Dysphagia - Swallowing Treatments

Normal Larynx

Behavioral Therapy

Behavioral Therapy are postural maneuvers or compensatory strategies that are implemented to insure a safe swallow.

For example, a HEAD TURN is implemented when it is found that a patient is numb on one side of their throat during a FEESST exam. By having the patient turn their head to the numb side, the area of the throat that is numb becomes narrowed so that incoming food gets directed towards the sensate side of the throat.

Types of Swallowing Behavioral Therapy include:

A. Postural Techniques

• Head Rotation to Weak Side or Strong Side - By rotating the head to the side of either motor or sensory weakness, the patient can eliminate the injured side of the pharynx from the food bolus path.
• Shaker Exercises - Another way to open the upper esophageal sphincter by having the patient lay flat on their back and, in a precise manner, slowly lift their chin to their chest.
• Chin Tuck - By placing the chin downwards toward the chest the patient: 

1. widens the vallecula to prevent bolus from entering airway 
2. puts the epiglottis in a more protective position 
3. narrows the laryngeal entrance

• place bolus in swallow position
• swallow while holding breath 
• cough after swallowing before inhaling (this clears any residue that may have entered the larynx)

Dietary Therapy
Pharmacotherapy
Surgery

A) Zenker's Diverticulectomy Three procedures have been described to treat a Zenker's diverticulum: diverticulectomy, diverticulopexy, and peroral endoscopic division of the party wall between the diverticulum and the esophagus. Diverticulectomy is usually selected for treating large diverticula in otherwise healthy patients. It involves an open-neck operation where the(Zenker's) hernia sac is identified and isolated. The sac is then resected its neck, taking care not to compromise the esophageal lumen by resecting too much mucosa, and closing the pharyngotomy with a watertight closure. A cricopharyngeal myotomy is performed as close to the posterior midline as is possible to minimize risk to the recurrent laryngeal nerves; the myotomy consists of dividing the entire circular cricopharyngeus muscle. Diverticuloplexy, combined with cricopharyngeal myotomy, is preferred by some surgeons for dealing with small diverticula or large diverticula in high-risk patients. The sac is isolated and tacked with permanent suture to the prevertebral fascia, such that the mouth of the sac is in a dependent position. Diverticulopexy avoids a pharyngotomy, reducing the risk of a pharyngocutaneous fistula or injury to the recurrent laryngeal nerves. Endoscopic peroral division of the party wall between the sac and the esophagus was first described by Dohlman in 1960. He used a special double-lipped esophagoscope, inserting one lip into the sac and one lip into the esophagus. Electrocautery was used to divide the party wall, including the cricopharyngeus muscle. Dohlman's procedure fell into disfavor because of an unacceptably high complication rate and mortality from mediastinitis. More recently, with some modifications to Dohlman's original technique such as utilization of an operating microscope and a laser, the endoscopic approach has gained acceptance, especially for very ill patients in whom an open procedure might pose greater risks. B) Cricopharyngeal Myotomy Dysphagia as a result of abnormalities with the cricopharyngeus muscle may be ameliorated by selective use of cricopharyngeal myotomy. Cricopharyngeal myotomy may be either surgical or pharmacologic (botulinum toxin). In general, cricopharyngeal myotomy is primarily useful for true cricopharyngeal achalasia such as after vagus nerve injury at the base of the skull where pharyngeal motor function remains otherwise intact. Cricopharyngeal myotomy is contraindicated in conditions when there is impaired pharyngeal peristalsis or when significant reflux disease exists. Many disease entities where cricopharyngeal myotomy was thought to be useful in improving dysphagia, such as myopathy and brainstem stroke, may actually be of no benefit. C) Salivary Diversion Procedures Dysphagia severe enough to result in the threat or actual circumstance of food and saliva constantly soiling the airway typically requires aggressive management. Surgical procedures that divert or diminish the flow of food and saliva from the airway include vocal fold medialization, tracheostomy, laryngeal stents, reversible laryngeal closure procedures, laryngotracheal separation and total laryngectomy. The application of any one of these treatment modalities depends on several patient factors such as underlying disease process and overall health status of the patient. Patients who are aspirating regularly frequently become malnourished, which only exacerbates their underlying condition. Therefore, as measures are considered to prevent aspiration, alimentation through non-oral means should be implemented as well. Feeding gastrostomy or jejunostomy tubes, placed endoscopically (percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ), are excellent ways to aliment patients who are at high risk for aspiration as a result of severe dysphagia. Laccourreye O et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994.

