved on flexion and two on extension of the head. In one patient with defective closure of the laryngeal vestibule in resting position swallowing in flexion showed an aggravated dysfunction. In four other patients the defective closure became more marked on extension. Four patients had less effective downward movement of the epiglottis with the head in extension. Of 10 patients with defective epiglottic movement with the head in resting position two were improved on tilting the head forwards. The results show that the position of the head influences the closure of the airways during swallowing. Patients with defective protection of the laryngeal vestibule should be instructed to swallow with the head tilted forwards.     

Snoring, sleep apnoea and swallowing dysfunction: a videoradiographic study

OBJECTIVES: Snoring is associated with subclinical pharyngeal swallowing dysfunction, probably owing to vibration trauma to the pharyngeal tissues caused by snoring. Negative intrathoracic pressure during apnoea causes stretching of the velum and pharynx. The aim of this study was to investigate whether patients with severe sleep apnoea have an increased frequency of videoradiographically diagnosed subclinical pharyngeal swallowing dysfunction compared with snoring patients with or without mild sleep apnoea as well as with non-snoring controls. METHODS: Eighty consecutive patients referred for sleep apnoea recordings because of snoring were examined. Fourteen of these patients were excluded because they suffered from dysphagia. Fifteen non-snoring, non-dysphagic volunteers served as controls. Videoradiography was performed to examine the oral and pharyngeal swallowing function in patients and controls. Overnight sleep apnoea recordings were used to evaluate the apnoea-hypopnoea index (AHI). RESULTS: Pharyngeal swallowing dysfunction was observed in 34/66 (52%) of the snoring patients and in 1/15 (7%) of the non-snoring controls. Pharyngeal swallowing dysfunction was observed in 50% of patients with an AHI of >or=30, in 61% of patients with an AHI of 5-29 and in 43% of patients with an AHI of <5. There was no significant difference in the frequency of pharyngeal swallowing dysfunction between snoring patients with different AHIs. CONCLUSION: Snoring patients run an increased risk of developing subclinical pharyngeal swallowing dysfunction independent of concomitant sleep apnoea.     

Radiologic evaluation of the oral stage of swallowing

The oral stage of swallowing was radiologically evaluated in 19 patients with swallowing complaints. Eight patients had had surgical resection and reconstruction due to tumours of the tongue, floor of the mouth or mandible. Eleven patients had suffered from cerebrovascular disease. All patients had incoordination of tongue movements including defective initiation of pharyngeal swallow. In patients who had undergone surgical resection, oral dysfunction correlated with the extension of resection as well as type of reconstruction, and was more profound compared with the disorder present in patients with cerebrovascular disease. Moreover, muscular derangement due to surgery of the floor of the mouth interfered with the elevation of the hyoid bone, larynx and pharynx and thereby the pharyngeal stage of swallowing also became abnormal. Cineradiography seems to be an appropriate method for evaluation of the oral stage of swallowing in patients with deglutition complaints.     

Videofluoroscopy of swallowing abnormalities in 22 symptomatic patients after cardiovascular surgery

OBJECTIVE: The aim of this study was to evaluate the types of swallowing abnormalities that occur in symptomatic patients who have undergone cardiovascular surgery. MATERIALS AND METHODS: From 1994 to 2001, 22 patients (17 males and five females; age range, 4-89 years; mean age, 64 years) who had swallowing abnormalities after cardiovascular surgery were referred for a videofluoroscopic swallowing study. Each study was analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, upper esophageal sphincter, and esophagus. Also, the performance of transesophageal echocardiography, long-term intubation, or both was noted. RESULTS: Swallowing abnormalities were present in 18 patients (81.8%) (range, one to eight functional abnormalities; mean, 3.9 functional abnormalities). The distribution of abnormalities across the functional units statistically significantly deviated (chi(2) = 14.4; df = 6; p = 0.025) from uniform distribution, with abnormalities most commonly involving the hyoid and larynx (13 patients [59.1%]) and the pharynx (10 patients [45.5%]). Aspiration was found in 13 patients (59.1%) (predeglutitive, n = 1; intradeglutitive, n = 4; postdeglutitive, n = 3; and mixed, n = 5). In the 14 patients (63.6%) who underwent transesophageal echocardiography, long-term intubation, or both, we frequently found incomplete tilting of the epiglottis, pharyngeal weakness, and postdeglutitive aspiration. CONCLUSION: Most patients with swallowing problems after cardiovascular surgery present with multiple abnormalities that most commonly affect the hyoid and larynx and the pharynx and result predominantly in intra- or postdeglutitive aspiration. The performance of transesophageal echocardiography and long-term intubation may influence the types of swallowing abnormalities.     

Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia

OBJECTIVE: The purpose of our investigation was to determine the relationship between the degree of swallowing dysfunction observed on barium studies and the likelihood of developing pneumonia in a large series of patients. MATERIALS AND METHODS: The findings on videofluoroscopic swallowing studies in 381 patients were used to classify these patients into one of five groups: those with normal swallowing; those with abnormal swallowing but no laryngeal penetration or tracheobronchial aspiration; those with laryngeal penetration; those with tracheobronchial aspiration; and those with silent tracheobronchial aspiration. Clinical data were also reviewed to determine how many patients had developed pneumonia during the 6 months before or after the barium studies. The data were then analyzed to determine whether the risk of developing pneumonia increased significantly with each level of swallowing dysfunction seen on barium studies. RESULTS: No significant difference was found in the frequency of pneumonia in patients with abnormal swallowing but no laryngeal penetration or tracheobronchial aspiration compared with patients with normal swallowing on barium studies (p = 0.85). In contrast, patients with laryngeal penetration, tracheobronchial aspiration, or silent tracheobronchial aspiration were approximately four times (p = 0.008), 10 times (p < 0.0001), and 13 times (p < 0.0001), respectively, more likely to develop pneumonia than those with normal swallowing. CONCLUSION: Our findings indicate that the likelihood of developing pneumonia is directly related to the degree of swallowing dysfunction seen on videofluoroscopic studies. Patients with no laryngeal penetration-regardless of whether they had normal or abnormal swallowing-have the lowest risk of developing pneumonia. Patients with laryngeal penetration, tracheobronchial aspiration, or silent tracheobronchial aspiration are, in increasing order of magnitude, significantly more likely to develop pneumonia than patients with normal swallowing.     

喉癌影像诊断评估现状及进展

在过去的喉癌外科治疗中多强调行根治为主的喉全切术,近年来喉部分切除术受到重视,即重建喉形态,保留吞咽、发音功能,避免永久气管造口,以提高病人的生存质量,同时不增加术后复发率。选择准确的适应证、彻底切除肿瘤是治疗成功的关键。影像检查在喉癌的术前评价中发挥着重要作用,可指导肿瘤分期与治疗方案的制订,对放疗后疗效评估及术后随访亦具有重要价值。     

Der Pharynx nach tumorchirurgischen Eingriffen Variabilität der Erscheinungsbilder in der konventionellen Durchleuchtungsdiagnostik

The present study gives a survey of radiological findings after surgical treatment of laryngeal and pharyngeal carcinomas, whereby the surgical procedures and the localisation of tumours found special consideration. One important point of view of modern surgery is the improvement of quality of life. By reason of this point the role of reconstructive surgery will become increasingly important. Representative radiographs between 1997 and 1999 are discussed to show the difficulties to distinguish between normal and pathological postoperative findings after operations of hypopharyngeal diverticula, after partial and total laryngectomy as well as after different methods of surgical reconstructions of pharynx. The examinations which are shown were realized with the conventional radioscopy. Hereby the normal radiological findings and their comparison to the particular postoperative specials rank first. Furthermore the early and late postoperative complications are mentioned. A variety of surgical procedures in treatment of laryngeal and pharyngeal carcinoma make new demands on the postoperative diagnostic possibilities especially on the postoperative pharyngography. The variability of the postoperative radiographs complicates the differentiation between normal and pathological radiological findings and only the exact knowledge of the performed surgical procedure allows their differentiation.