Contemporary Management of Dysphagia

Educational Objectives

The goal of this program is to improve diagnosis and management of patients with dysphagia. After hearing and assimilating this program, the clinician will be better able to:

1. Collaborate more closely with speech and language pathologists in the evaluation and management of patients with swallowing disorders.

2. Use appropriate diagnostic tests based on history and physical examination to determine the etiology of dysphagia and devise an effective treatment strategy.

3. Choose the appropriate surgical technique, when indicated, for management of dysphagia.

Summary

Background: 20% of people >50 yr of age report dysphagia; incidence higher among nursing home residents and patients with significant neurologic illness or head and neck cancer; etiology multifactorial

Team approach: surgeons work directly with speech and language pathologists (SLPs); exercises and compensatory maneuvers taught by SLP critical; surgical management reserved for patients who do not improve adequately with medical and exercise swallowing therapy; team also includes gastroenterologists and neurologists; surgeons generally target cricopharyngeus (CP) muscle

Evaluation: if possible, perform entire assessment in single visit, which requires good relationship with radiologist (eg, appointment slots reserved for patients with dysphagia), and fluoroscopy unit located in office; billing issues can arise with single-visit evaluation (eg, combination of barium swallow with modified barium swallow [MBS]); goals of visit — identify and locate defects in swallowing mechanisms; direct patient to conservative treatment, compensation, or surgery (if warranted)

Medical history: important to uncover potential etiologies (eg, intubation, tracheostomy, stroke, thyroid surgery, anterior cervical vertebrectomy and fusion); ask about weight loss, periprandial coughing, time taken to eat meals, hoarseness, reflux, and consistency of food that produces dysphagia (eg, liquids may indicate neuromuscular issue, solids potentially associated with fixed anatomic lesion); guides remainder of evaluation process (eg, decision to order MBS vs transnasal esophagoscopy [TNE]); medications can contribute (eg, drying effects of anticholinergics); neurologic history — assess gait, tremors, speech (eg, problems with articulation) to rule out, eg, parkinsonism, brain tumors

Tests for evaluation: options include endoscopic swallowing evaluation, MBS, TNE, or conventional endoscopy; high-resolution manometry not practical; contrast studies critical (helpful for surgeon to be present when performed or at least view films personally); MBS limited and can result in failure to locate pathology further down in esophagus; CP muscle — ≈70% of adults >70 yr of age have cricopharyngeal bar that obstructs >50% of esophagus, but do not always have symptoms; obstruction of CP not likely etiology for dysphagia; esophagopharyngeal reflux — important to evaluate entire esophagus with radiology or manometry before surgical intervention (CP muscle may prevent gross regurgitation); endoscopic swallowing evaluation — provides assessment of native secretions (not possible through contrast studies); determines status of pharyngeal and upper esophageal sphincter function and severity of dysphagia; if endoscopic swallowing evaluation normal, give patient acetaminophen capsule to assess dysphagia for pills (can indicate need for surgical intervention at CP despite normal MBS and otherwise normal fiberoptic endoscopic evaluation of swallowing [FEES]); larynx — increased glottal competence improves voice and cough, but improves swallowing function only ≈50% of time; FEES — patients challenged to eat as quickly as possible to discover breakdown in swallowing mechanism; airway inspected toward end of examination

Transnasal esophagoscopy: every reported series shows rate of pathologic findings 45% to 55% in esophagus for general otolaryngology patients worldwide; TNE safer and less expensive than conventional endoscopy

High-resolution manometry (HRM): not standard or practical to do in office; determination of appropriate candidates equivocal, so possibly overused; excellent tool to evaluate pharynx, CP, and esophageal body; institutions that use HRM perform fewer surgeries but have improved outcomes from CP surgery; alternative to HRM — full-column MBS with close inspection to evaluate esophageal motility and esophagopharyngeal reflux

Swallowing therapy: first approach; patients may improve after few weeks with SLP and no longer require surgery; results in fewer surgeries but improves outcomes overall

Surgery: if indicated early on, CP usually targeted; dilation approached aggressively with largest possible dilator

In-office dilation: not performed as often as previously but remains option with topical anesthesia (viscous lidocaine); controlled radial expansion balloons used, up to 50 to 60 French size; challenges — only ≈60% of patients tolerate dilation well without sedation; requires 3 providers (one to drive endoscope, one to drive balloon, and one to operate hydrostatic gun); may be used more often as equipment improves

