A foreign body lodged in the sub-mental space through to the retro-pharyngeal area: a review of anatomical risks and surgical approaches

Background Foreign body inclusions are rare in head and neck. They are challenging in regard to anatomical risks and surgical approaches. This is the case of a particular foreign body with a curious trajectory, associated with a brief review of anatomical risks and surgical approaches. Case presentation This is the case of a 25-year-old male who has been attacked with a sharp object, which caused an inclusion of a part of the foreign body in the sub-mental and pharyngeal areas. The clinical exam showed a painful bulging in the sub-mental area, with moderately hemorrhagic sputum and difficulty while swallowing. The intra-oral exam showed a foreign body that was located at the right side of the base of the tongue, and which goes backwards and outwards to penetrate retro-pharyngeal mucosa. The patients underwent an angio-CT scan, which showed a curious fine and sharp metallic object, without direct signs of lesions to the jugular vein or carotid artery or any collateral branches. The patient underwent extraction through cervical approach, with satisfying bleeding control. Intra-oral exploration showed a retro-pharyngeal lesion of 2 cm, without particular bleeding. The cervical lesion and retro-pharyngeal lesions were closed. The lesion at the base of the tongue was of 1 cm, palpable but not accessible to sutures, and a naso-pharyngeal tube was inserted. The patient presented very satisfying post-operative outcome, without any complications. Conclusion When dealing with foreign bodies of head and neck, physicians must be precocious and prepared for the risk of bleeding after extraction. Thorough radiological exploration is necessary as long as the patient is stable. Direct and indirect radiological signs allow the clinician to understand the nature and the trajectory of the object, as well as the damage to collateral structures.

Nontraumatic Atlantoaxial Rotatory Subluxation: A Rare Complication of COVID-19 in Elderly Patient

Introduction: Nontraumatic Atlantoaxial Rotatory Subluxation (NAAS) or Atlantoaxial Rotatory Subluxation (AARS) without trauma or concomitant bone pathology was first described by Sir Charles Bell in 1830 in a patient with syphilis and pharyngitis, who developed lethal outcome due to spinal compression. The syndrome was named after Grisel who described two cases of pharyngitis and atlantoaxial subluxation in 1951. However, this is an uncommon condition of uncertain etiology characterized by NAAS, usually seen in children secondary to an infection and inflammation in the head and neck region or otolaryngeal procedures. Patients generally complain about neck stiffness and pain, and sometimes dysphagia may occur. Diagnosis is established based on the clinical and radiological findings. The etiopathogenesis and the underlying pathomechanics have not been clearly explained. A hematogenous spread of infection from the posterior pharynx to the cervical spine, according to the recent literature, with hyperemia and abnormal relaxation of the atlantoaxial ligaments is a widely accepted theory. The vascular plexus providing the drainage of poster superior pharyngeal area is responsible. The periodontoid plexus is connected with posterior nasopharyngeal veins via the pharyngovertebral vein. Any infective embolism may spread from superior pharyngeal area to upper cervical joints due to this plexus which does not have any lymph node, thus providing an anatomical explanation for the atlantoaxial hyperemia reported in Grisel's syndrome; however, the clinical picture and complications of COVID-19 are unclear until now and every day new symptoms and findings are reported as early and late complications. Methodology: An 86-year-old male presented to our clinic in KKT, Jeddah from Yanbu (which is 330 km away) with a complaint of neck stiffness in anterior-lateral position after recovery from COVID-19 six months back. The patient was treated at home without admission in hospital. He had no history of trauma. During the physical examination, the patient's neck was stiff, and there was neck pain with palpation and left-sided torticollis. The patient’s weight was 58 kg, height 160 cm, blood pressure 140/75 mmHg with a pulse rate of 72, SPO2 95, and BMI 22.7. There was no sign of fever or any type of inflammation in his body. The patient had previously consulted neurosurgeons at three different hospitals in Jeddah and was advised a medication with a cervical collar for a clinical follow-up. After three weeks of follow-up, they advised him to start physiotherapy for one month with no benefits seen in clinical finding, the patient then came to us. Direct radiogram of the cervical region showed suspicious findings at the atlantoaxial joint. Anterior view of the cervical radiography revealed tilted position of the head over neck, while the lateral view showed no thickening of the parapharyngeal soft tissue. The distance between the axis and dens was within normal values for his age (ADI = 3–4 mm). This confirms our diagnosis of type 1 atlantoaxial subluxation according to Fielding and Hawkins classification. Result: Based on the patient’s history and physical examination, there was no infection or neck operation causing an inflammation in the neck except the COVID-19 six months prior to the neck stiffness. With this case, we would like to highlight that atlantoaxial subluxation should be kept in mind when neck stiffness is seen in elderly patient without history of trauma but with a history of COVID-19 as a rare complication. Conclusion: NAAS is a rare but major complication that can often go unnoticed in its early and late phase, which can be a major cause of morbidity following COVID-19 infections, thus early recognition and diagnosis is mandatory especially in adult and elderly patients recovering form COVID-19.

