Symptoms Of Dysphagia Research Articles

Symptomatic Improvement in Adults and Adolescents with Eosinophilic Esophagitis Requires Higher Systemic Dupilumab Exposure than Histologic Response.

We assessed potential mechanisms behind the requirement for more frequent dupilumab dosing in eosinophilic esophagitis (EoE) compared with other approved indications. Results for the phase 3 LIBERTY EoE TREET study co-primary endpoints (proportion of patients achieving a peak intraepithelial eosinophil count of ≤6 eosinophils per high-power field and absolute change from baseline in Dysphagia Symptom Questionnaire total score) were pooled in exposure-response analyses. A steep initial relationship then plateau was observed between higher dupilumab steady state trough concentrations (Ctrough) and decreased eosinophilic infiltration at Week 24, while a graded exposure-response relationship was observed for symptomatic improvement at Week 24. Patients with the highest exposures were more likely to achieve greater symptomatic benefit, independent of strictures or history of dilation. The dupilumab 300 mg qw regimen approved for adults and adolescents with EoE weighing ≥40 kg is supported by dose- and exposure-response relationships.

Swallowing outcomes in brachytherapy radiation approach for head and neck cancer survivors- A twin case-based observations

Swallowing dysfunction is a prevailing state following radiotherapy in patients with head and neck cancer. The progress in the treatment techniques has allowed more precise radiation administration to the tumour and has reduced damage to adjacent issues. Nonetheless, a proportion of patients still suffer from swallowing dysfunction following radiotherapy. Brachytherapy is an advanced procedure to treat and manage cancers increasing in recent clinical practice. BT has been used as a tool to facilitate the delivery of a high tumour dose in which it eventually reduces the doses to neighbouring swallowing structures, compared with conventional RT. There are no studies reported the swallowing abilities following brachytherapy. Hence considering the lacunae in the literature and the effect of radiation on swallowing abilities the present case study was taken to represent the swallowing abilities in oral cancer patients received brachytherapy. Two cases diagnosed with carcinoma of buccal mucosa and tongue were given brachytherapy. The speech and swallowing abilities were affected in both the condition prior to brachytherapy. Following brachytherapy speech and swallow rehabilitation was carried out for one month and both of them showed significant improvement and case with buccal mucosa showed greater improvement than carcinoma of tongue. The present concludes that there will be organ specific dysphagia symptoms in brachytherapy and involvement of adjacent structures are minimal.

Computed tomography roadmap for post-operative fundoplication imaging with a novel structured reporting checklist.

With increasing numbers and acceptability of laparoscopic anti-reflux surgery (LARS) procedures over long-term medical treatment in the past decade, it follows that the complications of fundoplication wrap are seen intermittently with recurrent symptoms of heartburn and dysphagia. Endoscopy and barium swallow are the initial investigations performed for suspected fundoplication wrap failures. However, with easy availability of multislice computed tomography (CT) and the multiplanar reconstructions along with reduction in familiarity with barium examinations, it would be prudent for the surgeons to familiarise themselves with various appearances of wrap failure. Currently, there is no accepted standard to report a fundoplication wrap failure. We did a thorough literature review on the use of CT scans for fundoplication wrap failure, created a multidisciplinary hernia team with prominent radiologists and surgeons and discussed the role of CT scans in the management of suspected wrap failure. After completing a pilot study with around 43 patients of wrap failure, we created a standard CT reporting format which helped us in the management of even the most complex cases. This standard reporting format can be used by trainees and surgeons worldwide. This would lead to uniformity in reporting, would help in decision-making and would also help create national and international primary wrap failure and redo fundoplication registry. A total of 43 patients of wrap failure of multislice CT evaluation were analysed for type of failure along with factors responsible for the maintenance of integrity of the wrap. A novel checklist with structured reporting was used for the description of the post-operative imaging findings. The demographic characteristics, post-operative imaging and intraoperative findings were described. The different types of wrap failure - Hinder types and associated pathologies were analysed for relative frequency in wrap failures. The novel structured reporting included wrap integrity and failure complications in post-operative patients of LARS. Fundoplication wrap failure is not an uncommon complication seen after LARS. A novel structured report with checklist will help the surgeons to evaluate the post-operative patient with recurrent symptoms. Multislice CT is the ideal modality for imaging suspected wrap failures after primary endoscopic evaluation. Multiplanar imaging with coronal and sagittal reconstructions is useful for understanding the integrity of the wrap and its ability to detect failure/migration.

