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436 H. F. Mahieu and M. P. Kos
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Fig. 12 T1 preoperative saggital and axial magnetic resonance images demonstrating the large retropharygeal tumor
Fig. 13 a Removal of the tumor by an anterolateral approach. The longitudinal axis of the tumor was approximately 9 cm.
b Tumor protruding through neck incision. Arrow jugular vein
always easy to estimate, because at this moment the
intratracheal tube is still in place, preventing complete
obstruction of the laryngeal inlet.
If the patients did not already have a PEG tube,
they are given a transnasal feeding tube for the initial
postoperative period. It is advisable to perform a
temporary tracheotomy to guarantee a patent airway
in the postoperative period, because as a consequence
of the laryngeal suspension, the laryngeal entrance is
displaced anteriorly and cranially (Fig. 5), interfering
with intubation in the case of airway compromise.
This tracheotomy should be performed at the end of
the procedure, after the actual laryngeal suspension
procedure, so as not to limit the extent of the laryngeal suspension (Figs. 7, 8).
2.4 Dysphagia Caused by Extraluminal
Compression
2.4.1 Anterior Cervical Osteophytes
Anterior cervical osteophytes are a common but
rarely symptomatic finding mostly seen in the
geriatric population. They can occur in cases of
Surgical Aspects of Pharyngeal Dysfunction, Dysphagia, and Aspiration 437
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Fig. 14 a Endoscopic view of the semicircular oropharyngeal
stenosis fixed to the epiglottis in a patient following radiotherapy for T1 oropharyngeal carcinoma. b Five-year postoperative
endoscopic view of the larynx demonstrating only minor
degenerative disk disease, as part of the physiological or accelerated ageing process, but are most
marked in diffuse idiopathic skeletal hyperostosis,
also known as Forestier’s disease (Resnick et al.
1975; Matan et al. 2002). If symptomatic, dysphagia
appears to be the most common presentation,
caused by mechanical obstruction of the pharyngoesophageal segment by anterior cervical hyperostosis.
Exclusion of other causes of dysphagia is mandatory before blaming cervical osteophytes for dysphagic complaints. The surgical procedure is
performed in collaboration with an orthopedic surgeon (Fig. 9).
Dysphagia is mostly seen in cases of cervical
anterior osteophytes, mainly because C4–C7 are most
often affected and compression at this level causes
obstruction of the esophagus. Secondary aspiration can
occur in patients with severe obstruction of the
esophagus due to stasis. Primary aspiration can be
caused by large osteophytes at C3–C4 directly interfering with laryngeal elevation and closure in the
swallowing act. Primary aspiration can also occur as a
consequence of vocal fold immobility due to damage
of neural structures by the osteophytes (Giger et al.
2006). Dyspnea as a result of compression of the
remains of the stenosis at the oropharyngeal level and an
unobstructed view of the glottis. Circles the free edge of the
epiglottis, crosses semicircular strictures attached to the
epiglottis, A anterior, P posterior
pharynx and larynx is extremely rare (Matan et al.
2002). More common head and neck symptoms are
pain and problems with sensation (as a consequence of
compression of the cervical spine or vertebral artery),
Horner’s syndrome (Brandenberg and Leibrock 1986),
and obstructive sleep apnea (Girgis et al. 1982).
Dysphagia is often more severe with extension than
with flexion of the neck. Complaints are more pronounced for solid boluses than for liquid boluses.
Diagnostic investigation should include laryngoscopic ENT examination. A lateral plain radiograph
can be helpful in evaluation of the cervical spine
for congenital or degenerative changes. Computed
tomography or magnetic resonance imaging with
sagittal reconstruction is advised to enable location of
anterior bony lesions in relation to the surrounding
soft tissues, large vessels, and nerve sheets. Dynamic
videofluoroscopy is an important diagnostic tool, in
which the patient swallows a liquid and solid bolus so
that the dynamic process of deglutition can be evaluated. The level and cause of obstruction can be
determined if dynamic videofluoroscopy is combined
with conventional imaging of the spine. Manometry
can be helpful to exclude coordination disorders of
UES function.
