525019
research-article2014
AORXXX10.1177/0003489414525019Annals of Otology, Rhinology & LaryngologySilver and Gal
Article
Endoscopic CO2 Laser Management of Chemoradiation-related Cricopharyngeal Stenosis
Annals of Otology, Rhinology & Laryngology 2014, Vol. 123(4) 252–256 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003489414525019 aor.sagepub.com
Natalie Silver, MD, MS1 and T. J. Gal, MD, MPH1
Abstract Objective: Treatment of head and neck cancer with chemoradiation (CRT) can result in strictures of the cervical esophagus, often at the level of the cricopharyngeus. The objective of this study is to assess the feasibility of endoscopic CO2 laser cricopharyngeal myotomy for stricture ablation in the setting of prior CRT. Methods: A retrospective review of patients who underwent endoscopic CO2 laser cricopharyngeal myotomy for dysphagia after radiation for squamous cell carcinoma of the head and neck (SCCHN). Pre- and postoperative barium swallow and swallowing assessment were performed before and after surgery. Outcomes and complication rates were examined. Results: Endoscopic CO2 laser cricopharyngeal myotomy was performed in 10 patients with dysphagia secondary to cricopharyngeal stenosis/stricture, which developed following treatment for SCCHN with chemoradiation. All patients demonstrated radiographic improvement in stricture, with complete resolution of stricture in 9 of 10 patients. All patients noted improvement in dysphagia with 9 of 10 patients demonstrating significant advancement of diet by modified barium swallow. No complications were observed. Conclusion: Endoscopic CO2 cricopharyngeal myotomy can be performed safely in the setting of prior CRT, with significant improvement in swallowing in select patients. Indications and technical considerations will be discussed. Keywords dysphagia, chemoradiation, cricopharyngeal stenosis, myotomy, carbon dioxide laser
Chemoradiation (CRT) remains an integral modality in the management of squamous cell carcinoma of the head and neck (SCCHN). Unfortunately, dysphagia-related complications from chemotherapy are also well documented.1,2 This includes stricture or stenosis, which frequently occurs at the level of the cricopharyngeus muscle.3 Severe cricopharyngeal stenosis can lead to dysphagia, aspiration, and permanent dependence on gastrostomy tube.4,5 Cricopharyngeal myotomy is a well-described procedure for the management of cricopharyngeal stenosis. Open cricopharyngeal myotomy was first described by Kaplan in 1951 in the setting of postpoliomyelitis.6 Presently, this is most commonly performed for cricopharyngeal hypertonicity or achalasia. Known complications of open cricopharyngeal myotomy may include bleeding, mediastinitis, fistulas, esophageal stricture, and recurrent nerve paralysis.7 In the setting of the postradiation neck, increased soft tissue fibrosis and scarring can make transcervical access to the cricopharyngeus difficult at best, with the potential for delayed wound healing and increased complication rates. Not surprisingly, enthusiasm for open cricopharyngeal myotomy
after CRT is limited. In addition, the inability to address mucosal adhesions with this approach without esophagotomy further limits its utility. As a result, many of these strictures are managed endoscopically, usually with serial dilation and esophagoscopy.8 This approach avoids the risk of external approaches to the esophagus in the chemoradiated neck. They also allow for the potential to disrupt mucosal adhesions. However, these techniques often require several repeat dilations. Fibrosis of circular musculature of the cricopharyngeus muscle frequently results in only transient improvement with dilation. The past 10 years or so have seen advances in endoscopic management of the cricopharyngeus, particularly 1
Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, USA Corresponding Author: Natalie Silver, MD, MS, Department of Otolaryngology, University of Kentucky, 800 Rose St C236, Lexington, KY 40536, USA. Email: [email protected]
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Silver and Gal with the use of the CO2 laser.9-12 First described in 1994, endoscopic cricopharyngeal myotomy allows for a transoral, transmucosal approach for sectioning the cricopharyngeus.13 While this approach has been used for a number of etiologies of cricopharygneal dysfunction, including anatomic, neurologic, iatrogenic, inflammatory or idiopathic causes, the utility in the setting of postradiation dysphagia has received little attention. The purpose of this article is to present our experience with endoscopic laser CO2 cricopharyngeal myotomy in the management of CRT-related dysphagia.
