Otolaryngologic Clinics of North America

This article explores the landscape of dysphagia assessment in adults. Dysphagia, a complex condition affecting the lifespan and many health conditions, significantly compromises individuals' quality of life. Dysphagia is often underdiagnosed, emphasizing the need for comprehensive assessment methods to ensure timely and accurate intervention. It encompasses clinical history, physical examination, clinical and instrumental swallow evaluations. Procedures within each of these modalities are reviewed, highlighting strengths, limitations, and contribution toward a complete understanding of dysphagia, ultimately guiding effective intervention strategies for improved patient outcomes...

Esophageal dysphagia is a common yet difficult to diagnose condition. This article underscores the role of detailed patient history and physical examinations, including prompt endoscopic evaluation, for accurate differentiation between esophageal and oropharyngeal dysphagia. The authors discuss the heightened importance of early intervention in certain patient groups, such as elderly individuals and patients with head and neck cancer, to mitigate the risk of malnutrition and infection. The authors delve into etiologic factors highlighting the complexity of clinical presentations and the significance of tailored management strategies...

While many patients who present with dysphagia have a clinically identifiable cause of dysphagia, the etiology of swallowing difficulty is oftentimes a diagnostic enigma. The aim of this article is to review possible etiologies of dysphagia when objective evidence of dysphagia is lacking. Included in this discussion are cricopharyngeal spasm, retrograde cricopharyngeal dysfunction, muscle tension dysphagia, dysphagia secondary to medications, and functional dysphagia.

Dysphagia is a common manifestation of endocrine and metabolic diseases. Swallowing is a complex neuromuscular process, with an interplay of sensory and motor function, that has voluntary and involuntary control. Disruptions in any of these processes can cause significant dysphagia. Endocrine disorders and metabolic derangements are systemic conditions that affect multiple organ systems. They contribute to the development of neuropathies, myopathies, and motility disorders that lead to swallowing difficulty...

Swallowing is an elaborate process that requires neuromuscular coordination. Pediatric esophageal dysphagia is broadly categorized into structural and nonstructural causes. The structural causes of pediatric esophageal dysphagia are related to processes that narrow the lumen of the esophagus. Esophageal strictures are the result of scar tissue formation within the lumen of the esophagus, leading to stenosis. Vascular rings and slings cause external compression of the esophagus. Diagnosis requires an esophagram and computed tomography or magnetic resonance imaging...

This article provides an overview of neurogenic dysphagia, describing the evaluation and management of swallowing dysfunction in various neurologic diseases. The article will focus on stroke, Parkinson's disease, amyotrophic lateral sclerosis, and multiple sclerosis.

Obstructed breathing is the most common indication for tonsillectomy in children. Although tonsillectomy is performed frequently worldwide, the surgery is associated with a number of significant complications such as bleeding and respiratory failure. Complication risk depends on a number of complex factors, including indications for surgery, demographics, patient comorbidities, and variations in perioperative techniques. While polysomnography is currently accepted as the gold standard diagnostic tool for obstructive sleep apnea, studies evaluating outcomes following surgery suggest that more research is needed on the identification of more readily available and accurate tools for the diagnosis and follow-up of children with obstructed breathing...

Pediatric patients with persistent obstructive sleep apnea (OSA) after adenotonsillectomy often have additional sites of upper airway obstruction such as the tongue base or larynx. Sleep endoscopy and cross-sectional, dynamic imaging can be used to direct the surgical management of persistent OSA. The tongue base is one of the most common sites of obstruction in children with persistent OSA, especially for patients with Trisomy 21. Lingual tonsillectomy, tongue suspension, and/or posterior midline glossectomy may be used to address lingual tonsil hypertrophy and tongue base obstruction...

Insomnia and obstructive sleep apnea (OSA) are 2 of the most prevalent sleep disorders and frequently co-occur. Cognitive behavioral therapy for insomnia is the first line treatment for insomnia and has been shown to improve compliance with positive airway pressure therapy. Other alternatives to OSA treatment may have higher acceptance in those with comorbid insomnia and sleep apnea (COMISA). Surgery, particularly hypoglossal nerve stimulation, appears to be well tolerated and may improve insomnia in those with COMISA...

Obstructive sleep apnea in newborns and infants presents a unique challenge with distinct differences in sleep physiology, etiologies, and management compared to older children. The indications for and interpretation of polysomnography are less well defined in infants. There are also no broadly accepted clinical practice guidelines for treating sleep apnea in this age group. Etiologies include general causes of upper airway obstruction in infants such as laryngomalacia, micrognathia, and nasal obstruction in addition to adenotonsillar hypertrophy...

