RESUMO
Radiation-induced pharyngoesophageal stenosis is a frequent and unwanted consequence of nonsurgical treatment of hypopharyngeal carcinomas. Current treatment mainly includes endoscopic dilatations, but a poor response to this modality and/or a severe stenosis may lead to a radical resection (pharyngolaryngectomy) and reconstruction with tubed flaps, which allow oral feeding but fail to preserve speech. In this report, we present a case of radiation-induced hypopharyngeal stenosis treated with a pharyngoesophageal bypass using an anterolateral thigh (ALT) flap with the intention of preserving the larynx. We describe the case of a 59-year-old male with severe pharyngoesophageal stenosis after chemoradiotherapy due to a squamous cell carcinoma, where conventional dilatation treatment failed to restore pharyngoesophageal passage of solids or liquids. Since the patient rejected a pharyngolaryngectomy due the loss of speech entailed, a pharyngoesophageal bypass was performed using an ALT flap. The flap measured 13 × 20 cm, which ensured a 4-cm-diameter tube and enough length to communicate the lateral pharyngeal wall with the cervical esophagus. Endoscopy did not reveal flap failure, and during the immediate postoperative period, the patient had a small cervical leak detected only by imaging that did not affect the skin and resolved with antibiotic treatment. The patient also required a tracheostomy on day 4 and initially had no passage of saliva through the bypass; we attributed this to edema that resolved spontaneously after 1 month with complete liquid and solid passage and laryngeal competence that led to tracheal decannulation. Good functional results were achieved both for speech and swallowing at 5-year follow-up. We believe that this procedure may be considered before performing a pharyngolaryngectomy for the treatment of a persistent benign stenosis in patients with a functional larynx.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Quimiorradioterapia/efeitos adversos , Esôfago/cirurgia , Hipofaringe/cirurgia , Faringe/cirurgia , Lesões por Radiação/cirurgia , Retalhos Cirúrgicos , Constrição Patológica , Deglutição/fisiologia , Seguimentos , Humanos , Neoplasias Hipofaríngeas/terapia , Hipofaringe/efeitos dos fármacos , Hipofaringe/efeitos da radiação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Fala/fisiologiaRESUMO
BACKGROUND: The cricopharyngeal muscle is of the skeletal type and, in this way, unable to sustain continuous contraction for long periods. Despite of this it has been considered as the responsible by the high pressure area, registered by manometry into the pharyngoesophageal transition. For this reason, it has been the object of therapeutics that promote the rupture of its integrity. AIMS: To give the anatomical bases to define the limits of participation of the cricopharyngeal muscle in the pharyngoesophageal transition function. To consider a morphological and functional alternative to explain the high pressure area on pharyngoesophageal transition and the implications of the myotomy, use of the botulinum toxin and balloon dilatation on pharyngoesophageal transition function. MATERIAL AND METHOD: Study of the laryngopharyngeal region in their morphologic characteristics and relationships on 24 pieces obtained from adults' corpses of both sexes fixed in 10% formaldehyde solution. RESULTS: The cricopharyngeal muscle presenting its anterior-lateral insertion, with a C-shaped outline, on the posterior-lateral edge of the cricoid cartilage. This kind of morphology blocks the possibility to generate a predominant anterior and posterior high pressure during its contraction like that we find at the pharyngoesophageal transition. The observation of this kind of pressure has its explanation in a tweezers-like relationship exerted on one side by the vertebral body and on the other side by the posterior contour of the cricoid cartilage. CONCLUSIONS: The muscular organization of the laryngopharyngeal segment allowed us to sustain that a large myotomy of the pharyngoesophageal transition, that takes more than just the cricopharyngeal transversal fasciculus, hinders the ejection function in a region where the dimension do not need any parietal sectioning. Myotomy that encompasses only the transversal fasciculus can contribute to improve the pharyngoesophageal flux by a decrease of the local resistance. The efficiency of this myotomy depends mostly on some residual pharyngeal ejection force and also on a slight hyolaryngeal displacement. The transversal fasciculus of the cricopharyngeal muscle is a narrow strip of muscular mass to be injected by percutaneous way with solution of botulinum toxin; maybe endoscopically. For this reason, dose, dilution and injection sites have an important meaning in the cricopharyngeal therapeutics using botulinum toxin. The efficiency of this procedure, like myotomy, depends on some residual pharyngeal ejection force and on, at least, some hyolaryngeal displacement. The dilation of the pharyngoesophageal transition with pneumatic balloon does not seem to be an adequate procedure for a region that does not present a narrow lumen determined by fibrosis. For anatomical characteristics of the TFE region, mean pressure as registered by the manometric method does not evaluate either the effectiveness or inadequacy of surgical myotomy, denervation or dilation using pneumatic balloon.
Assuntos
Toxinas Botulínicas/administração & dosagem , Cateterismo , Hipofaringe/anatomia & histologia , Músculos Faríngeos/anatomia & histologia , Adulto , Cadáver , Cartilagem Cricoide/anatomia & histologia , Cartilagem Cricoide/cirurgia , Feminino , Humanos , Hipofaringe/efeitos dos fármacos , Hipofaringe/fisiologia , Masculino , Manometria , Músculos Faríngeos/efeitos dos fármacos , Músculos Faríngeos/fisiologia , Músculos Faríngeos/cirurgiaRESUMO
Se presenta un grupo compuesto por 70 pacientes portadores de síntomas atribuibles a reflujo faringolaríngeo y 20 pacientes controles. Se describen y proponen 3 estadios clínocos nasofibroscópicos de la enfermedad y se correlacionan con los síntomas digestivos, broncopulmonares y faringolaríngeos en los pacientes y controles. En los 70 pacientes se analizan los resultados del tratamiento médico propuesto, siendo bueno en el 88,4 por ciento de los casos y regular en 11,6 por ciento
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Hipofaringe/fisiopatologia , Doenças Faríngeas/diagnóstico , Refluxo Gastroesofágico/complicações , Omeprazol/uso terapêutico , Estudos de Casos e Controles , Famotidina/uso terapêutico , Distúrbios da Voz/etiologia , Cisaprida/uso terapêutico , Tosse/etiologia , Hipofaringe/efeitos dos fármacos , Doenças Faríngeas/tratamento farmacológicoRESUMO
The presence of metacyclical promastigotes of Leishmania pifanoi in the hypopharyngeal duct of Lutzomyia youngi is reported. The insects were experimentally infected by engorgement on the tarsal lesions of hamsters. The metacyclics, whose morphology is illustrated, appeared in the hypopharynx 5 to 9 days after engorgement; they were more frequently found in the insects fed on unrefined commercial sugar. They role of amino derivates of glucose and galactose, as well as of amino acids in the development and migration of metacyclics, is investigated.