Dysphagia: A Challenge to Manage

CP myotomy is a more invasive procedure that causes permanent changes to the CP muscle. Two different methods can be used: extramucosal myotomy or endoscopic myotomy. The procedure divides the mucosa and muscle fibers using a CO2 laser.

Be careful not to cut the fascia, Dr. Amin cautioned.

Evidence in support of CP myotomy for dysphagia is poor. In uncontrolled studies, response rates hover at about 60%. Response could be improved with good patient selection. According to the evidence, this procedure is not helpful for patients with neurological conditions or head and neck cancer, he stated.

Poor glottal closure places patients at increased risk of aspiration. Mechanical treatments, such as injection augmentation of the vocal fold, medialization laryngoplasty, and arytenoid adduction are used to improve glottal closure, but there is little reliable evidence to support these interventions. Uncontrolled case series suggest clinical improvement with these procedures.

Surgical Management of Dysphagia

There are two types of surgical approaches to dysphagia: type 1 to maintain the physiological airway and reduce aspiration and type 2 to divert or separate the physiological airway and eliminate aspiration, but at the cost of voice loss, explained Dinesh K. Chhetri, MD, Assistant Professor of Head and Neck Surgery and Director of the Swallowing Disorders Center at UCLA School of Medicine in Los Angeles.

Hypopharyngoplasty and hyolaryngeal advancement are type 1 surgical procedures. Hypopharyngoplasty can be combined with a medialization procedure such as arytenoid adduction, and CP myotomy is also concurrently performed, Dr. Chhetri explained.

The bottom line is that hypopharyngoplasty is excellent for dysphagia due to high vagal injury associated with a dilated pharynx. It allows more efficient passage of the bolus with no pharyngeal dilation, he told listeners.

Hyolaryngeal advancement is a straightforward technique for dysphagia due to hyolaryngeal elevation and UES dysfunction.

Type 2 surgical procedures include laryngotracheal separation, glottic closure, epiglottic oversew, and total laryngectomy. Laryngotracheal separation is typically done in children. Several studies show complete control of aspiration and a reduction in pneumonias and hospitalization following this procedure. Adult candidates for the procedure include those with neurological impairment and chronic aspiration complicated by pneumonia. A graded approach should be used in patients who are dependent on feeding tubes, have severe neurological disorder, or have experienced several espisodes of aspiration pneumonia.

Glottic closure eliminates the need for total laryngectomy in patients with dysphagia. This relatively straightforward procedure causes irreparable damage to the vibratory structures and voice, and most surgeons shy away from this, Dr. Chhetri said.