Methods Institutional review board approval was obtained for the retrospective study. Patients who underwent cricopharyngeal myotomy were identified by query of billing records using CPT codes (43030). Patients were excluded if they underwent open cricopharyngeal myotomy or if endoscopic myotomy was performed for reasons other than dysphagia after CRT for SCCHN. Information regarding patient demographics, indications for surgery, and complications was obtained. Preoperative barium swallow studies were performed as well as a postoperative barium swallow study approximately 1 month after surgery, and formal speech pathology evaluation were obtained in the course of routine management of these patients and were available for review. Patients were followed up by clinic visits and by telephone interview. Procedure efficacy was based on diet improvement and radiographic resolution of stricture. Due to the retrospective nature of the study, it was difficult to accurately determine the number of patients who were clinically and radiographically candidates for the procedure, and underwent diagnostic esophagoscopy, but in whom the procedure could not be performed due to limitations in access to the cricopharyngeus with the endoscope. The procedure for CO2 cricopharyngeal laser myotomy is well described elsewhere.11 In brief, patency of the esophagus is confirmed radiographically with barium swallow prior to the procedure. A cervical esophagoscope is first inserted to assess the patency of the esophagus. Any mucosal strictures identified, either at the cricopharyngeus or elsewhere in the upper esophagus are either bluntly dilated with Savory or Bougie dilators, or can be taken down with the laser if indicated and access permits. A Weerda diverticuloscope is inserted into the esophagus exposing the cricopharyngeus (Figure 1). It is placed just proximal to the cricopharyngeus. Opening of the blades of the scope results in the circular band of the cricopharyngeus muscle to be lifted above the level of the posterior blade of the scope. The microscope is brought into the field and used to focus on the mucosa overlying the posterior aspect of the muscle. The CO2 laser, coupled to the microscope and on a continuous 10 W setting, is used to incise the mucosa, exposing the
Figure 1. Diverticuloscope inserted into esophagus exposing CP stenosis.
Figure 2. Transmucosal myotomy using CO2 laser.
muscular bands of the cricopharyngeus. The laser is then used to transect the muscle until the longitudinal fibers of the esophagus are identified (Figure 2). Care is taken to prevent extension of the cut too far posteriorly beyond the boundaries of the buccopharyngeal fascia. Patients are left
Downloaded from aor.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 21, 2015
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Annals of Otology, Rhinology & Laryngology 123(4)
Table 1. Patient Demographics and Swallowing Outcomes.
1 2 3 4 5 6 7 8 9 10
Age, y
Sex
Tumor Site
TNM Stage
Therapy
Preoperative Diet
Postoperative Diet
77 49 78 55 54 56 54 63 77 78
F M M M M M M F F M
Glottis BOT SGL Tonsil FOMa Tonsil BOT SGL BOT Tonsil
T2N0M0 T1N2cM0 T2N1M0 UTO T2N1M0 T2N2bM0 T1N2bM0 T3N2cM0 T4aN2cM0 T2N1M0
CRT CRT CRT CRT CRT CRT CRT CRT CRT CRT
FT FT FT FT Liquid Liquid Liquid FT Liquid FT
Soft Soft Soft FT Liquidb Regular Regular Regular Regular Soft
Abbreviations: BOT, base of tongue; CRT, chemoradiation; FOM, floor of mouth; FT, feeding tube dependent/NPO; M/F, male/female; SGL, supraglottic larynx; UTO, unable to obtain. a Patient developed second primary of the larynx requiring total laryngectomy. b Patient remained on liquid diet with significant subjective improvement in swallowing.