Oropharyngeal Dysphagia as The Presenting Symptom of Myasthenia Gravis with Diabetes Mellitus

Background: Oropharyngeal dysphagia may caused by a variety of causes. Myasthenia gravis is a common autoimmune disease affecting the neuromuscular junction. While ocular symptoms are common in myasthenia gravis, bulbar symptoms such as dysarthria and dysphagia are less common. Aim: To present the importance of recognizing atypical presentations of myasthenia gravis and utilizing electromyography in diagnosis when AChR antibody testing is unavailable. Case Presentation: A 57-year-old woman was referred because of progressive dysphagia for both solid and liquid food. She also experienced weight loss, heaviness of the right eyelid, drooling, and chewing difficulty. Medical history revealed diabetes. Vital signs were stable. Physical examination revealed right ptosis without any other neurological deficits. Wartenberg test and dysarthria counting test were positive. Laboratory examination revealed a blood glucose level of 270 mg/dL and an HbA1c level of 9.4%. The barium swallow study revealedno abnormalities. Esophagogastroduodenoscopy revealed esophageal candidiasis. Electromyography showed more than 20% decremental response of the orbicularis oculi muscle. This result is suggestive of neuromuscular junction disorder. Improvement of the condition was achieved after the administration of intravenous steroids and oral pyridostigmine combined with therapeutic plasma exchange. Discussion: Oropharyngeal dysphagia accompanied by ptosis and positive Wartenberg & dysarthria counting test is suggestive of myasthenia gravis. Although an AChR antibody test cannot be performed, significant electromyography alongside relevant clinical presentation is sufficient to diagnose myasthenia gravis. Conclusion: It is crucial to recognize the accompanying signs and symptoms of oropharyngeal dysphagia. EMG may be used to diagnose MG in the appropriate clinical context.

Surgical management of achalasia.

Achalasia is a chronic esophageal motility disorder comprised of ineffective esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter. This disease had historically been managed through medical means as well as endoscopic dilations. However, surgical interventions are now considered standard of care, including minimally invasive Heller myotomy, which was popularized in 1990s, followed by per oral endoscopic myotomy in the 2010s. Both surgical approaches provide acceptable resolution of dysphagia symptoms. Classification of the achalasia as well as other patient-level factors may drive the clinical decision-making between the two approaches, as well as surgical training and surgeon preference.

BN SO30 - One hundred consecutive Laparoscopic Heller's Cardiomyotomy & Fundoplication – a personal series

Abstract Background Oesophageal Achalasia (OA) is an uncommon primary oesophageal motility disorder, characterised by the loss of inhibitory neurons in the oesophageal myenteric plexus. The primary goal of treating OA is to alleviate dysphagia caused by the functional obstruction of the distal oesophagus due to the inability of the lower oesophageal sphincter (LOS) to relax appropriately after swallowing. Heller's cardiomyotomy (HCM) remains a standard treatment for OA. The aim of this study was to assess the symptomatic improvement and post-operative outcomes following HCM with fundoplication at our centre. Method All patients underwent HCM through laparoscopic blunt muscle separation technique, between January 2005 and March 2024, by a single surgeon. Retrospective review of electronic and compiled paper patient records were analysed to assess patient demographics, preoperative symptoms, operative details, length of stay (LOS), complications, post-operative symptoms, gastroscopy and pneumatic dilation (PD) as well as revisional surgery. Primary outcomes assessed were binary changes in key symptoms of weight loss, dysphagia, retrosternal pain and regurgitation. Comparison of pre and post-operative outcomes were performed using paired t-test. A p-value of <0.05 was considered statistically significant. Results 100 procedures involving 99 patients (average age 50 years, 43% female), 1 conversion to open and 1 revision at 3 years. ASA grades were 1 (27%), 2 (58%), and 3 (15%). Median LOS was one day, median follow-up 99 months. Post-operatively; weight loss persisted in 11% of patients from 48%, dysphagia reduced from 98% to 42%, retrosternal chest pain from 39% to 20% and regurgitation from 57% to 24% (all p<0.05). 2 patients required (PD) ≤30 days (CD≥3). 36 patients underwent PD at median of 13 months, 20 needed repeat PD. None of the patients developed cancer. Conclusion As demonstrated in this large series of 100 consecutive patients, HCM remains one of the best treatment modalities for OA. Key symptoms of OA significantly reduced following HCM. Our technique avoided the use of energy devices, ensured a short hospital stay and durable symptom improvement, lends support to its continued application in managing this condition.

