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Objective: To perform a systematic review of studies reporting swallow-associated outcomes in patients who received surgery for head and neck cancer (HNC), informed by an anatomic and physiologic framework of pharyngeal phase of swallowing (Pearson's dual-sling model)., Methods: PUBMED and Google Scholar databases were searched for peer-reviewed papers published between 1990 and 2019 using relevant MeSH terms. Exclusion criteria were 1) discussions comparing reconstruction techniques, 2) case-report/series (n < 10), 3) perspective articles, 4) papers comparing objective instrumental methods of swallowing evaluation, 5) animal/cadaver studies, 6) no instrumental or validated swallow assessment tools used, 7) papers that discuss/include radiotherapy treatment, 8) systematic reviews, 9) papers that discuss swallow training or rehabilitation methods. Two investigators reviewed papers meeting inclusion/exclusions criteria. Muscles resected, anatomic resection site, swallow outcomes, and patient treatment variables were collected., Results: A total of 115,020 peer-reviewed papers were identified. 74 papers were relevant to this review, 18 met inclusion and exclusion criteria, and none discussed surgical impact on the pharyngeal phase of swallowing using Pearson's dual-sling model. Most papers discussed the effect of tongue-base, supraglottic, or regional anatomic resection. Post-surgical resection Follow-up times ranged from 1 to 13 months. 67% of studies used objective instrumental swallow studies; 22% used patient reported outcome measures. Follow up time since surgical resection, time to feeding tube removal, feeding tube present/absent, aspiration severity were used to define dysphagia endpoints., Conclusions: To date, no surgical HNC studies have used the dual-sling mechanism to guide study design, and dysphagia assessment has been inconsistent. To counsel patients on the effects of surgery on pharyngeal phase of swallow function, specialists need physiologically grounded research that correlates muscles resected with consistent measures of swallow function., (Published by Elsevier Inc.)

Background Context: Previous studies have called into question the safety of using rhBMP-2 in anterior cervical fusion due to the possibility of airway compromise and dysphagia. A retrospective chart review identified a significant increase in the severity of dysphagia after II-level ACDF with rhBMP-2 compared to patients who did not receive rhBMP-2. To date, this topic has not been studied prospectively., Purpose: Compare the incidence of dysphagia following anterior cervical discectomy and fusion (ACDF) when recombinant human bone morphogenetic protein-2 (rhBMP-2) is used with allograft compared to allograft alone., Study Design: Prospective cohort study., Patient Sample: A total of 114 patients completed a baseline SWAL-QOL survey and met the inclusion criteria. Thirty-nine patients underwent I- or II-level ACDF with allograft plus 0.5mg rhBMP-2/level. 44 patients underwent ACDF with allograft alone. Thirty-one patients undergoing a lumbar decompression were enrolled in a third cohort to control for dysphagia secondary to intubation., Outcome Measures: The primary outcome measure was the 14-point SWAL-QOL dysphagia questionnaire. Other patient factors obtained from anesthesia and operative records were examined to evaluate their potential relationship to postoperative dysphagia., Methods: The 14-point SWAL-QOL questionnaire was administered at multiple time points (pre-op, post-op 7 days, 6 weeks, 6 months, and at least 1 year). Multivariable repeated-measures analysis was applied to data., Results: Baseline adjusted SWAL-QOL means 7 days after surgery were significantly different between the three study groups. These differences resolved by 6 weeks postoperative, beyond which point there were no differences. At final follow-up, baseline adjusted SWAL-QOL means at 1 year were similar for the three study groups., Conclusions: This single-center study of anterior cervical surgery demonstrated that the addition of rhBMP-2 to an ACDF increased postoperative dysphagia at 7 days after surgery, but these patients recover to levels comparable to those who underwent ACDF without rhBMP-2 or lumbar surgery within 6 weeks., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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.)

Purpose: The aim of this meta-analysis was to investigate the effects of retropharyngeal steroid use during operation on bony fusion and dysphagia rate after ACDF., Methods: We searched the electronic literature database of PubMed, Embase and the Cochrane Library published from January 1990 to February 2020. The size of each group, mean age, proportion of female patients, dysphagia events and fusion rate at one-year follow-up were extracted. RevMan 5.3 was used for the meta-analysis., Results: A total of eight studies including six RCTs and two case-control studies met the inclusion criteria. This meta-analysis showed that retropharyngeal steroids could achieve significantly lower dysphagia rates (p < 0.001), higher fusion rates (p = 0.01), less moderate and severe events rates according to the Bazaz stratification (p < 0.001). However, there was no significant difference between two groups regarding operation time (p = 0.67), blood loss (p = 0.33), VAS scores at one day (p = 0.90) and VAS scores at two weeks (p = 0.80)., Conclusions: Retropharyngeal steroid use is an effective method in reducing dysphagia rate, severe dysphagia rate and increasing fusion rate during ACDF surgery, without increasing operating time, blood loss or VAS scores at one day and two weeks., Level of Evidence I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Background: Various endoscopic methods of dividing the cricopharyngeus muscle and the common wall of pharyngeal pouches have been described, most commonly the carbon dioxide laser and stapler. The potassium titanyl phosphate (KTP) laser is an alternate endoscopic method of treatment., Methods: The KTP laser is used in a similar fashion to the carbon dioxide laser to carefully divide the cricopharyngeus muscle fibres ± the common wall of the pharyngeal pouch, under microscopic visualization., Conclusion: The KTP laser is an alternative and safe technique for these surgeries., (© 2021. Crown.)

