Hy-fy Hitch- Zygomatico-hyoid Suspension for Dysphagia

Hy-fy Hitch- Zygomatico-hyoid Suspension system for the Managment of Post Surgical Dysphagia

abstract:

Dysphagia isn't only a main sign of the top and neck tumor but also the dangerous complication of the many surgical and other treatment modalities for the same. Though various studies have been done to detect this problem but very little is done towards the surgical management of the life intimidating condition. through this article the new surgical technique of handling oroesophgeal dysphagia by hyoid suspension system. Our strategy zygomatico-hyoid suspension is simple and logically effective way of handling dysphagia secondary to the surgical resection of lesion in the patient with head and neck cancer tumor. Though this technique is not attempted in large number of patients hence the long term benefits and overall improvement in patients standard of living is yet to be ascertained but still it's rather a new path in the medical mangament of dysphagia.

Introduction

Dysphagia is a term produced from the Greek words dys (difficulty) and phagein (to consume)1. It is a symptom that expresses a problem in the move of food and endogenous secretions (saliva) through top of the digestive system. Oropharyngeal dysphagia (OD) is a more anatomically constrained term referred to modifications in the copy of the bolus from the mouth to the esophagus (which means, in bolus propelling from the oral cavity to the pharynx, in the pharyngeal reconfiguration through the swallow, or in the beginning of top of the esophageal sphincter. 2

OD is an inescapable concern in the management of patients with dental malignancy. Being as an indicator at presentation, as an adverse impact during whatever the treatment, or as sequelae diminishing the quality of life of the patients, swallowing disorders need to be adequately expected and handled. For an final result to be considered functional, the patient has to be able to swallow in a powerful and safe manner. Actually, conserving a functional deglutition is usually the most crucial goal of the various function-preserving surgical techniques in mind and neck malignancy surgery.

Normal oropharyngeal swallowing:

swallowing is mainly split into three phases: 1) preparatory dental phase, 2) oral phase and the previous 3) pharyngeal and oesophageal phase. mechanically, several tightly coordinated actions are participating:(1) elevation and retraction of the tender palate with closure of oropharynx, (2) UES beginning, (3) laryngeal closure at the level of the laryngeal vestibule, (4) tongue loading (ramping), (5) tongue pulsion, and (6) pharyngeal clearance. a fundamental aspect of deglutitive pharyngeal reconfiguration is changing the oropharynx from a respiratory to a swallowing pathway by opening the inlet to the esophagus and sealing the inlet to the larynx. Laryngeal vestibule closure and therefore airway security during swallowing is achieved by laryngeal elevation and anterior tilting of the arytenoid cartilages against the bottom of the epiglottis. UES beginning results from anterior grip induced by contraction of the suprahyoid and infrahyoid musculature obvious fluoroscopically by anterior hyoid movements.

Pathophysiology of dysphagia:

Can be divided into two categories:

1) directly due to the resection of the tissue mixed up in swallowing i. e. tongue.

2) due to the damage caused by rays therapy by pursuing ways:

a: lowered pharyngeal peristalsis.

b: decresed or defective posterior inversion of the bottom of the tongue to the posterior pharyngeal wall structure.

c: reduced elevation of hyoid bone and larynx and lowered inversion of epiglottis. The use of laryngeal suspension as a technique to boost function following surgcial resection of the anterior floor of the mouth was 1st decribed by edgerton and duncan and DesPrez and Kiehn. 3, 4 later Jabaley and Hoopes simplified the idea of laryngeal suspension system after incomplete or complete resection of hyomandibular complex through much chromic catgut suture between the thyroid cartilage and mandibular symphysis on the premise that the main vector of pressure necessary to support the larynx is anterior and superior in the midline. 5 Goode R. L. also detailed the similar approach of laryngeal suspension system after total laryngectomy by thyroid mandibular suspension and he found that swallowing function was improved significantly with his method of laryngeal suspension. 6 Hillel A. D. and Goode R. L. provided lateral laryngeal suspension system technique where the throid cartlage was suspended to the condyle of resected mandible an adjustment of Goode R. L`s original technique, the advantage of this technique could it be triggers superior as well as lateral activity motion of larynx which widens the opening of reverse hypopharynx. 7 al these techniques have proven that the hyoid suspension will improve swallowing function to some extent but each one of these techniques are hyomandibular suspension system and our techniques is the one technique where we have used zygomatic bone a support bone through which hyoid is suspended and in our view this strategy provieds the most steady and most effective way of displacing hyoid anterio-superiorly resulting in the better swallowing control. in this specific article we explain our method of hyoid-zygomtic suspension.