OGC SO29 - Patient perceptions survey on the best timed oesophago-gastric dietetic pathway

Abstract Background It is well established that patients with oesophago-gastric (OG) cancer often present with malnutrition and impact symptoms such as anorexia, dysphagia and abdominal symptoms. Dietetic input is imperative in assessing and managing these symptoms early to improve outcome measures such as nutritional status, clinical outcomes and quality of life. A service evaluation was conducted to explore patient perceptions of early dietetic intervention in the Greater Manchester OG two week wait (TWW) pathway. There is no known prior research exploring the aims of this project. The results provide a novel insight into patient perceptions. Method A mixed methods survey using Microsoft Forms including open and close-ended questions was completed using transcription of responses via telephone consultation for 8 participants. For multiple choice responses, quantitative analysis was undertaken utilising Microsoft Forms analytics. Thematic analysis was completed with the use of computer assisted qualitative data analysis software (CAQDAS). Results 100% of respondents strongly agreed that receiving information about eating and drinking during investigations was important to them. 100% of respondents disagreed that dietetic advice was difficult to understand and follow. 75% of respondents felt dietetic input to be helpful in managing nutritional impact symptoms. 25% of participants responded neutrally. 100% of respondents felt their individual needs and concerns were addressed and would recommend the service to friends/family (88% strongly agreed; 12% agreed respectively). Conclusion Dietetic input was viewed positively by service users undergoing the OG TWW pathway. Patients reported feeling reassured, and valued communication, accessibility, and a personal approach. Some patients experienced delays in receiving prescribed nutritional supplements. Consistency of nutritional information requires improvement across the multidisciplinary team. Unfamiliarity with dietetic input limits the ability of participants to provide perspectives on service improvement. These findings suggest that specialist nutritional assessment and advice is beneficial to patients. Future research should be conducted to explore the long-term impact of early dietetic interventions on health outcomes in OG cancer patients.

BN O05 - Physiological Transit Assessment of the Oesophagus In Patients With Anti-Reflux Surgery

Abstract Background High-resolution manometry (HRM) is the gold-standard investigation for oesophageal motility in patients with dysphagia. The HRM findings may influence surgical decision for myotomy or anti-reflux surgery (ARS). However, HRM pitfall is the inability to measure oesophageal transit in parallel to the motility during physiology testing. Both transit and motility are complementary that offer insights in the pathophysiology and aetiology of the dysphagia symptoms. This research evaluates the multichannel intraoesophageal impedance transit (MIIT) concept [1] to assess the oesophageal transit in symptomatic patients who undertook the postoperative oesophageal physiology testing between January 2020 and June 2024. Method This cross-sectional retrospective study selected patients with intact Nissen fundoplication (NF) wrap on gastroscopy or with known LINX implant in-situ. HRM with Chicago Classification (version 4.0)[2] compared the ARS cases with augmented antireflux barrier [AARB] from the surgery to healthy treatment naïve controls. The multichannel impedance-pH studies assessed both reflux and the MIIT [1]. MIIT >0.76 minutes were considered positive and comparable to GOJ outflow obstruction [1]. This project was approved by the NHS institution and the local research ethics committee (REC 18/NW/0120)(IRAS 333800). Results 60 patients were found (NF 54, LINX implant 6)(females 30, mean age 51.3 years). 11 patients(18.3%) had pathological reflux despite ARS(DeMeester scores >14.72); 2 patients (18.2%) demonstrated hypotensive AARB. Conversely, 6 patients(10%) showed poor relaxation from the AARB and were compatible to outflow obstruction (5 patients [83.3%] showed conformation with MIIT >0.76 minutes). Patients with ineffective oesophagus (20%) and absent contractility(11.7%) showed MIIT >0.76 minutes in respectively two-thirds with ineffective oesophagus and in all patients with absent contractility. Normal HRM study was observed in 35 patients (58.3%) with 27 patients (77.1%) demonstrating MIIT >0.76 minutes. Conclusion MIIT was able to explain the post-surgical dysphagia in majority of patients from the equivalent transit to outflow obstruction (n=52 patients, 86.7%). Half of these cases had a normal HRM study and would have been perceived as having functional dysphagia. We would recommend performing MIIT adjunctive testing as part of postoperative oesophageal physiology assessment in symptomatic patients. Incidentally, we observed 16 patients (26.7%) having hypotensive AARB post ARS comparing to healthy treatment naïve controls with 2 patients (12.5%) having persistent pathological reflux who may still benefit from surgical revision.

