Esophageal Inlet Research Articles

Swallowing function after near-total laryngectomy, cricohyoidoepiglottopexy (CHEP), and cricohyoidopexy (CHP)

We studied postoperative swallowing in 4 patients undergoing CHEP and 1 undergoing CHP. Swallowing was obtained by intense swallowing rehabilitation since only 1/4 of the larynx remained after near-total laryngectomy. Our swallowing rehabilitation program is detailed in this paper. The improvement of swallowing is classified into 3 stages. In stage I, volus directly intrudes into the trachea. In stage II, volus stagnates between laryngeal inlet and tracheal stoma. In stage III, volus directly flows through the esophageal inlet. Stage III indicates that rehabilitation is almost completed. Stage I is shortest at 2 to 14 days and Stage II longest at 7 to 80 days. The MTF (Method, Time, Food) score described by Fujimoto et al was used to analyze swallowing. Three cases following CHEP showed high scores shortly after the introduction of rehabilitation and reached the maximum score at discharge (15 points = normal swallowing). At present, these 3 patients are satisfied with swallowing and enjoy a good quality of life. In 2 other cases (1 CHEP and 1 CHP), both had a wide laryngeal inlet and still have some difficulty with liquids. Further modification of the surgical technique is needed especially for CHP.

多発性筋炎による嚥下障害例の臨床的検討

Polymyositis and dermatomyositis are characterized by non-specific inflammation of the systemic skeletal muscles. Involvement of the pharyngolaryngeal muscles causes swallowing and articulatory disorders. In this report, the clinical aspects of 8 patients with polymyositis or dermatomyositis who complained of dysphagia were analyzed. The patients mean age was 66.6 years and the duration of their dysphagia ranged from 10 days to 7 years. Videofluorography showed impaired pharyngeal clearance and laryngeal elevation. In the majority of patients, cricopharyngeal obstruction was identified which resulted in aspiration. Manometric examination revealed weakened pharyngeal contraction and normal relaxation of the cricopharyngeal muscle. These findings suggested that the obstruction of the esophageal inlet was due to an impaired passive dilatation of the cricopharyngeal muscle. The clinical course of dysphagia did not correlate with the laboratory data or systemic muscle symptoms. In two patients, cricopharyngeal myotomy successfully treated sustained and severe dysphagia.

Heterotopic gastric mucosa of the cervical esophagus: A case of high-grade dysplasia treated with argon plasma coagulation and a case of adenocarcinoma

Heterotopic gastric mucosa in the cervical esophagus appears to result from incomplete replacement of the original columnar epithelium by stratified squamous epithelium in the embryonal period. 1 Gray SW Skandalikis JE. The esophagus. in: Embryology for surgeons. The embryological basis for the treatment of congenital defects. : WB Saunders, Philadelphia1972: 63-100 Google Scholar This condition should be distinguished from the acquired metaplastic process in Barrett's esophagus that results from chronic gastro-esophageal reflux disease. 2 Feurle GE Helmstaedter V Buehring A Bettendorf U Eckardt VF Distinct immunohistochemical findings in columnar epithelium of esophageal inlet patch and Barrett's esophagus. Dig Dis Sci. 1990; 35: 86-92 Crossref PubMed Scopus (53) Google Scholar Islands of gastric mucosa, or inlet patches, are seen in 4% to 10% of patients referred for EGD. 3 Jacobs E Dehou MF. Heterotopic gastric mucosa in the upper esophagus: a prospective study of 33 cases and review of the literature. Endoscopy. 1997; 29: 710-715 Crossref PubMed Scopus (62) Google Scholar , 4 Jabbari M Goresky CA Lough J Yaffe C Daly D Cote C. The inlet patch: heterotopic gastric mucosa in the upper esophagus. Gastroenterology. 1985; 89: 352-356 Abstract PubMed Google Scholar , 5 Borhan-Manesh F Farnum JB. Incidence of heterotopic gastric mucosa in the upper esophagus. Gut. 1991; 32: 968-972 Crossref PubMed Scopus (127) Google Scholar Despite publications asserting that heterotopic gastric mucosa is a benign condition, 14 cases have so far been reported of adenocarcinoma and 1 of high-grade dysplasia arising in such an inlet patch. 6 Lauwers GY Scott GV Vauthey JN Adenocarcinoma of the upper esophagus arising in cervical ectopic gastric mucosa. Rare evidence of malignant potential of so-called “inlet patch.”. Dig Dis Sci. 1998; 43: 901-907 Crossref PubMed Scopus (60) Google Scholar , 7 Mion F Lambert R Partensky C Cherkaoui M Berger F. High-grade dysplasia in an adenoma of the upper esophagus developing on heterotopic gastric mucosa. Endoscopy. 1996; 28: 633-635 Crossref PubMed Scopus (34) Google Scholar , 8 Tagaki A Ema Y Horii S Morishita M Miyaishi O Kino I. Early adenocarcinoma arising from ectopic gastric mucosa in the cervical esophagus. Gastrointestinal Endosc. 1995; 41: 167-170 Abstract Full Text PDF PubMed Scopus (36) Google Scholar , 9 Sperling RM Grendell JH. Adenocarcinoma arising in an inlet patch of the esophagus. Am J Gastroenterol. 1995; 90: 150-152 PubMed Google Scholar Almost certainly inlet patch, and dysplasia and adenocarcinoma arising in an inlet patch, are under-diagnosed. This article presents 2 cases, one of high-grade dysplasia treated with argon plasma coagulation (APC), and one of an adenocarcinoma treated with esophageal resection arising in heterotopic gastric mucosa in the cervical esophagus.

