For over a century, circumferential pharyngoesophageal junction reconstruction posed significant surgical challenges. This review aims to provide a narrative history of pharyngoesophageal junction reconstruction from early surgical innovations to the advent of modern free-flap procedures.

The review encompasses three segments: (1) local and/or locoregional flaps, (2) visceral transposition flaps, and (3) free-tissue transfer, focusing on the interplay between pharyngoesophageal junction reconstruction and prevalent surgical trends.

Before 1960, Mikulicz-Radecki's flaps and the Wookey technique prevailed for circumferential pharyngoesophageal junction reconstruction. Gastric pull-up and colonic interposition were favoured visceral techniques in the 1960s–1990s. Concurrently, deltopectoral and pectoralis major flaps were the preferred cutaneous methods. Free flaps (radial forearm, anterolateral thigh) revolutionised reconstructions in the late 1980s, yet gastric pull-up and free jejunal transfer remain in selective use.

Numerous pharyngoesophageal junction reconstructive methods have been trialled in the last century. Despite significant advancements in free-flap reconstruction, some older methods are still in use for challenging clinical situations.

The loss of a scalpel or a needle during surgery can threaten the health of the patient and lead to additional costs, and radiographical assistance during surgery has been the only recovery method. This study evaluates the efficacy of a metal detector compared with conventional radiology for recovering a needle lost in the oropharynx during surgery.

Different fragment sizes of needles normally used in pharyngoplasty were embedded at different locations and depths in a lamb's head. Three experienced and three junior otolaryngologists searched for the needle fragments using a metal detector and conventional radiology.

All fragments were found with each method, but the mean searching time was 90 per cent shorter with the metal detector.

A metal detector can be a useful tool for locating needles that break during ENT surgery, as it requires less time than conventional radiology and avoids exposing patients to radiation.

A pathological communication between the trachea and oesophagus – a tracheoesophageal fistula – may be congenital or acquired, benign or malignant, necessitating a multidisciplinary approach. Conservative attempts at closure of this abnormal connection are ineffective; the interposition of healthy vascular tissue offers the least chance of recurrence.

Outcomes of an islanded fasciocutaneous internal mammary artery perforator flap applied for tracheoesophageal fistula management were assessed in four radiated patients with laryngeal carcinoma using retrospective records.

Four male patients, with an average age of 60.75 years, underwent tracheoesophageal fistula closure between September 2017 and February 2021. A left-sided second internal mammary artery perforator flap was used in all cases, with an average dimension of 10.5 × 4.5 cm. There were no complications of tracheoesophageal leak, flap issues or donor site morbidity on follow up.

Recent advances in angiosomal territory mapping and microvascular dissection techniques, combined with an understanding of tracheoesophageal fistula pathology, have changed management perspectives in these difficult-to-treat patients.

Electrothermal bipolar vessel sealing devices are electrosurgical devices that seal tissues and blood vessels up to 7 mm in diameter. This paper discusses our experience using electrothermal bipolar vessel sealing devices in transoral head and neck surgery.

Electrothermal bipolar vessel sealing devices were used in five patients with lesions of varying size and type within the pharyngo-larynx. These were treated transorally by the otolaryngology department at the Royal Adelaide Hospital. Either the Medtronic LigaSure or BiZact devices were used for transoral resection, debulking or division of these lesions.

Electrothermal bipolar vessel sealing devices were considered helpful in four out of the five cases. Success was dependent on suitable transoral access. A single unsuccessful case reflected the LigaSure jaw's inability to engage a large tumour effectively.

Electrothermal bipolar vessel sealing devices can be safely deployed transorally to treat lesions of the upper aero-digestive tract in selected patients. Further studies investigating additional indications would broaden applications of this approach.

To explore the effects of pharyngeal packing on antral cross-sectional area, gastric volume and post-operative complications.

In this prospective, randomised, controlled study, 180 patients were randomly assigned to a control group or a pharyngeal packing group. Gastric antral dimensions were measured with pre- and post-operative ultrasound scanning. Presence and severity of post-operative nausea and vomiting and sore throat were recorded.