438 H. F. Mahieu and M. P. Kos
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Fig. 15 Same case as in Fig. 14. a Preoperative videofluoros-
copy demonstrating the oropharyngeal stenosis (white arrow),
penetration of contrast material in the larynx (black arrow),
primary aspiration into the trachea, and an almost absent
pharyngeal constrictor muscle activity. b Postoperative
The treatment of patients with diffuse idiopathic
skeletal hyperostosis depends on the degree of the
symptoms. Initial therapy involves adaptation of food
consistency. Conservative treatment with nonsteroidal
anti-inflammatory drugs and antibiotics can be successful in cases with an inflammatory component
(Oga et al. 1993). The symptoms will often have a
more acute or subacute character in these cases.
When dysphagia is directly caused by obstruction
of bony protrusions, the symptoms will be more
chronic and slowly progressive. In these cases, or
when there are more severe symptoms such as chronic
aspiration and weight loss, surgical intervention
should be considered (Richter 1995). Especially in
older patients, who have a diminished cough reflex
and thus an elevated risk of developing aspiration
pneumonia, surgical treatment may be indicated.
Surgical approaches include anterolateral, posterolateral, and transoral approaches. Our preferred
videofluoroscopy in the pharyngeal phase revealing complete
reduction of oropharyngeal stenosis, an increased bolus
passage, and no penetration or aspiration. Of course, the
pharyngeal constrictor activity is still insufficient
approach is anterolateral, because it provides optimal
exposure of the large cervical vessels and vagal nerve
anda good exposureoftheprevertebralspace,butitdoes
place the recurrent laryngeal nerve at greater risk than
the other approaches (Akhtar et al. 2000). The posterolateralapproachoffers wide exposureof the prevertebral
space but requires more retraction of the carotid sheath
(Carrau et al. 1990). The transoral approach has the
advantage of cosmetic appeal as well as limited risk to
the aforementioned structures compared with the
anterolateral and posterolateral approaches. However,
thedisadvantagesinclude limitedexposureaswellasthe
potential riskoffascial infectionorosteomyelitis due to a
contaminated surgical field.
Spondylodesis is only indicated in the case of
instability after removal of cervical hyperostosis
(Richter 1995; Krause and Castro 1994). If sufficient
anterior ossification remains between the vertebrae,
there is a low risk of postoperative cervical instability.
Surgical Aspects of Pharyngeal Dysfunction, Dysphagia, and Aspiration 439
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Fig. 16 a Craniocaudal and b posteroanterior views of the
larynx and hypopharynx: the pharyngoplasty procedure. In each
case the left side shows the situation after dissection and
resecting the strictures, and before transpositioning of the
mucosal flap from the piriform sinus, and the right side shows
the situation after transpositioning of the mucosal flap and
2.4.2 Dysphagia and Dyspnea Caused
by Multiple Cervical Anterior
Meningoceles
Type 1 neurofibromatosis may present with a wide
spectrum of pathological anomalies. Very rarely it
may present as a spinal meningocele, a protrusion of
spinal meninges through a defect in the vertebral
column or foramina. The pathogenesis of the lesion
remains unclear, but several theories have been proposed, such as trauma (Freund and Timon 1992),
dural (Bensaid et al. 1992), and/or regional bony
dysplasia (Erkulurawatra et al. 1979). Magnetic resonance imaging is the preferred diagnostic tool for
most spinal abnormalities. This modality accurately
demonstrates the morphologic properties of a lesion,
and changes in the longitudinal contour of the spinal
cord can easily be detected. Computed tomography
can be helpful in showing a relation of nervous
structures to complex bony anatomy or in patients
unable to undergo magnetic resonance imaging.
suturing. The raw surface of the epiglottis edges remained
uncovered. The raw surface of the lateral free edge of the
epiglottis and pharyngeal wall is marked with R. The donor site
of the transposition flap is marked with D and its corresponding
end position points are marked with A, B, and C
Meningoceles may be asymptomatic, and do not
necessarily require treatment. The probability of the
gradual enlargement of the meningocele with time
and the possibility that it may cause pain, dysphagia,
and dyspnea should be weighed against the risks of
surgical resection of the meningocele. The goal of
surgical treatment of a basal meningocele is ligation
of its neck at the intervertebral foramina and resection
of the sac. Figures 10 and 11 demonstrate a patient
with type 1 neurofibromatosis who harbored a large
retropharyngeal mass, consisting of two cervical
meningoceles, causing dysphagia and dyspnea, and
requiring surgical removal. The procedure is performed in collaboration with a neurosurgeon.
