Recurrent Aspiration Pneumonia Research Articles

Investigating Holistic Natural Strategies for The Management of Huntington's Disease

Huntington's disease (HD), a multifaceted neurological disorder, presents a complex clinical scenario. An autosomal dominant neurodegenerative ailment called Huntington's disease is brought on by increase in number of CAG (Cytosine-Adenine-Guanine) repeats, which causes the creation of a mutant Huntingtin protein (mHTT) resulting in neuronal death and mental disabilities in human beings. End signs and symptoms can include significant weight loss, difficulty swallowing or breathing, recurrent aspiration pneumonia, declined health and uncontrolled pain. The excessive production of ROS (Reactive Oxygen Species) in nervous tissues is considered a significant risk factor in most of the neurological diseases including HD. Transcriptional regulation, immunological system, and mitochondrial function are all disrupted by mHTT. Although natural products have shown promise in ameliorating symptoms, it is important to note that no singular "phytoconstituent" has been definitively linked to its therapeutic intervention. Nevertheless, certain naturally occurring compounds have exhibited promising outcomes in preclinical investigations. This article focuses on a few phytoconstituents that are known to have a variety of neuroprotective effects through a wide range of biological activities. By stimulating the Nrf2 (Nuclear factor erythroid 2-related factor) pathway and suppressing NF-κB (Nuclear Factor Kappa-light-chain-enhancer of activated B cells), astaxanthin, berberine, and sulfarophane increase the antioxidant and anti-inflammatory activity, resulting in neuroprotection. Curcumin leads to metal chelating effect and decline in reactive oxygen species which are certainly one among the vital processes to impede and manage the disorders causing neurodegeneration including HD. This affects the upregulation of HSPs (Heat Shock Proteins) which helps in HD management. Naringin reduces level of oxidative stress and inflammation by free radical scavenging, NF-κB stimulates cell survival and prevents apoptosis by upregulating anti-apoptotic genes expression and downregulating proapoptotic genes.

Anterior mediastinal tracheostomy for severe tracheal stenosis in a child with severe motor and intellectual disabilities: a case report

BackgroundOwing to recurrent aspiration pneumonia and airway stenosis secondary to thoracic deformities, tracheostomy or laryngotracheal separation are often necessary in children with severe motor and intellectual disabilities. However, these procedures are associated with the risks of tracheal stenosis due to tracheal granulation and tracheoinnominate artery fistula formation. We report a case of a child with severe motor and intellectual disabilities treated with an anterior mediastinal tracheostomy.Case presentationThe patient was a 15-year-old boy with severe motor and intellectual disabilities due to intractable epilepsy. Due to thoracic deformity and tracheomalacia, the patient had a flattened and narrowed trachea. Accordingly, laryngotracheal separation was performed 4 months before admission to avoid aspiration pneumonia. Due to a common cold, the patient required frequent sputum suctioning, which exacerbated the tracheal stenosis. Bronchoscopy revealed tracheal stenosis 4–5 cm caudal to the tracheostomy site, tracheal mucosal ulcers, and pulsation of the innominate artery on the anterior wall of the trachea. We performed an anterior mediastinum tracheostomy to release the tracheal stenosis and prevent tracheoinnominate artery fistula formation.ConclusionsAnterior mediastinal tracheostomy has several advantages. Including sufficient release of bony compression, release of tracheal hyperextension, and relief of tracheal and innominate artery contact ensures a cannula-free tracheostomy, and there is no need to dissect the brachiocephalic artery. It is the procedure of choice in cases of head and neck malignancies requiring extensive tracheal resection and could be a good surgical option for severe tracheal stenosis and tracheoinnominate artery fistula in children with severe motor and intellectual disabilities.

