Foreign Content in the Throat

Photos:

Closeup, magnified examination finds barbecue brush bristle base of tongue: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress

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 Modification for Dysphagia

Diet modification 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.


Solid Food Dysphagia Due to an Unexplained Benign Mass

Visual Portfolio, Posts & Image Gallery for WordPress

Benign mass (1 of 4)

This elderly man is having a hard time swallowing solids. There is a mucosa-covered mass (marked with lines) between the posterior pharyngeal wall (longer dashed line) and the arytenoid towers ( marked with A). "V" denotes the right vocal cord.

Closer view (2 of 4)

At much closer range while having the patient perform a trumpet maneuver.

One week post-op (3 of 4)

This is a week after laser excision of this mass. The dashed line again shows the posterior pharyngeal wall and A and V again denote arytenoid apices and V, the right vocal cord. The pathology examination shows only fibrosis and other nonspecific benign findings.

Trumpet maneuver post-op (4 of 4)

Now performing trumpet maneuver (as in photo 2), the upper edge of the excision is shown (dashed line, left of photo). In spite of a very sore throat, this man can already sense improvement in his swallowing.

Swallowing Therapy

Swallowing therapy is typically provided by a speech-language pathologist (and, more informally and adjunctively, by other healthcare professionals). General areas of teaching might include: choosing wisely which food types and consistencies to eat; swallowing maneuvers such as tucking the chin, double swallow, effortful swallow, head turning, and supraglottic swallow; and direct exercises for the tongue, pharynx, palate, and larynx.

Videos:

https://youtu.be/_dBPKBg8jXM
Swallowing Trouble 101
This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or cricopharyngeal dysfunction), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).

Pharyngocutaneous Fistula

Pharyngocutaneous fistula is 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 neck 1. Then, the drain is removed, shortened, and replaced a series of times to allow the tract to close from top to bottom.

Pharyngocutaneous Fistula

Visual Portfolio, Posts & Image Gallery for WordPress

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.)

Closer view (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.

Anterior Commissure-to-subglottis Fistula Complication of Radiation

Visual Portfolio, Posts & Image Gallery for WordPress

Larynx losing function (1 of 4)

This man underwent supraglottic laryngectomy and radiotherapy nearly 20 years ago. A biopsy was done some years later elsewhere, and triggered radionecrosis. Hyperbaric oxygen treatments back then saved the day. This larynx has continued to lose function slowly over time, necessitating tracheotomy, and with deteriorating voice quality. The latest problem is coughing on liquids, and they are coming out his tracheotomy tube. Here, you see the arytenoid apices (each marked with A). Epiglottis and false vocal cords are surgically absent. Base of tongue (BoT) was pulled down to the level of the vocal cords. Click to enlarge this photo to see the dots marking the upper surface of each cord.

Swallowing (2 of 4)

Now looking deep into the surgically-minimized laryngeal vestibule, the two larger dots are again on the vocal cords, for comparison with photo 1. The fine dotted line encircles a fistula. When the patient swallows, food or liquid can enter in the direction of the arrow. Where it goes next is seen in the following photos.

View from between vocal cords (3 of 4)

The scope has entered between the cords (between the dots in photo 2), and is now viewing the subglottis. “T” near the top of the photo marks where the tracheotomy tube is seen entering the trachea. The anterior subglottic fistula is seen at the bottom of the photo with the sidewall of the tracheotomy tube seen at the lower-case “t.”

Swallowing water (4 of 4)

Remaining in the anterior subglottis while the patient swallows pale blue-stained water, you see a part of the bolus “exploding” through the fistula, and this series of 4 photos taken together fully explain why this man is having so much difficulty with liquids that he swallows coming out his tracheotomy tube.
References
  1. Bastian RW, Park AH. Suction drain management of salivary fistulas. Laryngoscope. 1995;105(12 Pt 1):1337-41.[]

Post-swallow hypopharyngeal reflux

Refers to when, shortly after a person swallows, some swallowed material returns from below the esophageal entrance back up into the hypopharynx. This finding is an almost certain diagnostic indicator of cricopharyngeal dysfunction, usually with an associated Zenker’s diverticulum.

