The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Evaluation of Modified Killian’s Method: A Technique to Expose the Hypopharyngeal Space Shigeyuki Murono, MD; Akira Tsuji, MD; Kazuhira Endo, MD; Satoru Kondo, MD; Naohiro Wakisaka, MD; Tomokazu Yoshizaki, MD Objectives/Hypothesis: The objective of this study was to evaluate the “Modified Killian’s method,” a recently proposed endoscopic technique to observe a wider area of the hypopharngeal space than is possible with the conventional method. Study Design: Prospective case series. Methods: Fifty-seven patients underwent transnasal flexible endoscopy in a sequence of eight different procedures with or without head torsion, the Valsalva maneuver, and a position similar to bowing named “the modified Killian position.” The visibility of subsites of the hypopharynx and esophageal inlet was evaluated based on a 5-point scale. Results: The Modified Killian’s method, a combination of all three procedures of head torsion, the Valsalva maneuver, and the modified Killian position, demonstrated a highly significant score for hypopharyngeal visibility. Previous treatment with radiotherapy or chemoradiotherapy did not significantly affect the visibility of the hypopharynx. Conclusion: The newly proposed Modified Killian’s method provides an effective view of the entire circumference of the hypopharyngeal space even in patients receiving radiotherapy. This useful procedure can be performed easily and should be a part of flexible laryngoscopy for outpatients. Key Words: hypopharyngeal space, flexible laryngeal endoscopy, Valsalva maneuver, head torsion, Killian position. Level of Evidence: 4. Laryngoscope, 124:2526–2530, 2014
INTRODUCTION Flexible laryngeal endoscopy is a safe, practical, and indispensable examination for observation of the larynx and hypopharynx. However, the view of the hypopharynx is limited due to closure of the space. Although marked innovations in endoscopic technology, including a narrow band imaging (NBI) system, have enabled the detection of superficial hypopharyngeal cancers,1,2 it is useless without a wide view of the area. In addition, the key to successful transoral surgery and larynxpreserving partial hypopharyngectomy, whose rates have increased due to the development of functional surgical techniques,3 is the accurate determination of the primary tumor site and its extent. Several techniques for improving the view of the hypopharynx with a flexible laryngoscope have been reported. These include head torsion,4 the modified Valsalva technique,5 trumpet maneuver,6 anterior neck skin traction,7 combination of the Valsalva maneuver and anterior neck skin traction,8 combination of the trumpet maneuver and anterior neck skin traction,9,10 and the
From the Department of Otolaryngology, Head and Neck Surgery, Kanazawa University, Kanazawa, Japan. Editor’s Note: This Manuscript was accepted for publication May 6, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Shigeyuki Murono, Department of Otolaryngology, Head and Neck Surgery, Kanazawa University, 13-1 Takaramachi, Kanazawa 920–8640, Japan. E-mail: [email protected] DOI: 10.1002/lary.24760
Laryngoscope 124: November 2014
2526
Killian position.11,12 Recently, Sakai et al. reported a new procedure named the “Modified Killian’s method” (MK method), a combination of a modification of the Killian position, head torsion, and the Valsalva maneuver, to open the hypopharynx more widely.13 The present study aimed to evaluate the effectiveness of the MK method in comparison with some classical maneuvers.
PATIENTS AND METHODS Patients Among outpatients who had been followed up for hypopharyngeal or laryngeal disease, a total of 57 patients—including 49 males and eight females—were randomly selected between July 2013 and December 2013, and enrolled in the present study. These consisted of 24 patients after chemoradiotherapy (CRT) for hypopharyngeal or laryngeal cancer, eight patients after radiotherapy (RT) with or without transoral surgery for hypopharyngeal or laryngeal cancer, nine patients after transoral surgery for laryngeal or hypopharyngeal cancer, and 16 patients after treatment or during the observation of other diseases of the hypopharynx or larynx. The mean and median ages of the enrolled patients were 67.4 and 68.0 years old, respectively, ranging from 50 to 86 years old.
