Chapters Transcript Dysphagia Dr. Matthew Rohlfing, MD shares an overview of swallowing and how to evaluate dysfunctions of swallowing. So, Doctor Matthew Rolfing earned his medical degree at Wake Forest School of Medicine in Winston, Salem, North Carolina. He then completed his residency in otolaryngology at Boston University Medical Center in Boston Massachusetts and his fellowship in laryngology and care of the professional voice at Vanderbilt University Medical Center in Nashville, Tennessee. He is currently an assistant professor in the division of o laryngology at Barnes Jewish Hospital where he sees patients there. And at Barnes Jewish West County Hospital, he sees patients for complex airway management, subglottic steno stenosis tracheal stenosis, laryngeal stenosis, bilateral vocal fold paralysis, advanced hm Tracheostomy management, voice disorders, professional voice issues, vocal fold paralysis, aging, voice, muscle tension, dysphonia, hoarseness, swallowing problems, Zenker's diverticulum. I'm not sure what that were copal obstruction and awake treatment of laryngeal disease. KTP laser treatment of recurrent respiratory Pittis and duco. But I, I'm sorry, I'm making these horrible words of awake, vocal fold, medicalization, injection. So sorry about that. I'm sure you'll have a much better pronunciation in your talk if you talk about a few of those. Thanks, Nicole. Um I appreciate the introduction, the invitation today. Um Although yes, I do all of those different things in the course of practice. As a laryngologist, today's talk is gonna focus on swallowing. Uh We'll talk about a bit about normal swallowing and swallow pathology. I don't have any disclosures to go over objectives and some of these were shared, uh you know, officially in the um in the program today. Um but we'll talk first about normal swallowing and talk about different phases of swallowing. Um It's important to talk about some of the normal functions so that we can um start localizing um dysfunction and swallow pathology. Uh We'll talk about different swallowing, uh diagnostic techniques. Um We will talk about surgery to some degree. Uh and then go over some potential indications for referral. Um So this will start relatively generic and then we'll get more specific into different swallow pathology. But um this just starts with recognizing that swallowing is one of those really key parts of what makes us human. We swallow and eat socially. It's a, it's a big way that people um experience pleasure in the world. Um This isn't really about dietary choices, that's what the photos are there to demonstrate. Of course, there are healthier and unhealthier diets, but it doesn't really matter once somebody isn't able to swallow at all. Um A lot of our patients or people who have had to start, you know, really thinking about it every time they swallow or maybe worrying that swallowing is gonna become dangerous for them. Um Not to mention all of those uh more quality of life concerns that can come along with, with swallow, dysfunction. Um Couple of definitions to, to start with um dysphagia, of course, uh is a word that just represents difficulty swallowing. Um It is often confused with the very, very similar term dysphagia. Um Maybe that is a typo, a lot of times that'll come through on the dictation system to the point where I've developed a little bit of a habit of over pronouncing the G when I dictate. Um, dysphasia is a different problem which refers to impairment in speech. Um And dysphagia is the, is the topic of our conversation today. Um We'll talk about um other potentially associated symptoms and what those might clue us into. Um things like pain was swallowing changes in voice, uh g global sensation. Um And of course, things like pain and bleeding first. Like I said, we're gonna talk about some of these normal uh swallow functions and separate swallowing into different phases. First being oral preparatory and oral phase. Um Then pharyngeal and esophageal phases of swallowing. You will also see us sometimes combine these phases to um refer to something as an oropharyngeal swallow problem. Um And that's meant to be kind of a combination of oral and pharyngeal phase. Similarly, we can refer to things as a pharyngoesophageal um dysfunction being a combination of the pharyngeal and esophageal phase of swallowing. The oral preparatory phase is how we start to prepare the food or liquid in the mouth. Um If you start really thinking about these functions, it's a bit more complicated than we would usually give it credit for. Um, you don't quite notice some of these things until they stop working, but it is very important that somebody is able to close their lips. Um We use the muscles in the side of the mouth to maintain a certain amount of tension in order to avoid food and drink from collecting in the um basically the gutters between our gums and cheeks. Uh of course, we chew uh and then the the tongue is going to assist in that chewing by um kind of um arranging and shifting the food around the area by your teeth. Um And then during that oral preparatory phase, the pharynx is closed to prevent a premature spillage of food or drink by um contraction and bulging of the soft palate to separate the oral cavity from the oropharynx. And that all just happens with food in the mouth once we have prepared the food by chewing or otherwise arranging