NPO for 24 hours at which point they are started on clear liquids. They are observed for 24 to 48 hours for symptoms of mediastinitis, specifically fever, chest pain, back pain, or tachypnea. Gastrograffin swallow study is not routinely performed immediately postoperatively as all patients will demonstrate radiographic evidence of leak, usually with air or fluid contained to the regional buccopharyngeal space that resolves spontaneously.
Results During the study period, 10 patients with prior treatment for SCCHN with CRT were identified with dysphagia as a result of cricopharyngeal stenosis/stricture by barium swallow. Patient characteristics are presented in Table 1. Six out of the 10 patients had obtainable radiation records, these patients were treated to an average of 70 Gy with adjuvant cisplatinum chemotherapy. Endoscopic CO2 laser cricopharyngeal myotomy was performed on all patients. All patients had radiographic resolution of the cricopharyngeal stricture. One patient was noted to have persistent narrowing of the cervical esophagus postoperatively, independent of the cricopharyngeal stenosis, which responded to dilation. No clinically relevant leakage or mediastinitis was observed. No complications were observed. A representative illustration of a typical case is illustrated in Figures 3 through 5. Modified barium swallow was performed by our speech and swallowing pathologists on all patients. Preoperatively 6 of the patients were completely feeding tube dependent. Of these, 4 were able to be advanced to a soft diet, with 1 patient advancing to a completely regular diet. This group includes the patient with incomplete radiographic resolution of her esophageal stenosis. The other patient remained feeding tube dependent secondary to severe
Figure 3. Preoperative barium swallow showing stricture at the level of the CP muscle.
oropharyngeal dysphagia and laryngeal fixation despite compete radiographic resolution of his cricopharyngeal stricture. The remaining 4 patients were taking a liquid diet preoperatively. Three were advanced to a regular diet. The fourth remained on a liquid diet but reported subjective clinical improvement in ease of swallowing. Unfortunately, this particular patient, with an oral cavity primary, went on to develop a second larynx primary necessitating total laryngectomy. Minimum follow-up time was 12 months.
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Figure 4. AP view of preoperative barium swallow.
Figure 5. Barium swallow 1 month after CO2 laser myotomy with resolution of stricture.
Discussion and Conclusions
they may also occur as a late effect of radiation, when soft tissue fibrosis of the neck may render open access nearly impossible. Conversely, the loss of soft tissue planes and fibrosis of potential spaces in the neck may actually limit the development of complications related to leakage when the procedure is performed endoscopically. Unfortunately, the same issues that may make endoscopic myotomy advantageous in the post-CRT setting also limit its universal application. The key to endoscopic cricopharyngeal myotomy is the proper placement of the diverticuloscope to expose the cricopharyngeus and place it under adequate tension using the bivalved mechanics of the scope. Many of these patients have limitations with transoral access, usually due to radiation-related trismus or neck mobility. A number of these stenoses that are evident radiographically may not be accessible transorally. Even if the cricopharyngeus can be identified with a cervical esophagoscope, it may not be possible to properly place the larger caliber diverticuloscope into the cervical esophagus. The most significant limitation of this study is that there were a number of patients who were identified as candidates for this procedure where appropriate access could not be obtained. Due to the retrospective nature of the study, it was difficult to accurately determine from review of operative reports the number of cases where the procedure