Endoscopic Procedure In the present study, observation of the hypopharynx was attempted in eight head positions with or without the Valsalva maneuver. All examinations were performed in a seated position. Firstly, the patient was asked to phonate “e” in the normal position (normal-Ph). Secondly, the patient’s head was rotated laterally and the patient was again asked to phonate “e”
Murono et al.: A New Technique to Expose the Hypopharynx
TABLE I. Grade of Visualization of Hypopharynx. Score
Description
1 2
Only pyriform sinuses are observed. Part of postcricoid area is observed.
3
Whole postcricoid area is observed.
4 5
Greater than whole postcricoid area is observed. Upper esophageal sphincter is observed.
(torsion-Ph). Thirdly, the Valsalva maneuver was performed in the normal position after resuming a normal head position (normal-Va). Fourthly, the Valsalva maneuver was performed while resuming head torsion (torsion-Va). After returning to the normal seated position, the patient was placed in the Killian position, in which the neck was bent forward and the chin was depressed far enough so that the patient was able to look down at the umbilicus.13 The patient was bent further forward from the original Killian position, as if bowing. This posture is the MK position.13 Fifthly, the patient was asked to phonate “e” in the MK position (MK-normal-Ph). Sixthly, the patient’s head was then rotated laterally and the patient was asked to phonate “e” (MK-torsion-Ph). Seventhly, the Valsalva maneuver was performed in the MK position after returning the head rotation (MK-normal-Va). Eighthly, the Valsalva maneuver was performed in the MK position while resuming head torsion again (MK-torsion-Va). This combination of the MK position, head torsion, and the Valsalva maneuver was the “MK method” proposed by Sakai et al., which was precisely described in their original report.13
Evaluation of Hypopharyngeal Observation Only three previous reports concretely demonstrated the level of visualization, although many other reports only showed images of a well-visualized hypopharynx.9,14 One adopted a 3grade system consisting of: pyriform fossae (referred to as PS in the present study), postcricoid (PC) subsite, and upper esophageal sphincter (UES) can be observed.9 Others were an estimate of the overall percentage visualization of each of four subsites: the left and right PS; PC; and UES14; and 3-graded score of visualization in PS, PC and UES.10 In the present study, we developed the first grading system into a 5-point scale, as shown in
Table I. Score 1 was given when only PS was observed. Score 2 was given when a part of PC was observed, but PC still contacted with PW. Score 3 was given when a space between PC and PW was confirmed, and the whole PC could be observed. Score 4 was given when the space between PC and PW opened widely, but UES could not be clearly confirmed. Score 5 was given when UES was clearly observed. The best view in each position or maneuver was captured, and images were preserved in an electronic medical record system in our hospital. Two otolaryngologists blindly reviewed and graded those images, and the average was calculated for further analyses.
Statistical Analysis Differences in scores between two groups and among more than three groups were compared using the Mann-Whitney U test and one-way ANOVA with Bonferroni correction, respectively. All analyses were carried out using SPSS 19.0 software (SPSS Inc., Chicago, IL). In all tests, P < 0.05 was considered significant.
RESULTS Visibility of Hypopharynx Using Head Torsion, the Valsalva Maneuver, and the Modified Killian Position Mean scores using each position or maneuver are shown in Figure 1. Mean scores (6 standard deviations) with normal-Ph, torsion-Ph, normal-Va, and torsion-Va were 1.11 (6 0.36), 1.35 (6 0.52), 1.53 (6 0.63), and 1.84 (6 0.62), respectively. In addition, mean scores (6 standard deviations) with MK-normal-Ph, MK-torsion-Ph, MK-normal-Va, and MK-torsion-Va were 1.79 (6 0.70), 2.18 (6 0.73), 2.79 (6 0.90), and 3.39 (6 0.94), respectively. Among these eight positions or maneuvers, highly significant differences in mean scores were observed between any two of them (all P
Rhinological and Otological Society, Inc.