Effect of Esophageal Dilation History on Efficacy Outcomes in Patients With Eosinophilic Esophagitis Receiving Budesonide Oral Suspension.

The effect of esophageal dilation history on efficacy outcomes in patients with eosinophilic esophagitis (EoE) receiving swallowed corticosteroids is not well established. This post hoc analysis assessed data from a 12-week, randomized, double-blind, placebo-controlled phase 3 study (NCT02605837) of budesonide oral suspension (BOS) 2.0 mg twice daily in patients aged 11-55 years with EoE and dysphagia. Coprimary efficacy outcomes were histologic (≤ 6 eosinophils per high-power field [eos/hpf]) and dysphagia symptom (≥ 30% reduction in Dysphagia Symptom Questionnaire scores from baseline) responses at week 12. Secondary efficacy outcomes included histologic response (< 15 eos/hpf) and change from baseline to week 12 in Dysphagia Symptom Questionnaire scores and EoE Endoscopic Reference Scores. Data were analyzed post hoc by esophageal dilation history (dilation history vs no dilation history). Of 318 patients who received ≥ 1 dose of study drug, 42.8% had a history of esophageal dilation (dilation history: BOS, n = 91; placebo, n = 45; no dilation history: BOS, n = 122; placebo, n = 60). Histologic responses (≤ 6 and < 15 eos/hpf) were similar regardless of dilation history. Fewer BOS-treated patients with dilation history than no dilation history achieved a dysphagia symptom response (44.0% vs 59.0%); conversely, a slightly greater improvement from baseline in total EoE Endoscopic Reference Scores was observed for BOS-treated patients with dilation history than no dilation history (least-squares mean [SE of the mean]: -4.1 [0.3] vs -3.4 [0.4]). Esophageal dilation history may confound the association between histologic outcomes and dysphagia symptom or endoscopic efficacy outcomes in patients with EoE receiving swallowed corticosteroids.

Comparison of Swallowing Measures to Patient-Reported Dysphagia Symptoms in Head and Neck Cancer Patients.

Head and neck cancer affects patient swallowing function. We set out to examine how objective measures of swallowing compare against subjective patient-reported outcomes in a cohort of head and neck cancer patients. Retrospective analysis of data collected from a large dysphagia HNC registry. Tertiary Academic Cancer Center. Between 2006 and 2019, objective measures of swallowing as scored on Modified Barium Swallow Study or Fiberoptic Endoscopic Evaluation of Swallowing and subjective measures using the SWAL-QOL were collected. Objective measures were scored by the Penetration-Aspiration Score (PAS); subjective measures were assessed by the Dysphagia Domain Score (DDS), collectively forming paired data points. Data on tumor site, T-stage, and treatment modality was collected and evaluated. A total of 253 paired data points were included in this study. A statistically significant relationship between PAS and DDS was observed across all patients (P < .05, chi sq). When stratified by tumor subsite, PAS and DDS relationships were strongest for oral cavity. When stratified by AJCC T-stage, T4 tumors had the strongest relationship between PAS and DDS. The relationship of PAS and DDS was less congruent the further removed from treatment completion. Objective and subjective measures of swallowing provide complementary evaluations of swallow function. The congruency of assessment varies by T stage and tumor subsite. Physicians and allied health professionals can use this information to better understand the value and limitation of objective and subjective swallowing assessments in evaluating head and neck cancer patients.

