Bronwyn Jones

Caustic ingestion injuries of the upper aerodigestive tract

Few reports have described in detail the injuries that occur to the oral cavity, pharynx, and larynx following caustic ingestion.1 The role of dynamic radiographic studies to delineate the extent of damage has been minimized.2 In‐depth radiographic analysis of such cases has not, to our knowledge, been previously reported. In order to examine the injuries and functional abnormalities of these sites following caustic ingestion, the records of The Johns Hopkins Swallowing Center were reviewed. Five patients were identified as having significant upper aerodigestive tract caustic injuries. All patients had dysphagia, epiglottis injuries, and incomplete laryngeal protection with aspiration. Four of five had sustained some degree of esophageal stenosis. Also noted were pharyngeal muscle dysfunction, nasopharyngeal regurgitation, tongue fixation, and hypopharyngeal stenosis. Roentgenographic findings are described and illustrated. The multidisciplinary approach to the management and rehabilitation of these patients is discussed.

Intrasphincteric Botulinum Toxin for the Treatment of Achalasia

BACKGROUND Achalasia is a disorder of swallowing in which the lower esophageal sphincter fails to relax. We report the use of botulinum toxin, a paralytic agent, for the treatment of this condition. METHODS In a double-blind trial, 21 patients with achalasia received either 80 units of botulinum toxin or placebo, injected endoscopically into the lower esophageal sphincter. One week later, the response to treatment was assessed on the basis of changes in the symptom scores (measured on a scale from 0 to 9), pharyngoesophagograms, and results of esophageal manometric and scintigraphic studies. Patients who received placebo initially were subsequently treated with botulinum toxin. After six months, esophageal scintigraphy was repeated. RESULTS One week after treatment, the mean decrease in the symptom score was 5.4 points for the patients treated with botulinum toxin and 0.5 point for the placebo group (P = 0.001). The mean decrease in the pressure of the lower esophageal sphincter was 33 percent in the treatment group, as compared with a mean increase of 12 percent in the placebo group (P = 0.02), and the mean increase in the width of the opening of the lower esophageal sphincter was 204 percent in the treatment group, as compared with a mean decrease of 14 percent in the placebo group (P = 0.02). Nineteen of the 21 patients treated with botulinum toxin had symptomatic improvement initially; after six months 14 patients were still in remission. This improvement was accompanied by a decrease in esophageal retention that was sustained at six months (46 percent, as compared with a pretreatment value of 77 percent; P = 0.04). There were no serious adverse effects. CONCLUSIONS Injection of botulinum toxin into the lower esophageal sphincter is an effective, safe, and simple method of treatment for achalasia, with results that are sustained for several months.

Treatment of achalasia with intrasphincteric injection of botulinum toxin. A pilot trial.

Achalasia is a disorder characterized by a failure of the lower esophageal sphincter to relax with swallowing and by a lack of esophageal peristalsis. The sphincteric abnormalities in achalasia are thought to be caused by a selective loss of inhibitory neurons in the myenteric plexus, resulting in the relatively unopposed excitation of the smooth muscle by acetylcholine and other mediators. Our previous studies in animals [1] have shown that locally injected botulinum toxin, a potent inhibitor of acetylcholine release, can reduce lower esophageal sphincter tone. We report our initial experience with this agent for the treatment of achalasia in humans. Methods Ten symptomatic adult patients with achalasia were prospectively evaluated by barium video-esophagograms, esophageal scintigraphy, and manometry. Clinical response was evaluated by scoring three symptoms (dysphagia, regurgitation, and chest pain) on a scale ranging from 0 to 3 (0 = none, 1 = occasional, 2 = daily, and 3 = with each meal) [2]. At the time of upper endoscopy, 80 units of botulinum toxin was injected through a 5-mm sclerotherapy needle into the lower esophageal sphincter as estimated by endoscopy (1 mL of a 20 U/mL solution in each of the four quadrants). Patients were re-evaluated 1 week later. The study was approved by the Johns Hopkins Hospital Institutional Review Board. Statistical analysis was done using the student t-test. Unless otherwise stated, results are expressed as the mean SE. Results The study group consisted of 4 men and 6 women whose mean age was 51 years (range, 24 to 80 years). Patients had been symptomatic for an average of 4.7 years, during which time most patients had had esophageal dilatation at least once. One week after treatment, clinical scores for the 10 patients decreased from 5.3 0.4 to 0.7 0.3 (P < 0.001), and all three symptoms improved significantly. Seven patients became asymptomatic after one injection. Two patients with initially modest improvement required a second injection for a satisfactory response. One patient remained unsatisfied with the clinical response despite three injections; this treatment was thus considered a failure. All objective measurements of esophageal function improved. In 7 patients for whom results were available, lower esophageal sphincter pressure decreased from 46.0 5.5 mm Hg to 26.0 3.7 mm Hg (P = 0.007); in 9 patients, esophageal diameter decreased from 5.2 0.7 cm to 4.3 0.7 cm (P = 0.002); and in 9 patients, 5-minute esophageal retention decreased from 75% 8.9% to 56% 13% (P = 0.02). Of the nine initial responders, three relapsed approximately 2 months later. The other six patients remained asymptomatic after a single injection of botulinum toxin for a median duration of about 12 months (range, 11 to 14 months). Most patients gained weightin one case, as much as 16 kg. Clinical remission was accompanied by a sustained improvement in esophageal retention, as measured in two patients (the mean 5-minute retention at an average of 6 months after treatment was 26.3% compared with 38.5% before treatment; P = 0.01). The symptoms of three patients recurred approximately 1 year after treatment. Two of these patients have since been re-treated with botulinum toxin, and their symptoms completely resolved once again (Figure 1). No adverse effects were seen in any patient. No esophagitis was seen at follow-up endoscopy 1 week after injection. Figure 1. The change in esophageal clearance in one patient in response to injections of botulinum toxin. Discussion Traditional treatment of achalasia consists of balloon dilatation or myotomy. Although these procedures may relieve symptoms, they carry a significant risk for complications, notably perforation and gastroesophageal reflux [3-5]. A need therefore exists for alternative ways to treat this condition. Our preliminary open-label trial of botulinum toxin in patients with achalasia did not use control injections. Nevertheless, our results are encouraging and suggest that this treatment is potentially safe and relatively simple. An initial response was seen in 9 of the 10 patients (90%); 60% had a satisfactory long-term response (defined arbitrarily as >6 months). This compares favorably to the response rates after a single pneumatic dilatation (approximately 60%) and surgery (64% to 95%) [2, 6, 7]. The response of symptoms in our patients was accompanied by significant improvement in all objective esophageal test results. Most importantly, lower esophageal sphincter pressure decreased by about 50%, a change equivalent to that reported after balloon dilatation (41% to 50%) [2, 8, 9]. Symptoms seem to recur in the long-term responders about 1 year after the initial injection. However, it appears that in these patients, further injections at this stage retain their efficacy. Pneumatic dilatation also has a high rate of relapse after the first dilatation [2]. This necessitates further dilatations, each with its own risk for perforation. Botulinum toxin therapy is therefore an attractive alternative to dilatation, even if repeated injections are required. Although locally injected botulinum toxin has been used in several disorders of skeletal muscle spasm [10], this is the first report of its use in a disorder of gastrointestinal smooth muscle. Further studies are needed to confirm the initial promise of this new approach to treating achalasia.

Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2–8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.

The videofluorographic swallowing study.

This article describes the evidence for the physiologic foundation and interpretation of the videofluorographic swallowing study (VFSS). The purpose and clinical efficacy of VFSS are explained. Standardization of the VFSS procedure, protocol, interpretation, and reporting is highlighted as a critical step in future clinical practice and research. Individualized evidenced-based rehabilitation strategies are presented as key components that are systematically applied during the VFSS procedure and integrated into the swallowing management plan. A new tool that has been developed and tested for the quantification of swallowing impairment is introduced.

Submucosal accumulation of fat in inflammatory bowel disease: CT/pathologic correlation.

A prominent submucosal layer of decreased attenuation was demonstrated on CT in three patients with inflammatory bowel disease. On pathologic examination this zone proved to be due to extensive submucosal fat accumulation and not active inflammation. The potential significance of this finding is discussed.

Pharyngoesophageal interrelationships: observations and working concepts

Simultaneous disorders of the pharynx and esophagus are so frequent that the complete swallowing chain should be examined in all patients with dysphagia. Data are presented to support the concept that such simultaneous disorders represent related phenomena; the mechanism involves changes in cricopharyngeal function seen radiographically as cricopharyngeal prominence. If neurologic disease has been excluded, cricopharyngeal prominence may be the clue to esophageal disease. When cricopharyngeal prominence is found during dynamic imaging of the pharynx, intensive examination of the esophagus and a search for signs of compensation or decompensation in the pharynx should be undertaken.

Computed tomography of abdominal carcinoid tumor

Surgicalomputed tomography of the abdomen was performed in 10 patients with pathologically proven carcinoid tumor. In four patients numerous tiny punctate and radiating densities were seen in the mesentery. Two of these patients also had rounded mesenteric masses, 2.5–5 cm in diameter. The presence of punctate or radiating mesenteric densities reflecting desmoplastic reaction, when combined with rounded mesenteric masses or liver metastases, is highly suggestive of carcinoid tumor. The CT appearance of the hepatic metastases, is highly suggestive of carcinoid tumor. The CT appearance of the hepatic metastases in this group of patients was also assessed and found to be nonspecific

Dynamic imaging of the pharynx

The technique of dynamic imaging of the pharynx and some supplementary maneuvers which can be tailored to the individual patients needs are discussed in detail. An approach to the analysis of normal and abnormal swallowing studies is presented.

Vagal Reflexes Referred from the Upper Aerodigestive Tract: An Infrequently Recognized Cause of Common Cardiorespiratory Responses

OBJECTIVE To review the physiologic basis for normal and abnormal vagal reflexes arising from the pharynx, larynx, and esophagus, as well as the relevance of vagal reflexes to the pathogenesis of such clinically common cardiorespiratory responses as bradycardia, tachycardia, dysrhythmia, coronary angiospasm, bronchospasm, laryngospasm, prolonged apnea, and singultus (hiccups). DATA SOURCES Pertinent articles and reviews were identified through a MEDLINE search (April 1966 to October 1991). Older studies and others not identified in the MEDLINE search were found through a manual search of the bibliographies of the retrieved articles. STUDY SELECTION Experimental studies in both humans and animals, as well as case series and single case reports, were selected for evaluation and citation. In instances where a similar phenomenon was described in multiple independent reports, only studies that provided a novel finding or interpretation were cited. More authoritative book chapters and peer-reviewed summaries were also cited in support of commonly accepted principles. DATA EXTRACTION AND SYNTHESIS Most of the clinical data are derived from case reports and small case series and are therefore anecdotal; equal weight was given to all such studies. Reports of conflicting observations or interpretations were clearly identified and were cited without exception. CONCLUSIONS Stimulation of the upper aerodigestive tract can lead to clinically significant cardiorespiratory responses. Although the prevalence of and risk factors for such responses have not been established, we suggest that a pharyngeal, a laryngeal, or an esophageal source for abnormal cardiorespiratory responses be sought whenever a detailed clinical evaluation fails to reveal a cause, particularly when there are concurrent symptoms or signs of upper aerodigestive tract disease, such as dysphagia or gastroesophageal reflux.