Background: Patients with scleroderma often suffer from dysphagia and gastroesophageal reflux disease (GERD). Partial fundoplication is a validated anti-reflux procedure for GERD but may worsen dysphagia in scleroderma patients. Its utility in these patients is unknown. Here, we evaluate the efficacy and acceptability of partial fundoplication for the treatment of medically refractory GERD in patients with scleroderma., Methods: Analysis of a prospectively maintained database of patients who underwent fundoplication across 14 hospitals between 1991 and 2019. Perioperative outcomes, reintervention rates, heartburn, dysphagia, and patient satisfaction were assessed at 3 months, 1- and 3-years post-surgery., Results: A total of 17 patients with scleroderma were propensity score matched to 526 non-scleroderma controls. All underwent a partial fundoplication. Perioperative outcomes including complication rate, length of stay, and need for reoperation were similar between the two groups. Compared to baseline, both groups reported significantly improved heartburn at 3 months, 1- and 3-years following partial fundoplication. Surgery was equally effective at controlling heartburn across all follow-up timepoints in patients with or without scleroderma. Dysphagia to solids was more common in patients with scleroderma than controls at 3-months post-surgery, but was not significantly different to controls at 1- and 3-year follow-up. Satisfaction scores were high and comparable between both groups across all postoperative timepoints, with 100% of patients with scleroderma reporting that their initial choice to undergo surgery was correct., Conclusions: Partial fundoplication controls reflux and is associated with a transient period of dysphagia to solids in patients with scleroderma. This approach is safe, effective and acceptable for patients with scleroderma and medically refractory GERD., (© 2021. Société Internationale de Chirurgie.)

The optimal revision surgical strategy for patients who develop symptomatic adjacent segment disc degeneration (ASD) is controversial. The risks of intraoperative complications, especially the incidence of dysphagia, were relatively high for revision surgeries. This study was aimed at comparing the efficacy of revision surgery using a traditional plate-cage construct and zero-profile anchored spacer (ROI-C) device in treating symptomatic ASD after initial anterior cervical discectomy and fusion (ACDF) surgery. Forty-two patients who developed symptomatic ASD were retrospectively analyzed and classified into two groups (plate-cage group and ROI-C group). The clinical and radiological results were compared. We further evaluated the complication of dysphagia and dysphagia-related risk factors in these patients. The JOA and NDI scores, C2-7 lordotic angle, and intervertebral space height were significantly improved after revision surgery in both groups. The operative time and intraoperative blood loss both significantly decreased in the ROI-C group. The incidence of postoperative dysphagia was much lower in the ROI-C group than in the plate-cage group (18.75% vs. 57.69%; P = 0.01). The presence of dysphagia after initial surgery ( P = 0.003) and revision surgery type ( P = 0.01) was significantly related to the presence of dysphagia after revision surgery. These results indicated that both the plate-cage construct and ROI-C are effective in treating symptomatic ASD. However, compared with the traditional plate-cage construct, ROI-C with less operative time, less blood loss, and lower incidence of dysphagia is more suitable. Furthermore, ROI-C should preferably be used for patients who present with dysphagia after initial cervical surgery. This study will provide clinical guidance for spinal surgeons to choose the zero-profile device in treating specific and complicated cases, which will significantly improve the therapeutic efficacy of symptomatic adjacent segment degeneration., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this paper., (Copyright © 2021 Junjie Niu et al.)

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..)

Introduction: The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients., Methods: A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05., Results: 449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05)., Conclusion: In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation., (Copyright © 2021 Elsevier B.V. All rights reserved.)

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).)

Objectives: Airway reconstruction for laryngotracheal stenosis (LTS) encompasses several procedures. Dysphagia is a well-recognised sequela of LTS and airway surgery, however studies have employed mostly non-validated assessments post-operatively in small, heterogenous samples, perpetuating uncertainty around the contributions of LTS and its management to impaired deglutition. Consequently, considerable variation in LTS perioperative nutritional management exists. Our objective was to characterise baseline and post-operative dysphagia with instrumental assessment in an LTS cohort undergoing airway reconstruction and provide a gold-standard management framework for its management., Design, Setting, Participants and Main Outcome Measures: We performed a retrospective cohort study of adult airway reconstruction procedures from 2016-2020 at our quaternary centre. Patient background, LTS aetiology, procedure type, tube feeding duration, length of stay and serial Functional Oral Intake Scale (FOIS) and International Dysphagia Diet Standardisation Initiative (IDDSI) scores were noted. Baseline, post-operative day one and post-stent removal Fibreoptic Endoscopic Evaluation of Swallow (FEES) generated Penetration Aspiration Scale (PAS) scores., Results: Forty-four patients underwent forty-six reconstructions. Baseline incidence of penetration-aspiration was considerably higher than the general population and worsened in the immediate post-operative period, however FOIS and PAS scores generally returned to baseline by discharge. Post-operative FOIS correlated negatively with tracheostomy or airway stent placement. At discharge, 80% tolerated soft or normal diet and 93% were feeding tube independent., Conclusions: We present the largest adult airway reconstruction cohort with instrumental swallow assessment perioperatively. LTS patients have a higher incidence of underlying dysphagia but swallowing tends to return to baseline with appropriate postoperative rehabilitation. Such practice may avoid the complications, costs and morbidity of prolonged nutritional support., (© 2021 The Authors. Clinical Otolaryngology published by John Wiley & Sons Ltd.)

