Closeup, magnified examination finds barbecue brush bristle base of tongue: Series of 4 photos
Pain in throat (1 of 4) While eating barbecued steak, this person felt a sharp pain deep in her throat. At this visit the next day, she continued to feel a sharp sensation, especially when swallowing. Note the faint dark line at the arrow.
Closer view (2 of 4) From a slightly closer vantage, the abnormality is seen better.
Bristle identified (3 of 4) At even closer range, the bristle is identified.
Bristle to be removed (4 of 4) At this final view, the metallic nature of the foreign body and stuck-on carbonaceous debris can be appreciated. This bristle was removed with cup forceps through a channel scope in an office setting.
Diet modifications for dysphagia are suggested dietary changes, particularly regarding food consistencies, directed at improving a patient’s ability to swallow and at avoiding aspiration. For example, an individual who is struggling with aspiration might be advised to avoid thin liquids and use thicker or carbonated liquids instead. Or this individual might be advised to avoid composite foods, since his or her swallowing deficiency could make it harder to “stay organized” with several consistencies in the mouth at once.
The leaking of saliva outside of the pharynx (“throat” part of the swallowing passage) through a defect in the pharyngeal mucosa lining. This may occur transiently in up to 20% of persons who have undergone total laryngectomy, with the sixth postoperative day the peak time of incidence. Prior radiation therapy seems to increase the risk of fistulization.
Traditionally, the treatment was to make a midline incision directly, insert a penrose drain, and then use pressure dressings. Modern treatment uses suction drains to control salivary leakage and allow the rest of the skin flap to adhere to the neck1. Then, the drain is removed, shortened, and replaced a series of times to allow the tract to close from top to bottom.
Pharyngocutaneous fistula : Series of 3 photos
Pharyngocutaneous fistula (1 of 3) Panorama of reconstructed hypopharynx one week after laryngectomy for persistent cancer after radiotherapy. (PPW = posterior pharyngeal wall. PE = pseudo-epiglottis, often seen after reconstruction. F's arrow = fistula. E = esophageal entrance.)
Pharyngocutaneous fistula (2 of 3) Closer view of fistula opening and esophageal entrance, with salivary pooling.
Pharyngocutaneous fistula (3 of 3) Patient receiving suction drain treatment. The suction tubing evacuates saliva drop by drop as it forms, eliminating the need for wound dressings and long term antibiotics. This treatment also prevents infection and causes less discomfort for the patient than traditional treatment.
If this reflux occurs during a videoendoscopic swallowing study, the clinician will see that, though there may be little to no hypopharyngeal residue immediately after the swallow, a moment later some swallowed material (e.g., blue-stained applesauce or water) reappears and wells up in the post-arytenoid area and into the pyriform sinuses. If this reflux occurs during a videofluoroscopic swallowing study, the clinician will see barium remaining in the Zenker’s sac and, immediately after each swallow, moving back upward into the hypopharynx.
Suspect Zenker's even if no prior radiographic proof: Series of 5 photos
Dysphagia and possible Zenker's (1 of 5) This middle-aged man has solid > liquid dysphagia, and x-rays elsewhere (not available at this visit) reportedly showed a Zenker’s diverticulum. Even without that prior knowledge, the highly organized hypopharyngeal salivary pooling is strongly suggestive of this diagnosis, but subsequent photos of VESS even more so.
After a complete swallow (2 of 5) During VESS, after completing a swallow of blue-stained applesauce, note the residue in the post-arytenoid area.
Additional material (3 of 5) A third of a second later, additional material has emerged from below, likely ejected upwards from the Zenker’s sac.
Hypopharyngeal residue (4 of 5) At the end of another swallow of the blue applesauce, the hypopharyngeal residue is again seen, but more important is that...
Two seconds later (5 of 5) ...again, about 2 seconds later, the left pyriform sinus fills from below as the material in the sac is ejected upwards.
Post-swallow hypopharyngeal reflux (Zenker's Diverticulum): VESS vs. VFSS: Series of 7 photos
VESS (1 of 7) In a patient with a known Zenker's Diverticulum, who has just finished swallowing blue-stained applesauce during VESS.
Reflux (2 of 7) Less than a second later, the applesauce and some saliva bubbles reflux upwards from the Zenker's sac into the postarytenoid area.
Post-swallow (3 of 7) Here, the patient has just swallowed a cheese cracker.
Reflux of cracker (4 of 7) About a second and a half later, this material, mixed with saliva, returns from the sac.
VFSS (5 of 7) Just after the patient has swallowed a bolus of barium
A second later, barium is "squishing" upwards from the sac.
Continued reflux (7 of 7) Additional barium has come upwards into the postarytenoid area (compare with Photos 2 and 4).
When a person feels unable to initiate the swallow. Normally, after the oral preparatory phase of swallowing (chewing, mixing with saliva), a person can voluntarily initiate the swallow reflex by moving the liquid or chewed food back to the base of the tongue, triggering the reflex. Occasionally, however, a person with otherwise normal swallowing feels unable to start or commit to the swallow. They often say, “The food just stays in my mouth; I can’t seem to get myself to swallow.” This problem can be neurogenic, but can also reflect a kind of phobia or sense of vulnerability about swallowing.
Choking is a term that, as used popularly, can describe at least a few distinct scenarios or disorders:
Minor aspiration. A person swallows and food or liquid “goes down the wrong tube” (down the airway), which provokes aggressive coughing.
Life-threatening aspiration. A person swallows food (a piece of meat, for instance) that enters the airway and plugs it, requiring a Heimlich maneuver.
Sensory neuropathic cough. A person uses the term “choking” to describe a severe episode of coughing, but without any aspiration of liquid or food.
Laryngospasm. A person uses the term “choking” to describe the sudden inability to breathe and the noisy inspiration of a laryngospasm attack.
When a patient uses the term “choke,” the clinician must ask a series of questions to verify whether the fundamental issue is dysphagia with aspiration, coughing unrelated to dysphagia or aspiration, or laryngospasm. View this article for more information.