Per-Oral Plication of (Neo)Esophagus: Technical Feasibility and Early Outcomes

BackgroundEndoscopic sleeve gastroplasty is an example of endoscopic sutured plications being used to remodel a gastrointestinal organ. With per-oral plication of the esophagus (POPE), similar plications are used to remodel the dilated and redundant megaesophagus of end-stage achalasia. Redundancies and dilations can also develop in the neoesophagus of a patient with prior esophagectomy. Megaesophagus and a redundant neoesophagus can both lead to debilitating dysphagia, regurgitation, and recurrent aspiration pneumonia. Traditionally, this anatomic problem requires complex revisional or excisional surgery, to which POPE offers an incisionless alternative. MethodsThis is a dynamic manuscript with video demonstration of POPE, as well as review of five cases performed in 1 year. Data were collected in a prospectively maintained database, and the institutional review board approved retrospective review for this publication. The procedure is performed using a dual-channel upper endoscope fixed with an endoscopic suturing device, with the patient supine under general anesthesia. ResultsPOPE was technically completed in all cases with no serious complications, and patients either went home the same day or spent one night for observation. Most patients reported immediate and substantial symptomatic improvement. Objective pre- and post-measures include esophagram and nuclear gastric emptying studies. ConclusionThis article discusses early experience at one institution with POPE, with detailed description of the procedure and technical considerations. An accompanying video reviews two cases, one with megaesophagus and one with a gastric conduit. While this novel procedure has limited and rare indications, it offers a low-morbidity solution to a challenging anatomic problem that traditionally requires invasive surgery.

Esophageal Perforation in a 76-Year-Old Man After C5-C7 Anterior Discectomy and Anterior Plate Fusion

Anterior cervical discectomy and fusion (ACDF) is indicated for the treatment of various cervical pathologies, including myelopathy, cervical disc degeneration, and radiculopathy. Esophageal perforation is a rare postsurgical complication of ACDF, although it poses serious and potentially fatal outcomes. Esophageal perforation has been described as the most fatal complication of the gastrointestinal tract as delayed diagnosis can lead to sepsis and death. Diagnosis of this complication is often difficult because it can be masked by various symptoms such as recurrent aspiration pneumonia, fever, dysphagia, and neck pain. While this complication usually occurs within the first 24 h post-surgery, it can also develop later and persist chronically in rare cases. Awareness and early recognition of this complication may improve outcomes and reduce mortality and morbidity. A 76-year-old man underwent C5-C7 ACDF in October 2017. A thorough review of the patient's postoperative condition included computed tomography (CT) and esophagogram, which were negative for signs of acute complications. The postoperative recovery was uneventful until several months post-procedure when he began to develop vague dysphagia and weight loss of unknown etiology. A CT scan was obtained 6 months postoperatively and was negative for perforation. He then underwent a battery of inconclusive procedures and scans at multiple institutions. After several months of persistent dysphagia and weight loss without a diagnosis, the patient presented to our network for further workup and treatment recommendations. Upper endoscopy was performed and showed fistulization between the esophagus and the metal hardware in the cervical spine. Esophagram demonstrated no obstruction but decreased peristalsis of the lower esophagus and lateral rightward deviation of the left upper cervical esophagus with minimal mucosal irregularities. These findings were secondary to mass effect of the cervical plate. The patient was successfully treated with a surgical approach using esophagogastroduodenoscopy (EGD) guided repair in layers and a sternocleidomastoid muscle flap. This report demonstrates a rare case of delayed esophageal perforation after ACDF and successful treatment of the perforation by surgical repair using the dual technique.

Association Between Oral Health and Swallowing Function in the Elderly.

Although the oral environment significantly affects the risk of pneumonia, there have been few studies regarding its relation with swallowing. There is no doubt that there is a significant link between the oral environment and the development of pneumonia; however, there have been few comparative studies of swallowing using video endoscopy (VE) and video fluorography (VF) as indicators to determine the actual availability of oral intake and the choice of food form. This study was performed to examine whether the oral environment or swallowing function contributes more to the development of pneumonia in the elderly. The study population consisted of 24 patients (7 men and 17 women; age range: 64-97 years; average age: 86 years) assessed using the Oral Health Assessment Tool (OHAT), VE and VF at Fukuoka Dental College Hospital. The most common disease was pneumonia (17 patients), followed by cerebral infarction (5 patients), pyelonephritis (4 patients), bronchitis (2 patients), Parkinson's disease (2 patients), scleroderma (1 patient), diabetes (1 patient), eosophageal cancer (1 patient) and Parkinson's syndrome> (1 patient). Some patients had multiple diseases. Oral intake was possible in 20 patients (80%), whereas tube feeding and gastric banding were required in 4 patients. The OHAT score was not correlated with either the VE or VF score. Furthermore, the OHAT score was not significantly different between the multiple- and no/single-pneumonia episode groups. The group with multiple episodes of pneumonia had lower VE and VF scores than those with no or only a single episode of pneumonia. Oral assessment, VE and VF are necessary to evaluate swallowing in patients with suspected dysphagia. Swallowing function, especially as assessed by VE and VF, is more important than examination of the oral environment for evaluating risk of recurrent aspiration pneumonia in the elderly. In addition, multiple factors contribute to recurrent pneumonia in patients with a good oral environment, including subclinical aspiration, pharyngeal clearance and delayed activation of the gag reflex.