Long-term dysphagia is a common problem for patients receiving CRT for SCCHN. Post-CRT stricture rates have been reported to be 13-46%2-4,14 and can cause significant dysphagia. Traditional endoscopic dilation using serial dilation most often requires several repeated procedures. The need for repeat procedures has been reported to be 33-65% in patients with esophageal stricture/dysphagia after receiving treatment for HNSCC.15-18 There was a recent large study conducted on patients who underwent endoscopic dilation for stricture after treatment for HNSCC with a repeat procedure rate of 49%. Those patients needing multiple procedures had a higher complication rate. Although our series is small, only 1 patient (10%) required an additional dilation.19 While cricopharyngeal stenosis is by no means the solitary cause of dysphagia in the post- CRT patient, it is 1 of the few potentially reversible etiologies, and can frequently limit progress with other aspects of dysphagia which may be amenable to therapy. The most significant advantage of endoscopic cricopharyngeal myotomy is the elimination of the need for any attempt at open approaches in the postchemoradiated neck. While symptoms from cricopharyngeal stenosis may be present relatively early after treatment,
Downloaded from aor.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 21, 2015
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Annals of Otology, Rhinology & Laryngology 123(4)
was attempted and aborted due to inadequate access. Furthermore, due to surgeon preferences within the institution, a number of potentially eligible patients were preferentially treated with dilation that might otherwise have benefitted from endoscopic myotomy. While it would be useful to demonstrate the proportion of patients in which this procedure may be performed when indicated, there remains some value in the ability to demonstrate that, when possible, endoscopic cricopharyngeal myotomy can be safely performed in the post-CRT patient. Thus it is reasonable to say, that if cricopharyngeal stenosis or stricture is identified in the work up of dysphagia after CRT for SCCHN, our series supports the use of endoscopic CO2 laser cricopharyngeal myotomy as a safe potential therapeutic option. Authors’ Note This research was presented as a poster at the American Academy of Otolaryngology–Head and Neck Surgery annual meeting in Boston, September 2010.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Abdel-Wahab M, Abitbol A, Lewin A, Troner M, Hamilton K, Markoe A. Quality-of-life assessment after hyperfractionated radiation therapy and 5-flourouracil, cisplatin, as paclitaxel (taxol) in inoperable and/or unresectable head and neck squamous cell carcinoma. Am J Clin Oncol. 2005;28: 371-378. 2. Guadagnolo BA, Haddad RI, Posner MR, et al. Organ preservation and treatment toxicity with induction chemotherapy followed by radiation therapy or chemoradiation for advanced laryngeal cancer. Am J Clin Oncol. 2005;28(4):371-378. 3. Lawson JD, Otto K, Grist W, Johnstone PA. Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer. Am J Otolaryngol. 2008;29(1):13-19. 4. Eisbruch A, Lyden T, Bradford CR, et al. Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2002;53(1):23-28.
5. Francis DO, Weymuller EA, Parvathanemi U, Merati AL, Yueh B. Dysphagia, stricture, and pneumonia in head and neck cancer patients: does treatment modality matter? Ann Otol Rhinol Laryngol. 2010;119:391-397. 6. Kaplan S. Paralysis of deglutition, a postpoliomyelitis complication treated by section of the cricopharyngeus muscle. Ann Surg. 1951;133:572-573. 7. Peretti G, Piazza C, Del Bon F, Cocco D, De Benedetto L, Mangili S. Endoscopic treatment of Zenker’s diverticulum by carbon dioxide laser. Acta Otorhinolaryngol Ital. 2010;30(1):1-4. 8. Dhir V, Vege SS, Mohandas KM, Desai DC. Dilation of proximal esophageal strictures following therapy for head and neck cancer: experience with savary gillard dilators. J Surg Oncol. 1996;63:187-190. 9. Lawson G, Remacle M. Endoscopic cricopharyngeal myotomy: indications and technique. Curr Opin Otolaryngol Head Neck Surg. 2006;14:437-441. 10. Lawson G, Remacle M, Jamart J, Keghian J. Endoscopic CO2 laser-assisted surgery for cricopharyngeal dysfunction. Eur Arch Otorhinolaryngol. 2003;260:475-480. 11. Pitman M, Weissbrod P. Ensocopic CO2 laser cricopharyngeal myotomy. Laryngoscope. 2009;119:45-53. 12. Takes RP, van den Hoogen FJA, Marres HAM. Endoscopic myotomy of the cricopharyngeal muscle with CO2 laser surgery. Head Neck. 2005;27:703-709. 