WASHINGTON, DC-Dysphagia is the dominant cause of morbidity and mortality in patients treated by otolaryngologists, and in fact, more people die from aspiration pneumonia following stroke than from all head and neck cancers combined.
Dysphagia is challenging and frustrating to treat, and there is no good evidence for many of the modalities we use to treat it, stated Albert L. Merati, MD, Director of the Laryngology Service in the Department of Otolaryngology-Head and Neck Surgery at University of Washington Medical Center in Seattle. Dr. Merati moderated a session on current nonsurgical and surgical options for the management of dysphagia and aspiration, during which he noted that nearly all surgical interventions are directed at restoring glottic competence or improving outflow from the pharynx to the esophagus.
Dysphagia should be managed by a multidisciplinary team, said the next speaker, Donna S. Lundy, PhD, Director of the Vocal Disorders Laboratory at the University of Miami in Miami, FL.
Obtaining a thorough history will provide some idea of the anatomical site(s) involved in swallowing difficulties. Patients should be asked for a detailed description of the onset of the problem and whether it is progressive, intermittent, or stable. Ask about associated neurologic symptoms and generalized debilitation, Dr. Lundy continued. Other areas to probe include weight loss and appetite, changes in diet to omit foods of certain consistencies, the presence and timing of coughing and/or choking, whether nasal regurgitation is present when swallowing, and location of any associated pain.
Bedside evaluation provides additional information on the locus of the problem. Assess the patient’s readiness for oral feeding and the oral reaction to various food consistencies. However, bedside evaluation is not enough, Dr. Lundy said, because 50% of aspiration is silent.
Bedside evaluation does not provide information on physiology of swallowing or the nature of dysphagia. It does not allow you to determine whether the patient can respond to various maneuvers, she said.
The presence of aspiration signals abnormal oropharyngeal function. Remember, aspiration is a symptom and not a diagnosis, she emphasized. You need to determine the etiology of the dysphagia and the efficacy of various maneuvers.
The gold standard for oropharyngeal physiological assessment is the modified barium swallow (MBS). This is the safest and most efficient diagnostic procedure and the results are predictive of the risk for aspiration pneumonia, Dr. Lundy commented.
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 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.
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.
Epiglottic oversew requires meticulous technique and potentially can spare the voice in selected patients. It is indicated for patients with intact neurological status and glottic function. Total laryngectomy is an excellent technique for relieving aspiration but the procedure (and voice loss) is irreversible.
©2007 The Triological Society