Post-operative antral cross-sectional area and gastric volume were significantly larger in the pharyngeal packing group compared to the control group. The incidence and severity of post-operative nausea and vomiting were significantly less in the pharyngeal packing group. More frequent and severe sore throat was observed in the control group within the ward. An increased Apfel simplified risk score and post-operative antral cross-sectional area were associated with post-operative nausea and vomiting during the first 2 hours, whereas septorhinoplasty and functional endoscopic sinus surgery, absent pharyngeal packing, and lower American Society of Anesthesiologists’ physical status were associated with post-operative nausea and vomiting within the ward.

Regardless of operation type, pharyngeal packing use resulted in smaller gastric volume, which was associated with reduced post-operative nausea and vomiting frequency and severity, and lower sore throat incidence.

A literature review and meta-analysis was performed to assess for difference in rate of complications and need for revision surgery between endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy. The hypothesis was that endoscopic stapler-assisted diverticulotomy has a lower complication rate but endoscopic carbon dioxide laser diverticulotomy has a lower need for revision surgery.

This was a systematic review of English-language studies comparing endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy for the treatment of Zenker's diverticulum. Meta-analysis of results with regard to rate of pharyngeal perforation, major post-operative complication and need for re-operation was performed.

Nine retrospective studies were included with pooled analysis of 417 endoscopic stapler-assisted diverticulotomy and 413 endoscopic carbon dioxide laser diverticulotomy cases. Meta-analysis found no significant difference in rate of pharyngeal perforation, major complication or need for re-operation between the two groups.

This study demonstrated both endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy to be a safe alternative to open surgery for Zenker's diverticulum. Both appear to be similar in terms of adverse events and efficacy. The authors recommend either approach, guided by surgeon's preference and experience, where patients are unsuitable for an open surgery approach.

Reconstruction of a pharyngoesophageal defect remains a challenging problem, especially with involvement of the neck skin. This study aimed to demonstrate the surgical technique of utilising a butterfly modification of the anterolateral thigh flap.

Reconstruction of the pharyngoesophageal defect was accomplished using the butterfly modification of the anterolateral thigh free flap. The flap was tubed on the leg while still being attached to the pedicle, to minimise the ischaemia time.

Butterfly anterolateral thigh free flap allows for multi-layer closure of the neopharynx and can be utilised for reconstruction of pharyngoesophageal and neck skin defects.

Migrated ingested foreign bodies in the aerodigestive tract can lodge within vital organs and vessels, causing potentially devastating complications. It is often difficult to localise these foreign bodies, with extrication resulting in the requirement for open approaches which may cause significant morbidity.

This paper presents the case of an ingested migrated stingray bone lodged adjacent to the vertebral artery in the upper cervical spine. This was managed via an endoscopic transoral approach, with the assistance of an image-guidance system.

Successful extraction of the foreign body was achieved, with minimal residual morbidity.

Our study showed that image-guided endoscopic surgery is a safe, precise and feasible option for the localisation and removal of migrated foreign bodies in the aerodigestive tract involving critical neurovascular structures.

Total rhinectomy is an invasive procedure that significantly impairs the intranasal turbulence, humidification and heating of inspired air. The use of uvulopalatopharyngoplasty for the treatment of sleep-disordered breathing disorders such as primary snoring and obstructive sleep apnoea has diminished over the past years because of the emergence of less invasive procedures and alternative therapeutic options. This clinical record presents the treatment of a long-term side effect of total rhinectomy using uvulopalatopharyngoplasty.

In 1997, a 62-year-old male underwent total rhinectomy for a nasal schwannoma, followed by rehabilitation with a nasal prosthesis. Twenty-one years later, he presented with severe complaints of nasal blockage and breathing difficulties during both daytime and night-time. Clinical examination revealed no major anomalies besides significant velopharyngeal narrowing. Thus, in 2019, uvulopalatopharyngoplasty was performed to re-establish velopharyngeal patency. Hereafter, the symptoms of nasal blockage disappeared, resulting in an improved quality of life.

