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Objective: Identification and evaluation of swallowing dysfunction in patients undergoing upper airway surgery for obstructive sleep apnea (OSA) is limited. This study evaluated subjective swallowing function pre and postoperatively in patients undergoing multi-level reconstructive pharyngeal sleep surgery., Methods: A retrospective analysis of prospectively-administered Eating Assessment Tool (EAT-10) scores was conducted among adult patients undergoing surgery for OSA at a tertiary sleep surgery center. Preoperative and 1, 3, and 6-month postoperative time points were assessed. Patients were subdivided into two groups based on the degree of upper airway reconstruction performed. All patients underwent uvulopalatopharyngoplasty +/-tonsillectomy and tongue-base reduction. Patients undergoing Phase 1 reconstructive surgery additionally underwent tongue-base advancement procedures., Results: A total 100 patients underwent airway reconstructive surgery. Forty-one patients underwent Phase 1 surgery; 59 patients underwent Mini-Phase 1 surgery. Neither group demonstrated preoperative dysphagia. Both groups experienced significant subjective dysphagia at 1-month postoperatively, which was greater among Phase 1 patients (mean EAT-10 14.8; SD 10.4) versus Mini-Phase 1 patients (mean EAT-10 6.7; SD 7.5) (p < 0.001). Swallowing function among both groups normalized by 3 and 6 months postoperatively. Phase 1 patients with pre-operative dysphagia (mean EAT-10 9.6; SD 5) demonstrated initial worsening of their swallowing postoperatively; however, reported improved swallowing versus pre-operative levels by 6 months postoperatively (mean EAT-10 3.6; SD 4.3) (p = 0.03)., Conclusion: Pharyngeal surgery resulted in no significant, persistent adverse change in swallowing function. Among both groups, significant subjective dysphagia was reported at 1 month postoperatively, yet returned to preoperative levels by 6 months postoperatively. OSA patients with pre-existing dysphagia undergoing Phase 1 surgery trended towards improved swallowing function postoperatively., Level of Evidence: 2 Laryngoscope, 133:199-204, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

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, 132:272-277, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Evaluate swallowing and airway outcomes following laryngotracheoplasty with posterior grafting (LTP PCCG)., Methods: Retrospective review of pediatric patients undergoing LTP PCCG from 2016 to 2019 at a tertiary care pediatric hospital. We included demographics, indications, approach, and revision status. We evaluated preoperative and postoperative instrumental and functional swallow evaluations, and we also gathered information on airway outcomes., Results: Thirty-one patients were included in the study. Median (interquartile range [IQR]) age was 4.0 (2.0, 7.0) years old. Primary indication for surgery was bilateral vocal cord immobility (BVCI) in 11 (35.5%) and posterior glottic stenosis (PGS) in 20 (64.5%). Mean (standard deviation) length of follow-up was 11.0 (8.3) months. Twelve patients had gastrostomy tubes (GT) before surgery, and no patients required placement of GT after surgery. Of the remaining 19 patients, 6 required nasogastric feeding for >4 weeks (average length 1.8 months, longest 3.5 months). At last follow-up, 25 (80.6%) patients were primarily orally fed. Eighteen patients had tracheotomies prior to surgery. No patients without a tracheostomy required placement of tracheostomy before or after surgery and only 1 patient had a tracheostomy at last follow-up. Average time to decannulation was 3.7 months, with surgery-specific success of 87.1% and overall success of 96.8%. Four (12.9%) patients required a major intervention to achieve decannulation., Conclusion: LTP PCCG is an effective surgical technique to address PGS and BVCI with high decannulation rates. It may cause temporary swallowing dysfunction, but in this series a majority of children were orally fed at last follow-up., Level of Evidence: 4 Laryngoscope, 131:2798-2804, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Objectives/hypothesis: To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes., Study Design: Observational, retrospective cohort study., Methods: We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing esophageal dilation performed between 2011 and 2017. Patients aged 18 to 100 who were continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. Postoperative mortality was assessed and International Classification of Diseases (ICD)9/10 codes for complications, including esophageal perforation, hemorrhage, mediastinitis, and sepsis were flagged., Results: We identified 202,965 encounters for esophageal dilation. Of these procedures, 193 were performed on a patient who underwent percutaneous endoscopic gastrostomy (PEG) during the study period and was analyzed separately. Another 244 dilations were excluded due to repeat entries. Of the remaining 202,528 procedures remaining, 42,310 were repeat dilations in the same patient. Data analysis was confined to each patient's initial dilation. 160,218 initial dilations remained. Of these, 62,107 were performed on male patients and 98,111 were performed on female patients. The average age was 57.7 years. There were 12 mortalities within 30 days postoperatively, representing 0.0075% of all dilations. Esophageal perforation and esophageal hemorrhage were the most common reported complications, with 139 and 110 occurrences, respectively. The overall per-dilation complication rate was 0.215%., Conclusions: Evidence from a national insurance claim database suggests that esophageal dilation is a safe procedure with a low rate of serious complications and a 30-day all-cause mortality rate of less than 1 per 10,000 dilations., Level of Evidence: 4 Laryngoscope, 131:2436-2440, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objective: Inclusion body myositis (IBM) is a progressive inflammatory myopathy with dysphagia as a debilitating sequalae. Otolaryngologists are consulted for surgical candidacy when there are findings of cricopharyngeal dysfunction. We aim to compare transcervical cricopharyngeal myotomy (TCPM) versus endoscopic cricopharyngeal myotomy (ECPM) in the IBM population with particular focus on objective swallow study outcomes, complications, and recurrence rates., Methods: A retrospective cohort study was performed on IBM patients who underwent TCPM or ECPM (1981-2020) in the Department of Otolaryngology at a tertiary academic center with a high volume IBM referral base. Videofluoroscopic swallow studies, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and follow-up visits. Baseline patient characteristics, intraoperative data, and postoperative course were recorded., Results: Forty-one patients were identified (18 TCPM; 23 ECPM). There was no significant difference in the recurrence rates, complications, hospitalization length, operative time, or return to preoperative diet between approaches. For the 12 patients (11 ECPM; 1 TCPM) that had subjective swallow data, there was a statistically significant difference in the pre and postoperative scores for EAT-10, RSI, and FOSS (P < .05). There was a statistically significant improvement in the degree of narrowing between pre and postoperative imaging for both approaches (P < .05)., Conclusion: Both TCPM and ECPM are safe approaches for the management of dysphagia in patients with IBM with objective evidence of cricopharyngeal dysfunction. Cricopharyngeal myotomy is a durable technique that has demonstrated improved subjective and objective outcomes in this patient population., Level of Evidence: 3 Laryngoscope, 131:E2426-E2431, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective/hypothesis: Tracheoesophageal diversion (TED) can prevent damage to the respiratory system in patients with swallowing disorders and/or repetitive aspiration pneumonia; however, TED may cause the loss of phonation. Our previous study demonstrated that TED with tracheoesophageal puncture (TEP) prevents aspiration while retaining phonation. In this study, we aimed to further evaluate the feeding status and phonation of patients who underwent TED with TEP to verify the reproducibility of this procedure., Study Design: Case series study., Methods: We retrospectively reviewed the medical records of 11 patients who underwent TED with TEP for intractable aspiration from February 2017 to August 2019 at Fukuoka Sanno Hospital. We evaluated the preoperative penetration aspiration score (PPAS), daily activities, preoperative and postoperative food intake level scale (FILS) score, nutrition route, maximum phonation time(MPT), and postoperative communication method., Results: The study population included 10 men and 1 woman (mean age, 66 years; range, 44-81) with a PPAS of 6.8 ± 1.0. The FILS score changed from 2.1 ± 0.5 preoperatively to 7.5 ± 2.0 postoperatively (paired t-test, P < .05), while the MPT changed from 7.9 ± 4.1 to 10.3 ± 4.2 s (paired t-test, P = .9). Preoperatively, a gastric fistula (eight patients [73%]) was the main nutrition route, followed by a gastric tube (two patients [18%]). Postoperatively, the main nutritional route for eight patients (73%) was oral, while the remaining three patients (27%) used the oral route occasionally. All patients maintained laryngeal phonation function, and eight (73%) used only laryngeal phonation for communication., Conclusions: Patients with intractable aspiration who wish to retain phonatory function should be advised to undergo TED with TEP., Level of Evidence: 4 Laryngoscope, 131:E1965-E1970, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