it in the oral cavity, um that food will get transported back towards the oropharynx and specifically the vallecular uh in order to do that, we have to again, kind of seal off these um these side gutters in the mouth. Um the buckle muscular term, meaning the cheeks have to contract to some degree to keep things directed midline backwards and then the tongue is gonna help to um to navigate that food or drink backwards towards the vallecula. Um as demonstrated in this photo is really where the reflexive point of swallowing begins. Of course, that oral preparatory phase and oral phase are very much um voluntarily controlled. Um And then we'll get into more of the reflexive parts of swallowing. The pharyngeal phase of swallow. Again, is quite a complicated arrangement of, of um muscular contractions. In order to have an effective oropharyngeal or pharyngeal swallow, we need to be able to close the palate against the pharynx. So it's via vop closure, the tongue base has to retract and push uh posteriorly in order to propel the bolus over and around the larynx and then towards the esophageal inlet. Um we can track the pharyngeal constrictor muscles um along with the base of tongue. Classically, there are three sets of pharyngeal constrictor muscles, superior, middle and inferior. Um And then in order to close the larynx and protect the airway, a few different things happen. Um I think that most people are familiar with the idea of epiglottic closure, but in addition to that, we're also closing the true vocal folds, we're elevating the larynx up. Um And uh and then importantly, opening up that outflow pathway, opening up the upper esophageal sphincter in order to have space for things to um to, to travel. Uh crag is the main muscle that makes up the upper esophageal sphincter. Um And that of course, has to open at the same time that our muscles contract in order to push things down the right way, once we get things past the upper esophageal sphincter, and it's into the esophagus that becomes entirely um uh reflexive. Um part of the pharyngeal swallow is reflexive mediated in the brain stem. Part of it is also um cortical and voluntary. But the esophageal phase of swallowing is regulated entirely by these. Um um by these kind of automatic nerve processes, mostly innervated by the biggest nerve peristalsis is triggered a couple different ways. One is that swallowing itself will start a peristaltic wave. Um But then we also trigger peristalsis by the um by the stretching of the esophageal musculature once that bolus is in the esophagus, um in order for that to complete successfully, the lower esophageal sphincter then has to open in order to um in order to allow that release of the bolus into the stomach where as an ear, nose and throat doctor, I certainly stopped thinking about it. So of course, plenty of things can go wrong and that's what we're here to talk about. Um is how we manage first, how we work up and then how we manage some of this pathology. Um When it comes to history taking, I think these are some of the most um important and key questions to be asking ourselves. Um You know, how bad is it? How hard is it, um, how dangerous is it? How serious is the issue? And then what are some of the other symptoms that are gonna help to clue us into, uh to what's actually going on with the patients following, starting with what is hard to swallow. I think this gives us quite a lot of clues. Uh major categories we think about are solids, liquids and pills. Specifically the uh the kind of end of the spectrum. The most, the most solid of foods if you wanna put it that way, um, are typically breads, meats and raw vegetables. It's very, very consistent that if a patient has solid food dysphagia, the first thing that they'll notice and report to their doctor is one of these, um, one of these food groups, there are some people who are surprised that bread is solid, they think, oh, it's soft and squishy. Um, but in reality, bread is just as difficult to swallow for most people. Um, as a steak and raw vegetables are somewhat the same way. Again, patient will think, oh, a salad is something I should be able to swallow. Um, but actually the, the raw crunchy vegetables, um, as well as the, uh, the variation in textures can make salad very difficult to swallow. Um, typical, uh, symptoms, patients will report things like food gets stuck. I feel like I'm choking because the food is stuck in my throat. Uh, it feels like it's slow going down. It just gets hung up here and it takes forever to go down. I have to chew in the smaller and smaller bites. I have to cut up my food smaller. It takes me forever to eat because of this. Um, those are things that I hear all the time and then the more serious things that we might, um, that we might hear along with that are things like weight loss regurgitation. I swallow. It doesn't go down and I have to cough and spit it back up and then um, food impaction, I swallow it get stuck and then it stayed there until I went to the emergency room and somebody took it out. All of these things would clue us into that swallow passage being obstructed somehow. Um And so we can think of it as too closed and that's gonna contrast with our liquid, um, with our liquid dysphasia. Um, most liquids are pretty intuitive, your water, juice and coffee. Um, some liquids are a little bit less intuitive, at least for