13. Halvorson DJ, Kuhn FA. Transmucosal cricopharyngeal myotomy with the potassium-titanyl phosphate laser in the treatment of cricopharyngeal dysmotility. Ann Otol Rhinol Laryngol. 1994;103:173-177. 14. Abdel-Wahab M, Abitbol A, Lewin A, Troner M, Hamilton K, Markoe A. Quality-of-life assessment after hyperfractionated radiation therapy and 5-fluorouracil, cisplatin, and paclitaxel (Taxol) in inoperable and/or unresectable head and neck squamous cell carcinoma. Am J Clin Oncol. 2005;28(4):359-366. 15. Hu HT, Shin JH, Kim JH, Park JH, Sung KB, Song HY. Fluoroscopically guided balloon dilation for pharyngoesophageal stricture after radiation therapy in patients with head and neck cancer. AJR Am J Roentgenol. 2010;194(4):1131-1136. 16. Ahlawat SK, Al-Kawas FH. Endoscopic management of upper esophageal strictures after treatment of head and neck malignancy. Gastrointest Endosc. 2008;68(1):19-24. 17. Dhir V, Vege SS, Mohandas KM, Desai DC. Dilation of proximal esophageal strictures following therapy for head and neck cancer: experience with Savary Gilliard dilators. J Surg Oncol. 1996;63(3):187-190. 18. Kozarek RA. Proximal strictures of the esophagus. J Clin Gastroenterol. 1984;6(6):505-511. 19. Chapuy CI, Annino DJ, Tishler RB, Haddad RI, Snavely A, Goguen LA. Success of endoscopic pharyngoesophageal dilation after head and neck cancer treatment. Laryngoscope. 2013;123(12):3066-3073.
Downloaded from aor.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 21, 2015
research-article2014
AORXXX10.1177/0003489414525019Annals of Otology, Rhinology & LaryngologySilver and Gal
Article
Endoscopic CO2 Laser Management of Chemoradiation-related Cricopharyngeal Stenosis
Annals of Otology, Rhinology & Laryngology 2014, Vol. 123(4) 252–256 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003489414525019 aor.sagepub.com
Natalie Silver, MD, MS1 and T. J. Gal, MD, MPH1
Abstract Objective: Treatment of head and neck cancer with chemoradiation (CRT) can result in strictures of the cervical esophagus, often at the level of the cricopharyngeus. The objective of this study is to assess the feasibility of endoscopic CO2 laser cricopharyngeal myotomy for stricture ablation in the setting of prior CRT. Methods: A retrospective review of patients who underwent endoscopic CO2 laser cricopharyngeal myotomy for dysphagia after radiation for squamous cell carcinoma of the head and neck (SCCHN). Pre- and postoperative barium swallow and swallowing assessment were performed before and after surgery. Outcomes and complication rates were examined. Results: Endoscopic CO2 laser cricopharyngeal myotomy was performed in 10 patients with dysphagia secondary to cricopharyngeal stenosis/stricture, which developed following treatment for SCCHN with chemoradiation. All patients demonstrated radiographic improvement in stricture, with complete resolution of stricture in 9 of 10 patients. All patients noted improvement in dysphagia with 9 of 10 patients demonstrating significant advancement of diet by modified barium swallow. No complications were observed. Conclusion: Endoscopic CO2 cricopharyngeal myotomy can be performed safely in the setting of prior CRT, with significant improvement in swallowing in select patients. Indications and technical considerations will be discussed. Keywords dysphagia, chemoradiation, cricopharyngeal stenosis, myotomy, carbon dioxide laser
Chemoradiation (CRT) remains an integral modality in the management of squamous cell carcinoma of the head and neck (SCCHN). Unfortunately, dysphagia-related complications from chemotherapy are also well documented.1,2 This includes stricture or stenosis, which frequently occurs at the level of the cricopharyngeus muscle.3 Severe cricopharyngeal stenosis can lead to dysphagia, aspiration, and permanent dependence on gastrostomy tube.4,5 Cricopharyngeal myotomy is a well-described procedure for the management of cricopharyngeal stenosis. Open cricopharyngeal myotomy was first described by Kaplan in 1951 in the setting of postpoliomyelitis.6 Presently, this is most commonly performed for cricopharyngeal hypertonicity or achalasia. Known complications of open cricopharyngeal myotomy may include bleeding, mediastinitis, fistulas, esophageal stricture, and recurrent nerve paralysis.7 In the setting of the postradiation neck, increased soft tissue fibrosis and scarring can make transcervical access to the cricopharyngeus difficult at best, with the potential for delayed wound healing and increased complication rates. Not surprisingly, enthusiasm for open cricopharyngeal myotomy
