Management of Dysphagia Requires a Team Approach

A Parkinson’s patient may have rigid vocal folds and related problems due to a combination of the disease and aging. Some may benefit from injection laryngoplasty as well as from exercises designed to strengthen the laryngeal valve and improve phonation output, said Dr. Dworkin. If you strengthen that valve, you also increase the ability of the patient to protect the airway during swallowing, he said.

The patient underwent a Botox injection into the hypertropic cricopharyngus along with medialization of the vocal folds, and had speech therapy. The diverticulum disappeared, and her voice handicap index improved. Her postoperative dysphagia inventory also improved significantly, Dr. Belafsky said.

However, a postoperative video fluoroscopic swallow showed some pooling in the vallecula. If the vallecula continues to pool with food residue, there is a chance that this person will experience coughing, choking, and mild aspiration. To work these things out you need a subsequent behavioural therapeutic program to minimize these, said Dr. Dworkin.

Dr. Postma agreed that a team approach is needed with these patients, and said he typically works with speech pathologists, gastroenterologists, and neurologists. Also, when he injects Botox, he tends to dilate the cricopharyngeus muscle as well.

Also, when he injects Botox, he dilates the upper esophageal sphincter at the same time, in the OR. That way, he can see whether the cricopharyngea is fibrotic or not.

Another panelist added a caution to dilating patients with diverticula. It needs to be done over a guidewire, said Milan R. Amin, MD, Chief of Laryngology at the New York University School of Medicine.

Generally, patients need complete workups prior to proceeding with treatment. Transnasal esophagoscopy (TNE) is especially useful, as it helps the otolaryngologist visualize what the esophagus is doing during the esophageal phase of the swallow, Dr. Amin said.

Case 2: Solid and Liquid Food Dysphagia, Weight Loss, Stroke

The second case presented was of a 60-year-old man with solid and liquid food dysphagia, who had had a 30-pound weight loss over the previous year. He had stable hyperthyroidism and a history of stroke three years earlier, with slight right-sided hemiparesis. His voice handicap index was normal, but his EAT-20 was 79. He had a significant delay in initiating swallows, and an endoscopic exam of swallowing showed some pooling of his secretions.

Secretion pooling in such a patient needs explaining, said Dr. Postma. It may be due to poor laryngopharyneal sensation, and it doesn’t take special instruments to figure that out, he said. A swallow evaluation should help the otolaryngologist determine sensory status.