Swallowing Evaluation and Treatment

What we try to accomplish during an initial consultation:

1. Obtain your general medical history
2. Understand your “swallowing experience” and the symptoms that bother you
3. Examine your palate, tongue, pharynx, and larynx because they comprise your “equipment” for swallowing
4. Study your swallowing function during an office-based videoendoscopic swallow study (VESS) because it is typically the best evaluation of the “propulsive” side of swallowing, that is, the oral and pharyngeal phases.
5. Review images from an xray-based videofluoroscopic swallow study (VFSS) because it is the better procedure to best understand the “receptive” side of swallowing both anatomically and functionally. That is, the cricopharyngeus muscle (aka upper esophageal sphincter), a Zenker’s diverticulum if present, and esophageal transit. These x-ray images may be available from:

a. A CD of this study you bring to the initial appointment from your prior workup elsewhere. In this case, we suggest you load the disc into your home computer

b. A CD of a VFSS done earlier in the day by per-arrangement at nearby Good Samaritan Hospital

c. A CD of a VFSS performed after the initial consultation at nearby Good Samaritan Hospital (if possible to arrange), and then brought back for review later that day

After all the above, we can usually describe in detail your issue is primarily propulsive or the “pitcher” of swallowing, or the “catcher” or receptive side (cricopharyngeus muscle and esophagus) – or both. Depending on the specifics of your case, we may suggest swallowing therapy, cricopharyngeus myotomy, or both.

Swallowing Therapy

If the main problem is with strength and organization of food and liquid propulsion (what we often call by the shorthand term “presbyphagia” in older adults), the primary approach is teaching/training. The evaluating physician may give tips and pointers and as appropriate, swallowing therapy provided by a speech pathologist may be recommended. Exercises for tongue, cheek, and throat muscles, head position, swallowing techniques, and careful food choices are some of the topics covered during swallowing therapy.

Cricopharyngeus Myotomy

If a major issue is non-relaxation of the cricopharyngeus muscle and “the catcher won’t open his glove”, cricopharyngeus myotomy (CPM) is often an option. The following is a summary of important information to know about CPM.

1. To reduce the likelihood of a complication called subcutaneous emphysema, it is crucially important that if you need to cough or sneeze in the first three days after surgery, this must be done with mouth wide open. Your surgeon will demonstrate how to do this and you should practice this many times at home before the day of surgery so that it is “second nature”.
2. Surgery is performed at nearby Good Samaritan Hospital, under general anesthesia.
3. We ask your permission for both endoscopic (through the mouth) and trans-cervical (through a neck incision) myotomy, even though the majority of procedures are done endoscopically. The trans-cervical operations are typically for the one of ten whose anatomy will not permist endocopic visualization.
4. Immediately upon waking, there will be discomfort from a very sore throat, often rated by patients as between 5 and 8 on a 10-point scale, and also the annoying discomfort of a tube in your nose.
5. That tube in the nose is placed in the operating room while you are asleep and is used to create gentle suction in the area of the surgery.
6. The day of surgery, we usually allow sips of liquids. The tube in your nose cannot be removed until you are able to swallow quite well around it. Most often the tube is removed the morning after surgery. In the uncommon event that a person is still unable to swallow by the next morning, the suction tube going through the nose can be repositioned to serve as a feeding tube. That occurs mostly in people who not only have cricopharyngeus dysfuntion (for which we are doing surgery) but also poor propulsion or “prebyphagia”. That is, both “pitcher” and “catcher” of swallowing are impaired.
7. Usual discharge is the morning after surgery whether we have done the endoscopic or trans-cervial approach. The suction tube is removed early in the morning of the day of surgery, to give time to verify ability to swallow liquids before going home.
8. IF you are unable to swallow around the suction tube, you would stay one or more additional days. This occurs in approximately one of five patients.

The great majority get through this procedure uneventfully. It is unpleasant due to the sore throat and initial tube in the nose, of course.

The risks of surgery overlap between endoscopic and trans-cervical methods of surgery:

For both approaches:

• a chipped or dislodged tooth (very uncommon)
• infection including rare mediastinitis (a severe central chest infection)
• anesthesia complications
• postoperative bleeding

For the endoscopic (through the mouth) approach, an added potential complication: subcutanrous emphysema (blowing air into the tissues of the neck, face, upper chest, etc. causing swelling for days)

For trans-cervical (neck incision) approach: vocal cord paralysis, or rarely a fistula (short-term leakage of saliva)