patients, for example, ice cream is basically a thin liquid because by the time you swallow it, it's a thin liquid. Um, patients will describe things like it feels like it goes down the wrong pipe. When I swallow, when I swallow liquids, it puts me into a big coughing fit or I feel like I'm choking. And then the more serious things that will get along with that are of course, aspiration pneumonia and weight loss. The liquid dysphagia typically makes us think of too open. Specifically the airway being too open. Um, sometimes this can come along with the swallow, uh, a passage being obstructed, but especially if it's, uh, if it's isolated liquid dysphagia, then we're usually thinking that they're having trouble protecting their airway and that their airway is too open in contrast to the two closed, uh, generalization with the, with the, um, solids when it comes to pill dysphasia, a little bit less, um, a little bit less specific. Um, I'll draw your attention to this bullet point down at the bottom that, um, there's an interesting, uh, study that surveyed a bunch of normal people who didn't feel like had significant trouble swallowing solids or liquids. And about half of them reported they had some trouble with swallowing pills. And so some degree of pill dysphasia, I think can be within the realm of normal for some people. It's not necessarily a cause for concern, but we take this into, um, into consideration with other factors and other context, those pill dysphasia that's new and getting worse and worse might be more concerning, um, or somebody who has pill dysphasia to the point that they're not able to actually take important medications, um, and can be concerning as well. Um, some patients on their own will crush their pills or work with their pharmacist to crush their pills, um, switch to liquids. Um, again, if it's on its own, apart from solid food dysphasia, it's hard to know how much to, uh, to, to make of it. Um, but again, very common complaints and I'm sure common complaints in the primary care world also. So bunch of different things that we can get with pill dysphagia. Um, and I usually don't think too much of it unless it's associated with solid or liquid dysphagia. Also. Next, when it comes to history is, um, how serious is the issue? What are some things that might clue us into this being more significant of a problem worthy of, of, um, of our work up. Of course, uh, pneumonia's aspiration, pneumonia would be of concern, especially when associated with those coughing and choking while swallowing symptoms. Um, the weight loss, I'm often asking patients, most people don't weigh themselves all the time. And so especially if it's a man who's wearing typical kind of masculine clothing, you might ask, you know, is your belt on the same belt loop, do your pants still fit? Um, and, um, also asking partners if they feel like somebody's change in size. Um, and then of course, if the swallow problems are landing them in the hospital, other symptoms, um, voice trouble, pain, bleeding would all be, uh, symptoms of concern. And then of course, using all those typical context clues that we use, uh, in our history taking. So that's my, that's my kind of very basic overview. Um, and then, um, we can reach somewhat of a um of a differential diagnosis based on somebody's history based on their presentation. Do we think this is most likely a problem with obstruction? Do we think this is most likely a problem with protection or maybe coordinations gotten through that part? So we can talk more about diagnostics and treatment. Um There are a number of different diagnostic options for work up of swallowing. Um Many of these are very appropriate to be used um in the primary care setting also, but I think it'll be worthwhile going through some of these different um some of these different options and um talking about the the value and the pros and cons of each starting with the clinical bedside swallow evaluation. Um This is I i it really can be a couple different ways. Um maybe familiar with this from the inpatient setting, a formal clinical bedside swallow evaluation which is typically done by a swallow, specialized speech and language pathologist. They might have quite a complex evaluation including things like um this whole list which is in front of you. Um They're also looking at things like um your oral cavity strength and tongue strength. Um but there's also a very simple way to do a clinical bedside swallow evaluation. Um that actually has quite a lot of evidence around it, which is this three ounce water swallow test. Um It is as simple as you could make it, which is to give the patient a three ounce cup of water, ask them to drink it. Um All at once, it uses thin liquids only. And if the patient is able to pass their three ounce water swallow tests, the chances of them having a clinically relevant aspiration problem are next to zero. This is the, this is the reference um if anybody wanted to actually use this test and wanted to look at the evidence behind it, but this is actually something that we use in the um Laryngology Clinic for swallow patients often as a as a matter of of reassurance beyond the clinical bedside follow evaluation um and getting into the the radiographic diagnostics. Um we'll start with the esophagram. Uh The esophagram is just an X ray evaluation with the patients following a radio pick