An anterior–lateral surgical extrapharyngeal
approach is used for optimal exposure of the anterior
cervical spine. A transoral approach is advised against
because of contamination of the surgical field and
the risk of postoperative meningitis. Surgery may
be difficult because of dural defects and fragility
440 H. F. Mahieu and M. P. Kos
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2.5 Strictures and Fibrosis
of the Pharynx and UES
Fibrosis and strictures of the pharynx and UES are
usually the result of caustic ingestion or chemoradiation and occasionally external neck trauma. Even
though the nutritional status of the patient can easily be
restored by tube feeding, swallowing problems generally have a considerable impact on quality of life and
might also lead to socialisolation (de Boer et al. 1995).
Strictures are usually found in the hypopharynx or
cervical esophagus, but also at more cranial levels in
the pharynx. Depending on the stricture site, dyspneic
complaints can be induced besides dysphagia and lifethreatening aspiration. Usually (repeated) endoscopic
bougienage or balloon dilations can be a successful
treatment strategy (Piotet et al. 2008). Other treatment
options have to be considered if stricture formation has
Fig. 17 Endoscopic view of the larynx of another patient
demonstrating a similar, but less severe stricture (crosses)of
the free edge of the epiglottis (circles) and the lateral
pharyngeal walls and the arytenoids with the posterior part of
the vocal folds below. In this case the esophageal stenosis was
complete in continuity with an obliteration of the piriform sinus
bilaterally. A anterior, P posterior
of the meningocele. A postoperative lumbar drain to
diminish cerebrospinal fluid pressure is advisable.
Following excision, respiration as well as deglu-
tion normalized.
2.4.3 Dysphagia and Dyspnea Caused
by a Retropharyngeal Tumor Mass
Dysphagia and dyspnea can be caused by any retropharyngeal tumor of benign or malignant origin. Here
we describe an example of a 87-year-old female
patient with severe dysphagia and dyspnea caused by
a large retropharyngeal myxofibrosarcoma.
Myxofibrosarcoma is one of the most common
sarcomas in the field of orthopedic surgery. Typically,
it grows in the subcutaneous tissue of the extremities
in elderly persons. Myxofibrosarcomas in the head
and neck region are rare, and only a few cases of the
disease in this area have been reported. Following
excision, respiration as well as deglution normalized
(Figs. 12, 13).
advanced to complete stenosis or if the stricture is at a
more cranial pharyngeal level.
2.5.1 Mucosal Flap Pharynxplasty
with the CO
Laser
2
Strictures of the oropharynx are rare and complex
problems. Severe stricture formation can occur
between the lateral edges of the epiglottis and the
lateral and posterior pharyngeal walls. In one patient
who underwent radiotherapy for a T1 oropharyngeal
carcinoma of the soft palate (Figs. 14, 15) such a
stricture left a lumen of no more than 3–4 mm.
Dyspnea in exercise became apparent as well as
obstruction for larger food fragments in this segment,
each time also obstructing his airway. The microendoscopic use of the CO
laser provided an excellent
2
approach to release these strictures from the epiglottis
with excellent visualization and working space.
Mucosal pharyngeal reconstruction flaps can be
transpositioned to prevent recurrent contracture and
stricture formation. A tracheotomy under local anesthesia was first performed to improve the working
space and visualization and secure the airway. Despite
the impaired pharyngeal and tongue-base muscle
activity and loss of laryngeal elevation and closure,
near normal oral intake was achieved in this case.
However, even the possibility of restoring minimal
oral intake can provide a great improvement in the
quality of life and is therefore worthwhile to try to
achieve (Figs. 16, 17).
Surgical Aspects of Pharyngeal Dysfunction, Dysphagia, and Aspiration 441
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Fig. 18 a Preoperative
videofluoroscopy
demonstrating stenosis in the
postcricoid area (white arrow)
and severe aspiration (black
arrow). b Postoperative
videofluoroscopy
demonstrating bolus passage
into the esophagus with
moderate residual stenosis
and absence of aspiration
2.5.2 Anterograde–Retrograde Rendezvous
Dilation for Complete Hypopharyngeal
or UES Stenosis
Hypopharyngeal or UES strictures are commonly
managed with bougie dilatation as long as there some
lumen is still to be found. Laurell et al. (2003)
reported a 78% success rate with dilatation of hypopharyngeal strictures secondary to radiotherapy for
head and neck malignancies. Patients with moderate
to severe strictures required one to eight dilations.