Objectives: To summarize the current evidence on surgical treatment for large bridging osteophytes of the anterior cervical spine from Diffuse Idiopathic Skeletal Hyperostosis (DISH). Overview of Literature: In the current review, the surgical treatment of secondary dysphagia from DISH was the most useful treatment. We propose a treatment algorithm for management of this condition because currently there are only case reports and retrospective studies available. Methods: Literature search was performed using the MeSH terms "Anterior Cervical Osteophyte," "Diffuse Idiopathic Skeletal Hyperostosis (DISH)," and "Dysphagia" and "Treatment" for articles published between January 2000 and February 2020. PubMed search identified 117 articles that met the initial screening criteria. Detailed analysis identified the 40 best matching articles, following which the full inclusion and exclusion criteria left 11 articles for this review. Results: Incidence of secondary dysphagia was associated with DISH in elderly patients (average 65 years). The major clinical findings were dysphagia or respiratory compromise, with the most common level of bridging osteophytes of the cervical spine at C3-C5. There were 10 articles on surgical treatment involving anterior cervical osteophytectomy without fusion, 1 for multilevel cervical oblique corpectomy, 1 for anterior cervical discectomy with fusion plus plate, and 1 for anterior cervical osteophytectomy with stand-alone PEEK cage or plus plate. All the cases resulted in significant improvement without recurrence, with only 1 case having post-operative complications. Follow-up duration was 3-70.3 months. Conclusions: Surgical intervention for anterior cervical osteophytectomy appears to result in improved outcomes. However, there could be disadvantages concerning cervical spine motion if cervical osteophytectomy with cervical discectomy and fusion (ACDF) plus plate system is done.

Introduction: Multiple therapeutic modalities including surgery and rigid and flexible endoscopy have been adopted to manage Zenker's diverticulum (ZD). Minimally invasive flexible endoscopic septotomy (FES) techniques have been increasingly favored over the past 20 years; however, long-term data are still scanty. The aim of this study is to evaluate early and long-term outcomes of FES for naive ZD in a single-center setting., Methods: From 2010 to 2017, ZD patients treated with FES were included in a prospectively maintained database (NCT03948438). Those who had already been treated surgically or endoscopically were excluded from the analysis. The Dakkak and Bennett dysphagia scale was used to rate the dysphagia. Persistent complete or near-complete resolution of symptoms (Dakkak and Bennett 0 or 1) was defined as clinical success. Postprocedural adverse events were reported according to ASGE lexicon., Results: Overall, 256 consecutive patients were treated. Mean pouch size was 29.8 ± 11.3 mm. The procedure was successfully completed in all scheduled patients, with an early clinical success of 96.1%. Adverse events occurred in 3.5% (9/256) of patients. Eight of them were mild/moderate with no fatal events, whereas one patient required surgery. Recurrences occurred in 31.3% (80/256) of treated patients after a mean time of 9 ± 3 months and 95% of recurrences were treated by a second FES. At an average follow-up of 5.5 years, 95.3% of patients were asymptomatic after a mean number of 1.3 procedures., Discussion: FES is a safe and effective treatment modality for patients with ZD. Recurrence rate is significant; however, endoscopic reintervention is associated with long-term relief of dysphagia., (Copyright © 2021 by The American College of Gastroenterology.)

Abstract: Self-expanding metal stents (SEMSs) in different geometric shapes are an established palliative treatment for malignant tumors of the esophagus. Mechanical properties and stent design have an impact on patient comfort, migration rate, and removability. SEMS with a segmented design (segSEMS) have recently become available on the market, promising new biomechanical properties for stent placement in benign and malignant esophageal diseases. In this study, we evaluated recurrent dysphagia, quality of life as well as technical success and complications for segmented SEMS-implantation in a retrospective study in palliative patients with dysphagia caused by malignant tumors of the esophagus.Between May 2017 and December 2018, patients presented to the interdisciplinary department of endoscopy of the University Hospital Cologne underwent segmented SEMS placement for malignant dysphagia. Patient follow-up was evaluated, and complications were monitored. Quality of life and functional improvement were monitored using the EORTC QLQ-C30 and QLQ-OE18.A total of 20 consecutive patients (16 men, 4 women; mean age: 65.5, range: 46-82) participated in the study and were treated with 20 segSEMS in total. The success rate of stent placement was 100%. Stent migration occurred in 3 patients (15.0%). Insertion of segSEMS immediately lead to a 48.0% reduction of dysphagia in the first 2 months (P < .001). Pain while eating (odynophagia) could also be significantly reduced by 39.6% over the first 2 months (P < .001).Implantation of segSEMS is a feasible and effective treatment for dysphagia in palliative patients with malignant tumors of the esophagus, offering immediate relief of symptoms and gain of physical functions., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Dysphagia is a highly prevalent symptom in Amyotrophic Lateral Sclerosis (ALS), and the implantation of a percutaneous endoscopic gastrostomy (PEG) is a very frequent event. The aim of this study was to evaluate the influence of PEG implantation on survival and complications in ALS. An interhospital registry of patients with ALS of six hospitals in the Castilla-León region (Spain) was created between January 2015 and December 2017. The data were compared for those in whom a PEG was implanted and those who it was not. A total of 93 patients were analyzed. The mean age of the patients was 64.63 (17.67) years. A total of 38 patients (38.8%) had a PEG implantation. An improvement in the anthropometric parameters was observed among patients who had a PEG from the beginning of nutritional follow-up compared to those who did not, both in BMI (kg/m 2 ) (PEG: 0 months, 22.06; 6 months, 23.04; p < 0.01; NoPEG: 0 months, 24.59-23.87; p > 0.05). Among the deceased patients, 38 (40.4%) those who had an implanted PEG (20 patients (52.6%) had a longer survival time (PEG: 23 (15-35.5) months; NoPEG 11 (4.75-18.5) months; p = 0.01). A PEG showed a survival benefit among ALS patients. Early implantation of a PEG produced a reduction in admissions associated with complications derived from it.