fluid most often barium. But we can also do it with um with the water soluble contrast material um which is typically chosen if there's concern for an esophageal leak. But as long as we're evaluating for um sort of traditional swallow pathology or even for aspiration barium is the appropriate ra pig liquid. Um it can show things like um gross aspiration. It can show esophageal pathology, it can show gastric pathology, things like esophageal stricture, hiatal hernia. Um The esophagram is often relatively simple to perform. It's done with uh it's done in radiology and radiology alone. It's interpreted by a radiologist. Um It does have some drawbacks, it does not always um focus in on the swallowing, part of swallowing. And what I mean is that, that oropharyngeal uh part of the swallowing, there have been a number of times when I've gotten esophagram studies that actually just show the esophagus. Um but especially with a little bit of direction, the radiologist um can capture some decent swallow images. It has the drawback of not having a more swallow specialized um clinician interpreting the study, which is in contrast to the modified Burum esophagram. And oftentimes, especially when I received these exams done elsewhere, they're uh they're communicated as still images. Only oftentimes the radiologist will only save and capture still images even though it's done with fluoroscopy. Um You'd be amazed how often that happens. Actually, um we will go to modified barium swallow next. Um But first to sort of almost in in order of of complexity. Um Simple video laryngoscopy is next. Um video, laryngoscopy is what we do in the clinic all day every day. Um Any patient with a new swallow complaint, I will um look in their throat, examine their throat. Typically takes me about 90 seconds to do a good laryngoscopy exam. And we can get quite a lot of information, including things like um their uh neuromuscular function. Do all the nerves and muscles work like they're supposed to including the pharyngeal constrictors, including the vocal cord muscles. Um Do the vocal cords close all the way. Are there any abnormal secretions or maybe pooling of secretions. And is there something like a mass or neoplasm? Quick video here just to demonstrate um uh a very normal laryngoscopy exam um where you can see the larynx here and the vocal cords opening and closing to define or review some more of this anatomy in front of the Piloti is the molecular where things are gonna collect before we swallow on the sides of the larynx or the pur form sinuses or the hypopharynx. And then back here would be that esophageal inlet. I have another example of an abnormal laryngoscopy exam. This is one of my, one of my patients who had a stroke which caused him a high vagal injury. The vagus nerve innervates the vocal cord, but also innervates the pharyngeal constrictors in the throat. And so you will see that he has weakness, um really a paralysis of the right true vocal fold. You'll notice the left opening and closing over here. And then he also has paralysis of his pharyngeal constrictor muscles on that side, which leads to uh I was trying to pause it to show you there's the pause. And so over here, um are the pharyngeal constrictor muscles on the left, is there sort of squeezing in? And then the muscles on the right remain flaccid. Additionally, he has this pooling of secretions over here in the right side of the hypo, which is actually a pretty consistent indicator of swallow pathology. So all of that is pretty good swallow information that's gathered just from my laryngoscopy exam or as I already knew this patient had a stroke. But it's a good example of some of those details that we can that we can find with this exam. A slightly different um a slightly more complex version of that. Um laryngoscopy is what's called a flexible endoscopic evaluation of swallowing or fees exam. This is often performed in the inpatient setting, for example, um it's become very popular to do in IC us when a patient is not uh is not stable enough for transport to uh radiology, but can be very useful in the outpatient setting as well. I often will perform a fees exam when evaluating patients with new swallow problems uh during a fees exam. Um the same scope is in place through the nose and then we have the patient swallow different textures. The most simple version would be doing something like a thin liquid, a puree and a solid like a cracker. Uh But we can also use things like um thickened liquids. If a patient has trouble with a particular food, they can even bring in the food they use during the exam. And then we're able to watch um mostly coordinate. Um is what the fees exam is showing us. Are we getting good basic tongue retraction? Are we getting good epiglottic inversion? And then are we getting clearance? In addition, we can evaluate for aspiration and it's actually quite a sensitive exam for aspiration because we can actually see uh directly with the camera if there is food or drink inside the uh inside the laryngeal vestibule itself. Um I do have a video for you here. This happens to be a patient with a um with a oropharyngeal tumor um just to make it a little bit more interesting. And so the lump, the lump coming from the left side of the throat, which is the right side of the screen is a tumor. Um and this is a patient prior to cancer treatment, undergoing a fees