A 77-year-old male underwent open reduction and internal fixation with placement of odontoid screws after sustaining C1 arch and odontoid fractures in a fall 14 months prior to presentation to the laryngology clinic for combined surgery with orthopedics. Serial imaging after the initial surgery demonstrated loosening of a screw and its entry into the pharyngeal lumen. The patient reported odynophagia, dysphagia, and dysphonia. He reported taking small bites and using liquid assist, vocal fatigue, and difficulty with pitch control. A surgical screw entering the pharynx just inferior to the level of the tip of the epiglottis was seen on flexible laryngoscopy. On phonation, the screw made intermittent contact with the right arytenoid resulting in restriction of full abduction of the right vocal fold. On flexible endoscopic evaluation of swallowing, there was pharyngeal and vallecular residue, and residue around the screw itself. The patient was taken to the operating room with orthopedic surgery, the screw was visualized with a combination of mouth gag and endoscopes. It was gently rocked with an orthopedic screw grabber and tapped toward the caudal pharynx. After successful removal, the mucosal defect was sutured. The patient reported improvement in swallowing postoperatively. Dysphagia is a described sequela of cervical spine surgery. We describe the presentation and treatment of a patient with a history of cervical spine surgery and subsequent exposure of an orthopedic screw in the pharynx. Laryngoscope, 131:1078-1080, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine the utility of preoperative penetration-aspiration scale (PAS) scores and clinical findings on modified barium swallow (MBS) in predicting advancement of diet after interarytenoid injection augmentation (IAIA)., Study Design: Retrospective review., Methods: In this retrospective cohort study, 372 consecutive patients who underwent IAIA for pharyngeal dysphagia between 2009 and 2019 were initially identified. Patients were excluded from the study if they had insufficient preop MBS, no postop MBS within 3 months of injection, supraglottoplasty, or underlying neurological condition. Ninety-three patients were included in the study. Pre- and postoperative PAS scores were recorded, as were pre and postop diets. PAS scores were calculated by a single pediatric speech and language pathologist., Results: Average PAS score on MBS was 5.87 (standard deviation [SD] 2.74); median (range) = 8 (1-8). Postop average was 4.29 (SD 3.02); median (range) = 2 (1-8), P < .001. Those with worse preop PAS scores had increased odds of improvement in diet (odds ratio 1.24, 95% confidence interval [CI] 1.02-1.49, P = .029). An improvement in PAS score of 3.0 or greater predicted an improvement in diet with a sensitivity of 76.7% and a specificity of 85.7%., Conclusions: PAS score on MBS can be a useful tool when assessing pediatric patients who may be candidates for IAIA. Prospectively comparing PAS score in patients post-IAIA to patients solely undergoing diet modification can help to better objectively assess differences in outcomes and understand the full utility of PAS score., Level of Evidence: Level III (Individual Cohort Study) Laryngoscope, 131:E1707-E1713, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration., Study Design: Retrospective case series at a tertiary children's hospital., Methods: Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born <34 weeks, with medical or genetic comorbidities, or who underwent surgical intervention for aspiration were excluded. Patients were followed until aspiration resolved on a swallow study. Kaplan-Meier survival analysis was performed., Results: Forty patients (25 patients [50%] by 6 months, 10 [20%] by 1 year, three [6%] by 2 years, and two [4%] at the end of the follow-up interval) were recommended a normal diet, and 10 patients (20%) were still aspirating by the end of the follow-up interval. Median time to resolution was 202 ± 7 days (range, 19-842 days), probability 48% (95% confidence interval [CI]: 0.34-0.62). The probability of resolution at 6 months was 46% (95% CI: 0.4-0.68), at 1 year was 64% (95% CI: 0.51-0.77), at 2 years was 76% (95% CI: 0.64-0.88), and at the end of the follow-up interval 81.3% (95% CI: 0.7-0.92)., Conclusions: The majority of infants with aspiration and without any other major comorbidities improved within 1 year. Future research should be directed toward better understanding swallowing dysfunction in neurologically normal infants., Level of Evidence: 4 Laryngoscope, 130:514-520, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To review experience, safety, and cost of office-based esophageal dilation in patients with history of head and neck cancer (HNCA)., Methods: The medical records of patients undergoing esophageal dilation in the office were retrospectively reviewed between August 2015 and May 2017. Patients were given nasal topical anesthesia. Next, a transnasal esophagoscopy (TNE) was performed. If the patient tolerated TNE, we proceeded with esophageal dilation using Seldinger technique with the CRE™ Boston Scientific (Boston Scientific Corp., Marlborough, MA) balloon system. Patients were discharged directly from the outpatient clinic., Results: Forty-seven dilations were performed in 22 patients with an average of 2.1 dilations/patient (range 1-10, standard deviation [SD] ± 2.2). Seventeen patients (77%) were male. The average age was 67 years (range 35-78 years, SD ± 8.5). The most common primary site of cancer was oral cavity/oropharynx (n = 10), followed by larynx (n = 6). All patients (100%) had history of radiation treatment. Four patients were postlaryngectomy. The indication for esophageal dilation was esophageal stricture and progressive dysphagia. All dilations occurred in the proximal esophagus. There were no major complications. Three focal, superficial lacerations occurred. Two patients experienced mild, self-limited epistaxis. One dilation was poorly tolerated due to discomfort. One patient required pain medication postprocedure. Office-based esophageal dilation generated $15,000 less in health system charges compared to traditional operating room dilation on average per episode of care., Conclusion: In patients with history of HNCA and radiation, office-based TNE with esophageal dilation appears safe, well-tolerated, and cost-effective. In a small cohort, the technique has low complication rate and is feasible in an otolaryngology outpatient office setting., Level of Evidence: 4. Laryngoscope, 128:2261-2267, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate functional outcomes and complication rate after total laryngectomy (TL) for dysfunctional larynx with end-stage dysphagia., Study Design: Retrospective chart review., Methods: Chart review was performed on all patients who underwent TL from January 2008 to July 2016 at a single tertiary academic medical center. Patients who underwent TL for dysfunctional larynx without preoperative evidence of malignancy were included. Main outcome measures were post-TL functional swallowing and speech outcomes, and complication rate., Results: The study included 19 patients from a cohort of 278 consecutive patients. All patients were previously treated with radiotherapy (RT), whereas 13/19 (68%) previously received chemoradiotherapy. The median time from RT to TL was 10.98 years (range, 0.67-23.94 years). Aspiration was evident preoperatively in 17/19 (89%) patients, with 11 experiencing recurrent aspiration pneumonia. Seventeen of 19 (89%) patients were nil per os (NPO) requiring enteral nutrition. Six of 19 (32%) patients had surgical complications, including three (16%) pharyngocutaneous fistulas. At 3-month and 1-year postoperative follow-up, there was significant improvement in mean Functional Oral Intake Scale (FOIS) score and aspiration, recurrent pneumonia, enteral nutrition, and NPO status rates (P < .05). At 1-year follow-up, no patients were NPO, and only one patient required gastrostomy tube supplementation. Mean FOIS score increased from 1.3 to 6.1 (P = .001). Eight of 13 patients (62%) were actively using a tracheoesophageal prosthesis at 1-year follow-up., Conclusions: Laryngectomy for dysfunctional larynx eliminates the morbidity of aspiration while improving diet and reducing gastrostomy tube dependence with an acceptable complication rate., Level of Evidence: 4. Laryngoscope, 128:597-602, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate the efficacy of various techniques of laryngohyoid suspension in the elimination of aspiration utilizing a cadaveric ovine model of profound oropharyngeal dysphagia., Study Design: Animal study., Methods: The head and neck of a Dorper cross ewe was placed in the lateral fluoroscopic view. Five conditions were tested: baseline, thyroid cartilage to hyoid approximation (THA), thyroid cartilage to hyoid to mandible (laryngohyoid) suspension (LHS), LHS with cricopharyngeus muscle myotomy (LHS-CPM), and cricopharyngeus muscle myotomy (CPM) alone. Five 20-mL trials of barium sulfate were delivered into the oropharynx under fluoroscopy for each condition. Outcome measures included the penetration aspiration scale (PAS) and the National Institutes of Health (NIH) Swallow Safety Scale (NIH-SSS)., Results: Median baseline PAS and NIH-SSS scores were 8 and 6, respectively, indicating severe impairment. THA scores were not improved from baseline. LHS alone reduced the PAS to 1 (P = .025) and NIH-SSS to 2 (P = .025) from baseline. LHS-CPM reduced the PAS to 1 (P = .025) and NIH-SSS to 0 (P = .025) from baseline. CPM alone did not improve scores. LHS-CPM displayed improved NIH-SSS over LHS alone (P = .003)., Conclusions: This cadaveric model represents end-stage profound oropharyngeal dysphagia such as what could result from severe neurological insult. CPM alone failed to improve fluoroscopic outcomes in this model. Thyrohyoid approximation also failed to improve outcomes. LHS significantly improved both PAS and NIH-SSS. The addition of CPM to LHS resulted in improvement over suspension alone., Level of Evidence: NA. Laryngoscope, 127:E422-E427, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To examine the effect of and predict the success of type 1 laryngeal cleft (LC-1) augmentation through swallowing evaluations., Study Design: Retrospective chart analysis., Methods: Sixty-eight patients with LC-1s underwent interarytenoid injection laryngoplasty (IL) and were examined. The median age at IL was 9 months. Swallowing evaluations were performed pre- and postoperatively using fiberoptic endoscopic examination of swallowing or modified barium swallow. The presence of aspiration or penetrations at various consistencies was recorded. McNemar's tests were used to detect changes in swallowing pre- and postoperatively. Logistic regression was used to assess factors affecting the odds of postoperative success., Results: Preoperatively, 89.7% of patients demonstrated penetration or aspiration. Post-IL, 69.1% were safe for thins, and 75% showed improvement in swallowing. Postoperatively, there was a significant reduction in patients experiencing problems with thin liquids (P < 0.001) and in those with frank or silent aspiration (P < 0.001). Patients with penetrations on thin liquids had higher likelihood of a successful IL (odds ratio [OR] = 3.68, P = 0.021). The probability of success with silent aspiration at any consistency was significantly decreased (OR = 0.26, P = 0.015). Fifteen patients underwent formal endoscopic surgical repair, and 90.0% were safe with thin consistencies postoperatively., Conclusion: A large proportion of patients with LC-1 and associated swallowing dysfunctions respond favorably to IL and formal repair. Children who demonstrated penetration with thin liquids had a higher rate of swallowing dysfunction resolution post-IL; whereas patients demonstrating silent aspiration had poorer responses to IL., Level of Evidence: 4. Laryngoscope, 126:2838-2843, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate the safety and feasibility of the da Vinci Surgical System in transoral robotic-assisted surgery for benign indications., Study Design: A multicenter, single-arm, retrospective case series., Methods: Perioperative outcomes were recorded for patients presenting with obstructive sleep apnea, airway obstruction, lingual tonsillar/tonsillar/tongue base hypertrophy, or dysphagia who underwent one or more transoral procedures, including lingual tonsillectomy and tongue base resection (partial glossectomy) at one of three US institutions., Results: Between January 2010 and October 2013, 285 patients (age 51.5 years, body mass index 30.5 kg/m(2) ) underwent 293 procedures. No conversions or blood transfusions were needed. The average operative time was 86.7 minutes, and the average volume of tissue resected (lingual tonsil and tongue base) was 8.3 mL. Hospital stays averaged 1.8 days, and the postoperative complication rate was 20.7%. There were no complications specifically related to the use the da Vinci Surgical System, and none of the complications were life threatening., Conclusions: These results demonstrate that it is safe and feasible to use the da Vinci Surgical System to perform lingual tonsillectomy and base of tongue resection (partial glossectomy) procedures for benign indications., Level of Evidence: 4, (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To describe indications, management, and outcomes of endoscopic CO2 laser cricopharyngeal myotomy (CPM)., Study Design: Case series with chart review., Methods: All patients treated with endoscopic CO2 laser CPM over a 6-year period were identified. A retrospective chart review was performed for surgical indication, history and physical examinations, and swallow evaluations. Swallowing outcomes were assessed using the Functional Outcome Swallowing Scale (FOSS); findings were compared across groups., Results: Eighty-seven patients underwent endoscopic CO2 laser CPM during the study period for cricopharyngeal dysfunction. Indications included Zenker's diverticulum (ZD) (39), DiGeorge syndrome (two), stroke (five), nerve injury (two), radiation for head and neck cancer (15), idiopathic (16), hyperfunctional tracheoesophageal speech (five) and dysphagia from cricopharyngeus stricture after laryngectomy (three). Mean, median, and mode time to feeding postoperatively were 1.4, 1, and 0 days respectively. Mean, median, and mode hospital stays were 1.8, 1, and 1 day respectively. Overall, FOSS scores improved from 2.6 to 1.6 (P < .001). Improvement was greatest for patients with ZD (2.4 to 1.0) and cricopharyngeal dysfunction from nerve injury (3.3 to 1.8) and least for those with prior radiation (3.9 to 3.2). All patients undergoing CPM for poor tracheoesophageal speech regained speech postoperatively. No patients developed mediastinitis, abscess, or fistula., Conclusions: Endoscopic CO2 laser CPM is a safe treatment for cricopharyngeal dysfunction of various causes, though swallowing outcomes may vary depending on the surgical indication. Early feeding postoperatively after CPM is safe and facilitates early hospital discharge., Level of Evidence: 4., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine symptoms and findings in patients with dysphagia related to epiglottic dysfunction. To analyze outcomes in patients who underwent partial epiglottidectomy due to dysphagia related to epiglottic dysfunction., Study Design: Review and analysis of clinical data obtained as part of the diagnosis and treatment of patients with dysphagia related to epiglottic dysfunction., Methods: A retrospective review was performed of all post-treatment head and neck cancer patients who underwent epiglottidectomy at a single tertiary care referral center. Objective pre- and postprocedure swallow findings, endoscopic evaluation, and subjective improvement based on patient self-reports were reviewed., Results: Seven patients were identified based on endoscopic evaluation and modified barium swallow study (MBSS) as having epiglottic pathology leading to dysphagia. Specific anatomic and functional findings included thickening of the epiglottis, absence of epiglottic deflection, vallecular bolus retention during and after the swallow, and bolus backflow from the pharynx to the oral or nasal cavity. Partial epiglottidectomy was performed in these patients. Postoperative MBSS was analyzed for changes in swallow efficiency and safety. Nearly all patients demonstrated improved pharyngeal bolus passage with little to no added swallowing morbidity., Conclusions: Preliminary findings suggest a role for partial epiglottidectomy in post-treatment head and neck cancer patients with swallowing disorders. Ideal candidates have intact tongue base contraction and poor retroflexion of the epiglottis, which results in bolus obstruction at the level of the valleculae. Partial epiglottic resection enables improved bolus passage in the pharyngeal phase. Minimal postoperative morbidity occurs in the appropriately selected patient., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