after CRT is limited. In addition, the inability to address mucosal adhesions with this approach without esophagotomy further limits its utility. As a result, many of these strictures are managed endoscopically, usually with serial dilation and esophagoscopy.8 This approach avoids the risk of external approaches to the esophagus in the chemoradiated neck. They also allow for the potential to disrupt mucosal adhesions. However, these techniques often require several repeat dilations. Fibrosis of circular musculature of the cricopharyngeus muscle frequently results in only transient improvement with dilation. The past 10 years or so have seen advances in endoscopic management of the cricopharyngeus, particularly 1
Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, USA Corresponding Author: Natalie Silver, MD, MS, Department of Otolaryngology, University of Kentucky, 800 Rose St C236, Lexington, KY 40536, USA. Email: [email protected]
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Silver and Gal with the use of the CO2 laser.9-12 First described in 1994, endoscopic cricopharyngeal myotomy allows for a transoral, transmucosal approach for sectioning the cricopharyngeus.13 While this approach has been used for a number of etiologies of cricopharygneal dysfunction, including anatomic, neurologic, iatrogenic, inflammatory or idiopathic causes, the utility in the setting of postradiation dysphagia has received little attention. The purpose of this article is to present our experience with endoscopic laser CO2 cricopharyngeal myotomy in the management of CRT-related dysphagia.
Methods Institutional review board approval was obtained for the retrospective study. Patients who underwent cricopharyngeal myotomy were identified by query of billing records using CPT codes (43030). Patients were excluded if they underwent open cricopharyngeal myotomy or if endoscopic myotomy was performed for reasons other than dysphagia after CRT for SCCHN. Information regarding patient demographics, indications for surgery, and complications was obtained. Preoperative barium swallow studies were performed as well as a postoperative barium swallow study approximately 1 month after surgery, and formal speech pathology evaluation were obtained in the course of routine management of these patients and were available for review. Patients were followed up by clinic visits and by telephone interview. Procedure efficacy was based on diet improvement and radiographic resolution of stricture. Due to the retrospective nature of the study, it was difficult to accurately determine the number of patients who were clinically and radiographically candidates for the procedure, and underwent diagnostic esophagoscopy, but in whom the procedure could not be performed due to limitations in access to the cricopharyngeus with the endoscope. The procedure for CO2 cricopharyngeal laser myotomy is well described elsewhere.11 In brief, patency of the esophagus is confirmed radiographically with barium swallow prior to the procedure. A cervical esophagoscope is first inserted to assess the patency of the esophagus. Any mucosal strictures identified, either at the cricopharyngeus or elsewhere in the upper esophagus are either bluntly dilated with Savory or Bougie dilators, or can be taken down with the laser if indicated and access permits. A Weerda diverticuloscope is inserted into the esophagus exposing the cricopharyngeus (Figure 1). It is placed just proximal to the cricopharyngeus. Opening of the blades of the scope results in the circular band of the cricopharyngeus muscle to be lifted above the level of the posterior blade of the scope. The microscope is brought into the field and used to focus on the mucosa overlying the posterior aspect of the muscle. The CO2 laser, coupled to the microscope and on a continuous 10 W setting, is used to incise the mucosa, exposing the
Figure 1. Diverticuloscope inserted into esophagus exposing CP stenosis.
