Efficacy of chin-down maneuver on pharyngeal residue following esophagectomy;
Prospective analysis
Yoshihiko Kumai, MD, PhD1;
Yuta Kamenosono, BSc1; Yasuhiro Samejima, MD, PhD1; Keigo Matsubara, BSc1; Naoya Yoshida MD, PhD2; Hideo Baba, MD, PhD2; Eiji Yumoto, MD, PhD1
1.Department of Otolaryngology Head and Neck Surgery, Kumamoto University Graduate School of Medicine
2.Department of Gastrointestinal Surgery, Kumamoto University Graduate School of Medicine
Abstract
Methods and Materials
Discussion
Objective: To quantitatively determine the efficacy of chin-down
maneuver following esophagectomy with three-field lymph node
dissection (3FL)
 Evaluations were performed by the three experienced raters
in blinded manner with VF still images of the lateral view
with/without chin-down maneuver.
 Inter-rater reliability was examined.
 The assessment five parameters of VF examination were set
as follows.
Aspiration is a common swallowing abnormality in patients
following esophagectomy as a consequence of factors such as
vocal fold paralysis, impaired epiglottic eversion, and incomplete
laryngeal elevation which generally results inefficient bolus
transit and impaired airway protection. Dumont et al1 found that
in a study of 309 patients who were surgically treated for
esophageal cancer, respiratory complications accounted for
64% of postoperative death, therefore, elimination of aspiration
is crucial for improving the morbidity of advanced esophageal
cancer. Dubrow et al2 demonstrated with radiographic studies
that the chin-down maneuver is simple technique to eliminate
aspiration that should be attempted in patients who aspirate
following esophagectomy. However, the specific mechanisms
responsible for minimizing aspiration with this maneuver
following esophagectomy remain unclear.
Study design: Prospective analysis of a series of consecutive
cases.
Materials and Methods: Videofluoroscopic (VF) evaluations of
20 patients (mean age, 65.6±6.2y) who received
esophagectomy with 3FL from May to August in 2014 were
reviewed. The assessment parameters of VF examination were
set as follows: amount of residue in the pyriform sinus (PS) and
vallecula after the 1st swallow, pharyngeal constriction ratio
(PCR), upper esophageal sphincter (UES) opening diameter
(UESD), duration of UES opening (DUES) and duration of
LVC(laryngeal vestibule closure)which was defined as the
duration of contact between the arytenoids and epiglottis base
during the 1st swallow. These parameters were calculated in the
VF still images of the lateral view and evaluated by three
experienced raters in blinded manner. Inter-rater reliability of
each parameter was examined using inter-rater correlation
coefficient and each parameter was compared before and after
chin-down.
Results: The inter-rater correlation coefficient of each
parameter was r=0.72～0.99 (p<0.01),which demonstrated
consistency in the evaluation. In comparison with before chindown, with chin-down， PCR, and residue in pyriform sinus were
significantly (p<0.01) smaller. Moreover, LVC, UESD and DUES
were significantly (p<0.05) larger with chin-down. However，the
amount of residue in vallecula was not significantly different
before and after chin-down (p=0.43).
Conclusion: Chin-down maneuver after esophagectomy with
3FL might help expedite swallowing ability by strengthening
pharyngeal constriction, widening the UES and enhancing
laryngeal closure.
PCR: pharyngeal
constriction ratio
PCR：PA(pharyngeal area) max
/ PA hold Leonard et al 2000
Pharyngeal strength
Three-field lymphadenectomy (3FL) in esophagectomy for
esophageal cancer is a surgical procedure to completely dissect
lymph nodes (LNs) around the recurrent laryngeal nerves
(RLNs) in the cervicothoracic region, where there is a high rate
of metastasis.
However, there are few studies regarding the details of
swallowing dysfunction and its proper rehabilitation maneuvers
after esophagectomy with 3FL.
The aims of this study were to quantitatively determine the
efficacy of chin-down maneuver on pharyngeal residue following
esophagectomy with three-field lymph node dissection (3FL) by
examining VF examination in prospective manner.
Contact
Yoshihiko Kumai MD, PhD
Dept. of Otolaryngology Head and Neck Surgery,
Kumamoto University Graduate School of Medicine
Email: kumayohis426yk@gmail.com
PA hold
According to Logemann et al,3 a chin-down maneuver is
helpful if patients delay triggering the pharyngeal swallow,
reduce tongue base retraction, and reduce airway entrance
closure. This maneuver widens the valleculae, and narrows the
entrance of the larynx to minimize penetration or aspiration. The
present study demonstrated that, in comparison with before
chin-down, with chin-down，PCR, residue in pyriform sinus and
LVC were significantly (p<0.01) smaller. These suggested that
chin-down would diminish pharyngeal residue by strengthening
both the pharyngeal constriction and brought the air way
protection consequently.
UES opening diameter: calculated at the level
of sub-vocal fold
Duration of UES opening: (Closing phase –
opening phase)/30
 Duration of LVC (laryngeal vestibule closure): Duration of
contact between the arytenoids and epiglottis base
Results
The inter-rater correlation coefficient of each parameter was
r=0.72~0.88, (p<0.01)
mm2
N.S.
p=0.5
180
* p<0.01 N=18
**
0.5
0.45
160
0.4
200
140
0.3
150
100
* * p<0.01 N=22
**
mm
*
*
Sec
14
0.7
12
0.6
Sec
1
0.9
10
0.5
0.7
8
0.4
0.6
0.25
80
100
60
50
0.5
0.2
6
0.3
0.15
4
0.2
2
0.1
0
0
0.05
N
C
0
0.4
0.3
0.1
20
N
C
0
* p<0.05 N=20
0.8
0.35
120
0
* * p<0.01 N=22
**
mm2
250
40
Since aspiration pneumonia has been identified as the major
factor associated with early death postoperatively, improvement
of swallowing dysfunction is indispensable for reducing
postoperative mortality of esophageal cancer.
PA max
Area of Pharyngeal residue in
vallecula and pyriform sinus
*
Introduction
PCR
N
C
N
C
0.2
McCulloch et al 4 demonstrated that swallowing pressure at
upper esophageal sphincter (UES) significantly decreased and
duration of lower swallowing pressure tended to be extended
with chin-down. The present study demonstrated that both
UESD and DUES were significantly (p<0.05) larger with chindown. Cerenko et al 5 pointed out that the magnitude of hyoid
excursion is inversely correlated with the negative pressure at
the UES during swallowing, whereas in a video manometric
study, Bulow et al.6 reported that the chin-down significantly
narrowed the distance between the mandible and hyoid bone
(i.e., hyoid excursion with relative descent of the mandible).
Many papers have noted that subatmospheric pressure acts as
a hypopharyngeal suction pump, is necessary for adequate
bolus transport.7,8 These suggested that chin-down would
promote widening the UES, possibly by narrowing the distance
between the mandible and hyoid bone with increasing greater
subatmospheric pressure in the UES, improving bolus passage
consequently.
0.1
N
C
Pharyngea Pharyngeal Pharyngeal UES
Duration
l residue in residue in Constriction opening of UES
vallecular piriform
Ratio
diameter opening
sinus
N:normal position
C:chin-down position
0
N
C
Duration
of LVC
Conclusions
Chin-down maneuver after esophagectomy with 3FL might
help diminish pharyngeal residue and expedite swallowing
ability by strengthening pharyngeal constriction, widening the
UES and enhancing laryngeal closure.
Detail information regarding the modulation of the swallowing
pressure examined with high resolution manometry (HRM)
would support our hypothesis in the near future.
References
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