Rehabilitation Medicine for Recurrent Aspiration Pneumonia

誤嚥は明らかな顕性誤嚥と明らかでない不顕性誤嚥の2種類に分けられ，特に唾液による不顕性誤嚥は肺炎発症に大きく関与する．現在最もエビデンスレベルの高い誤嚥性肺炎の治療，予防方法は降圧薬のangiotensin-converting enzyme inhibitor（ACE阻害薬）内服である．ただし死亡率低下への効果は判然としない．嚥下リハビリテーションは嚥下障害や嚥下能力を改善させる可能性や胸部感染症の発症率を下げる可能性が報告されたが，残念ながら非常に低いエビデンスレベルとされ，死亡率抑制への効果はない，と報告された．その他，誤嚥性肺炎の予防，治療，リハビリテーション治療の方法や今後の見通しなどについて述べる．

Expanding the spectrum of EEF1D neurodevelopmental disorders: Biallelic variants in the guanine exchange domain.

Protein translation is an essential cellular process and dysfunctional protein translation causes various neurodevelopmental disorders. The eukaryotic translation elongation factor 1A (eEF1A) delivers aminoacyl-tRNA to the ribosome, while the eEF1B complex acts as a guanine exchange factor (GEF) of GTP for GDP indirectly catalyzing the release of eEF1A from the ribosome. The gene EEF1D encodes the eEF1Bδ subunit of the eEF1B complex. EEF1D is alternatively spliced giving rise to one long and three short isoforms. Two different homozygous, truncating variants in EEF1D had been associated with severe intellectual disability and microcephaly in two families. The published variants only affect the long isoform of EEF1D that acts as a transcription factor of heat shock element proteins. By exome sequencing, we identified two different homozygous variants in EEF1D in two families with severe developmental delay, severe microcephaly, spasticity, and failure to thrive with optic atrophy, poor feeding, and recurrent aspiration pneumonia. The EEF1D variants reported in this study are localized in the C-terminal GEF domain, suggesting that a disturbed protein translation machinery might contribute to the neurodevelopmental phenotype. Pathogenic variants localized in both the alternatively spliced domain or the GEF domain of EEF1D cause a severe neurodevelopmental disorder with microcephaly and spasticity.

Prediction of refractory gastroesophageal reflux disease in young children.

Many children respond to medical treatment for gastroesophageal reflux disease (GERD). However, some may require invasive intervention for refractory disease. Due to the lack of prognostic tools in children, this study aimed to develop a predictive model for refractory GERD. A retrospective review was performed in children with symptoms of GERD at a university hospital. Refractory GERD was defined as an unresponsive disease after optimal treatment with medication for >8 weeks. The predictive model was constructed based on clinical features and 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring results. A total of 205 children were included with a median (IQR) age of 0.6 (0.3, 2.0) years. Over half of the patients (59.5%) had motor disabilities. Forty-four children (21.5%) were diagnosed with refractory GERD and subsequently underwent fundoplication. Multivariable analysis suggested that the refractory disease was associated with motor disabilities (OR: 5.35; 95% CI: 2.06-13.91), recurrent aspiration pneumonia (OR: 2.78; 95% CI: 1.24-6.26), prematurity with an onset of GERD at a post-conceptual age <40 weeks (OR: 6.76; 95% CI: 1.96-23.33), and abnormal total reflux episodes according to age (OR: 2.78; 95% CI: 1.24-6.19), but not the acid exposure time or symptom association analysis. The predictive model for refractory GERD based on associated factors revealed an area under the ROC curve of 76.8% (95% CI: 69.2%-84.3%) with a sensitivity of 77.3% and a specificity of 64% when applying a cutoff score of ≥2.5. The predictive model, using clinical features and MII-pH, may be an additional tool to predict refractory GERD in young children.