Figure 2. Transmucosal myotomy using CO2 laser.
muscular bands of the cricopharyngeus. The laser is then used to transect the muscle until the longitudinal fibers of the esophagus are identified (Figure 2). Care is taken to prevent extension of the cut too far posteriorly beyond the boundaries of the buccopharyngeal fascia. Patients are left
Downloaded from aor.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 21, 2015
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Annals of Otology, Rhinology & Laryngology 123(4)
Table 1. Patient Demographics and Swallowing Outcomes.
1 2 3 4 5 6 7 8 9 10
Age, y
Sex
Tumor Site
TNM Stage
Therapy
Preoperative Diet
Postoperative Diet
77 49 78 55 54 56 54 63 77 78
F M M M M M M F F M
Glottis BOT SGL Tonsil FOMa Tonsil BOT SGL BOT Tonsil
T2N0M0 T1N2cM0 T2N1M0 UTO T2N1M0 T2N2bM0 T1N2bM0 T3N2cM0 T4aN2cM0 T2N1M0
CRT CRT CRT CRT CRT CRT CRT CRT CRT CRT
FT FT FT FT Liquid Liquid Liquid FT Liquid FT
Soft Soft Soft FT Liquidb Regular Regular Regular Regular Soft
Abbreviations: BOT, base of tongue; CRT, chemoradiation; FOM, floor of mouth; FT, feeding tube dependent/NPO; M/F, male/female; SGL, supraglottic larynx; UTO, unable to obtain. a Patient developed second primary of the larynx requiring total laryngectomy. b Patient remained on liquid diet with significant subjective improvement in swallowing.
NPO for 24 hours at which point they are started on clear liquids. They are observed for 24 to 48 hours for symptoms of mediastinitis, specifically fever, chest pain, back pain, or tachypnea. Gastrograffin swallow study is not routinely performed immediately postoperatively as all patients will demonstrate radiographic evidence of leak, usually with air or fluid contained to the regional buccopharyngeal space that resolves spontaneously.
Results During the study period, 10 patients with prior treatment for SCCHN with CRT were identified with dysphagia as a result of cricopharyngeal stenosis/stricture by barium swallow. Patient characteristics are presented in Table 1. Six out of the 10 patients had obtainable radiation records, these patients were treated to an average of 70 Gy with adjuvant cisplatinum chemotherapy. Endoscopic CO2 laser cricopharyngeal myotomy was performed on all patients. All patients had radiographic resolution of the cricopharyngeal stricture. One patient was noted to have persistent narrowing of the cervical esophagus postoperatively, independent of the cricopharyngeal stenosis, which responded to dilation. No clinically relevant leakage or mediastinitis was observed. No complications were observed. A representative illustration of a typical case is illustrated in Figures 3 through 5. Modified barium swallow was performed by our speech and swallowing pathologists on all patients. Preoperatively 6 of the patients were completely feeding tube dependent. Of these, 4 were able to be advanced to a soft diet, with 1 patient advancing to a completely regular diet. This group includes the patient with incomplete radiographic resolution of her esophageal stenosis. The other patient remained feeding tube dependent secondary to severe
Figure 3. Preoperative barium swallow showing stricture at the level of the CP muscle.
oropharyngeal dysphagia and laryngeal fixation despite compete radiographic resolution of his cricopharyngeal stricture. The remaining 4 patients were taking a liquid diet preoperatively. Three were advanced to a regular diet. The fourth remained on a liquid diet but reported subjective clinical improvement in ease of swallowing. Unfortunately, this particular patient, with an oral cavity primary, went on to develop a second larynx primary necessitating total laryngectomy. Minimum follow-up time was 12 months.
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Silver and Gal
Figure 4. AP view of preoperative barium swallow.
Figure 5. Barium swallow 1 month after CO2 laser myotomy with resolution of stricture.