to evaluate their swallowing. Um You might notice him swallowing him or her. I'm not sure you might notice them swallowing um green tinted fluid. We often do dye the water green during the exam in order that we can see it better. And then during this video and then during this video, we can also see them swallowing puree. This is chocolate pudding. A lot of the chocolate pudding in this video gets hung up on the tumor itself, which is not too surprising, but we're again able to evaluate for aspiration. Um And there was no aspiration. Despite a lot of that getting stuck, they'll give the patient some water to help rinse down the puree. And all in all this was um a relatively reassuring exam. Despite the not very reassuring tumor, there are some limitations to A P exam. Um When the when the throat closes to swallow when those pharyngeal constrictors engage to swallow. Um, it actually cuts off the view for a split second. And that's what, uh, is known as this white out phase, uh, in the fees. And also we can't see far enough down to see the upper esophageal sphincter opening. Sometimes patients um, struggle with tolerance, but the large, large majority of patients do very well with laryngoscopy, uh, including during these fees, exams, modified barium swallow study can also be called video fluoroscopic swallow study or it can just be called modified barium swallow. So it goes by different acronyms M BS M BS SVFSS. Um But this is considered really the gold standard of diagnostic swallow evaluation. Um This is a fluoroscopy exam, a video fluoroscopy exam while the patient swallows different uh different types and consistencies of a radio pick liquid. Um And so we typically do um thin liquids, thickened liquids, purees, solids and pills. We're able to see the entire process of swallowing from that um from that oral preparatory phase, oral phase, pharyngeal and esophageal phase. And this is gonna be more sensitive for seeing things like uh like obstructive lesions um which are often just beyond what our laryngoscopy is able to see. Um I selected some videos here with pathology um so that we can see um in this case, a Zenker's diverticulum. Um the patient starts following here, you can see the dark material in the mouth and then as that goes through the throat and down past the larynx, which is up here, we see it going down that the upper esophageal sphincter is here. The pharyngeal swallow passages here, the esophagus is below. And then we can see this big, uh this big pocket or this big pool being caught in this patient's diverticulum or pouch coming off the back of the throat. Um These studies are typically done in a lateral view and then in an A P view. And so in the A P view, we see this patient takes a swallow and there's quite a lot of it collecting in that big pouch or diverticulum, which we'll talk about in a little bit more detail in a second, uh pros of this is that again, we're seeing a little bit farther down. We're seeing that um upper esophageal sphincter and cervical esophagus. And this test is uh is performed in collaboration with a radiologist and a speech language pathologist. Oftentimes we use these tests to plan therapy or to provide real time feedback. For example, testing different swallow modifications like um head turn breath, holding maneuvers, hard swallow maneuvers, um intentional cough, and those are all things that can be um that can be uh sort of coached by the S LP during the exam. Manometry testing uh is a little bit newer than the rest, not that it's incredibly um newer or, or cutting edge. But manometry is done with a catheter placed through the nose all the way down into the stomach like an NG tube. Um The patient swallows, typically, it's done as 10 separate swallows and then pressures are measured at different points all the way from the upper esophageal sphincter to the lower esophageal sphincter. Uh This slide demonstrates what that readout looks like it comes in this very cool kind of technicolor um readout and we can uh we can see things like um for example, uh lower esophageal sphincter achalasia in upper esophageal sphincter, achalasia um or an esophageal spasm by measuring the pressure at, at, at different points on that uh on that pathway. Um And this one B is the craph Achalasia um where there is this sort of cut off right at the top of the swallow passage finally. And the, the last diagnostic that we'll talk about is Ph testing. Ph Testing is the gold standard for reflex testing, but is often not performed um in lieu of using a um uh PP I trial for evaluation of reflex as a contributor to a patient's symptoms. Um It's rare that I have a patient who says I'd rather have a probe down my throat than just take a pill. And so oftentimes, um we are not doing formal reflex testing except for in specific situations. But when we do choose to do so, the uh PH pro is often left for 24 hours. The patient goes home with it. The patient is also given an event monitor in order to record when they have symptoms so that we can correlate their symptoms to their acid exposure. Um There are versions of this which include uh PH testing or impedance testing all the way up into the Pharynx to evaluate for pharyngeal reflux. Um typically done through the G I department, done through G I here, although I order it um on occasion and then EGD um EGD a little bit outside of the, of the realm of