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.     

Videostroboscopy of the pharyngoesophageal segment in total laryngectomees

Objectives: The reconstructed pharyngoesophageal segment (PES) serves as the neoglottis following total laryngectomy, as it provides the source of vibration for production of tracheoesophageal puncture (TEP) voice. To date, little information exists regarding the vibratory characteristics of the PES. The purpose of this investigation was to study the anatomy and physiology of the PES using videostroboscopy. Study Design: Prospective study investigating the anatomy and physiology of the PES in 34 laryngectomees who used TEP speech as their primary form of communication. Materials and Methods: Videostroboscopy and voice recordings were graded by three trained, blinded judges using a seven-point scale. Results: The patients demonstrated differences that allowed for separation of patients into two main groups: “poor” and “effective” TEP speakers. The voice quality differences were explained by anatomic and physiologic characteristics of the PES. Redundant, thick, and dyssynchronous PES features were observed in patients with poor TEP speech skills; the effective speakers exhibited less redundant, thinner mucosa and more synchronous vibratory patterns. Moreover, the latter subgroup consistently demonstrated a greater degree of volitional PES control and less spasmodic activity than their poorly speaking counterparts. Length of the PES opening (measured in the horizontal plane) as well as amount and consistency of secretions did not appear to influence TEP speech or voice proficiency. Conclusion: Videostroboscopy in laryngectomees is a noninvasive, inexpensive, easily performed procedure that may contribute valuable information regarding the anatomy and physiology of the PES, especially in patients who experience difficulties achieving satisfactory TEP voice and speech production.     

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.     

Microbial colonization of blom-singer prostheses in postlaryngectomy patients

The microbial colonization of 44 Blom-Singer valves obtained from 16 patients over an 11-month period was investigated both by standard microbial culture methods and scanning electron microscopy (SEM). The valves were all removed from the patients after failure to function correctly. The microbiology cultures revealed that Candida species and Staphylococcus aureus were present either individually or in combination on 43 valves. SEM showed yeast hyphae attached to and penetrating the surfaces of the 5 valves examined. Colonies of staphylococci were also seen on 2 of these 5 valves. Unlike similar investigations on other voice prostheses, Saureus colonization was associated with Candida colonization and valve failure.     

Surgical repair of postlaryngectomy pharyngocutaneous fistulas

Pharyngo-cutaneous fistula is a common complication after laryngectomy, which increases both the morbidity and the hospital stay. The incidence rate varies from 8.7% to 24.8% in different institutions. The continuous salivary leak is very much troublesome for the patients. There are various predisposing factors out of which preoperative radiotherapy, diabetes, malnutrition is very important. Spontaneous closure occurs in most of the cases on conservative management and only a few need surgical closures. Surgical methods used are direct surgical repair in two layers inner mucosa and outer skin, single distant flap like DP or PMMC, double distant flap like DP and PMMC one for inner mucosa and another for outer skin. Post operative swallowing was satisfactory in all the cases and there was no recurrence of fistula in one and half year follow up.     

Tongue flap repair of postlaryngectomy hypopharyngeal stenosis

Hypopharyngeal stenosis after total laryngectomy has been reported as high as 40%. The most consistent and important causal factor is the extent of the pharyngeal resection since cancers of the pyriform sinus and postcricoid region have the highest incidence of stenosis. Dilation is frequently unsuccessful in the management of postlaryngectomy hypopharyngeal stenosis probably because of its excessive length. The laterally-based tongue flap is effective for repair of these stenoses because of its proximity, epithelial compatibility, and ample length. The technique, details, and successful use in three patients are presented.     

