Pharyngoesophageal Segment Research Articles

Biomechanical Correlates of Surface Electromyography Signals Obtained During Swallowing by Healthy Adults

The purpose of this study was to describe biomechanical correlates of the surface electromyographic signal obtained during swallowing by healthy adult volunteers. Seventeen healthy adults were evaluated with simultaneous videofluoroscopy and surface electromyography (sEMG) while swallowing 5 mL of liquid barium sulfate. Three biomechanical swallowing events were analyzed: hyoid elevation, pharyngeal constriction, and opening-closing of the pharyngoesophageal segment. For each biomechanical event and from the sEMG signal, the authors identified onset, peak, and offset time points. From these points, duration measures were calculated. Means and 95% confidence intervals were calculated for each measure. Subsequently, correlations were evaluated between timing aspects of the sEMG traces and each biomechanical event. Swallow onset in the sEMG signal preceded the onset of all biomechanical events. All biomechanical events demonstrated a strong correspondence to the sEMG signal. The strongest relationship was between hyoid elevation-anterior displacement and the sEMG signal. These results suggest that the sEMG signal is a useful indicator of major biomechanical events in the swallow. Future studies should address the impact of age and disease processes, as well as bolus characteristics, on the biomechanical correlates of sEMG signals obtained during swallowing.

Insertion of Provox®2 voice prosthesis using the anterograde technique immediately after the secondary tracheoesophageal puncture

Insertion of a voice prosthesis through the tracheoesophageal puncture (TEP) is one way to restore the voice after total laryngectomy. The second generation Provox voice prosthesis is presently one of the most popular devices. Although TEP can be done primarily, there are many centres that prefer it to be done at a second stage for various reasons. However, secondary TEP for retrograde replacement of prosthesis can be difficult and general anaesthesia is very often necessary. Moreover, the presence of neck stiffness and fibrosis from the surgery or previous radiotherapy could affect the neck extension for proper positioning of the trocar. Similarly, it is difficult to insert the prosthesis if there is stenosis at the pharyngoesophageal segment. We describe a technique in which creation of secondary TEP and insertion of Provox2 is done with local anaesthesia under the same setting. The procedure is well tolerated and can be safely performed on an out-patient basis.

Anatomic Study of Laser-Assisted Endoscopic Cricopharyngeus Myotomy

Laser-assisted endoscopic cricopharyngeus muscle (CPM) myotomy has been used to correct dysphagia caused by CPM dysfunction. The aim of this study was to anatomically characterize this procedure in hopes of demonstrating its safety and efficacy. A Dohlman endoscope was used to isolate the CPM in 5 lightly preserved, thawed cadavers. A carbon dioxide laser at 10 W continuous power was used to section through the CPM in conjunction with a micromanipulator connected to an operating microscope. The specimens were then carefully dissected and photographed to demonstrate the anatomy of the pharyngoesophageal segment, including the location of the incision and the condition of the tissue planes. The CPM was harvested for histologic studies, sectioned, and prepared with modified Gomori trichrome stain. Gross examination of the retropharyngeal region revealed the presence of intact buccopharyngeal fascia between the lasered region and the retropharyngeal space. Histologic analysis demonstrated sectioning of the CPM with preservation of this fascia layer. Placement of the endoscope was difficult in 1 cadaver, in which we were unable to properly identify the CPM. The carbon dioxide laser-assisted endoscopic CPM myotomy is a potentially anatomically safe and viable procedure when properly performed. However, the potential for violation of the retropharyngeal space is real.

Quantitative Detection of Substitute Voice Generator During Phonation in Patients Undergoing Laryngectomy