Changes in Tongue Area, Pharyngeal Area, and Pharyngeal Airway Velocity after Correction of Mandibular Prognathism

This study aimed to investigate the correlation between the amount of mandibular setback, and the related changes of the tongue area, pharyngeal area, and pharyngeal airflow velocity. Twenty-five patients treated for mandibular prognathism, and serial cephalograms were obtained (T1: preoperation, T2: more than one year postoperation). The postoperative area of the tongue, pharyngeal airway space, and pharyngeal airflow velocity were investigated. Statistical analysis was performed with the Student t-test and Pearson correlation. The amount of mandible setback was significant after surgery (12.8 mm; p < 0.001). The pharyngeal area was significantly reduced 115.5 mm2 (p = 0.046). There was a slight reduction of the tongue area (43.2 mm2; p = 0.305) and an increase of pharyngeal airflow velocity (0.3 m/s; p = 0.133). The Pearson correlation coefficient test showed no statistical significance among the amount of horizontal setback and vertical movement of the mandible, such as the reductions in the tongue area, the pharyngeal airway space, and the increase in pharyngeal airflow velocity. Larger amounts of mandibular setback caused a significant reduction of pharyngeal airway area, but without significant changes of the tongue area and pharyngeal airflow velocity.

Review of some Perinereis Kinberg, 1865 (Annelida: Nereididae) species of Group 2 sensu Hutchings, Reid & Wilson, 1991 from the Eastern and South-eastern Asian seas

The present study reviews Perinereis Group 2 species from the Eastern and South-eastern Asian seas based on morphological analysis of the types, non-types and original descriptions, and the use of molecular evidence (COI and 16S rDNA) from newly collected material. These species are characterized by having two bar-shaped paragnaths on pharyngeal area VI, which are often deemed conical when small and pointed, triggering misidentifications as to Neanthes species. New terminology and definition for this particular type of bars are proposed, and the generic position of some resembling Neanthes species is also re-assessed. Five species are transferred to Perinereis: Perinereis babuzai comb. nov., P. belawanensis comb. nov., P. kinmenensis comb. nov., P. shigungensis comb. nov. and P. vitabunda comb. nov. ‘Perinereis aibuhitensis’ species group is newly proposed by encompassing species having proximal dorsal ligule similar throughout the body, dorsal cirri short, and blades of heterogomph falcigers straight with long terminal tooth forming a distinct tendon. Perinereis belawanensis comb. nov., P. linea and P. vitabunda comb. nov. are redescribed. Perinereis linea is regarded as a senior synonym of Nereis (Neanthes) orientalis and Perinereis vancaurica tetradentata based on type material, whereas its exotic status in the Mediterranean Sea is questioned. An identification key to all currently valid species within Perinereis Group 2 is also provided.

Which Physiological Swallowing Parameters Change with Healthy Aging?

Research suggests there are age-related changes in swallowing that do not constitute impairment (“presbyphagia”). The goal of this study was to explore the influence of age on quantitative measures of healthy swallowing by controlling for the effects of sex and sip volume in order to determine the specific characteristics of presbyphagia. Videofluoroscopy recordings of thin liquid swallows from 76 healthy adults (38 male), aged 21-82 were analysed. Blinded duplicate ratings of swallowing safety, efficiency, kinematics, and timing were made using the ASPEKT method. Hierarchical regression models were used to determine the effects of age, sex, and sip-volume on swallowing. There were no age-related changes in sip volume, number of swallows per bolus, frequency or severity of penetration-aspiration, duration of the hyoid-burst (HYB)-to-upper-esophageal-sphincter (UES) opening interval, time-to-laryngeal-vestibule-closure (LVC), peak hyoid position, hyoid speed, or pharyngeal residue. Significant changes seen with increasing age included: longer swallow reaction time, UES opening duration and LVC duration; larger pharyngeal area at rest and maximum constriction; and wider UES diameter. Male participants had larger sip volume and pharyngeal area at rest. Larger sip volumes were associated with multiple swallows per bolus and shorter hyoid-burst-to-UES opening intervals. These results help to define presbyphagic changes in swallowing that can be expected in healthy older adults up to 80 years of age, and distinguish them from changes that represent impairment. Certain parameters showed changes that were opposite in direction to changes that are usually considered to reflect impairment: longer UES opening, longer LVC duration and wider UES opening. These changes may reflect possible compensations for slower bolus transit. Further research is needed to determine the points along the age continuum where observed age-related changes in swallowing begin to emerge.