Introduction: Incidental papillomas of the pharynx can be found while examining the nasopharynx, oropharynx, and hypopharynx for other disorders of the head and neck. Purpose of the study is to explore the location, biopsy protocol, and decision to perform office-based versus operative management via potassium titanyl phosphate (KTP) laser when an oropharyngeal papilloma is discovered incidentally., Methods: A retrospective review of the senior author's patient population was performed using Current Procedural Terminology and/or International Classification of Diseases codes to identify patients who had KTP laser removal of incidental oropharyngeal papillomas. Patients were included based on the incidental nature of the papilloma and confirmed pathology report of squamous papilloma. Demographics, presenting complaint, lesion location, pathological analysis, type of intervention, and outcomes were recorded. When available, human papillomavirus (HPV) subtype was noted., Results: A total of 26 cases were identified, 13 females and 13 males. The median age at time of surgery was 58 years (range: 21-77). The most common presenting symptoms were difficulty swallowing and throat pain. The most common locations were the base of tongue, uvula, tonsils, and the soft palate. Of the 26 patients, 23 patients received KTP laser ablation therapy as an office-based procedure, while the remaining 3 were performed under general anesthesia in the operating room. Only 5 patients had a recorded recurrence that required reoperation. There were no operative or postoperative complications. There were 16 biopsy samples tested for HPV, where 12 were negative for HPV and 4 were positive for HPV., Conclusion: Oropharyngeal papillomas, when present, can be found incidentally during examination of the oropharynx for other symptoms. Office-based biopsy and KTP laser is a safe and efficient means of identifying and removing most oropharyngeal papillomas.

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.)

Most existing anterior cervical discectomy and fusion (ACDF) outcome studies omit emergency department (ED) use. To our knowledge, this study on ED use following ACDF surgery is the first to use a direct patient chart review and the first to include revision patients, 1-5 levels of ACDFs, and performance of corpectomy in the analysis. This study examines the frequency and basis of hospital service use within 30 days of ACDF surgery, specifically ED visits, hospital readmissions, and returns to the operating room. A retrospective chart review was performed for 1273 consecutive patients who underwent ACDF surgery at one institution from July 2013 to June 2016. Of the 1273 patients with ACDF, 97 (7.6%) presented to the ED within 30 days after surgery. Of 43 patients with revision ACDF, 9 (20.9%) returned to the ED, compared with 88 (7.2%) of 1230 patients with primary ACDF (P = 0.001). Of the 111 ED visits by 97 patients, 40 (36%) were for cervicalgia, 13 (12%) were for dysphagia, 8 (7%) were for trauma, 7 (6%) were for nausea, 4 (4%) were for medication refill, 3 (3%) were for dehiscence, 3 (3%) were for pneumonia, and 3 (3%) were for urinary tract infection. Of the ED presentations, 8 (7%) occurred during the first 2 days after surgery, and 46 (41%) occurred within the first postoperative week., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

A 75-year-old man presents to his general practitioner (GP) with dyspnoea, and dysphagia to liquids and solids, with regurgitation causing recurrent episodes of dyspnoea. He had a background of osteoarthritis, was an ex heavy smoker and had undergone coronary artery bypass graft five years previously. After several emergency admissions, initial investigation by the GP, and referral to ear, nose and throat specialists with no cause for dysphagia found, he underwent computed tomography imaging of the neck and thorax which demonstrated large cervical osteophytes at the level of C3-C4. He was referred to spinal orthopaedics and after multidisciplinary team discussion the cervical osteophytes were removed via an anterior approach, resulting in complete resolution of his symptoms.

Study Design: This was a systematic review and meta-analysis., Objective: The objective was (1) to measure rates of successful resolution of dysphagia in patients after undergoing surgical intervention for diffuse idiopathic skeletal hyperostosis (DISH); and (2) to determine if older age, longer duration of preoperative symptoms, or increased severity of disease was correlated with unsuccessful surgical intervention., Summary of Background Data: DISH, also known as Forestier disease, is an enthesopathy affecting up to 35% of the elderly population. Many patients develop osteophytes of the anterior cervical spine, which contribute to chronic symptoms of dysphagia causing debilitating weight loss and possibly resulting in the placement of a permanent gastrostomy feeding tube. For patients that fail conservative medical management, an increase in surgical interventions have been reported in the literature in the last 2 decades., Materials and Methods: A systematic search was performed on PubMed, Medline, Cochrane Library, and Embase. Studies measuring outcomes after surgical intervention for patients with dysphagia from DISH were selected for inclusion. Two independent reviewers screened and assessed all literature in accordance with Cochrane systematic reviewing standards., Results: In total, 22 studies reporting 119 patients were selected for inclusion. Successful relief of dysphagia was obtained in 89% of patients after surgical intervention. Failure to relieve dysphagia was associated with increased length of symptoms preoperatively (P<0.01) using logistic regression. Patients with more severe preoperative symptoms also seem to have an increased risk for treatment failure (risk ratio, 2.86; 95% confidence interval, 1.19-6.85; P=0.02). Treatment failure was not associated with patient age, use of intraoperative tracheostomy, implementation of additional fusion procedures, level of involved segments, or number of involved segments., Conclusions: Patients undergoing surgical intervention have a higher likelihood of failing surgery with increasing preoperative symptom length and increased preoperative symptom severity., Level of Evidence: Level III., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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).)