ETWST: An Extension to the Timed Water Swallow Test for Increased Dysphagia Screening Accuracy.

We aimed to fine-tuning the Timed Water Swallow Test (TWST) screening procedure to provide the most reliable prediction of the Flexible Endoscopic Evaluation of Swallowing (FEES) assessment outcomes, with age, sex, and the presence of clinical signs of dysphagia being considered in the assessment. Participants were healthy people and patients with suspected dysphagia. TWST performance and participants' reported dysphagia symptoms were assessed in terms of their utility in predicting the outcome of a FEES assessment the same day. The FEES assessors were blinded to the nature of the TWST performance. The water swallowing capacity levels and clinical observations during a screening performance that were indicative of dysphagia/no symptoms in FEES were determined. Convergent validity was assessed as the agreement with the Functional Oral Intake Scale (FOIS) in the FEES assessment. TWST predicted FEES findings (aspiration and dysphagia) with a sensitivity of 72 and 45% and a specificity of 75% and 80%, respectively. Extended analysis of the TWST procedure (eTWST) identified aspiration (sensitivity = 92%, specificity = 62%) and dysphagia (sensitivity = 70%, and specificity = 72%) more accurately and showed a high correlation with FOIS (ɸ = 0.37). Excellent inter-rater reliability was further observed (Kw = 0.83). The extended evaluation of TWST performance has superior criterion validity to that of TWST. eTWST displayed high convergent validity and excellent interrater reliability. We therefore believe that eTWST can be highly relevant for clinical dysphagia screening.

A Retrospective Review of Clinical Characteristics and Risk Factors of Dysphagia in Patients with Dermatomyositis.

Dermatomyositis is a rare autoimmune-mediated disease characterised by distinctive rash and progressive muscle weakness. Patients with dermatomyositis may develop swallowing disorders (dysphagia) due to the inflammation of muscles involved in swallowing which may lead to serious health consequences. However, to date, the clinical characteristics of and risk factors for dysphagia in dermatomyositis remain poorly understood. This retrospective study aimed to identify the characteristics and risk factors for dysphagia in dermatomyositis. All patients with clinical diagnosis of dermatomyositis (ICD-9-CM 701.3) were identified and retrieved retrospectively via hospital electronic record over a 10-year period for review. A total of 231 patients were identified with 149 fulfilled the inclusion criteria (median age [range] = 54.5 [3-92] years; 51 males) were recruited. The incidence of dysphagia was 18.8%, with predominantly pharyngeal phase impairments. Six patients had silent aspiration. Dysphagia was positively correlated with the age of diagnosis (r[148] = 0.187, p = 0.023), mortality (r[149] = 0.186, p = 0.023), presence of underlying malignancy (r[149] = 0.222, p = 0.007), methylprednisolone use (r[149] = 0.166, p = 0.042) and intravenous immunoglobulin (IVIg; r[149] = 0.217, p = 0.008), and negatively correlated with disease duration (r[147]=-0.273, p < 0.001). Moreover, it was more likely to have symptomatic dysphagia in patients prescribing systemic corticosteroid (OR[95%CI] = 4.43[1.02, 19.27], p = 0.047) and IVIg (OR[95%CI] = 6.39[1.14, 35.68], p = 0.035). Dysphagia was associated with advanced age, increased mortality and malignancy in patients with dermatomyositis. Routine screening of dysphagia is recommended at initial diagnosis and severe disease activity requiring high dose systemic steroid and IVIg use.

Sex-related differences in the presentation, management and response to treatment of eosinophilic esophagitis: Cross sectional analysis of EoE CONNECT registry.