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.


Photos:

Suspect Zenker’s even if no Prior Radiographic Proof

Visual Portfolio, Posts & Image Gallery for WordPress

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

Visual Portfolio, Posts & Image Gallery for WordPress

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.

X-Ray (6 of 7)

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).

Inability to Initiate Swallow

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

Choking is a term that, as used popularly, can describe at least a few distinct scenarios or disorders:

  1. Minor aspiration. A person swallows and food or liquid “goes down the wrong tube” (down the airway), which provokes aggressive coughing.
  2. Life-threatening aspiration. A person swallows food (a piece of meat, for instance) that enters the airway and plugs it, requiring a Heimlich maneuver.
  3. Sensory neuropathic cough. A person uses the term “choking” to describe a severe episode of coughing, but without any aspiration of liquid or food.
  4. 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.

Food Lodgment

Food lodgment refers to when food gets stuck somewhere along its path from lips to stomach. Lodgment is more of a “full stop” of the food’s digestive journey, as compared with pooling. Lodgment usually occurs at one of these points: in the vallecula (usually in cases of presbyphagia); at the level of the cricopharyngeus muscle (in cases of cricopharyngeal dysfunction, which is one kind of achalasia); somewhere in the esophagus (in cases of esophageal stenosis); or at the lower esophageal sphincter (in cases of lower esophageal sphincter achalasia).


VESS Assesses Equipment, Secretions, then Swallowing Ability

Visual Portfolio, Posts & Image Gallery for WordPress

Part Ia: Palate elevates normally (1 of 7)

This man has symptoms of cricopharyngeus muscle dysfunction (CPD), with frequent lodgment of solid food (never soft or liquid material) at the level of mid-to-low neck. This VESS sequence demonstrates his propulsive or “pitcher” ability. Here in VESS part Ia, palate elevates normally (arrows). Left palate is not drooping and there is no deviation.

Part Ib: phonation (2 of 7)

In Part Ib of VESS, the patient makes voice, to prove normal movement and good closure of the vocal cords. In addition, no secretional pooling is seen in vallecula or pyriform sinuses.

Part Ic: High pitch elicited (3 of 7)

Part Ic: Very high pitch is elicited. Pharyngeal walls contract inward (arrows), closing the pyriform sinuses. Part Ia,b, and c (Photos 1, 2, and 3) verify that there is good function of swallowing equipment, i.e. palate, pharynx, and larynx (and tongue).

Part IIa: applesauce (4 of 7)

Part IIa: Blue-stained applesauce is first, because puree is the “easiest” material for the majority of patients, whatever their diagnosis. Here, one sees only minimal residue after several boluses are swallowed.

Part IIb: cracker (5 of 7)

Part IIb: After an orange (cheese) cracker, lodgment in the vallecula, and…

Part IIb: continued (6 of 7)

...on the pharyngeal walls (arrows).

Part IIc: water (7 of 7)

Part IIc: After several boluses of blue-stained water, all cracker is washed away and there is no blue staining or residue within the laryngeal vestibule, subglottis, or high trachea. Given this man’s CPD symptoms, VFSS may show a cricopharyngeus muscle bar, indicating incomplete relaxation of the upper esophageal sphincter.

Cricopharyngeal Dysfunction, before and after Myotomy

Visual Portfolio, Posts & Image Gallery for WordPress

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Elderly patient with nearly a year’s duration of frequent lodgment of solid food at the level of the cricoid cartilage (at the mid-neck level). Note here the cricopharyngeus muscle “bar” which narrows the barium stream (indicated by green dotted line). This narrowing is due to incomplete relaxation of the muscle (aka upper esophageal sphincter) causing a smaller entrance to the esophagus. Liquids and very soft foods can still get through, but solid foods tend to get stuck or to require repeated swallows.

Cricopharyngeal dysfunction: after myotomy (2 of 2)

A month after endoscopic (through the mouth) cricopharyngeus myotomy (division of the muscle with a laser). The patient’s initial swallowing symptoms are completely resolved and the barium stream no longer shows narrowing and the cricopharyngeus bar is no longer seen (see green arrows).