Zhang Teng, Szczesniak Michal, Maclean Julia, Bertrand Paul, Wu Peter I, Omari Taher, Cook Ian J
Department of Gastroenterology and Hepatology, St George Hospital, Sydney, Australia School of Medicine, University of New South Wales, Sydney, Australia
Department of Gastroenterology and Hepatology, St George Hospital, Sydney, Australia School of Medicine, University of New South Wales, Sydney, Australia.
Otolaryngol Head Neck Surg. 2016 Aug;155(2):295-302. doi: 10.1177/0194599816639249. Epub 2016 Apr 26.
Postlaryngectomy, pharyngeal weakness, and pharyngoesophageal junction (PEJ) restriction are the candidate mechanisms of dysphagia. The aims were, in laryngectomees, whether (1) hypopharyngeal propulsion is reduced and/or PEJ resistance is increased, (2) dilatation improves dysphagia, and (3) whether symptomatic improvement correlates with reduced PEJ resistance.
Multidisciplinary cross-sectional study.
Tertiary academic hospital.
Swallow biomechanics were assessed in 30 laryngectomees. Patients were stratified into severe dysphagia (Sydney Swallow Questionnaire >500) and mild/nil dysphagia (Sydney Swallow Questionnaire ≤500). Average hypopharyngeal peak (contractile) pressure (hPP) and hypopharyngeal intrabolus pressure (hIBP) were measured from high-resolution manometry with concurrent videofluoroscopy based on barium swallows (2.5 and 10 mL). In consecutive 5 patients, measurements were repeated after dilatation.
Dysphagia was reported by 87%, and 57% had severe and 43% had mild/nil dysphagia. hIBP increased with larger bolus volumes (P < .0001), while hPP stayed stable and PEJ diameter plateaued at 9 mm. Laryngectomees had lower hPP (110 ± 14 vs 170 ± 15 mm Hg; P = .0162) and higher hIBP (29 ± 5 vs 6 ± 5 mm Hg; P = .156) than controls. There were no differences in hPP between patient groups. However, hIBP was higher in severe than in mild/nil dysphagia (41 ± 10 vs 13 ± 3 mm Hg; P = .02). Predilation hIBP (R(2) = 0.97) and its decrement postdilatation (R(2) = 0.98) well predicted symptomatic improvement.
PEJ resistance correlates better with dysphagia severity than peak pharyngeal pressure and is more sensitive to bolus sizes than PEJ diameter. Both baseline PEJ resistance and its decrement following dilatation are strong predictors of treatment outcome. PEJ resistance is vital to detect, as it is reversible and can predict the response to dilatation regimens.
喉切除术后、咽部肌无力及咽食管交界处（PEJ）狭窄是吞咽困难的可能机制。本研究旨在探讨喉切除患者是否存在以下情况：（1）下咽推进力降低和/或PEJ阻力增加；（2）扩张术能否改善吞咽困难；（3）症状改善是否与PEJ阻力降低相关。
多学科横断面研究。
三级学术医院。
对30例喉切除患者的吞咽生物力学进行评估。患者按悉尼吞咽问卷评分分为重度吞咽困难组（>500分）和轻度/无吞咽困难组（≤500分）。通过基于吞咽钡剂（2.5 mL和10 mL）的高分辨率测压结合同步视频荧光检查，测量下咽平均峰值（收缩）压力（hPP）和下咽团内压力（hIBP）。连续5例患者在扩张术后重复测量。
87%的患者报告有吞咽困难，其中57%为重度吞咽困难，43%为轻度/无吞咽困难。hIBP随团块体积增大而升高（P <.0001），而hPP保持稳定，PEJ直径在9 mm时达到平台期。与对照组相比，喉切除患者的hPP较低（110±14 vs 170±15 mmHg；P =.0162），hIBP较高（29±5 vs 6±5 mmHg；P =.156）。两组患者的hPP无差异。然而，重度吞咽困难组的hIBP高于轻度/无吞咽困难组（41±10 vs 13±3 mmHg；P =.02）。扩张术前的hIBP（R² = 0.97）及其扩张术后的下降幅度（R² = 0.98）能很好地预测症状改善情况。
与咽部峰值压力相比，PEJ阻力与吞咽困难严重程度的相关性更好，并且对团块大小的敏感性高于PEJ直径。PEJ的基线阻力及其扩张术后的下降幅度均是治疗效果的有力预测指标。检测PEJ阻力至关重要，因为它是可逆的，并且可以预测对扩张治疗方案的反应。
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