Eosinophilic esophagitis (EoE) predominantly affects males across all ages; however, little is known about sex differences for other aspects of EoE. To investigate associations between sex and clinical presentation, endoscopic features, treatment choice and response in EoE patients in real-world practice. Cross-sectional analysis of the multicenter EoE CONNECT registry. The independent contribution of patients' sex and other relevant variables were statistically assessed by multivariate models. A total of 2976 patients (76% male) were evaluated. Males were diagnosed at a younger age compared to females (32.7±14.8 vs. 34.8±15.6years, respectively; p=0.002) with similar diagnostic delay. EoE symptoms varied significantly between sexes, with food impaction predominating in males and dysphagia, heartburn, regurgitation and abdominal and epigastric pain in females. However, female sex contributed to higher symptom severity at diagnosis as measured with Dysphagia Symptom Score (R2=0.57; p=0.013) and presented higher peak eosinophil count in esophageal biopsies (p=0.005). Males showed increased risk of stricturing or mixed phenotypes (adjusted OR 1.43, 95%CI:1.05-1.96; p=0.024). No association was found between patients' sex and first-line treatment modality: proton pump inhibitors (PPI) were preferred over topical corticosteroids in patients with inflammatory phenotypes instead of stricturing or mixed phenotypes, and in patients who did not present food impaction. Both topical corticosteroids and dietary interventions were preferred over PPI in pediatric patients regardless of sex. Sex is associated with clinical and phenotypical presentation of EoE at diagnosis, with more fibrotic findings in males but higher symptom score in females.

DUPILUMAB: A NEW ALLY FOR THE TREATMENT OF EOSINOPHILIC ESOPHAGITIS?

INTRODUCTION: Eosinophilic esophagitis is a chronic, immune-mediated disease of the gastrointestinal tract, resulting from the interaction between genetic, environmental and immunological factors of the affected patient. The clinical picture is characterized by esophageal dysfunction, which may present as dysphagia, precordial pain, upper abdominal pain or food impaction. Treatment aims to improve clinical symptoms and prevent disease progression and subsequent complications. In this context, immunobiologicals are emerging and promising therapies, with Dupilumab being the first specific treatment approved by the FDA. It is an IgG4 monoclonal antibody that targets IL-4R alpha and, from there, reduces protein transphorylation, transcription and the T helper 2-regulated response. The objective of this systematic review is to evaluate the efficacy of this drug in the treatment of eosinophilic esophagitis, in comparison with the options already available on the market. METHOD: PubMed searches were performed using the keywords “eosinophilic esophagitis dupilumab” and “dupilumab treatment esophagitis eosinophilic”. Initially, 60 results were obtained, but after exclusion by title, abstract and full text, 14 articles were included. RESULT: all articles analyzed demonstrated improvement in patients using Dupilumab, with 13 of them indicating a reduction in eosinophil counts, 8 showing clinical improvement in symptoms, 8 indicating histological improvement, 7 indicating improvement in the endoscopic pattern, according to the Endoscopic Reference for Eosinophilic Esophagitis, and 4 indicating a reduction in the Dysphagia Symptom Questionnaire (DQQ) score. DISCUSSION: eosinophilic esophagitis is a rare disease, but with potential for progression, negatively interfering with the patient's quality of life. Therefore, since current drug therapy is nonspecific, the use of Dupilumab presents itself as an innovative and optimistic solution for the future, because it changes the understanding of disease management, expands therapeutic options and improves prognosis. CONCLUSION: the use of Dupilumab in the treatment of eosinophilic esophagitis has proven to be effective. However, for the treatment to be well established with regard to the doses used, frequency of administration and longitudinal monitoring, further studies are still required.

Robotic versus laparoscopic revision to Toupet fundoplication for failed Nissen fundoplication: a single-center experience.

Nissen fundoplication (NF) is a common surgical procedure to treat gastroesophageal reflux disease; however, a subset of patients may continue to experience symptoms or develop symptom recurrence despite a successful procedure. This study aims to compare laparoscopic and robotic approaches for treating failed NF and evaluate the outcomes after converting to Toupet fundoplication (TF). We conducted a retrospective analysis of patients who underwent robotic or laparoscopic revision to TF for failed NF between 2016 and 2023. The data collected included demographics, pre-operative workup, and peri- and post-operative outcomes. Symptom analysis and anti-reflux medication usage were collected using a patient questionnaire. Failed fundoplication was defined as the need for an additional operation due to unresolved GERD symptoms or the emergence of a new issue. Eighty-eight patients (56 laparoscopic, 32 robotic) were included. Mean operative time was 148.71 ± 53.64min for the total cohort and was significantly longer in the robotic group (RG) 167.43min vs 138.01min in the Laparoscopic group (LG) (p value = 0.012). The LG had a length of hospital stay of 2.16 ± 1.69days vs RG 2.21 ± 1.28days (p value = 0.867). The LG had a higher number of early readmissions (5.4%, p value = 0.629) and both the LG and the RG had 1 patient that required an early reintervention. Symptoms of dysphagia and reflux decreased in both groups at last follow-up, but the reduction in PPI use was not significant. Surgical revision to TF for failed NF provides significant symptom improvement with low rates of complications and recurrences. Our study shows that both approaches are safe and feasible and have comparable surgical and symptom outcomes.