The Effects of Midline Cerebellar rTMS on Human Pharyngeal Cortical Activity in the Intact Swallowing Motor System

We sought to compare the effects of 10 Hz cerebellar vermis (vs. unilateral hemispheric and sham) repetitive transcranial magnetic stimulation (rTMS) on cortical neuroelectrical activity and thereafter 10 Hz cerebellar vermis (vs. sham) rTMS on swallowing behaviour. Healthy participants (n = 25) were randomly allocated to receive vermis, unilateral hemisphere or sham 10 Hz cerebellar rTMS. Recordings were made using pharyngeal electromyography and manometry catheters, obtaining motor-evoked potentials (MEPs) and pressure recordings. The amplitudes of MEPs elicited using single-pulse TMS delivered to the pharyngeal areas of the motor cortex bilaterally were measured pre- and post-cerebellar stimulation. As in previous studies, abductor policis brevis (APB) MEPs were measured to assess post-rTMS modulation specificity. Swallowing was assessed using a swallowing accuracy task. Measurements were made at baseline and 15-min intervals for an hour post-intervention. Measurements involved TMS being used to elicit 10 MEPs bilaterally over the pharyngeal areas of the motor cortex, over the APB cortical representation adjacent to the pharyngeal area with the lowest resting motor threshold and 5 MEPs bilaterally over pharyngeal areas of the cerebellar hemispheres. Swallowing accuracy was assessed by giving participants 10 attempts to swallow and hit a digital target. Cerebellar vermis rTMS caused significant suppression of cortical pharyngeal MEP amplitudes compared with unilateral rTMS and sham (P = 0.0005, 0.002). APB and cerebellar MEP amplitudes were unaffected as were pharyngeal and APB MEP latencies. Following cerebellar vermis rTMS there was a significant reduction in swallowing accuracy compared with sham (P = 0.001). Our findings demonstrate cerebellar vermis rTMS exerts a suppressive effect on pharyngeal motor cortical activity and swallowing behaviour.

A Cross-Sectional, Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Amyotrophic Lateral Sclerosis

Purpose To date, research characterizing swallowing changes in individuals with amyotrophic lateral sclerosis (ALS) has primarily relied on subjective descriptions. Thus, the degree to which swallowing physiology is altered in ALS, and relationships between such alterations and swallow safety and/or efficiency are not well characterized. This study provides a quantitative representation of swallow physiology, safety, and efficiency in a sample of individuals with ALS, to estimate the degree of difference in comparison to published healthy reference data and identify parameters that pose risk to swallow safety and efficiency. Secondary analyses explored the therapeutic effect of thickened liquids on swallowing safety and efficiency. Method Nineteen adults with a diagnosis of probable-definite ALS (El-Escorial Criteria–Revised) underwent a videofluoroscopic swallowing study, involving up to 15 sips of barium liquid (20% w/v), ranging in thickness from thin to extremely thick. Blinded frame-by-frame videofluoroscopy analysis yielded the following measures: Penetration–Aspiration Scale, number of swallows per bolus, amount of pharyngeal residue, degree of laryngeal vestibule closure (LVC), time-to-LVC, duration of LVC (LVCdur), pharyngeal area at maximum constriction, diameter of upper esophageal sphincter opening, and duration of UES opening (UESOdur). Measures of swallow physiology obtained from thin liquid trials were compared against published healthy reference data using unpaired t tests, chi-squared tests, and Cohen’s d effect sizes (adjusted p < .008). Preliminary relationships between parameters of swallowing physiology, safety, and efficiency were explored using nonparametric Cochrane’s Q, Friedman’s test, and generalized estimating equations ( p < .05). Results Compared to healthy reference data, this sample of individuals with ALS displayed a higher proportion of swallows with partial or incomplete LVC (24% vs. < 1%), increased time-to-LVC ( d = 1.09), reduced UESwidth ( d = 0.59), enlarged pharyngeal area at maximum constriction, prolonged LVCdur ( d = 0.64), and prolonged UESOdur ( d = 1.34). Unsafe swallowing (i.e., PAS ≥ 3) occurred more frequently when LVC was partial/incomplete or time-to-LVC was prolonged. Pharyngeal residue was associated with larger pharyngeal areas at maximum constriction. Unsafe swallowing occurred less frequently with extremely thick liquids, compared to thin liquids. No significant differences in pharyngeal residue were observed based on liquid thickness. Conclusions Quantitative videofluoroscopic measurements revealed moderate-to-large differences in swallow physiology between this sample of individuals with ALS and healthy reference data. Increased time-to-LVC, noncomplete LVC, and enlarged pharyngeal area at maximum constriction were associated with impaired swallow safety or efficiency. Thickened liquids may mitigate the risk of acute episodes of aspiration in individuals with ALS. Further work is needed to corroborate these preliminary findings and explore how swallowing profiles evolve throughout disease progression.