Background: Capella ringed gastric bypass is a technical variant of gastric bypass which seeks to improve long-term outcomes with a greater restriction. Frequent complications are due to the band, due to its inclusion or slippage, without being able to reject others. Our purpose is to present the video of a revisional bariatric surgery made by laparoscopic approach in a patient with a previous open retrogastric retrocolic Capella gastric bypass., Materials and Methods: The patient presents dysphagia, gastroesophagic reflux disease (GERD), and pain, with a BMI of 36 kg/m 2 . Her supplementary tests show a hiatal hernia, GERD, and a Candy Cane Syndrome. The surgery was difficult due to multiple adhesions. Hiatal hernia was repaired and pillars were closed. The band was visualized intraoperatively close to the gastrojejunal anastomosis, although the high endoscopy did not detect neither stenosis nor difficulty of passage to the gastric pouch. It showed the retrogastric gastrojejunal anastomosis with a normal food loop and a 15-cm widened blind loop (Candy Cane Syndrome), which was resected., Results: She had a left pneumonia and damage in left hepatic lobe (LHL). She was discharged after antibiotic treatment for 7 days. The patient has improved clinically, without dysphagia nor GERD. Her current BMI is 29.8 kg/m 2 ., Conclusions: In conclusion, bariatric revisional surgery can lead to serious complications, but it is justified in patients with poor quality of life. A ringed retrocolic retrogastric bypass poses more difficulties in revisional procedures. It is mandatory to know which technique was performed before. The duration of the procedure can result in more complications like liver damage.

Atrophy of tongue after free-flap reconstruction often leads to functional problems like dysphagia and articulation disorders. Lipotransfer might resolve this issue. We describe a case of repeated lipotransfer into an atrophied reconstructed tongue.A 66-year-old patient with a squamous cell carcinoma of the tongue underwent hemiglossectomy and reconstruction of the tongue by a free radial forearm flap. After atrophy of the reconstructed tissue, repeated sessions of lipotransfer were undertaken to augment the atrophic tissue. Three sessions of lipotransfer resulted in satisfactory augmentation of the atrophied reconstructed tongue, leading to improvement of dysphagia and articulation.To our knowledge, this is the first report of lipotransfer used to augment a flap inside the oral cavity. We propose this tool as a potential aid to improve typical tongue reconstruction sequelae., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: There are many reports of the efficacy of laryngeal reinnervation on voice, but there is a paucity of literature regarding its impact on swallowing function. The goal of this study was to explore the impact of laryngeal reinnervation on swallowing outcomes among unilateral vocal fold paralysis (UVFP) patients., Methods: We reviewed 22 UVFP cases treated with laryngeal reinnervation at our institution. Ten patients had complete datasets, including Eating Assessment Tool (EAT-10) scores and appropriate follow-up. Wilcoxon signed-rank test was used to compare pre- and postoperative scores., Results: Over the study period, 10 cases (mean age 45.7 ± 13.3 years; 6/10 men) with UVFP underwent ansa cervicalis to recurrent laryngeal nerve anastomosis (6/10) or nerve-muscle pedicle procedure (4/10). The median time between injury and surgical reinnervation was 12.4 months (range 2.7-88.5 months). Based on EAT-10 scores 6/10 patients were found to have dysphagia. Of these, four improved their score after surgery, one remained stable, and one deteriorated. The median EAT-10 score of these patients improved from 13 to 7 after surgery, but this difference was not statistically significant (P = 0.138)., Conclusion: Laryngeal reinnervation procedure has the potential for restoring a near normal voice in UVFP. Laryngeal reinnervation of the vocal fold may be associated with a tendency toward improvement in the EAT-10 score in patients after surgery for hoarseness in the setting of UVFP., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Aim: In presence of malignant dysphagia, in patients unfit for surgery, the placement of a self-expandable metal stent (SEMS) represents a safe and effective palliative treatment. Esophageal stents (ES) present an over-the-wire mechanism where the stent is deployed under X-ray control. Recently a through-the-scope (TTS) ES was launched. The aim of our retrospective study is to assess the technical and clinical success of the new TTS-ES., Materials and Methods: Patients with malignant dysphagia caused by esophageal cancer or ab-extrinsic compression, who underwent TTS esophageal stent in six Italian endoscopic referral centers, were retrospectively reviewed., Results: A total of 40 patients were enrolled. TTS stent placement was successful in 39/40 patients (97.5%). 31 patients had an Ogilvie score of 4, nine an Ogilvie 3. After 2 weeks from stent placement 29 reported Ogilvie score of 0, eight a score of 1. None of the patients developed retrosternal pain requiring drugs. No patient experienced perforation, bleeding or migration. A total of seven patients (18%) developed dysphagia as late adverse event (AE)., Conclusion: Through-the-scope ES presented less AEs, in terms of bleeding and perforation, if compared to the previous published data. An anti-migration system could be helpful, especially when the stent is placed for "ab-extrinseco" malignant dysphagia., (© 2020 Japan Gastroenterological Endoscopy Society.)

Background and Aim: Plummer-Vinson syndrome (PVS) comprises triad of iron deficiency anemia, dysphagia, and post-cricoid esophageal web. PVS is rare nowadays due to improved nutritional status. However, we encountered patients with PVS regularly at our center. Data regarding PVS are limited; hence, we aimed to study the clinical features, treatment outcomes, and development of complications in patients with PVS., Methods: The study was conducted over a 10-year period (January 2008 to January 2018) in a medical college setting. All adults with dysphagia, anemia, and post-cricoid web or those with iron deficiency anemia and post-cricoids web were included in the study. Patients were treated with iron supplementation and Savary-Gilliard bougie dilation of the web. Patients were followed-up for the recurrence of dysphagia and development of complications., Results: Overall, 153 patients exhibited esophageal web, of which 132 (86.27%) patients had concomitant PVS and 21 (13.7%) patients did not. The mean age was 43.50 years (range 16-76) and 113 (85.6%) were women. Single session of Savary-Gilliard bougie dilation was successful in 90.7% of patients in relieving dysphagia and 9.3% developed recurrence, requiring repeated dilations. Four patients had concomitant squamous cell carcinoma of esophagus along with PVS and two developed upper gastrointestinal malignancy during follow-up., Conclusion: Plummer-Vinson syndrome is predominantly seen in middle aged women and present with symptoms of iron deficiency anemia and early grade dysphagia. Single session of Savary-Gilliard bougie dilation was successful in majority of patients in relieving dysphagia. Overall risk of developing upper gastrointestinal malignancy was 4.5%., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: To evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers., Methods: Fifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed., Results: The mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person., Conclusions: Laparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Taiwan LLC.)

