Dysphagia: A Challenge to Manage

MBS shows the dynamic interface of all swallowing phases and helps to quantify penetration/aspiration. It can assess swallowing efficiency as well as the effectiveness of interventions. Disadvantages include a small amount of radiation exposure, the need for patient cooperation, use of altered food substances, and the fact that it is time-consuming.

Flexible endoscopic exam of swallowing (FEES) provides an immediate view of the anatomy from the oropharynx down after intake of real food while swallowing. FEES is more portable than MBS and does not utilize radiation. It can be used to document clinical progress.

In several ways, MBS and FEES are equivalent, Dr. Lundy told listeners.

When to Consider Surgery?

Age and comorbidities should factor into the decision to undertake surgery. Perhaps most important is to determine whether the surgical technique truly addresses the abnormality causing the dysphagia. If you treat those areas, will the dysphagia improve? Or is there an underlying problem that surgery will not address? Sometimes a combined approach is required, Dr. Lundy said.

Nonsurgical therapies for dysphagia should be tried before resorting to surgery. When dysphagia is associated with neurologic disease, such as Parkinson’s disease, or occurs after debilitating medial illness, therapy should be initiated to improve swallowing before resorting to surgery.

Interventions

Interventions aimed at improving upper esophageal sphincter (UES) function and improving glottal closure were described by Milan Amin, MD, Director of the NYU Voice Center in the Department of Otolaryngology at NYU Medical Center in New York City.

Cricopharyngeal (CP) Botox injections, CP dilation, and CP myotomy are used to disrupt the UES. Indications for CP Botox injections include a tonically contracted CP muscle or incomplete relaxation of the CP muscle. The injections are placed at three different locations, staying away from the lateral aspects of the esophagus. Botox should be diluted in a small volume of saline, he said.

Dr. Amin pointed out that CP bar (posterior indentation at UES) on a videoscopic swallow study can be present without an abnormality; CP bar can represent different conditions, including fibrosis, stricture, and abnormal muscle or mucosa. A patient with CP bar should be sent for manometry, which is the key for proper selection of patients for Botox injections. Results of this procedure, or any procedure, depend on selection of patients, Dr Amin noted.

The indication for CP dilation is incomplete opening of UES during swallow; dilation is often used in combination with Botox injections, Dr. Amin said. Botox relaxes the CP muscle and dilation stretches it. They are not equivalent; use them together, Dr. Amin stated.