Uvulopalatopharyngoplasty may prove useful to treat selected patients with daytime breathing difficulties due to velopharyngeal narrowing.

There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks.

A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites.

A total of 225 procedures were performed (range of 1.2–9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres.

Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.

The National Institute for Health and Care Excellence referral guidelines prompting urgent two-week referrals were updated in 2015. Additional symptoms with a lower threshold of 3 per cent positive predictive values were integrated. This study aimed to examine whether current pan-London urgent referral guidelines for suspected head and neck cancer lead to efficient and accurate referrals by assessing frequency of presenting symptoms and risk factors, and examining their correlation with positive cancer diagnoses.

The risk factors and symptoms of 984 consecutive patients (over a six-month period in 2016) were collected retrospectively from urgent referral letters to University College London Hospital for suspected head and neck cancer.

Only 37 referrals (3.76 per cent) resulted in a head and neck cancer diagnosis. Four of the 23 recommended symptoms demonstrated statistically significant results. Nine of the 23 symptoms had a positive predictive value of over 3 per cent.

The findings indicate that the current referral guidelines are not effective at detecting patients with cancer. Detection rates have decreased from 10–15 per cent to 3.76 per cent. A review of the current head and neck cancer referral guidelines is recommended, along with further data collection for comparison.

Barbed pharyngoplasty aims to reduce lateral retropalatal obstruction by pulling up the soft palate anterolaterally. However, barbed pharyngoplasty can be less efficient in some cases of obstructive sleep apnoea, especially in the presence of an elongated uvula with redundant tissues over it. This paper describes an attempt to overcome this drawback by modifying barbed pharyngoplasty, using a single continuous suture technique.

Thirty-four patients were assigned to two groups based on the surgical procedure performed. Those with an elongated uvula were treated with modified barbed pharyngoplasty (n = 17); the others were treated with barbed pharyngoplasty (n = 17). Pre- and post-operative quality of life questionnaires, and questionnaires concerning diet, pain and return to activity, were completed. Pre- and post-operative polysomnography was performed as an objective measurement.

There was no significant difference between barbed pharyngoplasty and modified barbed pharyngoplasty in terms of outcomes. However, reductions in the apnoea/hypopnea index, Epworth Sleepiness Scale and snoring visual analogue scale scores were greater in the modified barbed pharyngoplasty group.

Modified barbed pharyngoplasty is a safe and feasible method, and eliminates the need for surgical resection of the redundant soft tissues around the uvula while lifting up the uvula base.

Many people seek health information from internet sources. Understanding this behaviour can help inform healthcare delivery. This study aimed to review Google Trends as a method for investigating internet-based information-seeking behaviour related to throat cancer in terms of quantity, content and thematic analysis.

Data was collected using Google Trends. Normalised data was created using the search terms ‘throat cancer’, ‘cancer’, ‘HPV’, ‘laryngeal cancer’ and ‘head and neck cancer’. The search data was used to analyse the temporal and geographical interest pattern of these terms from 2004 to 2015.

Three important peaks in searches for ‘throat cancer’ were identified. The first and greatest increase in interest was in September 2010, and there were also peaks in June 2013 and in October 2011.

Internet-search analysis can provide an insight into the information-seeking behaviour of the public. Mass media can hugely affect this information-seeking behaviour. Possessing tools to investigate and understand information-seeking behaviour may be used to improve healthcare delivery.

Parapharyngeal space biopsy is an important investigation in the management of parapharyngeal space tumours. These tumours are relatively rare and the surgeon is often faced with a wide range of differential diagnoses. There are several ways to access the parapharyngeal space, with varying degrees of associated morbidity.

This paper describes a seldom used, but a simple and safe, image-guided endoscopic approach to parapharyngeal space biopsy that enables tissue to be obtained transnasally. The procedure is conducted under general anaesthesia using computed tomography image guidance via the LandmarX system, with transnasal access to the parapharyngeal space achieved using a sampling needle.