A 6-month-old patient presented with dysphagia and failure to thrive. Video fluoroscopic swallow study (VFSS), esophagogastroduodenoscopy, and manometry were diagnostic for CA. A gastrostomy tube was placed at 8 months. Botulinum toxin injection improved symptoms, but within 10 weeks symptoms returned. At 18 months, an uncomplicated endoscopic CPM was performed. A postoperative VFSS demonstrated cricopharyngeal bar resolution. Within 3 months, patient was feeding orally without a G tube. Pediatric CPA treatment options consist of dilation, botox, and transcervical CPM. To our knowledge, this is the youngest patient treated with endoscopic CPM. Intraoperative video and photographs are presented., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: Surgical closure of the larynx (SCL) is a method to prevent aspiration that sacrifices vocal function. The aim of this report was to introduce our new surgical method and perform clinical analysis of these cases., Study Design: Retrospective review., Methods: We performed 32 cases of surgical closure using our original method in two institutions from 2003 to 2011. We analyzed leakage and other complications and pre- and postoperative routes of nutrition., Results: The main feature of our method is reduction of the entire structure of the larynx. To reduce the laryngeal space, we excised both edges of the cut thyroid cartilage. Sutures were made collectively in upper flaps (false folds) and lower flaps (vocal folds), with no need for insertion of a hinged muscle flap. No clinical leakage was encountered in any cases, and aspiration pneumonia was completely prevented postoperatively. Most patients (56%) became able to ingest orally alone or in combination with tube feeding., Conclusions: Prevention of aspiration pneumonia is very important in medical management, and we believe that our method offers a good means by which to achieve this goal., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Pharyngeal pouches are common, particularly in the elderly population, in whom they can cause significant morbidity. The advanced age of many patients and existing comorbidities mean that in some cases neither open nor endoscopic pouch stapling is possible. We present a technique of combined open and endoscopic pharyngeal pouch surgery, which may be used when other therapeutic options are limited., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: Cricopharyngeus muscle dysfunction (CPD) ranges from asymptomatic cricopharyngeal bar (CPB) to Zenker's diverticulum. Previous work suggests that CPD can result in dilation and weakening of the pharynx above the obstruction. The purpose of this investigation was to evaluate the ability of surgery on the cricopharyngeus muscle to improve pharyngeal area and strength., Study Design: Retrospective case study., Methods: Videofluoroscopic swallowing studies of all persons with CPD who underwent cricopharyngeus (CP) intervention followed by routine postoperative fluoroscopic study, between October 1, 1999 and January 1, 2010 were reviewed. Objective measures of pharyngeal area and constriction were obtained from pretreatment and post-treatment studies. Paired t tests and repeated measures analysis of variance were employed to compare results., Results: Fifty-four patients were included. Pharyngeal constriction and pharyngoesophageal segment (PES) opening improved significantly after intervention (P < .05).Pharyngeal dilation was unchanged (P > .05). PES opening improved more with CP myotomy than with dilation and botulinum toxin., Conclusions: Relief of CP obstruction by surgery or dilation improves pharyngeal constriction and PES opening. Dilation of the pharynx possibly related to prolonged outlet obstruction does not improve. CP myotomy appears more effective than dilation or botulinum toxin in relieving obstruction.

