xRead - Swallowing Disorders in the Adult Patient (October 2024)

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Key Words: aerodigestive disorders, best practices, cricopharyngeus hypertonicity disorders, cricopharyngeus muscle dysfunction, dysphagia, Zenker diverticula. Level of Evidence: Level III Laryngoscope , 134:2678 – 2683, 2024

INTRODUCTION Simply stated, the act of swallowing is a highly coordinated sequence of muscular constriction and relaxa tion to propel a bolus into the esophagus while protecting the airway. Perturbations in this process present as dyspha gia and/or aspiration. One subset of pharyngoesophageal dysphagia is cricopharyngeus muscle dysfunction (CPMD), which refers to the failure of the CP muscle to relax appro priately. 1 CPMD can occur with or without diverticula. Zenker diverticulum (ZD) is an outpouching of pharyngeal mucosa and submucosa through a natural weakness in the pharyngeal musculature cranial to the obstructing cricopharyngeus muscle. 1,2 This pulsion-type diverticulum develops due to increased intraluminal pressure within the hypopharynx forcing a false diverticulum to herniate between the oblique fi bers of the inferior pharyngeal con strictor and the circular fi bers of the cricopharyngeus mus cle, that is, Killian triangle. 3 The surgical treatment of ZD was fi rst described by Wheeler in 1886 in an open transcervical approach; however, multiple endoscopic methods have become popularized as early as 1960 with Dohlman ’ s fi rst description. 4,5 With the development of high-quality rigid endoscopes, surgical management of pharyngeal divertic ula has shifted in the past few decades to favor less invasive approaches. 6,7 In 2004, a survey of European oto laryngologists demonstrated strong preference for endo scopic techniques for surgical management of ZD. In this survey, 80% of physicians kept patients nil-per-os (npo) for up to 24 h postoperatively with 30% using a nasogastric tube (NGT) immediately postoperatively. 8 Most surgeons (80%) recommended discharge on postoperative day (POD) two. 8 In 2010, the American Broncho-Esophageal Associa tion (ABEA) surveyed members to understand American practices in management of ZD. Their survey demon strated that almost half of respondents recommend endo scopic repair over open to 100% of surgical candidates. 6 In contrast, Wang et al. repeated the ABEA survey in 2022, demonstrating that most practitioners employed a range of surgical techniques for management of ZD and tailored postoperative management (e.g., observation time) based on approach. 9 Endoscopic intervention has speci fi cally been advocated for decreased length of hospital stay and earlier time to oral intake. 6,8,9 However, these purported advantages are based primarily on expert opinion. Despite growing evidence comparing endoscopic versus open approaches there remains variability in postoperative management of ZD. At present, there is a dearth of data in the literature to assess the relationship between periopera tive factors and postoperative course, aside from presumed approach-based differences. The Prospective OUtcomes in Cricopharyngeus Hyper tonicity (POUCH) Collaborative was established in 2017 as a dysphagia interest group to develop a multicenter pro spectively enrolled database of patients with CPMD with

and without diverticula. The purpose of this study is to identify trends in postoperative management in persons undergoing surgery for Zenker diverticula (ZD) by evaluat ing length of stay (LOS), diet restrictions on discharge, and utilization of radiographic imaging. We hypothesized that LOS, diet on discharge, and radiographic imaging were affected by surgical approach (endoscopic vs. open) and suspicion of surgical complications. MATERIALS AND METHODS IRB approval was individually obtained by each of 11 insti tutions enrolled in the POUCH Collaborative. This is a prospec tively collected, longitudinal REDCap database for patients with CPMD with or without diverticula and with and without surgery, previously described by Howell et al. 10 Patients with an intraoperative diagnosis of ZD (of any size) between August 1, 2017 and February 1, 2023 were included. Demographics were extracted directly from the database. Surgical approaches were categorized as: (1) endoscopic procedure, de fi ned as a purely trans-oral approach without an external incision versus (2) open procedure, de fi ned as any approach to the diverticulum using an external cervical incision. 11 Endoscopic techniques included in our data were laser, stapler ligasure, botox injection, and balloon dilation. Open techniques included diverticulotomy, diverticulopexy, pouch inversion, and myotomy. Postoperative complications were categorized by the following: subcutaneous air, leak, hematoma, mediastinitis, recurrent laryngeal nerve (RLN) injury, acute dysphagia, oropharyngeal bruising/laceration, and other medical causes. Hospitalization time in days, referred here as LOS was categorized as less than 23-h observation, 48-h observation, and >48-h observation. Diet upon discharge from the hospital was categorized as (1) full diet without restrictions, (2) restricted diet, including soft, pureed/ liquid or a tapered advancement from either, or (3) npo with NGT. Presence of and results from any type of contrast esophagography (such as a barium or gastrogra fi n esophagram) obtained during the immediate perioperative period (veri fi ed by date as compared to surgical date) were also examined. Descriptive statistics such as frequency, percentages, means and standard deviation (SD), or medians with inter quartile range (IQR) (for non-normally distributed variables) were used to summarize characteristics of the patient population and the distribution of measured variables. Chi-square and Fish er ’ s exact tests, as appropriate, were used to compare association between LOS and open or endoscopic groups as well as diet at discharge and open or endoscopic group. RESULTS There were 298 patients with ZD and undergoing surgical treatment identi fi ed from the prospectively col lected REDCap database. The mean (SD) age was 71.8 (11.2) years and 60% male. There were 79.5% (237/298) patients who underwent endoscopic intervention versus 20.5% (61/298) with an open ZD surgery. Demographics of this cohort are summarized in Table I; clinical course of this cohort is illustrated in Figure 1. McKeon et al.: Postop Management of ZD, Contemp. Perspective 2679

Laryngoscope 134: June 2024