Laryngopharyngeal sensory deficits in patients with laryngopharyngeal reflux and dysphagia.

There are no reliable means of quantifying the edema that results from acid exposure to the posterior larynx in patients with laryngopharyngeal reflux (LPR). However, it is possible to quantify laryngopharyngeal sensitivity in these patients by endoscopic administration of air pulses to the laryngeal mucosa in order to elicit the laryngeal adductor reflex. The purpose of this study was to determine whether patients with LPR have sensory deficits in the laryngopharynx, and whether treatment of these patients with a proton pump inhibitor (PPI) results in resolution of sensory deficits. Flexible endoscopic evaluation of swallowing with sensory testing was prospectively performed in 54 patients with dysphagia without neurologic disease and in 25 healthy controls. The laryngopharyngeal sensory level, posterior laryngeal edema, and LPR were assessed. We defined LPR as passage of food material from the esophageal inlet retrograde into the hypopharynx. Patients with LPR were placed on 3 months of omeprazole or lansoprazole and then retested. Patients without LPR were placed on H2 blockers for 3 months and then retested. In the dysphagia group, 48 of 54 patients (89%) had edema of the posterior larynx, and 42 of 54 (78%) had laryngopharyngeal sensory deficits. We noted LPR in 38 of 54 (70%). In the control group, 1 of 25 subjects (4%) had edema, sensory deficits, and LPR. The differences in incidence of edema, sensory deficits, and LPR between the dysphagia group and the control group were significant (p < .001, chi2 test). Twenty-three patients with LPR placed on a PPI returned for follow-up, with improvement in laryngeal edema in 14 of the 21 (67%) who had pretreatment edema and resolution of sensory deficits in 15 of the 19 (79%) who had pretreatment deficits. In the non-LPR, non-PPI group, 11 of 16 patients returned for follow-up, with improvement in laryngeal edema in none of the 11 and improvement in sensory deficits in 1 of the 11 (9.1%). The differences in improvement in laryngeal edema and sensory deficits between the LPR, PPI group, and the non-LPR, non-PPI group were significant (p < .01, Fisher's exact test). We conclude that patients with dysphagia and edema of the posterior larynx as a result of LPR have sensory deficits in the laryngopharynx. Treatment of these patients with a PPI appears to result in resolution of laryngopharyngeal edema and improvement of sensory deficits, both subjectively and objectively.

Lighted stylet tracheal intubation: a review.

Tracheal intubation is older than the recognized his-tory of general anesthesia itself. In the late 18th cen-tury, The Royal Humane Society of London used tra-cheal intubation for resuscitating the near-drowned.Approximately 100 years later, MacEwan (1) per-formed a digital tracheal intubation in an awake pa-tient before a chloroform and air general endotrachealanesthetic for the resection of a tongue tumor, and in1928, Magill (2) incorporated blind nasal tracheal in-tubation as a part of a general anesthetic. Althoughlaryngoscopes were invented in the 19th century, tra-cheal intubation under direct visualization was greatlyenhanced by the development of a special laryngo-scope blade by Macintosh (3) in 1943.The first reported use of a lighted stylet used tofacilitate intubation came in 1957 when (by now SirRobert) Macintosh (4) described an 18-inch illumi-nated tracheal tube introducer, which was designed tostiffen the tube and better illuminate the cords bysupplementing the light of the laryngoscope. Berman(5) described a similar device in 1959 and said it wasuseful “when the fickle light of the laryngoscope hasgone out at the most inopportune time.” In the sameyear, Yamamura et al. (6) described a light bulb-tippedwire that was inserted into the tracheal tube beforeblind nasal intubation in awake patients. The tubeposition was then determined by the medial transillu-mination of the external throat and neck.In 1977, Foster (7) used a transilluminating fiberop-tic bundle to facilitate tracheal intubation in a youngchild with trismus, and Ducrow (8), in the followingyear, used a flexible surgical light (Flexi-lum™, Con-cept Corporation, Clearwater, FL) to achieve the sameend by first passing a guide (two plastic suction cath-eters connected end-to-end) into the trachea followedby passage of the tracheal tube over the guide. In acorrespondence to the latter article, Rayburn (9) com-mented that the Flexi-lum™ could be positioned in-side the tracheal tube, thereby shortening the intuba-tion sequence and claimed that the technique,nicknamed “lightwand intubation,” had been used forsome years at the Brooke Army Medical Center.