Objectives/hypothesis: Transoral treatment of cricopharyngeal bar and small Zenker's diverticulum remains a challenge. We propose a new transoral approach for transoral cricopharyngeal myotomy (TOCPM) for patients with cricopharyngeal spasm and pharyngeal bar, and for transoral resection of diverticula (TORD) with cricopharyngeal myotomy in the patient with small (<3 cm) Zenker's diverticulum., Methods: A retrospective review was conducted of 45 patients with cricopharyngeal spasm (21) and Zenker's diverticulum (24), where 14 patients were considered suitable for TORD and TOCPM. TOCPM used the Weerda laryngoscope (Karl Storz, Tuttlingen, Germany) to expose the cricopharyngeal bar using a microscope; the mucosa is cut and then the muscle is transected using monopolar cautery. A 0 degrees endoscope is inserted through the incision to ensure complete myotomy. Incision closure is by interrupted 4-0 Vicryl sutures (Ethicon Inc., Somerville, NJ) and fibrin glue. For the TORD procedure, the diverticular sac is everted and then resected using scissors. Through the sac opening, the TOCPM is completed. The sac opening is then closed as described in TOCPM. The patients are kept without food for 24 hours, followed by feeding and discharge. Modified barium swallow (MBS) evaluated functional results., Results: Fourteen patients underwent TOCPM (eight), and TOCPM+TORD (six). There was one case of TOCPM that was aborted due to excessive bleeding, which prevented full myotomy. The rest did well. All were discharged the next day. Two poor results from the TOCPM and TOCPM+TORD group were due to poor esophageal motility. The remainder of patients had resolution of dysphagia and normalized MBS. No patient developed stricture or complications., Conclusions: Short segment Zenker's diverticulum and cricopharyngeal bar can now be addressed completely with a transoral approach. Because there is complete closure of the mucosal incision, prolonged hospitalization can be avoided.

