Abstract
It has been reported that the larynx of patients with unilateral recurrent nerve palsy, associated laryngeal nerve palsies and hemilateral neck surgery does not rise evenly on the disturbed side. When the degree of the ill-balanced laryngeal elevation is severe, it can contribute to disorders of swallowing. However, the mechanisms by which these disorders of swallowing occur are not yet clear.
Here we describe four patients with severe ill-balanced laryngeal elevation and dysphagia. Two of these patients had undergone partial hypo-pharyngectomy and reconstructive surgery with a pectoralis major myocutaneous flap. The third patient underwent subtotal thyroidectomy, hemilateral extraradical neck dissection, mediastinal dissection and collagen injection to the disturbed vocal fold. The fourth patient underwent esophagectomy and reconstructive surgery with a reversed gastric tube esophagoplasty and left arytenoid rotation. Glottal closures were mostly conserved in all four patients. Video-fluorography of the swallowing motions with barium from a frontal view revealed for all of the patients the disturbed swallowing pattern described below.
(1) When the larynx rose unevenly on the disturbed side, a bolus was passed to the pyriform sinus of the affected side.
Bolus transport to the pyriform sinus on the contralateral side was reduced.
(2) When the laryngeal elevation was almost complete, the remaining bolus of the pyriform sinus on the affected side over-flowed into the glottic space and trachea.
(3) At the same time, the remaining bolus of the contralateral side was collected.
(4) On the next laryngeal elevation, the remaining bolus of the pyriform sinus on the contralateral side overflowed into the trachea.
Swallowing in a chin down position was not effective. Head rotation to the affected side during swallowing decreased the bolus transport to the pyriform sinus of the disturbed side, but the remaining and overflow volume of the pyriform sinus on the contralateral side was larger. Next, we set the patients' head position so that their cheeks were resting on their hands with a slight rotation to the affected side (“resting the cheek on the hand” position). Consequently, their aspiration improved greatly due to the enlarged pyriform sinus at the contralateral side and the correction of ill-balanced laryngeal elevation.