Association of Heterotopic Gastric Mucosa in the Upper Esophagus (HGMUE) with Pharyngolaryngeal Symptoms: A Systematic Review and Meta-Analysis

BackgroundHeterotopic gastric mucosa in the upper esophagus (HGMUE) is considered to be accompanied by pharyngolaryngeal symptoms, whereas the association strength between HGMUE and pharyngolaryngeal symptoms remains controversial. This study assessed the strength of the association between HGMUE and pharyngolaryngeal symptoms using a meta-analytic approach.MethodsPubMed, Embase, Web of Science, and CNKI databases were searched for relevant articles published between January 2010 and January 2024. The pharyngolaryngeal symptoms of chronic cough, dysphagia, hoarseness, and globus in patients with HGMUE were summarized. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model. The exploratory analyses were also performed, including sensitivity and subgroup analyses.ResultsA total of 17 observational studies (1 cohort study and 16 cross-sectional studies) with 626,369 patients (2414 HGMUE patients and 623,955 non-HGMUE patients) were included in the meta-analysis. HGMUE was significantly associated with an elevated incidence of chronic cough (OR: 3.36; 95% CI 1.25–9.01; P = 0.02), dysphagia (OR: 1.58; 95% CI 1.12–2.25; P = 0.01), hoarseness (OR: 4.13; 95% CI 1.47–11.56; P = 0.007), and globus (OR: 2.41; 95% CI: 1.43–4.04, P < 0.001). The association between HGMUE and the risk of dysphagia was found to be potentially influenced by study design, sample size, country, and diagnostic method, whereas the association between HGMUE with the risk of globus was potentially affected by the study design and country.ConclusionHGMUE was significantly associated with chronic cough, dysphagia, hoarseness, and globus. HGMUE should be taken into consideration for patients with pharyngolaryngeal symptoms.

The Impact of Vocal Tremor on Deglutition: A Pilot Study.

Vocal tremor (VT) poses treatment challenges due to uncertain pathophysiology. VT is typically classified into two phenotypes: isolated vocal tremor (iVT) and essential tremor-related voice tremor (ETvt). The impact of phenotypes on upper aerodigestive tract physiology during swallowing remains unclear. Qualitative and quantitative measures were employed to characterize tremor phenotypes and investigate the effects on swallowing physiology. Eleven ETvt participants (1 Male, 10 Female; x̄ age = 74) and 8 iVT participants (1 Male, 7 Female; x̄ age = 71) swallowed 20 mL boluses in cued and uncued conditions under standardized fluoroscopic visualization. Sustained/a/productions were captured to assess the rate and extent of fundamental frequency (F0) modulation. Penetration and Aspiration Scale (PAS) scores were obtained and swallowing biomechanics were captured using Swallowtail™ software. Participants also completed the Swallowing Quality of Life (SWAL-QOL) questionnaire. Hypopharyngeal transit was faster in both VT phenotypes compared with Swallowtail™ normative reference data. Total pharyngeal transit times, however, were only faster in patients with iVT, relative to reference data. No significant differences were observed on the SWAL-QOL or PAS between tremor phenotypes. SWAL-QOL scores revealed that these patients rarely reported dysphagia symptoms. Subtle differences in swallowing patterns were observed across VT phenotypes, possibly related to adaptive mechanisms resulting in quicker pharyngeal bolus transit. Most patients did not report swallowing issues or dysphagia symptoms. This study is foundational for larger studies on this challenging population. 4 Laryngoscope, 134:4599-4603, 2024.

To Dor or Not to Dor? Heller Myotomy, a Retrospective Study.