Objectives/hypothesis: Children with neurologically impaired (NI) swallow can undergo tonsillectomy safely and effectively., Study Design: Retrospective review., Methods: Forty-five children with documented dysphagia were compared to age- and procedure-matched normal children for operating room and clinical experience. Three further studies were limited to the NI children only: preoperative and postoperative video swallow studies (VSS), and polysomnography (PSG) for sleep-disordered breathing history. Long-term telephone follow-up of clinical outcomes was performed., Results: There were no differences between the two groups measured by tonsil size or intraoperative or late post-tonsillectomy hemorrhage, but lowest measured oxygen levels were statistically different. No intraoperative complications, early post-tonsillectomy hemorrhage, hospital readmission, or mortality occurred in either group. Three NI children each had an episode of aspiration pneumonia (early or late) without sequelae. Of the 32 VSS available for review, postoperative aspiration incidence was significantly improved, but with new-onset aspiration occurring in five children. Of available matched pre- and postoperative PSG, 91% confirmed resolution of identified preoperative obstructive sleep apnea. Long-term telephone follow-up of 20 NI children revealed improved breathing (95%), communication (90%), and feeding efficiency (55%)., Conclusions: This study suggests tonsillectomy in NI children can be performed safely with appropriate monitoring and precautions with a 48-hour hospital postoperative stay recommended. Swallowing safety appears to improve both objectively and subjectively in most NI children following tonsillectomy. Both preoperative and postoperative VSS are recommended for any NI child undergoing tonsillectomy. Long-term follow-up identified improved quality of life measures for the majority of the NI children queried.