Botulinum toxin: injected into CP muscle; can paralyze vocal cord if concentration too high; speaker uses 50 units in healthy patients and 30 units in elderly patients at first visit; pharyngeal strengthening exercises recommended (sometimes with electrical stimulation); if general anesthesia used, aggressive dilation also performed; series by speaker found subjective dramatic improvement in ≈50% of patients, little to no improvement in ≈40%, and definite worsening in ≈10%

Endoscopic CP myotomy: technique described by Pitman; important to stop at buccopharyngeal fascia to prevent significant complications; Weerda or Storz endoscope used to pinch CP muscle and perform myotomy with carbon dioxide (CO2) laser down to level of fascia; largest series in Belgium showed 85% subjective improvement; open approach — results equal to endoscopic, but with mild to moderate complication rate (higher than endoscopic approach)

Pharyngoesophageal (Zenker) diverticulum: correct approach (endoscopic vs open) not universally agreed upon; introduction of staple technique in 1980s enabled wide exposure with distending bivalve laryngoscope; multi-institutional trial that compares endoscopic vs open approach ongoing; caveats — visualization of tracheal wall critical; vascular catastrophe can occur by transection of anomalous vessels that traverse or run parallel to CP muscle (magnetic resonance angiography recommended if significant pulsation of CP muscle visualized); open approach controversial and majority of literature now favors endoscopic approach due to mortality and morbidity reported; size of pouch controversial; large pouch — food accumulation and symptoms can arise from leaving redundant tissue as atonic section of proximal esophagus (not studied); small pouch — difficult to get staple completely around CP muscle; can use sutures to pull pouch into staple gun, laser endoscopic myotomy, or CO2 laser between staple line and pouch; experience of surgeon critical; complication rates significantly lower for experienced surgeons than that cited in literature

Summary: concentrate efforts on CP muscle; work closely with SLP (lack of qualified SLP results in poorer surgical outcomes); multiple medical problems should be explored in assessment of patients with dysphagia

Readings

Suggested Reading

Bachy V at al: Long-term functional results after endoscopic cricopharyngeal myotomy with CO2 laser: a retrospective study of 32 cases. Eur Arch Otorhinolaryngol 2013 Mar;270(3):965-8; Belafsky PC et al: Muscle tension dysphonia as a sign of underlying glottal insufficiency. Otolaryngol Head Neck Surg 2002 Nov;127(5):448-51; Blitzer A et al: Recommendations of the Neurolaryngology Study Group on laryngeal electromyography. Otolaryngol Head Neck Surg 2009 Jun;140(6):782-793; Enriquez PS et al: Functional abnormalities of the LES found by TNE. Ear Nose Throat J 2003 Jul;82(7):498-500; Hiss SG, Postma GN: Fiberoptic endoscopic evaluation of swallowing. Laryngoscope 2003 Aug;113(8):1386-93; Koufman JA et al: Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999. Otolaryngol Head Neck Surg 2001 Jun;124(6):603-6; Lawson G, Remacle M: Endoscopic cricopharyngeal myotomy: indications and technique. Curr Opin Otolaryngol Head Neck Surg 2006 Dec;14(6):437-41; O’Rourke AK et al: Killian-Jamieson diverticulum. Ear Nose Throat J 2012 May;91(5):196; Pitman M, Weissbrod P: Endoscopic CO2 laser cricopharyngeal myotomy. Laryngoscope 2009 Jan;119(1):45-53; Postma GN et al: Endoscopic Zenker’s diverticulotomy. Ear Nose Throat J 2002 Jun;81(6):380; Postma GN: Transnasal esophagoscopy. Curr Opin Otolaryngol Head Neck Surg 2006 Jun;14(3):156-8; Sulica L et al: Current practice in injection augmentation of the vocal folds: indications, treatment principles, techniques, and complications. Laryngoscope 2010 Feb;120(2):319-25; Yamanaka H et al: Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation. Br J Anaesth 2009 Sep;103(3):452-5.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Postma and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Postma was recorded at the 13th Annual Charleston Magnolia Conference, held May 31 to June 1, 2013, in Charleston, SC, and sponsored by Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, and Office of Continuing Education. For information about upcoming CME events from the Medical University of South Carolina, please visit cme.musc.edu. The Audio-Digest Foundation thanks Dr. Postma and the Medical University of South Carolina for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT461901

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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