Dysphagia in Frail Elderly

Effective and safe swallowing is one of the basic needs for human survival. Dysphagia or swallowing disorders often occur in the elderly and increase with age. Patients often do not complain of dysphagia and compensate by modifying the texture of the food. Frailty is associated with an increased prevalence of dysphagia. Difficulty of chewing, formation and positioning bolus are associated with dysphagia. In addition, dysphagia can cause weakness because there is a disturbance due to decrease nutritional status, muscle function, and can cause recurrent aspiration pneumonia. Frailty and dysphagia can be described as a cycle and affect each other. Several interventions were carried out to overcome dysphagia, either compensatory, rehabilitative, or a combination of both.

Comparison Between Percutaneous Endoscopic Gastrostomy and Nasogastric Feeding in 160 Patients with Swallowing Disturbances: A Two-Year Follow-Up Study.

We retrospectively compared the complications, blood biochemical indexes and outcomes in patients with swallowing disturbances receiving nasogastric tube (NGT) feeding and percutaneous endoscopy gastrostomy (PEG). Among 160 patients, 72 cases received PEG and 88 cases received NGT. All patients were followed up for two years. We collected their clinical data from the medical records. Indicators, such as body mass index (BMI), white blood cell (WBC), hemoglobin (HGB), complications, including recurrent aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and outcomes (survival or death) were compared between the two groups semi-annually. SAt both six months and one year after receiving treatment, there was no statistical difference between the two groups in indicators, complications and outcomes, with all P >0.05. It can be seen that, when the patients were followed up for one and a half years18 months, ALB was lower in the NGT group (33.81±0.46) compared with the PEG group (36.14±0.50) (P <0.05). After two years of follow-up, differences between the NGT and PEG group could be seen in a variety of indicators, including BMI (20.08±0.27 vs 21.03±0.25), WBC (9.12±0.56 vs 7.08±0.29), ALB (33.11±0.43 vs 35.75±0.49), creatinine (55.07±1.83 vs 63.21±2.94), and the complications, such as aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and electrolyte disorder, in the PEG group were significantly reduced compared to the NGT groupthan that in its counterpart, P <0.05. In the two-year follow-up period, there were 13 and 22 patients died in the PEG group and NGT group, respectively. Both techniques are safe and effective in the short term. However, on a longer-term basis, PEG is shown to be superior to NGT feeding in improving nutrition and preventing common complications for patients with swallowing disturbances.

Carpe Communication: Seizing the Small Moments to Teach Interpersonal and Communication Skills on Inpatient Services.

Carpe Communication: Seizing the Small Moments to Teach Interpersonal and Communication Skills on Inpatient Services.

Tracheoesophageal Diversion and Laryngotracheal Separation Procedures for Radiotherapy-Related Intractable Aspiration Pneumonia in Nasopharyngeal Carcinoma

Background Intractable aspiration and aspiration pneumonia are complications after radiotherapy for nasopharyngeal carcinoma (NPC), and they may be life-threatening in severe cases. In the past, the efficacy of controlling aspiration and aspiration pneumonia in such patients was not ideal. Objectives We aimed to evaluate the effect of tracheoesophageal diversion and laryngotracheal separation (TED-LTS) procedures for these patients. Material and Methods. We retrospectively analyzed the medical data of five patients with intractable aspiration and recurrent aspiration pneumonia caused by NPC radiotherapy who underwent TED-LTS surgery. The patients were evaluated in terms of aspiration pneumonia control, body weight improvement, removal of tube feeding, oral feeding, and complications. Results Intractable aspiration and aspiration pneumonia were completely controlled in all cases, and the patients' body weight increased from 46.46 ± 4.6 (38.9-50.3) kg to 55.32 ± 2.7 (51.4-56.7) kg. Four patients were able to consume an oral semisolid diet, and one patient maintained an oral liquid diet. Tube feeding was not required in 4 patients. One patient developed postoperative esophageal fistula, which improved after conservative treatment. Conclusion TED-LTS is effective for intractable aspiration and aspiration pneumonia caused by NPC radiotherapy and can be used to restore partial oral feeding. However, strict surgical indications should be followed.