Material and methods:

We perform zygomatico-hyoid suspension system in every the patients undergoing total or incomplete glossectomy with or without mandible resection. the procedure was performed at the mahatma gandhi cnacer institute miraj.

Notes on Hyoid-zygomatic Suspension system Technique

The hyoid suspension system in which 24 gauge stainless steel line was prestreched and utilizing a awl 26cm long a circumzygomatic to the hyoid bone suspension system was completed by the main element steps were the next. the task was performed under genearal anesthesia while doing most important resection of the tumor. patient was placd in anti-trendelenburg position with neck hyperextension. Incision was presented with in natural pores and skin crease between the hyoid poor body and the thyroid notch. Median strap muscle dissection between two imaginary parasagittal planes crossing the minimal cornu of the hyoid bone was completed. Hyoid bone mobilizing test in anterosuperior path carried out long lasting hyoid fixation after having tested the correct position of the thyroid cartilage below the hyoid bone, following fixed steps that are the following:The zygomatic arch is palpated and puncture wound is performed at the foundation of the temporal procedure for the zygomatic bone. Two pre-streched 24 gauge wires are approved circumferentially round the hyoid bone in your community where in fact the insertion of the fibrous loop for the intermediate diagastric tendon is present. Later awl is put from the arch puncture wound and handed anterior to the masseteric muscle and brought to the hyoid bone body region where the already cable loops are present. The wire is fed in to the vision of the awl and later pulled out. This line is removed from the awls vision and stablised. The awl now is reinserted superficial to the arch brought out from the previous anterior massetric site to the hyoid bone, the other end of wire is given in the attention and the cable combined with the awl is brought out. Traction force is given bilaterally and the range of motion of the hyoid along with its infrahyoid element is analyzed. Mandibular movements need to be checked before the wire connections are twisted and stabilised. Untoward grip is to be avoided in order to avoid hyoid bone fractures. Incision lines are finished in layers.

Postoperative Followup

Postoperatively all patients tolerated the task well, without intra- or postoperative difficulties. patients. all patients were continued nasogatric pipe ( NGT ) feeding for least 3 weeks postoperative period and the decision to remove the pipe and dental feeding was considered on the basis of patient to patient potential to swallow. No special or additional post-operative good care or assessment is necessary.

Discussion

The hyoid is a u-shaped bone found in the anterior neck of the guitar midline, at the centre of three power vectors aimed, respectively, for the mandible, sternum, and mastoid process. It gives insertion to the middle constrictor muscles, which form the lateral wall of the hypopharynx. The suspension system of the bone to the Zygomatic bone restores the substandard collapse of the reconstructed floor and lateral mandibular region and enhance the tone of the middle constrictor muscles. this technique unlike all the prior technique doesnt take support of the mandible by any means hence where in mandible resection is performed along with the tongue or the larynx this system is just about the only option open to the medical expert to suspend the hyoid bone. Without resuspension, it is speculated that resection of submental lateral mandibular region can lead to second-rate and posterior displacement of the hyoid bone. A posterior displacementof the hyoid bone may be implicated in obstruction of the pharyngeal airway which in turn can lead to Dysphagia, or swallowing impairment. The postsurgical alteration in proportions and position of the hard and delicate tissues encircling the pharyngeal space is also responsible for the airway blockage.

CONCLUSION:

Cicumzygomatic hyoid suspension system approach is a innovative technique and it is the only technique of hyoid suspension in which rather than mandible the support is taken from zygomatic bone. as in this technique the vector is same path but its assisting bone absolutely nonmobile there giving higher elevation and stable anterior displacement compared to the other tehcniques of hyoid suspension system. we found that swallowing and infra hyoid functions improvedin our patient in doing so QOL increased. This Hyoid suspension system technique works well when short-term results are considered. The need of a more valuable anatomic-based diagnostic procedure is crucial to steer the patient selection. Long-term follow-ups and randomized potential trials with case-control series are needed to increase the level of proof this surgery.

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