Evaluation of Modified Killian’s Method: A Technique to Expose the Hypopharyngeal Space Shigeyuki Murono, MD; Akira Tsuji, MD; Kazuhira Endo, MD; Satoru Kondo, MD; Naohiro Wakisaka, MD; Tomokazu Yoshizaki, MD Objectives/Hypothesis: The objective of this study was to evaluate the “Modified Killian’s method,” a recently proposed endoscopic technique to observe a wider area of the hypopharngeal space than is possible with the conventional method. Study Design: Prospective case series. Methods: Fifty-seven patients underwent transnasal flexible endoscopy in a sequence of eight different procedures with or without head torsion, the Valsalva maneuver, and a position similar to bowing named “the modified Killian position.” The visibility of subsites of the hypopharynx and esophageal inlet was evaluated based on a 5-point scale. Results: The Modified Killian’s method, a combination of all three procedures of head torsion, the Valsalva maneuver, and the modified Killian position, demonstrated a highly significant score for hypopharyngeal visibility. Previous treatment with radiotherapy or chemoradiotherapy did not significantly affect the visibility of the hypopharynx. Conclusion: The newly proposed Modified Killian’s method provides an effective view of the entire circumference of the hypopharyngeal space even in patients receiving radiotherapy. This useful procedure can be performed easily and should be a part of flexible laryngoscopy for outpatients. Key Words: hypopharyngeal space, flexible laryngeal endoscopy, Valsalva maneuver, head torsion, Killian position. Level of Evidence: 4. Laryngoscope, 124:2526–2530, 2014
INTRODUCTION Flexible laryngeal endoscopy is a safe, practical, and indispensable examination for observation of the larynx and hypopharynx. However, the view of the hypopharynx is limited due to closure of the space. Although marked innovations in endoscopic technology, including a narrow band imaging (NBI) system, have enabled the detection of superficial hypopharyngeal cancers,1,2 it is useless without a wide view of the area. In addition, the key to successful transoral surgery and larynxpreserving partial hypopharyngectomy, whose rates have increased due to the development of functional surgical techniques,3 is the accurate determination of the primary tumor site and its extent. Several techniques for improving the view of the hypopharynx with a flexible laryngoscope have been reported. These include head torsion,4 the modified Valsalva technique,5 trumpet maneuver,6 anterior neck skin traction,7 combination of the Valsalva maneuver and anterior neck skin traction,8 combination of the trumpet maneuver and anterior neck skin traction,9,10 and the
From the Department of Otolaryngology, Head and Neck Surgery, Kanazawa University, Kanazawa, Japan. Editor’s Note: This Manuscript was accepted for publication May 6, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Shigeyuki Murono, Department of Otolaryngology, Head and Neck Surgery, Kanazawa University, 13-1 Takaramachi, Kanazawa 920–8640, Japan. E-mail: [email protected] DOI: 10.1002/lary.24760
Laryngoscope 124: November 2014
2526
Killian position.11,12 Recently, Sakai et al. reported a new procedure named the “Modified Killian’s method” (MK method), a combination of a modification of the Killian position, head torsion, and the Valsalva maneuver, to open the hypopharynx more widely.13 The present study aimed to evaluate the effectiveness of the MK method in comparison with some classical maneuvers.
PATIENTS AND METHODS Patients Among outpatients who had been followed up for hypopharyngeal or laryngeal disease, a total of 57 patients—including 49 males and eight females—were randomly selected between July 2013 and December 2013, and enrolled in the present study. These consisted of 24 patients after chemoradiotherapy (CRT) for hypopharyngeal or laryngeal cancer, eight patients after radiotherapy (RT) with or without transoral surgery for hypopharyngeal or laryngeal cancer, nine patients after transoral surgery for laryngeal or hypopharyngeal cancer, and 16 patients after treatment or during the observation of other diseases of the hypopharynx or larynx. The mean and median ages of the enrolled patients were 67.4 and 68.0 years old, respectively, ranging from 50 to 86 years old.