Laryngeal suspension and upper esophageal sphincter myotomy as a surgical option for treatment of severe aspiration

Severe aspiration remains a difficult condition to treat without sacrificing the laryngeal functions of respiration and phonation. Upper esophageal sphincter (UES) myotomy as a sole treatment proves to be insufficient in many cases. Deglutative laryngeal elevation can be considered the most important factor responsible for opening of the esophageal inlet during deglutition. Therefore, a combination of laryngeal suspension procedure and a UES myotomy may be an alternative for treatment of severe aspiration without separating the airway and alimentary tract. Laryngeal suspension has in the past been proposed as a reconstructive procedure in major ablative surgery involving the floor of the mouth and the hyoid. Ten patients with severe aspiration and insufficient laryngeal elevation and constrictor pharyngeal muscle activity during deglutition were surgically treated with a laryngeal suspension procedure and upper esophageal sphincter myotomy. Five of the 10 patients had a good result, enabling them to have an oral intake sufficient to fulfill their nutritional needs. Two other patients have improved after the procedure, but are still dependent on gastrostomy feeding. Three patients eventually underwent a total laryngectomy, 2 of them after initial successful prevention of aspiration. In these 2 cases, aspiration recurred as a result of progression of the muscular disease. Life-threatening aspiration can often successfully be corrected by UES myotomy and laryngeal suspension. After a high initial success rate, long-term overall success can be anticipated in approximately 50% of the cases because of relapses in some patients caused by progression of underlying diseases.

Acid secretion from an esophageal inlet patch demonstrated by ambulatory pH monitoring

Heterotopic gastric mucosa may occur throughout the gastrointestinal tract, including the upper esophagus. The capability of this ectopic mucosa to secrete acid has been suggested in different reports. We report for the first time a case of heterotopic gastric mucosa in the upper esophagus complicated by a stricture with secretion of acid demonstrated by prolonged ambulatory pH monitoring. Lansoprazole, 30 mg twice daily, produced symptom resolution, and repeat ambulatory pH showed complete acid suppression in the proximal esophagus. GASTROENTEROLOGY 1998;115:1574-1576

Upper Esophageal Sphincter Function During Antegrade and Retrograde Transit

The striated musculature of the UES, along with the cricoid and thyroid cartilages, the hyoid bone, their ligaments, and the supra- and infrahyoid musculature form a functional unit that selectively controls the opening and closing of the esophageal inlet. At rest, upper esophageal tone acts as a barrier against both entry of air into the esophagus and regurgitation of materials coming from the proximal esophagus. However, reflexive responses of the sphincter offer no substantial protection against regurgitation of stomach contents that cause substantial esophageal distension. Although esophageal distention can experimentally induce sphincter contraction, this potential protective reflex against esophago-pharyngeal reflux has not been observed during spontaneous gastroesophageal reflux episodes. Furthermore, owing to the effects of gaseous distention, regurgitation may be more likely when acid and gaseous contents gastroesophageal reflux together. Modulation of the timing and the extent of sphincter opening during swallowing is intimately correlated with the volume and physical properties of the bolus, along with coordinated activity of the tongue, pharyngeal constrictors, and hyoid musculature, which suggests continuous sensory feedback throughout the pharyngeal swallow.

Esophageal replacement in children who have caustic pharyngoesophageal strictures

Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx, and esophagus is a challenging reconstructive problem. The authors report on seven patients who required total esophageal replacement from the pharynx to the stomach. Injury occurred from alkali in six and acid in one. Age at injury ranged from 14 months to 14 years (mean, 4.5 years.) in five boys and two girls. Time from injury to esophageal replacement was 6 months to 10 years (mean, 3.5 years). Two required pharyngeal reconstruction before and one after esophageal replacement. Six patients had an isoperistaltic right or transverse colon interposition. One who had gastric necrosis had an ileo-right colonic substernal interposition with creation of a jejunal reservoir. Results of barium swallows showed intact anastomoses in all patients. There were no leaks. Most had some degree of mild to moderate aspiration, and one who had left vocal cord paralysis had initially massive aspiration. Three patients currently eat regular diets; four eat but still require supplemental tube feeds. The authors conclude that children who have hypopharyngeal scarring and obliterated esophageal inlet can undergo a successful colonic esophageal replacement with high proximal pharyngocolic anastomosis.