This procedure is relatively simple, safe and reproducible. It is a less invasive approach to parapharyngeal space biopsy, and one which has been successfully used by the senior author for years without any significant morbidity.

Transnasal image-guided endoscopic aspiration or biopsy of the parapharyngeal space is a novel technique that has not been previously described.

Platelet-rich plasma is a novel material that is being used more frequently in many surgical specialties.

A literature review on the current and potential uses of platelet-rich plasma in otolaryngology was performed.

There is limited evidence on the use of platelet-rich plasma in otolaryngology compared with other specialties: only 11 studies on various subspecialties (otology, rhinology and laryngology) were included in the final review.

Based on the limited number of studies, we cannot draw safe conclusions about the value of platelet-rich plasma in otolaryngology. Nevertheless, the available literature suggests that platelet-rich plasma holds promise for future research and may have a number of clinical applications.

Endoscopic stapling has become the primary procedure for pharyngeal pouch surgery because it is quick, less invasive and safe, but less is known about long-term outcomes.

Medical records were reviewed to compare rates of morbidity, operative failure, symptom control and revision surgery between open and closed procedures.

A total of 120 pharyngeal pouch procedures, carried out on 97 patients from 2000 to 2014, were studied. These included 80 endoscopic stapling and 40 open procedures. Twelve patients had complications (15 per cent) and there was one mortality (1.2 per cent) in the endoscopic stapling group. Ten patients (25 per cent) developed complications in the open procedure group, with no mortalities. Symptom recurrence was significantly greater in the endoscopic stapling group (26 per cent) than in the open procedure group (7.5 per cent). Multiple surgical procedures were required for 22 endoscopically stapled patients (32 per cent); none were required in the open procedure group. Although the male-to-female ratio for pharyngeal pouch incidence was 2:1, the ratio for multiple surgical procedures was 10:1.

Endoscopic stapling outcomes are not as good as those following an open approach on long-term follow up, and the early advantages are eliminated if pouch excision is avoided.

This study aimed to describe total volume and cross-sectional area measurement changes in obstructive sleep apnoea patients associated with a supine versus an upright position.

A retrospective chart review of patients who underwent cone beam computed tomography in upright and supine positions was performed, and the images were analysed.

Five obstructive sleep apnoea patients (all male) underwent both upright and supine cone beam computed tomography imaging. Mean age was 35.0 ± 9.3 years, mean body mass index was 28.1 ± 2.7 kg/m2 and mean apnoea–hypopnoea index was 39.3 ± 23.0 per hour. The airway was smaller when patients were in a supine compared with an upright position, as reflected by decreases in the following airway measurements: total volume; posterior nasal spine, uvula tip, retrolingual and tongue base (not significant) cross-sectional areas; and site of the minimum cross-sectional area (of the overall airway). Total airway volume decreased by 32.6 per cent and cross-sectional area measurements decreased between 32.3 and 75.9 per cent when patients were in a supine position.

In this case series, the airway of obstructive sleep apnoea patients was significantly smaller when patients were in a supine compared with an upright position.

Zenker's diverticulum is a propulsion diverticulum in the pharynx. Current practice for the management of symptomatic pharyngeal pouches includes endoscopic pharyngeal stapling, performed trans-orally, and external approaches via a cervical incision. There is no published recommendation on how to approach diverticula with extension into the mediastinum, which may not be adequately treated with the above methods.

We describe two cases in which thoracoscopic mobilisation of Zenker's diverticulum was performed using video-assisted thoracoscopic surgery together with traditional transcervical mobilisation and excision of the pouch. This allowed safe surgical access to the inferior limit of the pouch, and delivery of the sac into the neck incision following division of any inferior adhesions (to the great vessels in one case).

In the first report of this technique, we describe a thorough, safe method of dissecting large diverticula that extend into the mediastinum, which minimises the risk to mediastinal structures.