a, of a throat specialist. Um, although I do it occasionally depending on uh the indication but more effective for evaluating esophageal signs of, of dysphagia, things like strictures and chops rings, um evaluating for esophagitis or Barrett's esophagus and evaluating for things like eosinophilic esophagitis that takes us to the end of the diagnostic um part and we'll talk a little bit about um treatment. Of course, there are all these, um, more, uh more kind of simple or conservative things that we can do to treat, but I wanted to highlight a couple of surgical swallow problems. Um just because that's what gets us excited as surgeons. Um But certainly all of these other things are really important uh for swallow treatment often. Um, when we get into surgery for swallow problems, there's a few different categories we could break it up into. Um, one is glottic insufficiency or inability to protect the larynx most often due to vocal cord paralysis. Um One of the things that I think we are especially good at helping patients with as, as throat specialists is vocal cord paralysis. Um We're often performing medialization procedures, moving the paralyzed vocal cord towards the center, either using injection techniques or using thyroplasty, which is a, a permanent implant technique. Uh Next category would be an outflow or an obstruction issue. We can often open things up. Um If that means that the precogs or upper esophageal sphincter area, um we can open it up by uh by paralyzing the muscle with Botox, we can dilate it, we can cut the muscle and then if the patient does have something like a diverticulum, um then we'll talk about how we manage that. And then only as a last resort, there are ways that we can um that we can eliminate aspiration for a patient with true end stage swallow dysfunction, which is worth mentioning even though it's pretty rare that we use those techniques to start with opal hypertrophy. This is one of the more common um surgical swallow problems that we treat. Um It goes by a few different names. Um I think opal hypertrophy is probably one of the more appropriate names. Opal Achalasia is also a very good name, although that has gotten me into trouble with people confusing it with lower esophageal sphincter, achalasia, which is more commonly talked about. Um the cry pharynges muscle again, is the main contributor to the upper esophageal sphincter. Um It's essentially a au shaped or horseshoe shaped muscle, uh which connects to the cryo cartilage and then wraps around the back of the esophagus as is shown in this diagram here. Um This swallow problem comes from um chronic uh tightening of the muscle and inability to relax. We aren't entirely sure of the ideology of cargo geal hypertrophy and achalasia. It is most commonly um theorized that it could be related to acid reflux exposure. Um But that's not something that's been definitively proven. If somebody does have significant cry pharyngeal hypertrophy, it might look like this on a modified barium esophagram study or on an esophagram. Um This is what I am referring to is this posterior imprint at the level of the opera esophageal sphincter obstructing the flow of the contrast material as it passes from pharynx to esophagus. This is often referred to as a crary bar to me. Racco bar is a, is a description of the imaging finding and isn't necessarily a name for the actual pathology. Uh But rehal bar is another common name used for this problem. And then on the right side of the screen, I've uh I've included a uh surgical photo. Um This is what it looks like when somebody has a tight craph ornge when we perform rigid esophagoscopy, where this is this big bulky muscle. Um That's obstructing the uh the passage of the scope into the esophageal lumen, the esophageal lumen designated by the white arrow at the top. So if somebody does have significant cry pharyngeal hypertrophy, if they have a modified brains, follow study that looks like this and they are having solid food dysphagia, pill, dysphagia, discomfort, globus sensation. Um, it depends. Um, the patient certainly doesn't have to have it intervened on. Um, if they are minimally symptomatic, if they're happy to manage, I've had plenty of patients who say, you know what, if you tell me, all I have to do is chew my food a little bit better. I'm fine with that. I say great. I'm fine with that too. Uh But for those people who aren't really bothered and want something to be done, um There's a few different kind of levels of how we treat it. One would be just a simple dilation. Um I don't often do simple dilation. Um just because I think it's not very durable, but it's often done, for example, um as combined with an EGD procedure by a, by a G I doctor. Most often, if I'm doing something conservative, I'll do Botox to the muscle with dilation. That's what the photo on the right is demonstrating is a needle passing into the bop pharynges through that surgical exposure and we can inject Botox into the muscle, which typically provides relief for upwards of 4 to 6 months. Uh I'll dilate it at the same time in order to maximize effect. Um There are some potential adverse effects just like there is with any invasive procedure. Specifically, we're losing the function of the upper esophageal sphincter, which is, well, it's meant to open and close. And if we have it permanently open, it can leave somebody open to