輪状咽頭筋切断術例の筋組織所見と嚥下病態

Cricopharyngeus muscle specimens obtained during bilateral lateral cricopharyngeal myotomy were examined histopathologically. Ten cases of dysphagic patients with neuro-muscular diseases were subjected to this study. The results were summarized as follows; 1. In three cases, myogenic atrophy was found unilaterally. The histopathological feature was scattered muscular atrophy with slight fibrosis in these cases. 2. Four cases with unilateral nuclear and/or infranuclear vagal paralysis showed a group muscular atrophy and degeneration of muscle fibers ipsilaterally. 3. Four cases clinically presented with a failure of appropriate relaxation of the esophageal inlet. Two of them showed neurogenic muscular atrophy whereas the other two did not show such a histopathological feature. 4. In two cases of Wallenberg's syndrome neurogenic muscular atrophy was found in the cricopharyngeus and thyropharyngeus muscles. 5. There was no positive histopathological findings in the cricopharyngeus muscle of a case with cricopharyngeal dysphagia.

片側声帯麻ひにおける誤えんのメカニズム 特に梨状陥凹部の機能に関して

The pathogenetic mechanism of aspiration accompanying unilateral vocal cord paralysis was assessed from the function of the piriform sinuses examined by fluoroscopy and manometry in 31 patients who complained of subjective swallowing difficulty and/or aspiration. The types of aspiration and pharyngeal clearance was determined by fluoroscopy. Swallowing pressures were measured simultaneously in the esophageal inlet, the piriform sinus on the paralyzed side, the vallecula and the oropharynx and compared with the corresponding pressures in normal subjects. The swallowing pressure in the piriform sinus on the unaffected side was measured when possible and compared with the pressure in the piriform sinus on the affected side.Fluoroscopy showed aspiration in 20 patients. Two (10%) showed aspiration in the elevating phase of laryngeal movement, 11(55%) in the falling phase, 7 (35%) in both phase. Bolus retention in the piriform sinus on the affected side and then in the inflow from the arytenoid into the larynx after swallowing was observed in 18 (90%) of the 20 patients. The swallowing pressure in the piriform sinus on the affected side was significantly decreased in 15 (75%) of the 20 patients with aspiration. Swallowing pressure could be determined in both piriform sinuses of 16 patients. It was significantly lower on the affected side in 14 (88%) of them. Eleven patients without aspiration showed good clearance and no decrease in swallowing pressure on the affected side.These result suggest that the impaired clearance accompanying decreased contraction of the piriform sinus on the affected side is partly responsible for aspiration in patients with unilateral vocal cord paralysis.

Rhabdomyoma of the cricopharyngeus in an infant

Rhabdomyoma is a rare benign tumor characterized histologically by striated skeletal muscle. Rhabdomyomas can be classified into adult and fetal variants. The majority of adult variants arise in the head and neck region and are derived from the skeletal muscles of the pharyngeal (branchial) arches. The majority of cases of fetal variant rhabdomyomas have been described in the postauricular region of young children and the vulvovaginal region in middle-aged women. We present a case of a 15-month-old infant with a circumferential rhabdomyoma of the cricopharyngeus muscle requiring excision of the esophageal inlet and reconstruction with a free microvascular jejunal interposition graft. This case represents the youngest reported case of adult variant rhabdomyoma. The clinical, radiographic, and histologic findings of this unusual case and a review of reported cases of rhabdomyoma in the pediatric population will be presented.

Pharyngoesophageal perforation after blunt neck trauma

Pharyngoesophageal perforation secondary to blunt neck trauma is an uncommon injury that can cause serious morbidity and mortality if not recognized and treated. Pharyngeal perforation secondary to blunt trauma sustained while boxing is reported. Review of the world literature found 10 cases of pharyngoesophageal perforation secondary to blunt neck trauma. Analysis of these cases indicates that perforations less than 2 cm and limited to the pharynx may be treated medically with close observation. Large perforations and those perforations that extend to the esophageal inlet or involve the esophagus exclusively are best treated surgically.

