Nasopharyngeal Reflux Research Articles

Congenital cricopharyngeal achalasia: Diagnosis and surgical management

Background: Congenital cricopharyngeal achalasia is a rare condition in which a newborn presents with dysphagia, choking, nasal reflux, and salivation. Awareness of this condition is important because simple myotomy of the cricopharyngeus muscle often solves the problem. Methods: The diagnosis and the surgical management of cricopharyngeal achalasia were reviewed based on 4 cases experienced over the last 13 years. Results: The severity of the symptoms and the age of onset were dependent on the severity of achalasia. The cine-fluoroscopic swallow is an important diagnostic procedure. Surgery should be performed early enough for infants to learn how to swallow properly. The surgical procedure involves complete myotomy of cricopharyngeus, allowing the submucosa of the esophagus to bulge out in the posterior midline region. Postoperatively, nasopharyngeal reflux may resolve immediately or decrease over several months, depending on the timing of surgical intervention and the patient's ability to learn the act of swallowing. Conclusions: Early surgical intervention for this disease is recommended to achieve early recovery from dysphagia and to establish buccopharyngeal swallowing during the appropriate period of development. J Pediatr Surg 37:E12. Copyright 2002, Elsevier Science (USA). All rights reserved.

Gastroesophageal reflux contributing to chronic sinus disease in children: a prospective analysis.

To explore the possible role of gastroesophageal reflux (GER) in children with chronic sinus disease (CSD). A descriptive prevalence study of the frequency of GER and nasopharyngeal reflux in children with CSD. Pediatric otolaryngology and gastroenterology outpatient clinics of a regional medical center. Consecutive children aged 2 to 18 years referred for evaluation of CSD from December 1, 1996, through April 30, 1998. Participants underwent 24-hour monitoring with dual pH probes, and participants (or their parents) completed questionnaires before treatment and at specific intervals after treatment. Prevalence of GER and nasopharyngeal reflux in children with CSD, and the response of sinusitis to treatment in those diagnosed with GER. Nineteen (63%) of 30 patients demonstrated esophageal reflux, which is well above the expected prevalence of GER in the healthy general population. Six (32%) of these 19 patients demonstrated nasopharyngeal reflux. Fifteen (79%) of 19 patients improved after treatment for GER. The children in this population had a prevalence of GER that was significantly higher than expected. Furthermore, most children with GER demonstrated improvement of sinus disease after treatment of GER. We recommend that children with CSD refractory to aggressive medical management be evaluated for GER and, if GER is present, be treated accordingly, before sinus surgery is considered.

Barium studies in esophageal cicatricial pemphigoid.

Cicatricial pemphigoid (CP) (benign mucous membrane pemphigoid) is a rare, blistering disease of skin and mucous membrane. The disease rarely extends to involve the esophagus, and there are only a few cases reported in the radiological literature. The aims of this study were to document the frequency of esophageal involvement and to describe the findings on upper GI barium studies. A total of 197 patients with CP were seen at our institution from 1981 to 1991. The clinical and radiological findings of these patients were reviewed and compared with findings reported in the literature. Esophageal involvement was documented in seven patients. Cervical esophageal webs were found in five of the seven patients. Two patients had single esophageal webs while three had multiple webs. Frank strictures of the esophagus were also seen in five patients. These were most common in the cervical esophagus, but strictures were also found in the mid and lower esophagus. Two of the strictures resulted in significant dysphagia and required multiple endoscopic dilatations. One of the dilatations was complicated by mucosal injury, and follow-up barium examination showed dissection of the esophageal mucosa from the cervical esophagus to the esophagogastric junction. One patient demonstrated intramural pseudodiverticulosis in the cervical esophagus. Functional disturbances demonstrated on barium studies included tracheal aspiration in two patients and nasopharyngeal reflux in three. CP involves the esophagus in approximately 5% of cases. The hypopharynx and cervical esophagus are most commonly involved, but any portion of the esophagus may be involved, and multiple levels of involvement may be seen. Cervical esophageal webs, often multiple or complex, are the most common appearance on barium studies, but frank strictures are also found. Secondary manifestations of esophageal involvement include nasopharyngeal reflux, tracheal aspiration, and intramural pseudodiverticulosis.

Swallowing Dysfunction and Aspiration in Neonates and Infants

In children, swallowing dysfunction and aspiration are common causes of recurrent pneumonia and can be fatal. The underlying mechanism is still unknown. In this study, we evaluated the swallowing function in 72 neonates and infants by fluoroscopy and followed the course of 39 patients for more than one year. The results of all the examinations were recorded on videotape or a digital imaging system. All 10 patients with neurologic disorder presented cricopharyngeal dysfunction. Of the 12 patients with near miss sudden infant death syndrome, 10 showed nasopharyngeal reflux, and 5 demonstrated cricopharyngeal dysfunction. In the 50 patients without neurologic disorder, 29 revealed cricopharyngeal dysfunction. Laryngeal elevation was not seen in 75%. Three of these 29 patients had no other abnormality. All patients without neurologic disorder recovered well. Seven patients demonstrated prolonged aspiration. Four of them had neurologic disorder, and the rest had near miss sudden infant death syndrome. Fluoroscopic examination showed two types of aspiration: one was caused not only by pharyngeal but also by lingual muscles. It was not associated with any neurologic disorders and the symptoms were transient. The other was caused by cricopharyngeal dysfunction and most of these patients had neurologic diseases and prolonged symptoms.