a little bit more reflux or regurgitation. Um And then finally, as a more permanent uh means of treatment, uh myotomy where we can actually cut the muscle, uh could be done endoscopic or could be done open. Um We often use the Botox procedure as almost a test case to make sure if we relax that muscle, that the patient's symptoms truly do improve. And for a patient whose symptoms do improve dramatically, they would have the option of either repeating their Botox procedure or undergoing a myotomy for more, more permanent management, almost always that can be done endoscopically. Um But of course, it can be done open. Also moving past grange uh hypertrophy. This is this could be considered actually on the same spectrum of disease. We think that Zenker's diverticulum starts with racco hypertrophy. But then over time, the increased pressure um in the pharynx leads to uh leads to dilation and out pouching um within the hypopharynx. So the cops is tight for a long, long time. There's all this increased pressure as somebody is swallowing against what is effectively a closed valve. And then this is a a drawing looking from the back of the um of the pharynx and the esophagus. There is this little weak spot in between the inferior constrictor muscle and the gryphus and over time starts with just a little out pouching and then a little more and a little more and a little more. And ultimately, that weak spot can extend into this big pouch, which we call Zenker's diverticulum. Classic symptoms include things like um, food sticking, but usually more than that regurgitation. After meal times, sometimes patients will say that things will spill back up into their throat when they bend over, commonly gurgling or bubbling in the throat as well. This is a really fun problem to identify because we're usually able to cure the patient's symptoms. And we love that this is what it looks like endoscopically where in the center is the cryo thynus muscle itself and then behind is the zinker diverticulum pouch ahead is the, is the um esophageal lumen. And then what we typically do, there's really two ways to do it. We can just divide the wall with a laser. But more often we're using an endoscopic stapler in order to um in order to divide that wall between and essentially take what starts as this anatomy divide the wall between, combine them into one big swallow passage. And this is an example of what that looks like in a real patient in a before and after where this patient started with a small Z acre diverticulum. Here, we were able to divide this wall in between and left them with a normal uh a normal caliber swallow passage without that pouch. Um there to retain contest z diverticulum surgery also, um can be done open. I typically reserve open technique for somebody who has failed endoscopic treatment usually due to inadequate exposure. Um And so if we're unable to expose that nice view through the um through the mouth and in the throat, then we can do an open procedure where the esophagus is, uh the esophagus is approached through the neck, we divide the pre GS muscle. Um and then we're able to um to dissect out a pouch like this and staple it off from the outside. Again, typically reserved for folks who um who are uh for whatever reason, impossible to expose endoscopically. The rico tracheal separation and functional laryngectomy um are just these kind of end stage treatments just to, just to kind of close the loop. Um If somebody is aspirating chronically and we're unable to correct it via other means. Um This is kind of the ultimate surgical technique in order to um keep them from aspirating where we can create a permanent stoma in the front of the neck. Um And basically, so the bottom of the larynx shut to avoid um aspirated contents getting into the lungs. This is an example during a tracheal separation is when the larynx is left in place. Functional laryngectomy is when the larynx is removed and the patient is left with a permanent stoma in the front of their neck. Um, relatively rare. Um, but I'm actually, I have a patient who are doing one of these coming up. I think everybody is interested in knowing kind of what's, what's new, what's different. Um, truth is in general. I don't think there's that much new in swallowing medicine. A lot of this stuff has been around for, for at least a decade or two, but there is 11 new thing, um, that might be worth being aware of. Um It's a diagnosis that was essentially invented within the last five years or so. It goes by the name retrograde copal dysfunction or R CPD. It is known by patients as no Burp syndrome. Uh No Burp syndrome is kind of a fun story that I like telling people about because uh these this disease did not exist until these patients found each other on the internet. Um Specifically these patients found each other on the website reddit where basic I I don't know how it first happened, but there is a, there was a subreddit created called No Burp and people found other people and said no way. I thought I was the same one. You have the same symptoms I do. And they found more people that said I have the same symptoms you do. These are the symptoms that they have bloating and discomfort after eating gurgling noises. They all have the gurgling noises, often audible to others, often, socially embarrassing, excessive flatulence. And then most importantly, inability to belch, they