Objectives/hypothesis: Endoscopic repair has become the preferred method of treatment for Zenker's diverticuli. The objective of this study is to compare the endoscopic stapling technique with a novel technique using the Harmonic Ace device (Ethicon Endo-Surgery, Inc., Cincinnati, OH)., Study Design: A retrospective chart review., Methods: Medical records of 48 consecutive patients who underwent endoscopic repair of a Zenker's diverticulum were reviewed. Data were gathered for demographics, symptoms, treatment techniques, and outcomes. Analysis was made using standard statistical methods., Results: A total of 52 endoscopic procedures were attempted and 50 performed: 28 stapler assisted, 20 Harmonic Ace assisted, and 2 using both techniques. Three procedures were aborted due to anatomic limitations. Forty-four (88%) patients reported complete resolution of their symptoms. Overall, there were six (12%) reported complications. Five (17.9%) complications involved the stapler technique and 1 (5%) using the Harmonic Ace. The difference between these two groups was not significant (P < .38). The average diverticulum size was smaller in the Harmonic Ace group compared to the stapler group (P < .0017). Patients with diverticuli larger than 2 cm were more likely to have postoperative complications than those with smaller ones., Conclusions: Stapler and Harmonic Ace assisted endoscopic repair of Zenker's diverticulum are two safe and effective minimally invasive techniques. Postoperative complications are more likely due to size of the diverticulum and not the device used. The Harmonic Ace used alone or in combination with the stapler may offer additional advantages over conventional open and stapler assisted techniques, addressing size limitations and persistent symptoms.

Objectives: Fifty-six consecutive neurologically impaired pediatric children underwent laryngotracheal separation (LTS) for acute recurrent and chronic aspiration in the last 18 years. The population demographics, indications for surgery, and comorbidities are reviewed. This study reports early and late complications and survivorship including admissions for pneumonia/aspiration. Diagnosis related group (DRGs) and work relative value units (wRVUs) were measured to document the potential benefits before and after LTS., Study Design: Retrospective review of patient charts and records in an electronic medical record during an 18 year period., Methods: Information was obtained by a chart review and utilization of the electronic medical record. Patient specific DRG and wRVU data on their hospitalizations and outpatient encounters at the Alfred I. duPont Hospital for Children of the Nemours Foundation and survival data were recorded. Data was analyzed using chi-square analysis, a two-tailed t test, and a Fisher's Exact test., Results: Laryngotracheal separation achieved complete control of aspiration in all the children. A significant reduction in the number of hospital admissions for pneumonias after surgery was noted. After LTS there was a reduced average number of DRGs per month (p < .001) as well as wRVUs. Transient fistula formation (11%) was the most common complication. No patient had his or her procedure reversed to date., Conclusion: Laryngotracheal separation is 100% effective in controlling aspiration in all of neurologically impaired children in this study, It is a valuable procedure to prolong the life of children who have intractable aspiration. After LTS, a decrease in DRGs and wRVUs reduces health care costs for these patients. Prior to LTS, all medical and surgical treatment options for aspiration should be discussed and considered, based on the extent of the child's underlying neurologic status, ability to verbally communicate, degree of upper airway obstruction, and hope of recovery of neurologic function.

Diagnostic esophagogastroduodenoscopy (EGD) is generally a very safe procedure. We report the first case of iatrogenic esophageal submucosal dissection after an attempted diagnostic gastroscopy in a patient with a small previously undiagnosed Zenker's diverticulum (ZD). After EGD, she developed severe dysphagia with the inability to swallow solids, liquids, and even her own saliva. On barium swallow study, there was a column of contrast below the upper esophageal sphincter, and this was misdiagnosed as a large ZD by the radiologist. The resultant stricture was successfully managed with endoscopic balloon dilatation under fluoroscopy with wire-guided cannulation. The ZD was treated with flexible endoscopic clip-assisted diverticulotomy. Iatrogenic submucosal dissection is a unique complication of upper endoscopy. Endoscopists, otolaryngologists, radiologists, and cardiothoracic surgeons should be aware of this condition and prepare to manage it appropriately. If the patient is stable and the possibility of perforation is small, conservative and supportive care can be tried first. A surgical gastrostomy tube can be placed for enteral feeding. In patients with ZD, ZD recognition and gentle manipulation is strongly recommended during esophageal intubation.