Distinct immunohistochemical findings in columnar epithelium of esophageal inlet patch and of Barrett's esophagus

Immunohistochemistry was performed on biopsies of columnar mucosa from 11 patients with Barrett's esophagus and 11 patients with columnar mucosa in the cranial esophagus, the "inlet patch." Both epithelia contained endocrine cells, immunoreactive to antisera against serotonin, glucagon, somatostatin, and pancreatic polypeptide; the specialized mucosa of Barrett's esophagus contained, in addition, neurotensin-immunoreactive cells, and in the mucosa of an inlet patch we found a gastrin cell. These findings are not compatible with some of the current theories on the origin of these epithelia. The mucosa of the inlet patch has been considered to consist of heterotopic gastric mucosa. The mucosa of the adult human stomach, however, does not contain glucagon cells. These cells are only present in the early embryonic stomach, and they disappear during embryonogenesis. According to our findings, the mucosa of the inlet patch therefore represents embryonic gastric mucosa. The specialized columnar epithelium of Barrett's esophagus has been considered to have evolved from gastric mucous neck cells. However, although glucagon cells are a feature of the embryonic stomach, neurotensin-immunoreactive cells have not been found in the gastric mucosa. Our study suggests that the specialized columnar epithelium of Barrett's esophagus originates from a very immature multipotent gastrointestinal stem cell.

Nevus sebaceous of jadassohn: The head and neck manifestations

The nevus sebaceus of Jadassohn (SNJ) is a congenitally-occurring, hamartomatous disorder of the skin and its adnexa of infrequent occurrence. This presentation of five cases emphasizes the smooth, waxy, yellow-brown lesion's progression into a thickened sebaceous tumor of premalignant predilection. The incidence of neoplastic degeneration of these hamartomatous nevi may be as high as 30% with the capacity of metastasis occasionally reported. Because of malignancy risks as well as cosmetic considerations, early surgical removal is recommended. Previously unreported problems of dysphagia and malnutrition secondary to pulsion diverticulum at the esophageal inlet and cleft palate, obliterative aural stenosis with associated conductive hearing loss are documented. Regardless of SNJ's occurrence as either an isolated lesion or as the fully developed syndrome, including mental retardation and epilepsy, this congenital malformation of the skin, its hair, and sebaceous glands presents rare and histologically intriguing problems for the practitioner.

Primary Reconstruction of Palatal Defects

Removal of the soft palate can cause marked functional deficit in deglutition and phonation. Most commonly, treatment of this deformity with prosthetic obturation has been less than ideal. Numerous reconstructive techniques have met with only partial success, while deforming distant structures. We will present a technique of reconstruction of the soft palate by use of a superiorly based pharyngeal flap. It has been used successfully in five patients who underwent soft palatectomy for malignant disease. The flaps have been the full width of the pharynx and extended down to the esophageal inlet. Viability of the flap is excellent, and the donor site is allowed to heal by secondary intention. Excellent function has been achieved in all cases with no compromise of oncological principles.

Innervated partial hemi‐tongue pseudoepiglottis: An experimental study

AbstractA conventional supraglottic laryngectomy with simultaneous bilateral arytenoidectomy and lateralization of the true vocal cords, in order to “freeze the glottic inlet,” was performed in 15 dogs. The posterior half of the hemi‐tongue was mobilized, everted and delivered into the hypopharynx where its free distal margins were sutured to a raw area created on the postcricoid and upper esophageal region. This flap constituted the innervated part hemi‐tongue pseudoepiglottis. The healing of the pseudoepiglottis was complete in eight dogs. Endoscopic examination demonstrated the pseudoepiglottis to cover the glottic inlet while the dog breathed around it. All these dogs ate solids and drank liquids by mouth. Four dogs demonstrated the ability to drink fluids well, as opposed to the rather laborious effort by the rest. Barium swallow showed the passage of dye over the superior surface of the pseudoepiglottis. The dogs were sacrificed at four to six weeks. A pneumonic process was demonstrable in one dog only. Prior to sacrifice the ipsilateral hypoglossal nerve was exposed in the neck of one dog. Its stimulation electrically demonstrated contraction of the pseudoepiglottis with elevation of the esophageal inlet.

Dysfunction of the esophageal inlet: Treatment by upper esophageal sphincter myotomy

Three patients have been studied manometrically after division of the upper esophageal sphincter for dysphagia associated with posterior pharyngeal diverticulum. The postoperative results have been satisfactory clinically and the operation itself avoids the morbidity and mortality associated with diverticulectomy. We found no evidence that achalasia or dyscoordination of the upper esophageal sphincter can be cited routinely as the basic underlying pathophysiology.