B. Compensatory Strategies

• Effortfull Swallow - The patient is instructed to bear down, or to squeeze hard with all of their head and neck muscles while swallowing.
• The Supraglottic Swallow - Four step maneuver, inhale and hold breath (this closes the vocal folds)
• The Supra - Supraglottic Swallow - The patient follows the same procedure as with the supraglottic swallow but additionaly he/she  bears down while holding his/her breath. 
• Mendelsohn Maneuver - A technique that opens the upper esophageal sphincter. The patient is instructed to hold the thyroid cartilage up for several seconds. In this way, the larynx is kept tilted forward and elevated, thereby allowing the upper esophageal sphincter to relax.

You can learn more by watching a video with the swallowing strategies presented by a clinician-

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

During the FEESST test  it may become evident that certain types of food cause the patient to cough or choke, but other foods do not. During the FEESST exam the various food volumes and consistencies are used until it is determined which combinations allow the patient to swallow easily and safely.

Pharmacotherapy is therapy when certain medications may be prescribed which can help the patient swallow safely.

Depending on the results of the swallowing evaluation, certain medications may be prescribed which can help the patient swallow safely

A)  Mucolytic agents: Medications that thin-out thick secretions. Sometimes patients have very thick phlegm and mucus that makes it difficult for patients to swallow. Mucolytics can thin thick secretions so that they could be more readily expectorated and coughed.

B) Anti-acid medications: Swallowing problems are sometimes due to untreated, or insufficiently treated, acid reflux disease. The acid causes swelling in the throat which can contribute to swallowing difficulties. Under those circumstances, anti-acid medication is prescribed in order to help alleviate the throat swelling that may be contributing to the swallowing problem.

The surgical management of the patient with dysphagia primarily depends on the etiology of the dysphagia. The more common etiologies of dysphagia that lend themselves to surgical correction are described.

References:

1. Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticulum. A roentgen cinematographic study. Arch Oto Head Neck Surg 1960. 
2. Ian Overbeek JJM. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994.
3. Wisdom G, Blitzer A. Surgical therapy for swallowing disorders. Oto Clin NA 1998.
4. Pou AM. Surgical treatment of swallowing disorders: Cricopharyngeal myotomy in Carrau RL, Murray T (eds.) Comprehensive Management of Swallowing Disorders. Singular Publishing Group, Inc. San Diego, CA 1999.
5. Stevens KM, Newell RC. Cricopharyngeal myotomy in dysphagia. Laryngoscope 1971; 81: 1616-1620.
6. Lebo CP, Sang K, Norris FH. . Cricopharyngeal myotomy in amyotrophic lateral sclerosis. Laryngoscope 1976.
7. Calcaterra TC, Kadell BM, Ward PH. Dysphagia secondary to Cricopharyngeal muscle dysfunction: surgical management. Arch Otolaryngol Head Neck Surg 1975. 
8. Netterville JL, Stone RE, Luken ES, Civantos FJ, Ossoff RH. Silastic medialization and arytenoid adduction, a review of 116 procedures: the Vanderbilt experience. Ann Otol Rhinol Laryngol 1993.
9. Eliachar I, Nguyen D. Laryngotracheal stent for internal support and control of aspiration without loss of phonation. Otolaryngol Head Neck Surg 1990.
10. Castellanos PF. Method and clinical results of a new transthyrotomy closure of the supraglottic larynx for the treatment of intractable aspiration. Ann Otol Rhinol Laryngol 1997. 
11. Biller HF, Lawson W. Total glossectomy. Arch Otolaryngol Head Neck Surg 1983.
12. Lindeman RC, Yarington CT, Sutter D. Clinical experience with the tracheoesophageal anastomosis for intractable aspiration. Ann Otol Rhinol Laryngol 1976.
13. Cannon CR, McClean WC. Laryngectomy for chronic aspiration. Am J Otolaryngol 1982.