To evaluate the vibration pattern of the substitute voice generator of patients who have undergone laryngectomy. For automatic quantification of the oscillations of the pharyngoesophageal (PE) segments, image processing of digital high-speed video sequences is applied. Physiologic analysis. An acute care hospital. Endoscopic recordings were taken of 10 men who underwent laryngectomy (mean +/- SD age, 61.5 +/- 5.2 years) during sustained phonation of a vowel using a 90 degree endoscope coupled to a high-speed camera. An image-processing algorithm was developed to automatically define the pseudoglottis in each recording and track its movements. The clinical assessment of the high-speed technique for the endoscopic examination of the substitute voice generator yields the following results. The forms and oscillation characteristics of the pseudoglottides varied considerably: 3 pseudoglottides were circular, 6 were split shaped, and 1 was triangle shaped. A quasi-periodic opening and closing were observed and automatically detected by the described algorithm in each recording independently from quality of the recording and from morphologic and oscillation characteristics of the PE segment. The frequencies of the extracted oscillations of the pseudoglottides correspond to the structure of the acoustic signals. Automatic image processing of PE segments derived from high-speed endoscopic recordings enables the detection and quantification of the substitute voice generator's oscillations in high temporal resolution. These data directly prove that the detected pseudoglottis is the source of the substitute voice. Close relations between substitute voice and functional properties of the PE segment exist. In the future, these data will be interpreted by applying biomechanical models of the PE segment. Presumably, results may help to optimize surgical and adaptive procedures for specific substitute voice restoration.

Use of tubed gastro-omental free flap for hypopharynx and cervical esophagus reconstruction after total laryngo-pharyngectomy.

In case of total laryngo-pharyngectomy (TLP), replacement of the pharyngoesophageal segment is more often done with jejunal flap; however, in some cases, this flap doesn't represent the best surgical technique of reconstruction. The tubed gastro-omental free flap (TGO) offers an alternative procedure in selective cases. The objective of the study was to assess the TGO as a method of pharyngoesophageal reconstruction. Our study was based on a literature review and a retrospective study of six consecutive cases of TGO reconstruction after TLP. Six patients aged from 52 to 70 years underwent TGO reconstruction after TLP. Five patients had previously received systemic chemotherapy and external irradiation at curative doses, and three had undergone previous surgery. No abdominal complication occurred. Partial necrosis of the gastric flap occurred in one case. Except for this case, the feeding tube could be removed after 15 days. One patient was successfully treated with pneumatic esophageal dilatation for stricture 2 months after surgery. Four patients died of loco-regional tumor evolution or distant metastatic disease. For both of the patients who survived (mean follow-up, 40 months), a normal diet and an esophageal voice were obtained. The TGO offers a safe method of reconstructing the pharyngoesophageal segment in a surgical field compromised of previous multimodal therapy.

The relationship between MBS findings and dysphagia-specific QOL

Objectives: The modified barium swallow (MBS) is frequently used to evaluate dysphagia in the head and neck cancer population. The relationship between MBS findings and dysphagia symptoms, however, is not well understood. The present study seeks to determine whether an association exists between MBS parameters and the M.D. Anderson Dysphagia Inventory (MDADI), a dysphagia-specific quality of life (QOL) measure. Methods: Cross-sectional study of adult subjects (n = 42) with no evidence of disease 12 months or more after treatment of a stage III or IV squamous cell carcinoma of the oropharynx or larynx. All subjects completed the MDADI followed by MBS. The MBS examinations were scored for the nonlaryngectomy group (n = 28) using the validated Pentration-Aspiration Scale (PAS). Additional MBS parameters assessed include tongue base retraction, maximal hyoid excursion, maximal laryngeal excursion, and maximal pharyngo-esophageal segment opening. Results: There were no significant differences in MDADI scores between subjects with penetration and/or aspiration on MBS when compared to subjects with no penetration and/or aspiration. The penetration-aspiration group demonstrated a trend ( P = 0.09) toward worse scores on the functional subscale of the MDADI which may indicate greater difficulty when eating in public and with food preparation. Conclusions: The presence of penetration or aspiration on MBS does not predict the degree to which dysphagia effects quality of life. Some patients with penetration and aspiration have few dysphagia-related symptoms, whereas others without penetration or aspiration are greatly impaired. The identification of MBS parameters that are more predictive of dysphagia-related quality of life may help to improve the validity and reliability of the MBS.