Videofluoroscopic Analysis of the Infant Swallow

A better understanding of the abnormal infant swallowing mechanism requires better knowledge of the normal infant swallow. Twenty-one full-term infants under six months of age were examined using videofluoroscopy of the swallowing portion of upper gastrointestinal examinations. Components of the oral and pharyngeal stages of swallowing were evaluated. Results showed high reliability between two raters in obtaining measurement data. There was variability in suck and oral transit time, which was correlated to the number of sucks per swallow. All infants appeared to move their tongue in a "stripping" motion, and collected the material in various sites in the oral cavity or oropharynx before initiation of the swallow. The incidence of nasopharyngeal reflux was low (9.5%). The majority of infants demonstrated a slight residue in their valleculae and hesitation in the cervical esophagus. These findings indicate that videofluoroscopy provides an objective and systematic method for analyzing the infant swallowing mechanism.

The value of serum IgE assay in milk aspiration and the sudden infant death syndrome.

Global serum levels of IgE (PRIST, Phadebas) and specific anti-cow's milk IgE (RAST) were measured in populations of infants with a history of one or more episodes of milk aspiration (n = 12), victims of the sudden infant death syndrome (SIDS) (n = 18), "near miss" SIDS infants (n = 23), siblings of a SIDS victim ((n = 21) and control infants (n = 38). Only the infants with a past history of milk aspiration had significantly raised global and specific IgE. The absence of raised specific IgE in the subjects who died from SIDS argues against the hypothesis of sensitisation to cow's milk proteins during a previous episode of aspiration. Nasopharyngeal reflux is frequently seen in near-miss infants. This reflux is more often responsible for reflex apnoea due to stimulation of the laryngeal chemo-receptors than to a fatal aspiration.

Derangement of swallowing in children with myelomeningocele.

Barium esophagrams performed in 13 children with myelomeningocele demonstrated a variety of swallowing disorders: difficulty in bolus formation, nasopharyngeal reflux, tracheobronchial aspiration. Cricopharyngeal spasm was not identified in this group. Antegrade peristalsis in the distal two-thirds of the esophagus was normal. Gastroesophageal reflux was demonstrated in 8 of the children. Vocal cord paralysis (8/13) and death in early children (7/13) occurred with greater frequency than in the general myelomeningocele population. Correct management of these children may require tracheostomy, gastrostomy, and fundoplication.

Infant apnea: findings on the barium esophagram.

Barium esophagrams of 160 infants who were being examined for apneic episodes were obtained at a referral center for the investigation of sudden infant death syndrome (SIDS). The studies were standardized as closely as possible to evaluate swallowing, esophageal function and anatomy, and the gastroduodenal regions. The level and frequency of gastroesophageal reflux were carefully assessed. The most common abnormality identified was gastroesophageal reflux (54%). Other abnormalities included nasopharyngeal reflux (27%), aberrant right subclavian artery (3%), and aspiration into the airway (3%). Swallowing dysfunction, esophageal dysmotility, antral dysmotility, chalasia, and tracheoesophageal fistula were each found in less than 1% of the infants.

Extended cervical esophagomyotomy for cricopharyngeal dysfunction

Forty adult patients have undergone a 7 to 10 cm cervical esophagomyotomy (from the superior cornu of the thyroid cartilage to behind the clavicle) for cricopharyngeal dysfunction. A Zenker's diverticulum was present in 12 patients (30%) and in five was recurrent. Preoperative symptoms included cervical dysphagia (85%), expectoration of saliva (40%), and intermittent hoarseness (30%). Four patients were being fed through tubes because of total inability to swallow. "Heartburn" was experienced by one half of the patients, but only 12 had acid or food regurgitation. The duration of symptoms ranged from 1 month to 11 years (average 3.9 years). Weight loss had occurred in 15 patients (38%) and ranged from 5.5 to 40.9 kg (average 16 kg). Barium swallows showed no abnormalities in 10 patients. Abnormal findings included a Zenker's diverticulum (12), prominent cricopharyngeal sphincter (11), nasopharyngeal reflux or incoordinated initiation of deglutition, or both (seven), a sliding hiatal hernia (11), and abnormal esophageal motility (seven). Esophageal manometry revealed abnormalities of upper esophageal sphincter (UES) function in only 16 patients. Of 36 patients undergoing standard acid reflux testing, one third had moderate-to-severe gastroesophageal reflux. Seven patients underwent staple resection of a Zenker's diverticulum at the time of cervical esophagomyotomy. Postoperative complications included transient vocal cord paresis (four), vocal cord paralysis (one), and salivary fistula (one). There were no postoperative deaths. After 2 to 48 months (average 16 months) of follow-up, 34 patients (85%) have had a good to excellent result, and six (15%) have not been benefited by operation.

Palatal reconstruction utilizing retrieved forehead flap.

Ablation of tumors involving the tonsil and retromolar trigone complex often require partial resection of the soft palate. The pharyngeal wall defect is well reconstructed with the forehead flap. We have used the distal portion of the severed inserted forehead flap to reconstruct the soft palate defect successfully in 35 cases. The nasopharyngeal surface is lined with a book-flap from the remaining palate. This provides full palatal reconstruction with nasopharyngeal mucosa lining: thus preventing flap contracture and the unwanted sequelae of nasopharyngeal air and fluid reflux.