Background: Data about percutaneous endoscopic gastrostomy (PEG) insertions in small infants are limited, and most studies include older children. We aimed to evaluate the safety of PEG placement in infants weighing ≤5 kg together with their follow-up results., Methods: A retrospective evaluation was made of records between January 2005 and December 2019., Results: A total of 43 infants were ≤5 kg at the time of PEG insertion. The mean age was 5 ± 3 (19 days-16 months) months and the mean weight was 4.3 ± 0.6 (2.7-5.0) kg. The primary diagnoses were neurological disorders in 25, metabolic disorders in nine, cleft palates in four, muscular disorders in four, and a cardiac disorder in one. All procedures were completed successfully. A self-resolving pneumoperitoneum developed in one (2.3%). The tube was extruded in six (14%) patients postoperatively which required suture-approximation of the skin and subcuticular tissues. The tube was removed in four (9%) patients with achievement of oral feeds on the long-term. Eighteen (42%) died of primary diseases. The tubes were in situ for a median of 12.4 (17 days-73 months) months in these patients. A total of 20 (46.5%) patients are currently being followed up and their tubes are in situ for a median of 50.3 (4.7 month-9.8 years) months., Conclusions: Percutaneous endoscopic gastrostomy placement is safe in small infants with associated morbidities. Complications related to the procedure are within acceptable limits. The accidental extrusion of the tube was a special consideration in this patient group. The overall mortality was high because of underlying primary diseases., (© 2020 Japan Pediatric Society.)

Introduction: Esophageal window defect in patients with esophageal resection could be challenging to repair. In this case report, a free posterior tibial artery perforator flap (FPTAPF) was used for semi-circumference patch esophagoplasty., Patient Concerns: For this 47-year-old male patient with recurrent laryngeal nerve schwannoma invading cervical and upper thoracic esophagus, cervical and upper thoracic esophageal reconstruction following tumor resection was needed DIAGNOSIS:: Pathologic result demonstrated recurrent laryngeal nerve schwannoma. Ultrasound examination detected a tumor (7 cm × 6 cm × 3 cm) located behind the right thyroid lobe, and contrast-enhanced computed tomography scan revealed that tumor was located between the cervical esophagus and trachea, and compressed these structures., Interventions: The tumor had a size of 7 cm × 6 cm × 3 cm, and the semi-circumference defect of the cervical and upper thoracic esophagus was about 7 cm in length after complete tumor resection. A 7 cm × 4 cm FPTAPF was designed and harvested for esophageal reconstruction., Outcomes: The posterior tibial flap survived well and satisfactory recovery of esophageal function was obtained with no significant complications. No local tumor relapse was indicated by computed tomography during the 2-year postoperative follow-up., Conclusion: This case highlights the stable performance of FPTAPF when used for the reconstruction of large esophageal window defect.

A 69-year-old female suffering from severe dysphagia due to an aberrant right subclavian artery was treated with a two-step approach. A right carotid-subclavian bypass was followed 2 weeks later by a robotic-assisted thoracoscopic resection of the aberrant right subclavian artery. The postoperative course was uneventful, and the patient immediately recovered from her dysphagia. In our case, the robotic-assisted technology offered major advantages and, based on our experience, may be useful in the treatment of this rare disease., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: Vascular rings are often diagnosed after evaluation for swallowing and breathing difficulties. Data regarding symptoms following vascular ring repair is sparse. We sought to determine whether symptoms persist using chart review and a survey., Methods: Sixty-three patients underwent open vascular ring repair from July 2007 to May 2018. Data regarding vascular anatomy, demographics, pre- and postoperative symptoms, and chromosomal abnormalities were collected. Freedom from reoperation, 30-day mortality, and complications were assessed. Patient families were contacted for a symptom focused survey., Results: The median age of surgical intervention was 14.4 months (IQR 5.8-34.7 months) for single aortic arches with an aberrant subclavian artery (SAA), and 5.3 months (IQR 1.3-10.1 months) for double aortic arches (DAA) (Table). Prior to surgery, all but two SAA were symptomatic. There was no operative mortality. Three patients required re-exploration for chylothorax, and three required late aortopexy. At last follow-up, 45% (18/40) SAA and 65% (15/23) DAA had post-operative symptoms. Fourteen patient families completed the symptom survey (10 SAA, 4 DAA). Five SAA had breathing and swallowing symptoms, and 3 SAA and 3 DAA had breathing difficulties., Conclusions: Open vascular ring repair remains a safe repair. However, further investigation of the persistent symptoms in these patients is merited., Study Type / Level of Evidence: Retrospective Comparative Study, Level III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate outcomes of injection laryngoplasty (IL) and endoscopic surgical repair for the treatment of type 1 laryngeal clefts (LC1) and to determine the most common presentations of LC1., Methods: Primary studies were searched for in PubMed, Scopus, OVID, and Cochrane Library using search terms laryngeal cleft and laryngotracheoesophageal cleft for articles published from database inception through August 2019. The search identified all articles pertaining to the symptomatology and management of LC1. Meta-analysis was performed on presenting symptoms and improvement of clinical symptoms and swallow function., Results: Twenty-four studies, comprising 713 patients with a mean age of 33.7 months (range 0-168 months), were included. The most common presenting symptoms were aspiration (80%, CI [55%-96%]), dysphagia (61%, CI [47%-74%]), and choking (57%, CI [37%-76%]). Gastroesophageal reflux disease (GERD) was the most common comorbidity (68%, CI [51%-83%]) and premature birth comprised 27% [21%-32%] of the patients. Overall, 38% of patients received IL as a primary therapy. Prior to injection, 91% [87%-94%] of patients aspirated on swallow evaluations, and 62% [55%-68%] aspirated post-injection. At an average follow-up time of 6.8 months, 90% [70%-100%] of parents reported symptom improvement. An additional 54% of patients underwent endoscopic surgical repair as primary treatment. The rate of aspiration decreased from 73% [43%-94%] to 28% [13%-46%] after repair. At a mean follow-up of 14.2 months, 80% [67%-91%] reported symptom improvement., Conclusion: A high level of clinical suspicion is necessary to detect LC1 since its most common presenting symptoms overlap with other diseases commonly found in this patient population. Both IL and formal surgical repair were effective in managing LC1., (Copyright © 2020. Published by Elsevier B.V.)