Endoscopic Procedure In the present study, observation of the hypopharynx was attempted in eight head positions with or without the Valsalva maneuver. All examinations were performed in a seated position. Firstly, the patient was asked to phonate “e” in the normal position (normal-Ph). Secondly, the patient’s head was rotated laterally and the patient was again asked to phonate “e”
Murono et al.: A New Technique to Expose the Hypopharynx
TABLE I. Grade of Visualization of Hypopharynx. Score
Description
1 2
Only pyriform sinuses are observed. Part of postcricoid area is observed.
3
Whole postcricoid area is observed.
4 5
Greater than whole postcricoid area is observed. Upper esophageal sphincter is observed.
(torsion-Ph). Thirdly, the Valsalva maneuver was performed in the normal position after resuming a normal head position (normal-Va). Fourthly, the Valsalva maneuver was performed while resuming head torsion (torsion-Va). After returning to the normal seated position, the patient was placed in the Killian position, in which the neck was bent forward and the chin was depressed far enough so that the patient was able to look down at the umbilicus.13 The patient was bent further forward from the original Killian position, as if bowing. This posture is the MK position.13 Fifthly, the patient was asked to phonate “e” in the MK position (MK-normal-Ph). Sixthly, the patient’s head was then rotated laterally and the patient was asked to phonate “e” (MK-torsion-Ph). Seventhly, the Valsalva maneuver was performed in the MK position after returning the head rotation (MK-normal-Va). Eighthly, the Valsalva maneuver was performed in the MK position while resuming head torsion again (MK-torsion-Va). This combination of the MK position, head torsion, and the Valsalva maneuver was the “MK method” proposed by Sakai et al., which was precisely described in their original report.13
Evaluation of Hypopharyngeal Observation Only three previous reports concretely demonstrated the level of visualization, although many other reports only showed images of a well-visualized hypopharynx.9,14 One adopted a 3grade system consisting of: pyriform fossae (referred to as PS in the present study), postcricoid (PC) subsite, and upper esophageal sphincter (UES) can be observed.9 Others were an estimate of the overall percentage visualization of each of four subsites: the left and right PS; PC; and UES14; and 3-graded score of visualization in PS, PC and UES.10 In the present study, we developed the first grading system into a 5-point scale, as shown in
Table I. Score 1 was given when only PS was observed. Score 2 was given when a part of PC was observed, but PC still contacted with PW. Score 3 was given when a space between PC and PW was confirmed, and the whole PC could be observed. Score 4 was given when the space between PC and PW opened widely, but UES could not be clearly confirmed. Score 5 was given when UES was clearly observed. The best view in each position or maneuver was captured, and images were preserved in an electronic medical record system in our hospital. Two otolaryngologists blindly reviewed and graded those images, and the average was calculated for further analyses.
Statistical Analysis Differences in scores between two groups and among more than three groups were compared using the Mann-Whitney U test and one-way ANOVA with Bonferroni correction, respectively. All analyses were carried out using SPSS 19.0 software (SPSS Inc., Chicago, IL). In all tests, P < 0.05 was considered significant.
RESULTS Visibility of Hypopharynx Using Head Torsion, the Valsalva Maneuver, and the Modified Killian Position Mean scores using each position or maneuver are shown in Figure 1. Mean scores (6 standard deviations) with normal-Ph, torsion-Ph, normal-Va, and torsion-Va were 1.11 (6 0.36), 1.35 (6 0.52), 1.53 (6 0.63), and 1.84 (6 0.62), respectively. In addition, mean scores (6 standard deviations) with MK-normal-Ph, MK-torsion-Ph, MK-normal-Va, and MK-torsion-Va were 1.79 (6 0.70), 2.18 (6 0.73), 2.79 (6 0.90), and 3.39 (6 0.94), respectively. Among these eight positions or maneuvers, highly significant differences in mean scores were observed between any two of them (all P