0853 The role of sleep-disordered breathing in the optimization of pediatric epilepsy management

Abstract Introduction There is a known bidirectional relationship between epilepsy severity and disordered sleep; however, both the potential scoring limitations of polysomnograms (PSGs) of children with epilepsy and the effect of treatment of sleep disordered breathing (SDB) on epilepsy severity in these children remain poorly understood. Report of Cases: We describe a 7-year-old male with a history of prematurity (ex-34 weeks), bronchopulmonary dysplasia, recurrent aspiration pneumonia, and refractory nocturnal epilepsy who experienced acute hypoxemic respiratory failure in the setting of co-infection with rhinoenterovirus and parainfluenza 4 virus. The patient’s epilepsy history is notable for multiple nocturnal seizures most days of the week for a period of several years. His mother endorsed that the nocturnal seizures began shortly after his SDB symptoms, and that the severity of his nocturnal seizures seemed to be associated with the quality of his sleep. Two years prior to admission, he underwent adenotonsillectomy for mild obstructive sleep apnea (AHI 2.5, REM AHI 8.9, minimum SpO2 86%). He continued to have persistent SDB symptoms (e.g. witnessed apneas, nocturnal arousals 5-10 times/night, daytime sleepiness) despite adenotonsillectomy. Notably, the background EEG (in the context of epilepsy) demonstrated obscured sleep architecture and led to unreliable staging of sleep states and cortical arousals. Given the disorganized background EEG, arousal-based hypopneas could have been underestimated. In the setting of acute respiratory failure, our patient was hospitalized and treated with noninvasive ventilation for 6 days. Collateral benefits included improvements in SDB (evidenced by decreased nocturnal awakenings, lack of obstructive features) and reduction in seizure frequency. His mother noted that this hospitalization was the first time in years that her son did not experience nocturnal seizures. Conclusion Sleep apnea can be an important modifiable factor in the treatment of pediatric epilepsy. Some PSGs of children with epilepsy may be falsely reassuring given the potential difficulty with scoring cortical arousal-based hypopneas. Therefore, careful clinical correlation should be made between nocturnal seizures and sleep symptoms, even in the context of reassuring PSG parameters. Support (If Any) Cystic Fibrosis Foundation Training Grant, AIRE grant, NIH 2T32HL110952-06

EP159: A TOPBP1 variant associated With BAFopathy methylation pattern

DNA Topoisomerase II Binding Protein 1 (TOPBP1) is a topoisomerase involved in maintaining genomic integrity via numerous functions including the regulation of DNA replication and replication stress response. A number of studies have shown that TOPBP1 also interacts with the BAF complex. The BAF complex is a group of ATP-dependent chromatin remodeling enzymes, including 10-12 proteins that regulate the nucleosomal structure by altering histone-DNA interactions. For example, the BRCT motif of TOPBP1 interacts with E2F1, a transcription factor, by recruiting BRG1/BRM, a core member of the BAF complex, to prevent apoptosis. In addition, TOPBP1 directly associates with BRG1(SMARCA4) and BAF250a (ARID1A) in the BAF complex to prevent DNA entanglement during mitosis. While TOPBP1 is not currently associated with a genetic syndrome, the BAF complex proteins with which it interacts are associated with BAFopathies such as Coffin Siris Syndrome (CSS) and Nicolaides-Baraitser Syndrome (NCBRS). For example, the gene encoding BRG1 (SMARCA4) is mutated in 11% of individuals affected by CSS, and the gene encoding BRM (SMARCA2) is mutated in almost all NCBRS patients. The gene encoding BAF250a (ARID1A) is also associated with CSS. We have previously demonstrated overlapping DNA methylation episignatures in individuals with CSS and NCBRS, consistent with a common functional basis of these disorders. A 15-month-old boy, born to first cousin Syrian parents, presented with respiratory distress, recurrent aspiration pneumonia, failure to thrive, seizure disorder, cortical blindness, microcephaly, and severe developmental delay. He was born at term weighing 2.2 kg and started having seizures at 4 months. At 8 months, after his first aspiration pneumonia, he stopped sucking and swallowing. At 15 months, he was very small with weight, length, and head circumference at a 4 to 8 month level. He made few attempts to move spontaneously and had no head control. He did not fix or follow, showed no blinking response to threat, and had disconjugate and roving eye movements. There was no response to sounds. He had a right plagiocephaly, deficiency of the lateral eyebrows, high arched palate, and long ears. No organomegaly was noted. He had significant central hypotonia with head lag. There was spasticity with flexion contractures in the upper extremities. Lower extremities had normal tone with hyperreflexia. He had intermittent spontaneous hip flexion. Family history was positive for a sister who developed seizures at 8 months, had poor vision and developmental delay, and died at 7 years. A brother has mild to moderate intellectual delay with no history of seizures or poor vision. MRI of the head showed severe cerebral atrophy with nonobstructive hydrocephalus ex-vacuo. An echocardiogram showed moderate aortic root dilatation. Metabolic testing was negative. Chromosome microarray was normal. Exome sequencing with trio analysis showed a de novo variant of uncertain significance in a candidate gene, NM_007027.3(TOPBP1):c.2396C>T, p.(Ala799Val). He was also hemizygous for a maternally inherited VUS in MAP7D2 and heterozygous for a paternally inherited VUS in TGFBR3. DNA from peripheral blood was analyzed by EpiSign version 3 which includes an episignature for BAFopathies based on pathogenic variants in ARID1A, ARID1B, SMARCB1, SMARCA4, and SMARCA2. Results showed a methylation pattern which was inconclusive with mild methylation differences overlapping the episignature for CSS and NCBRS. There is an overlap between this patient’s phenotype and the features of CSS and NCBRS. For example, CSS and NCBRS can present with variable degrees of developmental delay, seizures, feeding difficulties, hypotonia, visual deficits, slow growth, and microcephaly. NCBRS can also present with regression or lack of developmental progress, especially at the onset of seizures, and CSS is associated with frequent upper respiratory tract infections. In this patient with a VUS in TOPBP1, the overlap of methylation profile with CSS and NCBRS is intriguing, given the known interaction of TOPBP1 with the BAF complex. We propose that the child’s clinical features and methylation findings may be due to a disruption of the TOPBP1-BAF interaction and that the TOPBP1 variant is actually pathogenic. Since there is currently no known association between TOPBP1 and any genetic syndrome, we suggest that any cases with TOPBP1 variants identified through exome sequencing be assessed for the episignature associated with the BAFopathies.

DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS-MEDIATED DYSPHAGIA

A 62-year-old man who presented with recurrent aspiration pneumonia and weight loss was diagnosed with oropharyngeal dysphagia due to unilateral vocal cord paralysis. Imaging of the neck by CT as well as ancillary tests have revealed diffuse idiopathic skeletal hyperostosis ('DISH') as the cause, mediated by pressure of an osteophyte on the recurrent laryngeal nerve. With the ageing of the populations clinicians may increasingly encounter diffuse idiopathic skeletal hyperostosis and should be aware of the syndrome and its unusual complications.

Instrumental swallowing assessment in children

Children can present with a wide range of swallowing impairments. This may affect from neonates, infants,toddlers, young children to early teens. The most serious outcome of a severe swallowing impairment is gross aspiration leading to violation of airway and its consequences such as recurrent aspiration pneumonias, sepsis, poor weight gain, failure to thrive and long term developmentalsequel. Assessment of swallowing is done in children using perceptual clinical swallowing assessment by a speech and language therapist. This isa subjective assessment and may not clearly identify the defective phase of swallowing and may miss silent aspiration. Instrumental swallowing assessment is a method to identify swallowing impairment by objective evaluation of the entire swallowing process. This would identify the phase and quantify the severity of the impairment. It is mainly done in two ways. i.e. the Functional Endoscopic Evaluation of swallowing (FEES) and Video Fluoroscopic Swallow Study (VFSS). Both are valuable methods as they separately assess different phases of swallowing. The results are invaluable in further treatment of these children to overcome or mitigate their impairment. FEES involves inserting a fibro-optic pediatric laryngoscope in the child’s pharynx via the nose and simultaneous observation of swallowing mechanism while feeding orally. VFSS involves fluoroscopic viewing of the swallowing process while giving food mixed with a radio opaque substance. VFSS is further helpful in intra proceduralpositional maneuversand change in food consistencies to overcome the given impairment.