Achalasia is a neurodegenerative disorder affecting esophageal sphincter function. Treatment options include non-surgical and surgical approaches, such as Heller myotomy (HM). Combining Dor fundoplication with HM is controversial but may prevent gastroesophageal reflux disease (GERD). This retrospective cohort study aimed to assess whether HM with Dor fundoplication reduces GERD rates and increases dysphagia rates. Eighty patients who underwent HM between January 2018 and August 2023 were included. Sixty-four patients had Dor fundoplication and were matched 4:1 to 16 patients without fundoplication. Records were reviewed for GERD and achalasia symptoms at various postoperative time points. No significant differences in GERD or dysphagia symptoms were found between the two groups at any time point. Similarly, there were no significant differences in chest pain or dysphagia treatment. In conclusion, this study suggests that the addition of Dor fundoplication to HM does not significantly impact postoperative GERD or achalasia-related symptoms.

Association Between Dysphagia and Depressive Symptoms: Propensity Score Matching Approaches.

The co-occurrence of depression and dysphagia is obvious to clinicians and has been the focus of several research investigations. Dysphagia not only leads to physical complications but also exerts a negative emotional impact, resulting in a decline in quality of life. The purpose of the study was to investigate the association between dysphagia and depressive symptoms at the population level while accounting for various demographics and health conditions. This study was a cross-sectional design using the 2022 National Health Interview Survey. The study subjects were American adults who completed the survey questionnaires about depressive symptoms, swallowing problems, and health conditions. Regression models and three different propensity score matching approaches were utilized to estimate associations between dysphagia and depressive symptom. Data analyzed in the study showed that among 25,651 U.S. adults, 1,664 (6.48%) reported dysphagia. Among patients with dysphagia, 976 (58.65%) were women, and the average age was 55.48 years. The differences in demographics and health conditions between individuals with and without dysphagia were balanced by three propensity score matching approaches (p >.05). After adjustments using population-weighted multivariable logistic regression, the inverse probability of treatment weighting (IPTW) with both normalized weights, IPTW with stabilized weights, and Greedy algorithms with 1:1 matching method, the risks of having depressive symptom in those with dysphagia were significantly higher than those without dysphagia (odds ratios ranged from 1.763 to 2.402, p <.0001). The study supports that dysphagia and depressive symptoms frequently co-occur in U.S. adults, highlighting the need for comprehensive care that addresses both physical and mental health aspects of swallowing impairments.

Left aortic arch and aberrant right subclavian artery in children: spectrum of symptoms and response to surgical intervention.

Children with left aortic arch and aberrant right subclavian artery may present with either respiratory or swallowing symptoms beyond the classically described solid-food dysphagia. We describe the clinical features and outcomes of children undergoing surgical repair of an aberrant right subclavian artery. This was a retrospective review of children undergoing repair of an aberrant right subclavian artery between 2017 and 2022. Primary outcome was symptom improvement. Pre- and post-operative questionnaires were used to assess dysphagia (PEDI-EAT-10) and respiratory symptoms (PEDI-TBM-7). Paired t-test and Fisher's exact test were used to analyse symptom resolution. Secondary outcomes included perioperative outcomes, complications, and length of stay. Twenty children, median age 2 years (IQR 1-11), were included. All presented with swallowing symptoms, and 14 (70%) also experienced respiratory symptoms. Statistically significant improvements in symptoms were reported for both respiratory and swallowing symptoms. Paired (pre- and post-op) PEDI-EAT-10 and PEDI-TBM-7 scores were obtained for nine patients, resulting in mean (± SD) scores decreasing (improvement in symptoms) from 19.9 (± 9.3) to 2.4 (± 2.5) p = 0.001, and 8.7 (± 4.7) to 2.8 (± 4.0) p = 0.006, respectively. Reoperation was required in one patient due to persistent dysphagia from an oesophageal stricture. Other complications included lymphatic drainage (n = 4) and transient left vocal cord hypomobility (n = 1). Children with a left aortic arch with aberrant right subclavian artery can present with oesophageal and respiratory symptoms beyond solid food dysphagia. A thorough multidisciplinary evaluation is imperative to identify patients who can benefit from surgical repair, which appears to be safe and effective.