The reported mortality rate was 5% secondary to
esophageal perforation.
In the case of complete obstruction of the hypopharynx/cervical esophagus, an anterograde–retrograde
dilatation technique can beconsidered. In thistechnique
a guide wire retrogradely introduced through a (preexistent) percutaneous gastrostomy and the lumen of the
esophagus can safely be detected from the hypopha-
Fig. 19 Rigid endoscope introduced through the percutaneous
endoscopic gastrostomy opening with a Savary dilation wire
(arrow) introduced. The flexible tube attached to the endoscope
is used for insufflation purposes
ryngeal side without creating a false route in the mediastinum, with the risk of mediastinitis. Often a rigid
endoscope is required to enter the esophagus from
below,becauseflexibleendoscopestendtocurlupinside
the stomach instead of passing through the LES into the
esophagus. After the lumen has been resorted, intermittent anterograde bougie dilatation is often required.
The anterograde–retrograde rendezvous technique
was first described by van Twisk et al. (1998), and
several other small series were reported later (Petro
et al. 2005; Maple et al. 2006). The advantage of this
technique is that a stenosis can be punctured with a
dilation guide wire away from the mediastinum,
avoiding a false route in this direction and thus
reducing the risk of mediastinitis. Sometimes transillumination is used from both sides to determine the
direction of puncture. If the stenosis extends over a
longer distance, anterograde dissection with a blunt
instrument or the CO
laser can be performed toward
2
an illuminated poststenotic lumen. Most patients
treated this way have responded well to subsequent
serial dilations and most have been able to discontinue gastrostomy tube use (van Twisk et al. 1998;
Petro et al. 2005; Maple et al. 2006) (Figs. 18, 19).
442 H. F. Mahieu and M. P. Kos
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with a transparent oblique-end hood attached to the tip and a
3 Conclusion
As in all elective surgical procedures, the dysphagic
patient has to be fit enough to overcome the stress
related to general anesthesia, the surgical procedure,
and the recovery period. However, the patent
with a severe dysphagic problem is often not in a
good condition and many patients have serious
comorbidity. This restricts the use of a surgical
treatment option in many cases. Furthermore, not all
disorders resulting in oropharyngeal dysphagia can be
successfully corrected surgically. Therefore, only a
minority of dysphagic patients will be able to benefit
from surgical treatment. However, the results presented in this chapter show that it is worthwhile to
take into consideration the several procedures which
have been described, in order to optimize the quality
of life of the dysphagic patient. Since the focus of this
chapter was on the surgical treatment of oropharyngeal dysphasia and no mention was made of swallowing rehabilitation, it should be stated that in
almost all patients following surgical treatment, with
the exception of patients with extraluminal compression and patients with ZD, an extensive postoperative
swallowing rehabilitation program is an integral part
of the treatment.
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The Post-Operative Pharynx and Larynx
https://t.me/med1917
Anita Wuttge-Hannig and Christian Hannig
Contents
1 Introduction.............................................................. 445
1.1 Altered Anatomy ....................................................... 446
1.2 Adapted Physiology of Swallowing.......................... 447
1.3 Adaptation Methodology ........................................... 449
1.4 Morphological and Functional Swallowing
Abnormalities............................................................. 449
1.5 Laryngectomy ............................................................ 449
1.6 Hemi-pharyngectomy ................................................ 451
1.7 Post-Therapeutic Pharyngeal Cancer ........................ 452
1.8 Cleft Palate ................................................................ 452
2 Post-Traumatic, Post-Lesional and Post-Surgical
Brain Lesions............................................................ 454
3 Scarring and Post-Surgical Instabilities
of the Pharynx.......................................................... 455
4 Conclusion ................................................................ 456
References.......................................................................... 456
A. Wuttge-Hannig (&)
Gemeinschaftspraxis für Radiologie,
Strahlentherapie und Nuklearmedizin,
Dres. Wuttge-Hannig-Rosskopf-Schepp-Sindelar,
Karlsplatz 3–5, 80335 Munich, Germany
e-mail: Olle.Ekberg@med.lu.se
C. Hannig
Institut für Röntgendiagnostik des Klinikums rechts der
Isar, Technische Universität München, Ismaningerstrasse
22, 82756 Munich, Germany
Abstract
Dysphagia is often seen in patients following
surgery to the pharynx and larynx. It may be due to
altered anatomy, altered physiology or altered
function. Dysfunction may be due to sensory
disturbances or altered biomechanics due to resection of muscles or repositioning of muscles.
