Videofluoroscopy-Guided Balloon Dilatation for the Opening Dysfunction of Upper Esophageal Sphincter by Postoperative Vagus Nerve Injury: A Report on Two Cases
A 62-year-old man had cervical spinal cord injury (neurological level, C8; American Spinal Injury Association D [ASIA-D]) after accidental fall. He underwent anterior fixation on C3-C7 and laminoplasty by posterior approach after four weeks, on the same level. After the second operation, sudden dyaphagia occurred. The patient could not swallow food and showed aspiration sign during mealtime. On physical examination, he presented hoarseness and deviated tongue to the left. Left vocal cord palsy was found on laryngoscopy. He was diagnosed as palsies of left vagus and hypoglossal nerves.\nFor the treatment plan, videofluoroscopic swallow study (VFSS) with 2 mL and 5 mL of radiopaque yogurt pudding and mineral water was done. The patient could not swallow the food, and aspiration was evoked by an overflowing of pyriform sinus remnant (). For 5 weeks, he was nourished by nasogastric tube and had conventional dysphagia therapy for UES opening, which included manual laryngeal elevation and Shaker exercise for five days a week. The patient showed no improvement.\nWe performed videofluoroscopy-guided balloon dilatation of UES. Checking images on fluoroscopy, 16-Fr Foley catheter with deflated balloon was inserted through the nasal cavity until the balloon part of catheter was estimated to be under the lower margin of UES. Then balloon was gently inflated using 3 mL of contrast media, and we pulled the inflated catheter slightly upward, locating the balloon at middle of UES (). We kept balloon at UES for 30 seconds so that UES could be dilated mechanically. If the balloon was thrown upward from UES, we promptly deflated and repositioned the balloon at UES and continued the procedure. The procedure was done ten times with one minute interval per session. At the end of each session, VFSS with yogurt pudding was done. When UES opening improved as much as possible to start pudding intake, VFSS was performed three days after the session. When VFSS demonstrated no aspiration and pyriform sinus residue was less than 10% of width, the ballooning treatment was terminated. Before and after ballooning, we measured clinical symptom score, disability rating scale for swallowing impairment and the amount of pyriform sinus residue [] ().\nAfter six ballooning sessions with a periodic interval of five days per month, pyriform sinus residue decreased from grade 3 to 1 () without aspiration (). The patient started oral intake. The clinical symptom score and disability rating score also improved from 9 to 0 and 4 to 0, respectively. Other neurologic symptoms like tongue deviation, vocal cord palsy and hoarseness continued for four months after the termination of ballooning. Dysphagia has not recurred for over a year.