Pharynx and oesophagus evaluation during the swallow using helical computerized tomography

Purpose: Videofluorography (VF) and endoscopy are commonly used for dynamic imaging (DI) of pharyngeal swallowing but do not offer transverse plane (TP) information. The aim of the present study was to evaluate helical computerized tomography (HCT) to measure the DI capability pharyngeal swallowing in the TP.Methods: The HCT scan technique used was a single-slice cine mode with scan times of 100 ms. All 15 subjects were studied supine during dry swallow, swallowing of barium sulphate jelly and 3, 10, 15 or 20 ml of a 40% barium sulphate solution. Nine subjects repeated the test twice at more than 1 week's interval to determine the test-retest reliability.Results: Swallowing leads to closure of the vocal folds, pharyngeal constriction and narrowing of the piriform sinuses allowing jelly passage between the sinuses. Laryngeal elevation then occurrs with the opening of the pharyngoesophageal segment (PES). Swallowing a bolus of 20 ml produced the maximum anteroposterior and transverse diameters as well as the maximum opening area of the PES. The test-retest intraclass correlation coefficients with liquid deglutition ranged from 0.86 to 0.98.Conclusions: This study shows that HCT enables visualization of TP of PES complementing VF or endoscopic swallowing studies.

High-speed imaging of the voicing source in laryngectomees during production of voiced-voiceless distinctions for stop consonants

This study presents results from high-speed imaging recordings of the voice source, that is the pharyngo-esophageal segment, in four laryngectomized men. The subjects were asked to produce VCV-syllables with voiced and voiceless stop consonants during simultaneous high-speed imaging recordings and audio recordings. A general and detailed visuo-perceptual analysis of the shape and vibratory pattern in the pharyngo-esophageal (PE-) segment was made, as well as acoustical measurements of voice onset time (VOT) and closure duration for each syllable. The syllables were also audio-perceptually evaluated by five expert listeners. Results show that the subjects had a high overall intelligibility as judged by the listeners. All four subjects were able to make opening gestures in the PE-segment while producing voiceless stop consonants. In cases where misperceptions were predominant, the acoustical analysis with spectrograms and the detailed analysis of the vibration in the PE-segment gave information about probable causes of the mishearings.

頭頚部癌術後えん下障害患者に対する姿勢調節法の効果―えん下造影画像解析による直立姿勢と健側傾斜姿勢との比較検討―

Postsurgical dysphagia in patients with head and neck cancer is often improved by postural techniques, one procedure for compensatory treatment.This study was done to analyze videofluorographic (VF) images of postsurgical patients with head and neck cancer by comparing upright posture with head tilting posture on the stronger side. Twelve postsurgical patients with head and neck cancer whose aspiration was improved by head tilting posture on the stronger side were studied.The tilting magnitude, vallecular angle, and epiglottic angle were measuredon VF prints. Retained amounts of swallowed barium were evaluated in the oral region, vallecular region, and pyriform sinus on VF images.Pharyngeal delay time, pharyngeal passage time, and pharyngo-esophageal (PE) segment opening time were measured on VF images. The results were as follows:1) There was no correlation between any two of the following three variables: tilting magnitude, vallecular angle, and epiglottic angle.2) The retained amount of swallowed barium swallow in tilting posture on the stronger side was less than that in upright posture in 10 of 12 subjects.3) As compared with upright position, pharyngeal delay time and pharyngeal passage time were shorter in tilting posture on the stronger side.

Advances in Alaryngeal Communication and the Art of Tracheoesophageal Voice Restoration

Advances in Alaryngeal Communication and the Art of Tracheoesophageal Voice Restoration

Videofiberoptic examination of the pharyngoesophageal segment and esophagus in patients after total laryngectomy.

Posttreatment follow-up in patients with squamous cell carcinoma of the head and neck is critical because of the high risk of recurrence or a new primary tumor. However, in patients who have undergone total laryngectomy, evaluation of the pharyngoesophageal segment (PES) and esophagus is difficult. Sixty patients who had undergone total laryngectomy received a videofiberoptic examination of the PES and esophagus at the OPD office during follow-up. Satisfactory examination was achieved in 56 (93%) of the patients. Each procedure was completed within 15 minutes. Although only 11 (18%) of the patients were symptomatic at follow-up, 19 patients (34%) had significant findings, including one local recurrence and two secondary esophageal cancers. Patients were asymptomatic in all three cases. Videofiberoptic examination is a simple, effective, and relatively noninvasive method that can be performed in the OPD office to evaluate the PES and esophagus in patients after total laryngectomy.