found each other online. And then um it was actually a physician in Chicago, a guy named Bastian who decided that he was gonna take this on that he was going to really validate these people in their experience and then also create a solution. The solution is also um a procedure on the cryo erge muscle. The theory is that the cryo erge muscle has a, a discordination that prevents it from opening in order to release pressure. And what he started doing was to um repurpose this procedure that we use for swallow, trouble, use the same procedure for patients who can't burp and by relaxing the upper esophageal sphincter with Botox, we can allow the patient to burp. It sounds silly, it sounds silly to all of us too. But for the most part, patients do incredibly well. Um And interestingly, we know that Botox only lasts for 3 to 4 months. That's the pharmacologic duration of Botox. But the large majority of patients actually retain their improvement after their Botox is fully worn off. And that has been true for the patients who I've treated as well. And so I bring this up both to introduce a new phenomenon. Um and also to um to emphasize that we, we don't know everything patients know a lot about their own disease. Um There are uh sort of new and different ways for patients to find each other, for patients to find support and also for us to be able to identify uh and uh and pioneer new treatments. We'll skip that. I wanted to talk a little bit about um dysphasia referral. Um There are many, many different people who have a role to play in dysphasia management. Um S LP S are incredibly valuable. We work directly with that with S LP S in our clinics. Um We have a couple swallow specialists within our, within our department. Of course, there are um home based S LP S. There are neuro rehabilitative S LP S. There are cognitive S LP specialists and depending on the pathology, all of them can be useful. The gastroenterologists I think are, may, may even be the more traditional home for patients with swallowing problems. Um but if a patient doesn't have an esophageal phase swallow problem, um they can be left sometimes without answers, sometimes frustrated. Um And so certainly in this institution, we very much work together. Um The otolaryngologist tends to be the the key provider for that oral and oropharyngeal phase dysfunction. Um We tend to be the key provider for um for concern for swallow safety or aspiration. And certainly if a patient is at high risk for an upper digestive tract malignancy, for example, if they're a tobacco user, then the otolaryngologist is probably a very good person to be managing. Um I tried to make kind of a simple guide, what are some things that would be very, very clear indications for referral, things like progressive or worsening symptoms, uh recurring or frequent aspiration, weight loss, high risk of malignancy, concern for a neurologic injury or a degenerative neurologic process. I think all of those are really wonderful automatic reasons. Um For referral, I think that this uh this middle category would be things that are a little bit more of a gray area, persistent global sensation without other concerning symptoms. We're always happy to see and work them up. Um, but also if a patient isn't especially concerned and they don't have concerning symptoms, we don't necessarily have to be that concerned. Either. Same goes for, um, kind of minor changes and swallow that people notice but aren't getting worse and aren't causing any, any more significant, um, problems, um, little bit of pain and swallowing as well. Um, if it's not getting worse, if it's not associated with other symptoms, it may be something that we can monitor. Um, and then things that are, I think very appropriate to manage in a nonspecialist setting. Um, simple reflux which responds well to a depression. I think, um, some of the kind of globus throat discomfort and cough that doesn't come with any concerning signs and is not bothersome with the patient and then changes which are within expectations for age, right? The 85 year old who has to chew slowly and pay attention when they swallow. Wonderful. We're happy they're still swallowing. Um, and, um, I think that some of those things can be called um sort of within expectations for, for older adults. Um Certainly we're always happy to, to see folks. Um This is myself and my partner. Um And then I would add that um we do work very closely with the G I department and specifically Dr Prakash Awali is one of our go to folks in the G I department who really specializes in esophageal um medicine and treatment. And for that reason, um he's a very important um sort of collaborator and colleague for us. Also, always happy to see folks, always happy to hear from you. Um Here are our direct email addresses. Um And um that's all I have for you today. Thank you so much. That was great. Did anybody have any questions? And if not, you know, I have their email addresses and like I said, I will be sending out an email right after this. Um So I, you can always send me a question if it comes up later on and you think of one, I can always get it to them as well. So, thank you so much. Enjoy the rest of your day, Doctor Ralph. We appreciate it. Thank you. Thank you for your time. Created by Presenters Matthew L. Rohlfing, MD Assistant Professor of Otolaryngology—Head & Neck Surgery View full profile