Objectives: Over the past 10 years, endoscopic cricopharyngeal myotomy laser surgery has been proposed as an alternative to transcervical cricopharyngeal myotomy. We will describe the technique and review the literature so that it may gain credence as a viable option for the treatment of cricopharyngeal achalasia., Methods: A literature review of endoscopic and transcervical cricopharyngeal myotomy will be performed. The technical aspects of endoscopic cricopharyngeal myotomy will be presented and accompanied by intraoperative photographs, illustrations, and an online video demonstration., Results: Endoscopic cricopharyngeal myotomy is a well-tolerated procedure with low morbidity and good outcomes. It can be performed by surgeons who are comfortable with transoral laryngopharyngeal laser surgery., Conclusions: Endoscopic cricopharyngeal myotomy is a viable alternative to classic transcervical cricopharyngeal myotomy with equivalent outcomes and comparable if not less morbidity.

Objective: To present our experience with successful reversal of laryngotracheal separation in patients with chronic aspiration, to discuss our surgical technique, and to review the literature., Study Design: Retrospective case review., Methods: The medical records of two patients who underwent a successful reversal of laryngotracheal reversal after separation were reviewed. The two patients were evaluated clinically with videostroboscopy and videofluoroscopy., Results: Both patients presented with intractable aspiration despite protective tracheostomy because of impairment of lower cranial nerve function. After laryngotracheal separation, swallowing rehabilitation was safely possible, and neurologic improvement allowed reversal of the separation procedure. For reversal, we present the use of a partial cricotracheal resection with tracheocricothyropexia similar to the technique used for subglottic stenosis. Both patients were successfully reversed. Satisfactory voice and swallowing function 7 and 10 years after reversal, respectively, could be assessed through our evaluation. Review of the literature revealed a total of 13 cases of successful reversal after laryngotracheal separation. Technical details of surgery and functional results are rarely reported.

Objective: The development of a cricopharyngeal dysfunction is associated with a hypertonic cricopharyngeus (CP) muscle. Therefore, CP myotomy has been advocated by some authors to be an essential part of repair of this condition. However, little objective data exists to show that there is improvement in the upper esophageal sphincter (UES) after CP myotomy. This study assesses the impact of CP myotomy on UES opening., Study Design: Prospective., Methods: Twenty patients treated at a university tertiary care center for cricopharyngeal dysfunction between 1998 and 2003 were identified. All patients underwent CP myotomy with or without Zenker's diverticulectomy. These patients had videofluoroscopic swallow studies before and after repair. The values of UES opening for 3 mL boluses from pre- and postrepair studies were compared with each other as well as with normal controls. Sixty percent (12/20) of the patients had a Zenker's diverticulum. Of these 12 patients, 5 had undergone previous attempts at surgical correction. Cricopharyngeal myotomy by way of an external approach, with or without Zenker's diverticulectomy, was performed in all patients by the senior author., Results: Before Zenker's diverticulectomy and CP myotomy, the mean UES opening (n = 20) for a 3 mL bolus was 0.30 cm +/- 0.17, which was 57% of the mean of 60 normal controls (0.52 cm +/- 0.15) (P < .001). After repair, the mean UES opening for the same bolus size improved to 0.51 cm +/- 0.16 (P < .0001). The UES opening size in patients who have undergone repair is comparable with that of the normal controls (P > .05)., Conclusions: UES opening size in patients with cricopharyngeal dysfunction is 57% of the size in normal controls. CP myotomy helps to normalize the UES opening in cricopharyngeal dysfunction repair.

Objectives/hypothesis: Percutaneous endoscopic gastrostomy tube (PEG) placement by means of the "pull" method has been reported to result in a significantly higher complication rate when compared with "push" PEG placement. These findings have led to a renewed interest in the push, or Russell introducer, method of PEG placement at the authors' institution when PEG is required before definitive treatment of advanced head and neck cancer. The authors sought to determine whether the push method of PEG placement is associated with a lower incidence of complications in this patient population., Study Design: Nonrandomized, retrospective patient analysis., Methods: The medical records of all patients presenting to the Medical College of Georgia (Augusta, GA) who received a diagnosis of squamous cell carcinoma of the head and neck between 1999 to 2001 were retrospectively reviewed. Patients who required PEG placement as part of their treatment comprised the study population., Results: The push PEG technique was used in 29 patients, and the pull technique was used in 50 patients. There was a statistically significant difference in the complication rate between the two techniques. Patients who underwent placement by means of the pull technique had an overall complication rate of 30% (15 of 50) versus a 0% (0 of 29) complication rate in patients undergoing the push technique (P =.0006, Fisher's Exact test)., Conclusion: The push PEG technique appears to have a significantly lower risk of complications compared with the pull technique in patients with advanced head and neck cancer. The authors recommend considering the use of the push method when PEG placement is required.