Lateral Upper Arm Free Flap for Primary Reconstruction of Pharyngeal Defects in Ablative Oncological Surgery

Free microvascular flaps are an established method for soft tissue reconstruction following ablative oncological surgery in the head and neck. Functional reconstructions of the hypopharynx and the pharyngoesophageal segment (PES) are of particular relevance, as they are highly demanding surgical procedures. So far, the radial forearm free flap (RFFF) and the free jejunal transfer have been the transplants predominantly used for this purpose. The lateral upper arm free flap (LUFF) presents an alternative method for the fasciocutaneous tissue transfer. We report on our experience with the LUFF in a 56-year-old male patient with a pT3pN0M0 squamous cell carcinoma of the hypopharynx. A pharyngocutaneous fistula developed 5 days after pharyngolaryngectomy with bilateral neck dissection. The fistula was localized between the pharyngeal constrictor muscle and the esophagus and was closed with an LUFF from the left arm. Excellent flap adaptation to the remaining pharyngeal mucosa was observed. Although the length of the vascular pedicle and the diameter of the vessels in the LUFF are smaller than those in the RFFF, neither pedicle length nor vessel diameter proved to be a problem. The LUFF can be recommended as a well-vascularized, relatively safe and reliable flap for reconstruction of tubular structures such as the hypopharynx and the PES after tumor ablation and as an alternative to the RFFF. The flexibility of the LUFF allows surgeons to reconstruct the anatomy of the lost soft tissues as adequately as possible.

Babies With Tracheostomies

Babies With Tracheostomies

Voice restoration with low pressure blom singer voice prosthesis after total laryngectomy.

The main problem after total laryngectomy is permanent loss of voice. Current methods of vocal rehabilitation after total laryngectomy include development of esophageal speech, use of artificial larynx, tracheoesophageal shunt operations and more recently surgical restoration of the voice with prosthesis. Primary voice restoration using Blom- Singer voice prosthesis after total laryngectomy and pharyngeal myotomy was performed in 187 patients between October 1992 and July 2000. There were 184 male and 3 female patients of average age 63.7 years (range 42-76). Mean follow up period was 62 months. Satisfactory speech was achieved in 156 patients (83.5%). During the follow-up period, we experienced complaints of insufficient voice in 31 (16.5%) patients, due to partial spasm in 17 and total spasm in the pharyngoesophageal segment in 14. Furthermore, 24 (12.8%) patients preferred esophageal speech or electro larynx because of low socioeconomic level. The overall success rate was 70.7%. In this study the results of the surgical technique and prosthesis insertion, as well as the associated complications and socioeconomic levels of the patients, are discussed.

Reconstruction of circumferential pharyngoesophageal defects with laryngotracheal flap and pectoralis major myocutaneous flap.

Hypopharyngeal cancer often presents at an advanced stage. Radical surgery has played an important role in the treatment of these cases; however, it always results in a large, or even a circumferential, defect of the pharyngoesophageal segment (PES) that causes some difficulties during reconstruction. Twelve patients with advanced hypopharyngeal cancer and cervical esophageal invasion received surgery resulting in a circumferential defect of PES, which was reconstructed with the contralateral unaffected laryngotracheal flap and a patch-on pectoralis major myocutaneous flap (PMMCF). The operation time of this method was shorter compared with free flap reconstruction. Only two minor complications and no pharyngocutaneous fistulas were found postoperatively. Nine patients can resume a regular diet. During the follow-up period (median, 38 months), there were no local recurrences and only one contralateral neck recurrence. The preliminary result shows this technique is a simple and effective method with low morbidity and satisfactory oncologic and functional results.

Acoustic cues to the voicing feature in tracheoesophageal speech.

Tracheoesophageal (TE) speakers often have difficulty producing the voiced/voiceless distinction. This limitation has been attributed to use of the pharyngoesophageal segment as the phonatory source. The nature of this tissue may preclude precise control of voicing onset, a contributing cue to a phoneme's voicing feature, at least in laryngeal speech. The purpose of this study was to determine whether voiced and voiceless consonants produced by TE speakers could be differentiated from those produced by laryngeal speakers using four acoustic measures associated with the voicing characteristic of consonants in laryngeal speech. Sixteen TE and ten laryngeal speakers produced five stop and fricative cognate pairs embedded in a carrier phrase. Three of the four acoustic measures contributed significantly to the discriminant models that differentiated accurately perceived TE and laryngeal samples. The three variables were consonant sound pressure level, consonant duration, and preceding vowel duration. In general, values for each measure were higher/longer for the TE group. The discriminant functions were interpreted as a reflection of TE speaker attempts at overarticulation.