Oral mucosa exhibit clinical manifestations of a variety of systemic conditions and can serve as an indicator of overall health of an individual. Various systemic conditions like autoimmune, endocrine and haematological disorders can present with oral mucosal lesions, which can serve as an important diagnostic feature. These oral lesions can vary from oral ulceration, bleeding gums, xerostomia, chronic glossitis, to erosion and sensitivity of teeth. It is important that a clinician must be aware of the oral presentations of systemic conditions, so that timely diagnosis can be made and the necessary treatment is executed. This paper presents an unusual case of severe oral mucosal ulcerations and dysphagia in an elderly patient diagnosed with Zenker's diverticulum. Patient was relieved of all oral symptoms once the underlying gastrointestinal tract pathology was diagnosed and surgically corrected., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

On April 14, the Society of Swallowing and Dysphagia of Japan (SSDJ) proposed its position statement on dysphagia treatment considering the ongoing spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main routes of transmission of SARS-CoV-2 are physical contact with infected persons and exposure to respiratory droplets. In cases of infection, the nasal cavity and nasopharynx have the highest viral load in the body. Swallowing occurs in the oral cavity and pharynx, which correspond to the sites of viral proliferation. In addition, the possibility of infection by aerosol transmission is also concerning. Dysphagia treatment includes a broad range of clinical assessments and examinations, dysphagia rehabilitation, oral care, nursing care, and surgical treatments. Any of these can lead to the production of droplets and aerosols, as well as contact with viral particles. In terms of proper infection control measures, all healthcare professionals involved in dysphagia treatment must be fully briefed and must appropriately implement all measures. In addition, most patients with dysphagia should be considered to be at a higher risk for severe illness from COVID-19 because they are elderly and have complications including heart diseases, diabetes, respiratory diseases, and cerebrovascular diseases. This statement establishes three regional categories according to the status of SARS-CoV-2 infection. Accordingly, the SSDJ proposes specific infection countermeasures that should be implemented considering 1) the current status of SARS-CoV-2 infection in the region, 2) the patient status of SARS-CoV-2 infection, and 3) whether the examinations or procedures conducted correspond to aerosol-generating procedures, depending on the status of dysphagia treatment. This statement is arranged into separate sections providing information and advice in consideration of the COVID-19 outbreak, including "terminology", "clinical swallowing assessment and examination", "swallowing therapy", "oral care", "surgical procedure for dysphagia", "tracheotomy care", and "nursing care". In areas where SARS-CoV-2 infection is widespread, sufficient personal protective equipment should be used when performing aerosol generation procedures. The current set of statements on dysphagia management in the COVID-19 outbreak is not an evidence-based clinical practice guideline, but a guide for all healthcare workers involved in the treatment of dysphagia during the COVID-19 epidemic to prevent SARS-CoV-2 infection., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier B.V.)

Background: Parapharyngeal area is one of the most complex areas of head and neck anatomy. Tumors of the parapharyngeal region are very rare among head and neck tumors. Lipomas also constitute a tiny proportion of parapharyngeal tumors so parapharyngeal area lipomas are very rare in the literature. Due to anatomical location, these tumors treatment is challenging., Clinical Report: A 20-year-old male patient admitted to our department with complaints of swallowing difficulty and a mass on the right side of the neck. Magnetic resonance imaging was performed, and it was reported as a 6 × 4.5 cm lipoma. He underwent excision of parapharyngeal area lipoma by a transoral approach., Conclusion: Parapharyngeal lipomas are very rare, and difficult to diagnose before they turn out symptomatic. The primary treatment approach in tumors of the parapharyngeal area is surgery and the surgical approach should be chosen according to the anatomical location of the lesion.