Objectives/hypothesis: To determine the utility of preoperative feeding assessments in children undergoing airway reconstruction, identifying parameters that correlate with functional deficits in swallowing and postoperative feeding difficulties., Study Design: Prospective, sequential enrollment., Methods: Two hundred fifty-five patients with structural abnormalities of the upper aerodigestive tract underwent endoscopic swallow studies. Classification of preoperative feeding abilities, specific feeding disorders, and abnormal endoscopic feeding parameters were used to predict the postoperative course of patients undergoing airway reconstruction. The relationships between diagnoses and functional feeding categories and postoperative outcomes and functional feeding categories were appraised by chi2 analysis., Results: The median age of the study population was 2.5 years. Fifty-three percent of the patients were tracheotomy dependent. Only 13% of the patients had diagnoses limited to the airway, with 45% of patients having three or more diagnoses. Worse preoperative feeding abilities were associated with the presence of a tracheotomy, age 2 years or less, and multiple underlying diagnoses. Neurological diagnoses were associated with worse feeding abilities. Preoperative feeding assessments directly altered the course of management of 15% of operative patients, by recommending a delay in the surgical correction, the placement of a gastrostomy tube preoperatively, or a modification in the surgical reconstruction planned for the patient. Postoperative airway protection predictions were 80% accurate. Twelve percent of the predictions involved patients who developed unforeseen complications that required additional treatments or prolonged the hospital stay secondary to difficulties with airway protection. There was no correlation between the preoperative feeding abilities of the patients and their postoperative course after airway reconstruction., Conclusion: Transient dysphagia is common after laryngotracheal reconstruction. Preoperative feeding abilities do not correlate with the postoperative airway protection abilities of a patient. Feeding assessments before pediatric airway reconstruction provide a means of identifying patients with poor airway protection mechanisms that may compromise the patient after reconstruction. Findings on swallowing evaluations that predict poor airway protective mechanisms are 1) pooling of secretions in the hypopharynx, 2) poor oral motor skills, allowing premature spillage of material into the hypopharynx where it penetrates the larynx, and 3) residue that persists in the hypopharynx after multiple swallows. The integration of information generated from the preoperative swallowing assessment promotes the selection of operative procedures that are optimal for that patient and highlights specific therapy issues that may need to be addressed in the postoperative management of the patient that may not have been obvious without the study.

Caustic material ingestion, either accidental or intentional, may result in tissue and organ destruction leading to a wide range of complications, including loss of speech and the ability to eat. The esophagus can be reconstructed successfully, but reopening the larynx and upper airway poses a significant therapeutic dilemma. External reconstruction may put the neoesophagus at risk. Loss of the normal swallowing mechanism and the protective supraglottic structures often results in fatal aspiration. The authors present three cases of successful endoscopic laser recannulation of the larynx with esophageal replacement. The discussion includes surgical technique and the tools used to determine the success of the reconstruction, including computed tomographic scanning, modified barium swallow, placement of an upper esophageal anastomosis, psychologic support, and speech and swallowing therapy.

Thirty-eight patients with swallowing disorders underwent cricopharyngeal myotomy. The causes of the disorders were muscular in 12 cases, neurologic in 12, cricopharyngeal achalasia in 7, and unknown in 7. Surgery succeeded in 21 patients, gave a partial improvement in 4, and failed in 13. The quality of residual pharyngeal propulsion on clinical, manometric, and radiologic assessment appeared to be a more important predictor of surgical outcome than upper esophageal sphincter relaxation and the major factor in establishing the indications for cricopharyngeal myotomy. Achalasias in the elderly and oculopharyngeal muscular dystrophies had the most favorable outcome.

LTS is an effective surgical procedure that results in the elimination of intractable aspiration. Most of these patients have major neurologic impairment due to progressive neurologic disease or devastating injury secondary to stroke, trauma, or surgery. The procedure can be performed in ill, debilitated patients and is well tolerated, even with local anesthesia. Few patients lose communicative speech, and some patients gain the ability to swallow following the procedure. LTS should be considered in the management of patients with intractable aspiration before performance of a tracheotomy because the procedure is technically easier to perform at this time and may reduce the risk of a wound-healing complication. Postoperative nursing care is decreased, and most patients can be discharged or transferred to a chronic-care facility within 2 to 3 weeks following the procedure.

Damage to any one of these nerves results in sufficient morbidity to warrant therapy; however, most patients will compensate for isolated loss of function. It is with multiple nerve injuries, as often seen in glomus surgery with the resection of cranial nerves IX, X, and XII that the full efforts of the rehabilitation team are called on. After vocal cord medialization and palatal adhesion, younger healthier patients will eventually resume adequate oral intake. However, the time it requires to return to a reasonably enjoyable diet often extends up to 1 year postoperatively. A few never attain the goal of enjoyable intake and continue to struggle to maintain adequate nutrition. The latter situation is the rule, not the exception, in the elderly population. Our experience over the years has led us to a more conservative treatment of glomus tumors in the elderly debilitated patient.

Reported herein is the experience of the authors with 38 amyotrophic lateral sclerosis (ALS) patients for whom cricopharyngeal myotomy was performed. The major surgical objectives were facilitation of swallowing and amelioration of the tendency of these patients to aspirate ingestants and secretions. In the group of these patients in which the follow-up information has been adequate, 64% were improved and 36% experienced no significant benefits. The authors' surgical indications, methods of anesthesia, surgical technique, and postoperative care are described.

Cricopharyngeal myotomy is an effective procedure for the treatment of swallowing disorders due to dysfunction of the upper esophageal sphincter and pharyngeal musculature. Eight patients with documented pharyngeal and sphincteric dysfunction have undergone myotomies with significant improvement in swallowing associated with restoration of oral feeding without aspiration in 5, while 3 patients have not improved. The preoperative work-up and evaluation is discussed as well as criteria that may identify those patients most likely to benefit from this treatment.

Deglutition is a complex neuromuscular act. Alterations in anatomy and physiology may lead to dysphagia. The role of the cricopharyngeus appears to be the keystone in the rehabilitation of many patients with dysphagia. This paper examines the physiology of swallowing as well as the patho-physiology of its abberations. Techniques and complications of cricopharyngeal myotomy are presented. Cases of dysphagia due to ablative surgery of the head and neck, dermatomyositis, cerebrovascular accidents, and cricopharyngeal achalasia in which cricopharyngeal myotomy was utilized, are reported. It would appear from this small number of cases, that cricopharyngeal myotomy is indicated in the rehabilitation of dysphagia in patients with varied disease states.