Space-time pressure structure of pharyngo-esophageal segment during swallowing.

We applied high-resolution manometry with spatiotemporal data interpolation and simultaneous videofluoroscopy to normal pharyngeal swallows to correlate specific features in the space-time intraluminal pressure structure with physiological events and normal deglutitive transsphincteric bolus flow to define normal biomechanical properties of the pharyngo-esophageal (PE) segment. Pressures were recorded by microperfused catheter, and the two-dimensional space-time data sets were plotted as isocontours. On these were superimposed bolus trajectories, anatomic segment movements, and hyo-laryngeal trajectories from concurrent videofluoroscopy. Correlation of the highly reproducible space-time-pressure structure with radiographic images confirmed that primary deglutitive PE segment functions (pressure profile, laryngeal elevation, axial sphincter motion, timing of relaxation, contraction) are accurately discernible from single isocontour pressure visualization. Pressure during bolus flow was highly dependent on axial location within PE segment and time instant. The intrabolus pressure domain, corresponding to the space-time region between bolus head and tail trajectories, demonstrated significant bolus volume dependence. High-resolution manometry accurately, comprehensively, and highly reproducibly depicts the PE segment space-time-pressure structure and specific physiological events related to upper esophageal sphincter opening and transsphincteric flow during normal swallowing. Intrabolus pressure variations are highly dependent on position within the PE segment and time.

Intelligibility of stops and fricatives in tracheoesophageal speech

Listener accuracy in identifying voiced and voiceless stops and fricatives in tracheoesophageal (TE) and laryngeal speech were compared. Sixteen TE and ten laryngeal speakers produced ten phonemes embedded in a nonsense word in a carrier phrase. Four experienced listeners phonetically transcribed the experimental phonemes. As expected, perceptual error rates were higher for the TE samples for all comparisons completed. The dominant error for laryngeal samples was a misperception of manner of production. The dominant error for TE samples was a perception of voiced for voiceless phonemes. Such voicing misperceptions occurred more frequently for fricatives than stops. Previous studies have implicated the vibratory characteristics of the pharyngoesophageal (PE) segment for the voicing errors in TE speech. However, PE features would not fully explain why stops were less affected than fricatives and why the expected error was reversed for two TE phonemes (perceptions of voiceless for voiced consonants). Learning outcomes: (1) As a result of this activity, the participant will be able to identify the most common listener misperceptions of tracheoesophageal speech. (2) As a result of this activity, the participant will be able to discuss possible reasons for the predominant error that occurs.

Radial forearm free flap pharyngoesophageal reconstruction.

This study evaluates the outcome of pharyngoesophageal reconstruction using radial forearm free flaps with regard to primary wound healing, speech, and swallowing in patients requiring laryngopharyngectomy. Retrospective review in the setting of a tertiary, referral, and academic center. Twenty patients underwent reconstruction of the pharyngoesophageal segment using fasciocutaneous radial forearm free flaps. All free flap transfers were successful. An oral diet was resumed in 85% of the patients after surgery. Postoperative pharyngocutaneous fistulas occurred in 4 patients (20%) with 3 resolving spontaneously. Distal strictures also occurred in 20% of the patients. Five patients who underwent tracheoesophageal puncture achieved useful speech. Advantages of radial forearm free flaps for microvascular pharyngoesophageal function include high flap reliability, limited donor site morbidity, larger vascular pedicle caliber, and the ability to achieve good quality tracheoesophageal speech. The swallowing outcome is similar to that achieved after jejunal flap pharyngoesophageal reconstruction. The main disadvantage of this technique relates to a moderately high incidence of pharyngocutaneous fistulas, which contributes to delayed oral intake in affected patients.

Application of computer simulation to the evaluation of pathophysiology of the pharyngo-esophageal (PE) segment

Application of computer simulation to the evaluation of pathophysiology of the pharyngo-esophageal (PE) segment