Scintigraphic assessment of swallow efficiency postlaryngectomy

There have been reports of a high incidence of hypopharyngeal stenosis in total laryngectomy patients when the surgery requires a partial pharyngectomy for pyriform sinus involvement. In this study, three groups were compared: total laryngectomy patients without partial pharyngectomy, total laryngectomy patients with partial pharyngectomy, and normal controls. All patients had received radiation therapy following surgery. All were maintaining oral nutrition, and none complained of dysphagia. Patients were tested between 1 and 7 months postradiation therapy, with a mean of 3 months. Measures of swallowing efficiency were based on scintigraphic data for a liquid swallow. Patients with partial pharyngectomy had abnormally long oropharyngeal transit times and low efficiency scores. For a subgroup of patients with partial pharyngectomy, swallowing data were available postsurgery and postradiation therapy. Postsurgery this patient group did not differ significantly from normal patients in swallowing efficiency, and swallowing efficiency deteriorated in postradiation therapy. This scintigraphic methodology is shown to be a sensitive method of assessing swallowing function in this patient population.     

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.     

Fibrin glue-reinforced closure of postlaryngectomy pharyngocutaneous fistula

Pharyngocutaneous fistulization is a dreaded and devastating complication of laryngectomy. Although the specific risk factors are controversial, a history of prior radiation therapy has generally been accepted to be a major risk factor for developing this complication. We present a case of a postlaryngectomy pharyngocutaneous fistula developing in a previously irradiated patient that was successfully managed by incorporating fibrin glue into the surgical closure. We also discuss the underlying theoretical basis for this approach by reviewing the relevant literature.     

Surgical treatment of pharyngoesophageal spasm

The clinical course of 17 laryngectomees with pharyngoesophageal spasm who underwent pharyngeal myotomy was studied to determine clinical response and complications. The influence of speech therapy on the development of volitional control of pharyngoesophageal spasm, tracheoesophageal speech fluency, and the efficacy and complications of surgical treatment for pharyngoesophageal spasm were assessed. Volitional control of tracheoesophageal speech was never achieved. Ninety-four percent of the patients (16/17) were successfully rehabilitated following surgical therapy. The complications following pharyngeal myotomy were acceptable.     

Prevention of postlaryngectomy pharyngocutaneous fistula: the Memorial University experience

OBJECTIVES: The purpose of this study was to compare the efficacy of a pectoralis major myogenous flap in the prevention of pharyngocutaneous fistula in patients who have undergone total laryngectomy. Our secondary objective was to estimate the economic saving to our health care system. DESIGN: Retrospective clinical study. SETTING: Grace General Hospital, St. Clare's Mercy Hospital, H. Bliss Murphy Cancer and Research Centre, St. John's, Newfoundland. MATERIALS AND METHODS: Two hundred and twenty-three consecutive total laryngectomy procedures performed between June 1978 and December 2001 were reviewed. The fistula rate in laryngectomy patients prior to 1988 without pectoralis major myogenous flaps (group A) was compared with that of patients after June 1988 who had this flap routinely used at primary surgery (group B). Analysis of risk factors within those two groups was essentially similar. RESULTS: In group A, the overall pharyngocutaneous fistula rate was 22.9%. The fistula rate in group B was less than 1%. CONCLUSION: Our study has demonstrated that at our tertiary care head and neck oncology centre, we have dramatically decreased the incidence of postlaryngectomy pharyngocutaneous fistula. By the routine addition of a pectoralis major myogenous flap to cover the pharyngeal defect at surgery, we have substantially and dramatically reduced patient morbidity and mortality and reduced hospital stay, with major financial savings to the health care system.     

Perforating and migrating pharyngoesophageal foreign bodies: a series of 5 patients

Ingestion of a foreign body is a problem seen in nearly all otolaryngologic practices. One of the least common complications of foreign-body ingestion is penetration and migration, which may lead to serious morbidity or even death. We report the findings of a retrospective review of a series of 5 patients who had presented with a complete foreign-body penetration. All of them had radiologic evidence of a foreign body, but findings on rigid endoscopy were negative. Computed tomography is the radiologic study of choice to identify penetrating foreign bodies. The foreign bodies in all 5 patients were extracted via an external approach.