Radiotherapy with or without chemotherapy often
contributes substantially to dysfunction. Mucosal
abnormalities are best evaluated during endoscopy
while extraluminal abnormalities including tumour
recurrence are evaluated with MR or CT.
1 Introduction
Considerable progress has been made in the past few
years in the diagnosis and treatment of swallowing
disorders of neurological, anatomic or vascular origin.
The treatment has been expanded to include patients
with cancer and others with a rather limited time
prognosis (Cantarella 1998; Denk et al. 1997; Groher
1992; Hannig and Wuttge-Hannig 1987, 1999; Han-
nig et al. 1989; Wuttge-Hannig and Hannig 1999;
Lazarus et al. 2000; Leonard et al. 2001; Logemann
et al. 1994).
This chapter will deal with patients who have
undergone ear, nose and throat (ENT) surgery, minor
or extensive and/or radio-, chemo- and the more
recent use of radioimmunotherapy and gamma-knife
therapy etc., including the sequelae of therapy
(Eisbruch et al. 2002; Furia et al. 2000).
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2012_650,
Springer-Verlag Berlin Heidelberg 2012
445
446 A. Wuttge-Hannig and C. Hannig
https://t.me/med1917
The development in recent years of newer
diagnostic and therapeutic modalities, including
combined surgical and chemotherapeutic and radiotherapeutic schemesresulting in cure or remissioneven
in advanced tumour stages, prompted the urgency to be
aware and recognise swallowing complications before
sequelae such as aspiration pneumonia become
apparent (Hannig et al. 1995a, 1991; Jung and Adams
1980; Walther et al. 1990).
The differentiation between anatomical causes and
functional origins related to sensory disturbances
which often occur a year or two following the original
treatment requires precise analysis in order to initiate
appropriate therapy (Hannig and Wuttge-Hannig
1999; Wuttge-Hannig and Hannig 1995). It is also
important to exclude submucosal spread of tumour,
which may escape endoscopic detection (WuttgeHannig et al. 2001). Late consequences of subcutaneous and muscular fibrosis may occur resulting in the
restriction of the antero-superior movement of the
larynx during swallowing (Hannig 1995).
1.1 Altered Anatomy
Dysphagia is often the result of the altered anatomy
following surgery such as laryngectomy, whereby
separation of the larynx from the anterior pharyngeal
wall produces a so-called pharyngeal tube seen
especially in wider resections of pharyngeal structures. The configuration and diameter of the pharyngeal tube can vary with different surgical and sewing
methods producing wide morphological variations in
the radiological appearance (Hannig et al. 1994, 1996;
Hannig 1995; Jung and Adams 1980; Martin et al.
1993) (Fig. 1).
The medical literature reports 15–20 % of dysphagia in partial and total laryngectomized patients
(Di Santis et al. 1983; Hannig 1995). In our own
series of 312 patients treated for laryngeal cancer,
37 % complained of dysphagia and 19 % of an
annoying globus sensation. The higher incidence in
our patients is probably due to stricter pre-selection of
our interdisciplinary group, a heightened awareness as
well as better patient education and compliance.
Post-therapeutic dysphagia following laryngectomy may be caused by the following pathology:
• Tumour recurrence (Fig. 2).
• Scarring and benign stenosis (Fig. 3).
Fig. 1 Normal post-surgical anatomy of the pharyngeal tube after
total laryngectomy.The pseudoglottis isseenasacircularnarrowing
• Functional disorder ofthe ‘‘pharyngealtube’’ andthe
pharyngo-esophageal transit zone (pseudoglottis)
(Fig. 4).
Functional disorders are difficult todiagnosewithvideo
endoscopy or conventional radiological procedures but
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