PMC6881234_01
Clinical findings in case 1. (A) Preoperative fiberoscopic view. Vocal cord abduction was insufficient bilaterally, and saliva was aspirated into the subglottic area (arrow). (B) Preoperative high-resolution manofluorography (HRMF) finding. The black arrow shows the level of the upper esophageal sphincter (UES). The white arrow shows the level of the proximal esophagus (PE). HRMF revealed UES opening impairment during swallowing (white arrowhead) and abnormal deglutitive proximal esophageal contraction (ADPEC, the area surrounded by a white broken line). (C,D) Schemas of the surgery. Lateral view (C) and axial view (D). The removed area is encircled by a red line, and the location of the permanent tracheostoma is encircled by a blue line. (E) Postoperative HRMF finding. The resting UES pressure became low, and ADPEC disappeared postoperatively (the area surrounded by a red line). (F) Laryngeal fiberoscopic view after the surgery. The supralaryngeal mucosal surface appears smooth (arrow). (G) The videofluoroscopic swallowing study showed laryngeal closure without leakage and sufficient UES opening (arrow). (H) Permanent tracheostoma after surgery.
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F1
Laryngeal fiberoscopy showed bilateral vocal cord abduction impairment (Figure 1A). High-resolution manofluorography (HRMF) showed deficient relaxation of the UES during swallowing and abnormal deglutitive proximal esophageal contraction (Figure 1B). As cricopharyngeal myotomy appeared to insufficiently contribute to the improvement of UES opening during swallowing due to physical obstruction by the remaining lamina of the cricoid cartilage, modified central-part laryngectomy, which is less invasive and reduces the pressure of the UES by removing the whole cricoid cartilage, was performed (Figures 1C,D). Postoperatively, VFSS showed a wide upper esophageal opening and smooth bolus passage from the pharynx to the cervical esophagus without leakage at the surgical site (Figure 1E). HRMF on day 11 postoperatively revealed hypotensive resting UES pressure and disappearance of abnormal deglutitive proximal esophageal contraction (Figure 1F). The patient was able to restart oral intake 13 days postoperatively, and the tracheal cannula could be removed from his tracheostoma (Figure 1G). One month postoperatively, the mucosal surface of the closure site at the supraglottic area became smooth (Figure 1H), and the patient could enjoy regular oral food intake.
PMC6881234_02
Clinical findings in case 2. (A) Preoperative videofluoroscopic swallowing study (VFSS). The arrow shows contrast agent aspiration into the trachea during swallowing. (B) Operative schema. The removed area is encircled by a red line, and the place of the permanent tracheostoma is encircled by a blue line. The glottic closure site is shown as a brown line. (C) Postoperative VFSS. (D) View of the permanent tracheostoma without a cannula.
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F2
VFSS showed deteriorated pharyngeal contraction, impaired laryngeal elevation, and silent aspiration without clearance from the airway (Figure 2A). Considering his poor general condition with acute hepatobiliary function impairment and methicillin-resistant Staphylococcus aureus pneumonia with pleural effusion, glottic closure under local anesthesia was performed and a large permanent tracheostoma was created (Figure 2B). As VFSS on day 11 postoperatively showed no leakage at the surgical site (Figure 2C), he could restart oral liquid intake. Although solid food intake was difficult due to the impaired oral phase of swallowing and poor food passage at the UES portion, the frequency of secretion suctioning was dramatically decreased postoperatively, and the patient was discharged without a tracheal cannula (Figure 2D).
PMC6881234_03
Clinical findings in case 3. (A) Preoperative videofluoroscopic swallowing study (VFSS). (B) Operative schema. The removed area is encircled by a red line, and the permanent tracheostoma is located in the area surrounded by a blue line. (C) Postoperative VFSS. The arrow shows sufficient upper esophageal sphincter opening. (D) Postoperative laryngeal fiberoscopic view.
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F3
VFSS revealed that there was no obvious aspiration during liquid swallowing, except for short duration of velopharyngeal closure and small volumes of pharyngeal residue (Figure 3A). Subglottic closure with total cricoidectomy (Figure 3B) was performed under general anesthesia to shorten the operation duration and avoid postoperative pharyngoesophageal passing disturbance due to the tracheal cannula burden and the artificial ventilation tube. VFSS and laryngofibroscopy on day 13 postoperatively showed no leakage or infection at the surgical site (Figures 3C,D).