Explore This IssueNovember 2013
VANCOUVER—Difficulty swallowing is one of the most serious problems otolaryngologists see, and navigating the terrain of diagnosis and treatment can involve assessing factors that are sometimes subtle, a panel of experts said here at the 2013 AAO-HNS Annual Meeting.
“It is the one diagnosis in our specialty that kills more patients than any other,” said panel moderator Catherine Lintzenich, MD, associate professor of otolaryngology at Wake Forest Baptist Medical Center in Winston-Salem, NC, to the session audience. “I feel very strongly that no other specialty or physician out there is better equipped to evaluate and treat swallowing problems than [otolaryngologists].”
Panelists included Albert Merati, MD, chief of laryngology at the University of Washington School of Medicine in Seattle; Greg Postma, MD, director of the MCG Center for Voice and Swallowing Disorders at Georgia Regents Health System in Augusta; and Milan Amin, MD, director of the New York University Voice Center.
Dr. Lintzenich said patients often come to her after doctors in other subspecialties check on a few specific issues and don’t uncover the problem. “If you don’t help them with their swallowing problem, you can be 100 percent positive that there’s really nobody else who will, nobody else who can and certainly nobody else who wants to,” she said.
The panelists made observations and drew lessons from several cases.
The first was a 54-year-old man with a six-month history of food sticking in the throat and a cough. He’d had no voice changes. He had a history of high blood pressure, reflux, arthritis and a cervical spine fusion 15 years earlier.
Dr. Lintzenich said that when getting the patient history it’s important to specifically ask about weight loss and infections directly. “They often do not volunteer that information,” she said.
The panelists said that the pharyngeal squeeze maneuver, meant to gauge the pressure that can be generated by the pharynx by observing when a patient makes a high-pitched “E” sound, is a useful tool. Dr. Merati said it’s fast and easy to do, and studies have found correlation with manometry readings and predicts, at least anecdotally, success in some swallowing operations. “It is very helpful,” he said. “Do not underestimate it.”
Asked about the instrument evaluation of choice, Dr. Postma said that the most reasonable choice would probably be an endoscopic swallow evaluation. Dr. Merati added, though, that fiberoptic endoscopic evaluation of swallowing (FEES) probably could be skipped if you’re sure you’ll perform a modified barium swallow.
Dr. Amin said the type of evaluation depends on the type of swallowing difficulty. “I think there’s a fair understanding that if you have a liquid food dysphagia, FEES is a very, very good tool for that,” he said. “For solid food dysphagia, FEES is not a very good tool.”
Dr. Lintzenich said the location of the suspected swallowing problem has to guide which diagnostic tests you order. But, she added, “When a patient feels food sticking in the throat, a third of the time the problem is in the esophagus,” and the patient is just unable to pinpoint the location.
Dr. Postma emphasized that good speech pathologists interested in swallowing are available if they’re sought out. “When you’ve got speech therapists, not just in voice but in swallowing, your results and your patient outcomes are going to be remarkably better than if you try to go that kind of thing alone.”
Dr. Amin said asking the patient where the problem is might not be enough. “I think rather than going based upon where the patient sees the problem you should go based upon what type of bolus the patient is having a problem with,” he said. “A liquid bolus issue is going to happen more often with the pharynx, and you’re worried more about aspiration issues. If there’s a solid food issue, you’re going to probably focus more on the upper esophageal sphincter or the esophagus.”
However, Dr. Merati said, a problem with solids could also be another issue, such as poor tongue propulsion or a problem at the level of the vallecula.
In another case, a 56-year-old man had a problem with food sticking in his throat for two years, and it was worsening. He had no problem with liquids, no pneumonias or chest infections and no weight loss. There was some evidence of pharyngeal weakness.
Dr. Merati said the otolaryngologist would have to work closely with the speech language pathologist on the case, so it would help to have a good working relationship with the therapist. He wondered whether there was an underlying progressive neurologic problem in this patient or whether it might be related to an isolated event.
“You do need to be further assessing why this patient is having this problem,” Dr. Lintzenich said. “Even if this patient is 90 years old this is not normal to have a progression of pharyngeal weakness or tongue-based weakness, and you need to be evaluating that. At some point, you need to have a discussion with the patient about whether they should have a neurology evaluation.”
Generally, she added, dysphagia patients are “super, super motivated.” She added, “They want to eat. They want the symptom to go away. And they work hard.”
A third case involved an 80-year-old woman three weeks after the excision of an inflammatory cystic neck mass. The internal jugular vein was sacrificed, but the recurrent laryngeal nerve was spared. Since the surgery, she had been hoarse with swallowing problems. An exam showed that the patient was suffering from left vocal fold immobility and was aspirating liquids.
Dr. Lintzenich asked whether the timing of intervention is affected by the presence of dysphagia in a patient with vocal fold paralysis, when recovery is expected. Dr. Merati answered with an emphatic “Yes.” “If you have a vocal fold paralysis without dysphagia, the urgency is different,” he said. “Aspiration and vocal paralysis is urgent. This is a typical inpatient consult. The reason to act today is their aspiration, not because of their voice.”
Dr. Postma noted the high mortality rate among elderly patients who get aspiration pneumonia.
The panelists agreed that, in this case, laryngoplasty was in order, but Dr. Postma said dysphagia results might be lacking. “You’ll improve their voice without question; you’ll improve their cough, usually dramatically,” he said. “The results, as far as [the] dysphagia itself, are not outstanding…. I tell my patients it’s a coin flip.”
Assessing swallowing requires an objective evaluation because patients will likely say they are swallowing better when they’re feeling better overall due to other improvements.
Dr. Amin said direct improvement of aspiration might not be the goal. “The goal may actually be to improve their cough, so that what they do aspirate they can eject back out again,” he said. “And that, I think, I can reasonably promise them.”