Dysphagia affects more than 20% of the population over the age of 50. Fortunately, newer diagnostics and treatment approaches are not only helping improve the care and quality of life for these patients, but have also expanded what the otolaryngologist can do.
Indeed, the otolaryngologist can deal with the diagnostics, and both the medical and surgical treatment. But a team approach, along with a mix of medical, behavioral, and surgical treatments, can provide even further benefits to patients. These were among the messages highlighted in a panel at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery on contemporary dysphagia management.
We really advocate a team consisting of otolarygnologists and speech language pathologists as one-stop shopping for dysphagia, said Peter C. Belafsky, MD, PhD, Assistant Professor of Otolaryngology at the University of California, Davis, who moderated a panel that included otolaryngologic surgeons and a speech pathologist. Case studies were used to discuss diagnosis and treatments.
Case 1: Solid Food Dysphagia, Parkinson’s Disease
The first case was of a 77-year-old woman who suffered from solid food dysphagia. She’d had significant weight loss, minor dysphonia, a history of hypercholesteremia, coronary artery disease, and had a previous stroke with minor sequelae. She also had stable Parkinson’s disease. She had a voice handicap index of 28 and an Eating Assessment Tool (EAT-20) of 66.
Panelists agreed that taking the Parkinson’s disease into account was important, as it is a hypokinetic disorder that could limit tongue range and motion, or affect the pharynx or larynx.
A video fluoroscopic swallow exam was performed and showed regurgitation, a hypertrophic cricopharyngeous muscle, and a small Zenker’s diverticulum.
Gregory N. Postma, MD, Professor of Otolaryngology at the Medical College of Georgia, said that in patients such as this it’s critical that we know what’s going on south of this. It’s key to make sure the individual has reasonable esophageal motility. Allow the bolus to go a couple of inches further down before it obstructs. I always follow the video fluoroscopic study or manometry in someone like this.
Looking toward clinical management is important too, said James P. Dworkin, PhD, Professor of Otolaryngology and a speech pathologist at Wayne State University. The Parkinson’s disease could compromise how well the tongue, larynx, upper esophagus sphincter, and esophagus all function.
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.
Aspiration is a concern in these patients, although it’s amazing that many of these patients can have this kind of finding and not have a history of pneumonia, said Dr. Dworkin. Near the top of his list is testing the cough reflex of patients.
Patients with a strong cough can clear the tracheal-bronchial tree, and are often good candidates for various methods of management, including behavioral management to try to facilitate swallowing, he said.
Weight loss is a major concern; therefore, getting a nutritionist involved is important, said Dr. Amin. Patients who can tolerate liquids can be put on a nutritional liquid diet, which can help patients regain strength. A speech pathologist may be able to help with the dysphagia too, showing the importance of a multidisciplinary team.
Panelists agreed that they would want to investigate what is happening further down in such a patient, though there are some tricks to getting a scope past the vocal folds. An endoscopic swallow evaluation (FEES), which lets the otolaryngologist watch the oral and pharyngeal phases of swallowing, is extremely useful for this, said Robert J. Stachler, MD, Associate Professor of Otolaryngology at Wayne State University.
When performing a swallow study, panelists concurred that starting with either a very thick liquid or a puree is the way to go. Water is the most difficult for most dysphagic patients to handle, and so this should not be the first thing tried. Other medical colleagues need to be educated about the problems with water and thin liquids in dysphagia patients, said Dr. Postma.
If you’re not sure where the patient’s going to be in terms of what he can swallow, I usually start with applesauce, then move to nectar-thick, Dr. Stachler said. Exams can be tailored depending on the type of dysphagia patients have.
When doing a swallow test in the ICU, Dr. Dworkin advised waiting several minutes before leaving the patient’s bedside. A patient might have delayed coughing and aspiration.
Case 3: Solid and Liquid Food Dysphagia, Aspiration
The third case presented was of a 60-year-old male with solid and liquid food dysphagia. Fluoroscopic swallow and manometry showed that the patient had difficulty transporting a bolus through the hypopharynx, with aspiration that penetrated up to the level of the vocal fold.
Manometry was key for helping diagnose this patient, and evaluating the strength of the pharynx was important. The patient proved to have a weak pharynx, although an initial diagnosis couldn’t determine this.
A healthy pharyngeal pressure would be over 100 mmHg, but this patient ranged from 20 mmHG to 45-50 mmHg in the study. Manometry helped confirm where the obstruction might be-in this case at the cricopharyngeal bar, Dr. Stachler said.
Without manometry, there are other ways to determine pharyngeal strength. If you’re just doing endoscopy and you don’t see a whiteout, then that’s significant. It tells you that the pharynx is not contracting around your scope fully, said Dr. Amin. Another way would be to get the patient to say eeee vigorously. This brings in the side walls of the pharynx and can permit a sense of the pharyngeal closure.
The pharynx is critical to swallowing, said Dr. Postma. It is probably even more important than the tongue, in light of the fact that people with total glossectomy can be trained to swallow when a bolus is introduced in the oropharynx. However, from a clinical point of view, lingual problems are easier to deal with than pharyngeal problems.
Managing the pharynx is a very difficult thing from a behavioral point of view. It’s not accessible easily for manipulation. There are electrical stimulation techniques you can try to stimulate pharyngeal contractions. You can attempt various bolus manipulations and head adjustments, Dr. Postma said.
The patient ended up getting a Botox injection to the cricopharyngeous, using a combination of manometry and EMG. His eating assessment improved from 68 to 48, but still had residual dysphagia.
Sometimes tongue strengthening can help these patients. The tongue is the chief piston that prepares the food and pushes it back. If you can achieve stronger movement, perhaps you can compensate somewhat for pharyngeal difficulties, Dr. Dworkin said. He sometimes sends patients home with simple devices made from tongue depressors that can be used for tongue strengthening exercises.
New Technologies, Better Diagnosis and Treatment
The cases show how newer technologies are helping otolaryngologists, Dr. Postma said. Transnasal esophagoscopy (with improved optics) allows for great visualization. High-resolution manometry allows otolaryngologists to directly measure and time the contractions of the throat, esophagus, and its valves.
We can also do a great deal of intervention in the clinic with balloon dilations, Botox injections into the valves of the esophagus, and electrical stimulation of the throat muscles to improve swallowing, he said.
©2007 The Triological Society