Pediatric patients with persistent obstructive sleep apnea (OSA) after adenotonsillectomy often have additional sites of upper airway obstruction such as the tongue base or larynx. Sleep endoscopy and cross-sectional, dynamic imaging can be used to direct surgical management of persistent OSA. The tongue base is one of the most common sites of obstruction in children with persistent OSA, especially for patients with Trisomy 21. Lingual tonsillectomy, tongue suspension, and/or posterior midline glossectomy may be used to address lingual tonsil hypertrophy and tongue base obstruction...

Neurostimulation of hypoglossal nerve has emerged as an effective treatment option of obstructive sleep apnea (OSA). Since FDA approval in 2014, therapy has been widely used in select patients with moderate-to-severe OSA who do not benefit from positive airway pressure. Ongoing research and technological developments continue to advance the therapy to deliver personalized and efficient treatment to patients with OSA.

This article is a review of advances in pharyngeal surgery over the past 10 years regarding literature, surgical technique, assessment, collaboration, and future direction in the management of adult and pediatric obstructive sleep apnea.

Pediatric dysphagia is a common condition encountered in clinical practice. We review the physiology and development of swallow, presentation, epidemiology, and etiology of dysphagia. Additionally, comorbidities, associated conditions, and medical management of dysphagia are discussed.

Optimal surgical and medical management of obstructive sleep apnea (OSA) requires clinically reliable identification of patterns and sites of upper airway obstruction. A wide variety of modalities has been used to evaluate upper airway obstruction. Drug-induced sleep endoscopy (DISE) and cine MRI are increasingly used to identify upper airway obstruction sites, to characterize airway obstruction patterns, to determine optimum medical and surgical treatment, and to plan individualized surgical management. Here, the authors provide an overview of the applications of DISE and cine MRI in assessing upper airway obstruction in children and adults with OSA...

Foreign body ingestions commonly occur in children aged under 6 years. While serious complications of ingestions are rare, sharp objects, caustics, multiple magnets, and button batteries can be associated with poorer outcomes including gastrointestinal (GI) obstruction, perforation, necrosis, and fistula formation. Initial workup should include history, physical examination, and plain film radiographs that will identify radiopaque objects. Removal of the foreign body is typically warranted if the object is high risk, it is located higher up in the GI tract, the patient is symptomatic, or the object is retained for a prolonged amount of time...

While adenotonsillectomy is the primary treatment of pediatric obstructive sleep apnea (OSA), persistent OSA after surgery is common and may be due to residual obstruction at the nose, nasopharynx, and/or palate. Comprehensive evaluation for persistent pediatric OSA ideally includes clinical examination (with or without awake nasal endosocpy) as well as drug-induced sleep endoscopy in order to accurately identify sources of residual obstruction. Depending on the site of obstruction, some of the surgical management options include submucous inferior turbinate resection, septoplasty, adenoidectomy, and expansion sphincter pharyngoplasty...

Up to 80% of children with Down syndrome (DS) are affected by obstructive sleep apnea (OSA), and only 16% to 30% will have resolution of their OSA with adenotonsillectomy. Hypoglossal nerve stimulation is a well-established therapy for adults with OSA and was recently approved by the Food and Drug Administration for use in children with DS and residual OSA. There is robust experience with this therapy in adults that has led to well-established care pathways. However, given the challenges inherent to caring for a complex pediatric population, these pathways are not directly transferrable to children with DS...

Children with tracheostomies have multiple challenges with respect to achieving normal deglutition. These children may have underlying neurologic or genetic conditions that can predispose to dysphagia, but even in children without underlying comorbidities, the presence of a tracheostomy tube impacts the mechanics of swallowing, leading to difficulty with different consistencies as well as management of normal oral secretions. Intubation prior to tracheostomy also impacts sensation in the upper aerodigestive tract increasing the risk of aspiration...

The upper aerodigestive system is closely intertwined from an embryologic and functional perspective. Laryngotracheal anatomic abnormalities, such as laryngomalacia, stenosis, vocal cord paralysis, and laryngeal clefts, affect not only the respiratory function but also the swallow function. Laryngotracheal pathology can interfere with the suck-swallow-breathe mechanism in infants. It can also exacerbate gastroesophageal reflux. Chronic aspiration secondary to laryngotracheal anomalies can result in respiratory and pulmonary complications...