Esophageal Intramural Pseudodiverticulosis and Esophagobronchial Fistula Palliated with Esophageal and Bronchial Stenting: A Rare Case Report

Esophageal intramural pseudodiverticulosis (EIP) is a rare condition characterized by outpouchings from the esophageal lumen into the outer esophageal wall. It can lead to complications such as esophageal strictures presenting as dysphagia and esophagobronchial fistula (EBF) presenting as recurrent aspiration pneumonia. Only 1 other report of EIP with EBF has been reported in the literature. EIP itself is typically managed medically while a complication such as EBF, on the other hand, elicits far more invasive approaches in the form of open surgical intervention. We present the case of a 50 year-old male newly diagnosed with EIP complicated by EBF who was palliated with esophageal stenting. Upper endoscopy with esophageal stent placement offers a safe, feasible, and non-operative therapy for EIP and EBF.

Nutritional Evaluation by Nurses and Physical Recovery of Malnourished Patients after Esophagectomy

Following an esophagectomy, nurses’ patient nutrition observations are important for physical recovery and quality of life. The study proposed to identify the factors associated with physical recovery among esophageal cancer patients after surgery based on nurses’ observations and nutritional evaluations. Data were collected from the nursing records of 21 esophagectomy patients. The data included patients’ rate of weight loss, body mass index (BMI), energy intake, and postoperative complications. Patients were divided into two groups according to their weight loss rate: <8% and ≥8%. Patient outcomes were compared between the two groups. There was no difference in average BMI before or after surgery between the two groups. There was no difference in albumin levels during hospitalization; however, after esophagectomy, energy intake at discharge was insufficient in both groups. The ≥8% weight loss may be facilitated, or at least confounded, by the presence of recurrent nerve paralysis and aspiration pneumonia. Thus, the nursing records typically identified the need to check for recurrent laryngeal nerve palsy and aspiration pneumonia in conjunction with nutritional assessment to enhance patients’ physical recovery. When weight loss was significant, nurses provided oral intake support with the NST, and patients maintained oral intake levels similar to the group with weight loss under 8%. In order to better support physical recovery among malnourished, post esophagectomy patients, nurses need to monitor for signs of recurrent nerve palsy and aspiration pneumonia in addition to nutritional intake.

Surgical Interventions as a Treatment Option for Severe Dysphagia with Intractable Aspiration: Concept, Indications, and Efficacy

The incidence of dysphagia is increasing, particularly among the elderly according to varied of causes. Patients with severe dysphagia are unable to take food orally and are at risk for life-threatening aspiration pneumonia. Treatments for swallowing disorders focus on restoring oral food intake and preventing recurrent aspiration pneumonia. Therefore, swallowing rehabilitation and food texture modifications are essential. However, in cases with severe or progressive dysphagia, these conservative treatments may not restore oral feeding and prevent intractable aspiration pneumonia. In these cases, surgical interventions has recently been attracted as an alternative treatment option. In this article, we present its concept, indications, and efficacy. Surgeries to restore swallowing function address impaired pharyngolaryngeal motor function during the pharyngeal swallowing stage while preserving laryngeal functions. These procedures include laryngeal elevation, cricopharyngeal myotomy, and vocal cord medialization. Meanwhile, aspiration prevention surgeries reduce the risk of aspiration pneumonia by separating the lower respiratory tract from the pharynx and larynx. These procedures include total laryngectomy, laryngotracheal separation, and glottal closure; although they do not spare laryngeal functions, they prevent aspiration pneumonia completely, improve quality of life, and reduce the burden on caregivers. Clinicians should be aware of surgical interventions as a possible treatment option for intractable dysphagia. Establishment and popularization of the surgical indications are the future issues.

Zenker Diverticulum

Zenker Diverticulum is a multifactorial disorder of the Killian’s triangle in thehypopharynx characterized by the main symptoms of dysphagia affecting theseventh and eighth decades of age and rarely under 40 years of age. The existenceof factors that cause an increase in the intraluminal pressure of the pharynx willlead to the formation of a pocket located in the Killian’s triangle, an area with weakertone of the hypopharyngeal wall and a decrease in relative pressure in theretropharyngeal space. Zenker Diverticulum was first described by Ludlow in 1769,who reported abnormal dilatation of the posterior pharyngeal wall on postmortemexamination of a patient who complained a lifelong dysphagia. Zenker Diverticulumis thought to be associated with increasing age in relation to motor musclecoordination for swallowing functions and GERD (gastroesophageal reflux disease).Symptoms include dysphagia, regurgitation, malnutrition, and recurrent aspirationpneumonia. Management includes invasive surgery and non-invasive endoscopy.