Discussion and Conclusions
they may also occur as a late effect of radiation, when soft tissue fibrosis of the neck may render open access nearly impossible. Conversely, the loss of soft tissue planes and fibrosis of potential spaces in the neck may actually limit the development of complications related to leakage when the procedure is performed endoscopically. Unfortunately, the same issues that may make endoscopic myotomy advantageous in the post-CRT setting also limit its universal application. The key to endoscopic cricopharyngeal myotomy is the proper placement of the diverticuloscope to expose the cricopharyngeus and place it under adequate tension using the bivalved mechanics of the scope. Many of these patients have limitations with transoral access, usually due to radiation-related trismus or neck mobility. A number of these stenoses that are evident radiographically may not be accessible transorally. Even if the cricopharyngeus can be identified with a cervical esophagoscope, it may not be possible to properly place the larger caliber diverticuloscope into the cervical esophagus. The most significant limitation of this study is that there were a number of patients who were identified as candidates for this procedure where appropriate access could not be obtained. Due to the retrospective nature of the study, it was difficult to accurately determine from review of operative reports the number of cases where the procedure
Long-term dysphagia is a common problem for patients receiving CRT for SCCHN. Post-CRT stricture rates have been reported to be 13-46%2-4,14 and can cause significant dysphagia. Traditional endoscopic dilation using serial dilation most often requires several repeated procedures. The need for repeat procedures has been reported to be 33-65% in patients with esophageal stricture/dysphagia after receiving treatment for HNSCC.15-18 There was a recent large study conducted on patients who underwent endoscopic dilation for stricture after treatment for HNSCC with a repeat procedure rate of 49%. Those patients needing multiple procedures had a higher complication rate. Although our series is small, only 1 patient (10%) required an additional dilation.19 While cricopharyngeal stenosis is by no means the solitary cause of dysphagia in the post- CRT patient, it is 1 of the few potentially reversible etiologies, and can frequently limit progress with other aspects of dysphagia which may be amenable to therapy. The most significant advantage of endoscopic cricopharyngeal myotomy is the elimination of the need for any attempt at open approaches in the postchemoradiated neck. While symptoms from cricopharyngeal stenosis may be present relatively early after treatment,
Downloaded from aor.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 21, 2015
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was attempted and aborted due to inadequate access. Furthermore, due to surgeon preferences within the institution, a number of potentially eligible patients were preferentially treated with dilation that might otherwise have benefitted from endoscopic myotomy. While it would be useful to demonstrate the proportion of patients in which this procedure may be performed when indicated, there remains some value in the ability to demonstrate that, when possible, endoscopic cricopharyngeal myotomy can be safely performed in the post-CRT patient. Thus it is reasonable to say, that if cricopharyngeal stenosis or stricture is identified in the work up of dysphagia after CRT for SCCHN, our series supports the use of endoscopic CO2 laser cricopharyngeal myotomy as a safe potential therapeutic option. Authors’ Note This research was presented as a poster at the American Academy of Otolaryngology–Head and Neck Surgery annual meeting in Boston, September 2010.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Abdel-Wahab M, Abitbol A, Lewin A, Troner M, Hamilton K, Markoe A. Quality-of-life assessment after hyperfractionated radiation therapy and 5-flourouracil, cisplatin, as paclitaxel (taxol) in inoperable and/or unresectable head and neck squamous cell carcinoma. Am J Clin Oncol. 2005;28: 371-378. 2. Guadagnolo BA, Haddad RI, Posner MR, et al. Organ preservation and treatment toxicity with induction chemotherapy followed by radiation therapy or chemoradiation for advanced laryngeal cancer. Am J Clin Oncol. 2005;28(4):371-378. 3. Lawson JD, Otto K, Grist W, Johnstone PA. Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer. Am J Otolaryngol. 2008;29(1):13-19. 4. Eisbruch A, Lyden T, Bradford CR, et al. Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2002;53(1):23-28.
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