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 neck ((Bastian RW, Park AH. Suction drain management of salivary fistulas.Laryngoscope. 1995;105(12 Pt 1):1337-41.)). 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.
Anterior commissure-to-subglottis fistula complication of radiation: Series of 4 photos
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.
The inappropriate entry of saliva, food, or liquid into the nasopharynx during swallowing, usually due to palate weakness or dyscoordination (see palate elevation).
Aspiration that does not provoke an expected, normal response of coughing or throat clearing. Silent aspiration suggests a very high risk of aspiration pneumonia.
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: 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.
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