Background: Noncardiac chest pain often coexists with dysphagia in patients diagnosed with achalasia. The current standard treatment for achalasia, laparoscopic Heller myotomy with Dor fundoplication, has an insufficient effect on noncardiac chest pain. The aim of this study is to investigate the efficacy of circumferential Heller myotomy on esophageal chest pain in patients with achalasia., Methods: Twenty patients diagnosed with achalasia who complained of noncardiac chest pain were recruited and underwent circumferential Heller myotomy. Using an institutional achalasia database, we randomly selected 60 patients who underwent standard laparoscopic Heller myotomy with Dor fundoplication, based on a 3-to-1 propensity score-matching analysis. We compared surgical outcomes between the circumferential Heller myotomy and the laparoscopic Heller myotomy with Dor fundoplication groups., Results: Patients undergoing circumferential Heller myotomy had a higher rate of postoperative noncardiac chest pain relief than the laparoscopic Heller myotomy with Dor fundoplication group [95% (19/20) vs. 75% (45/60), p = 0.045]. No differences in dysphagia and vomiting were found between groups (p = 0.783 and p = 0.645, respectively). Patients in the circumferential Heller myotomy group had significantly better esophageal clearance. The prevalence of reflux endoscopic esophagitis was higher in the circumferential Heller myotomy group than in the control group [35.0% (7/20) vs. 10.0% (6/60), p = 0.015]., Conclusions: There is promising early evidence that circumferential Heller myotomy may be effective in the treatment of achalasia-related chest pain. Further research, including larger randomized studies with long-term follow-up, is warranted.

Purpose: Although dysphagia is known potential complication of cervical spine surgery, it rarely occurs after a posterior approach. We describe an unusual case of a retro-odontoid pseudotumor that suffered dysphagia following a C1 laminectomy and posterior atlantoaxial fixation. Materials and methods: A 79-year-old man presented with progressive tetraparesis and bladder and bowel dysfunction due to severe compression to cervical cord at C1 from a retro-odontoid pseudotumor. After C1 laminectomy and atlantoaxial fixation, the symptoms improved, but dysphagia and aspiration developed, associated with pharyngeal and esophageal stases on videofluoroscopy. Results and conclusions: Possible explanations for postoperative dysphagia include limitation of cervical spine motion, and cervical cord reperfusion injury in addition to the baseline anterior osteophyte and aging. This is the first case of dysphagia developing after laminectomy and posterior atlantoaxial fixation not involving the occipital bone.

Acute massive gastric dilatation (AMGD) is a rare event which is usually underdiagnosed. It can occur due to multiple etiologies, including medical and surgical, or as a postoperative complication. We report a rare case of AMGD as a result of closed-loop obstruction of the stomach following feeding jejunostomy in a patient with carcinoma oesophagus. A high index of suspicion, early diagnosis and prompt management is the key to the successful treatment. To the best of our knowledge, this is the second case report of a closed-loop obstruction of the stomach leading to AMGD in published literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Up to 50% of patients with vertical banded gastroplasty (VBG) experience failure or complications in the mid- and long-term and present for revisional bariatric surgery. This study aimed to review our experience for patient outcomes after VBG revisions and compare their benefits to those of primary laparoscopic Roux-en-Y gastric bypass (LRYGB) operations., Materials and Methods: Data from patients who underwent VBG revision between 2009 and 2015 at a center of excellence were reviewed. Patient demographics, symptoms, comorbidities, weight loss, reinterventions, reoperations, and hospital stay were analyzed and compared with those of primary LRYGB patients (control group)., Results: Fifty-two patients (88.5% female, 55 ± 9.6 years old) underwent revisional surgery during the study period (86.5% LRYGB, 11.5% VBG reversal, and 2% sleeve gastrectomy). Patients presented 17.3 ± 7.2 years after their VBG for weight regain (55.8%), dysphagia (19.2%), or both (25%). Patients who underwent conversion to LRYGB for weight regain and for mix-symptoms had similar weight loss to the control group (38.2 ± 11.8 vs 35.6 ± 7.7, p = 0.108), along with similar comorbidity resolution. However, even though the early (< 30 days) complication rate was similar between the two groups, the conversion group had higher 4-year reoperation rate (29% vs 9.5%, p < 0.001) and length of stay (5.4 ± 5.3 vs 2.6 ± 3.1, p < 0.001). Additionally, dysphagia resolved in all the patients of our cohort., Conclusions: VBG conversion to LRYGB leads to significant weight loss, resolution of dysphagia, and comorbidities similarly to the primary LRYGB operations. However, higher mid-term complication rates should be expected.

Objective: To determine the rate of surgical complications, unplanned readmission, and functional status after open hypopharyngeal surgery for dysphagia with early return to oral diet and hospital discharge., Methods: Retrospective chart review of patients who underwent open hypopharyngeal surgery for management of dysphagia from March 2013 to June 2018 at a single academic institution. A clear liquid diet is restarted the day of surgery and is advanced to a soft diet on postoperative day one. Univariate and multivariate logistic regression was performed to identify risk factors for postoperative complications and unplanned readmission., Results: Ninety patients met eligibility criteria; 62 patients underwent open cricopharyngeal myotomy, 13 underwent Zenker's diverticulectomy, 15 had a Zenker's diverticulopexy. Mean inpatient length of stay was 2.0 ± 2.0 days (range 0-11 days); 57 patients (63.3%) were discharged on the same day as surgery or on postoperative day one. Seven patients (7.8%) had postoperative complications; the most common complication was esophageal leak (n = 6). Six patients (6.7%) had unplanned readmissions within 30 days. Mean time to unplanned readmission was 12 days (range 2-19 days). Open diverticulectomy was associated with an increased risk of unplanned readmission with an OR = 7.63 (95% CI 1.29, 45.45, P  = .025). At last follow-up, 70% of patients had an increased functional oral intake by at least one scale score (FOIS) after surgery (mean follow-up 0.8 ± 1.1 years, range 0.02-5.1 years)., Conclusion: An early diet and discharge may be safe for patients undergoing open surgery without a mechanical or suture closure of their esophageal mucosa, whereas in those undergoing diverticulectomy, NPO status and a radiological check before resuming drinking and eating are advised., Level of Evidence: 4.