Evaluation and Treatment of Swallowing Problems
1. Evaluation of Swallowing
The larynx (voice box) protects the airway by preventing materials such as food and liquid from entering into it (penetration or aspiration). At Lakeshore Professional Voice Center we assess swallowing problems. Below are listed some tests frequently used during the evaluation of swallowing disorders or “dysphagia”.
2. Flexible Endoscopic Evaluation of Swallow (FEES)
Flexible Endoscopic Evaluation of Swallow (FEES) is a test that assesses oral-pharyngeal (mouth to throat) swallowing function. During this test, a flexible scope is passed through the nose to look below at the larynx swallow as the patient swallows.
During this test, the patient is asked to drink and eat several consistencies (water, thickened juice, applesauce, cracker, etc.) while his/her swallow is video-recorded. The doctor and speech pathologist may make recommendations for safer swallowing, including referral for swallowing therapy or surgical intervention if needed.
3. Transnasal Esophagoscopy
Transnasal esophagoscopy is the evaluation of the esophagus with a thin esophagoscope that is passed through the nose after topical anesthesia is applied.
A patient with reflux or swallowing problems requiring esophagoscopy can now have this performed without having to be sedated for esophagogastroduodenoscopy (EGD). The procedure takes no more than a few minutes. Patients may return to work the same day.
4. Barium Swallow or MBSS
A patient may be referred to the radiology department at a local hospital for a barium swallow study (esophagram) or a modified barium swallow study (videoesophagram). These tests use x-ray and video imaging to capture the swallow function.
The barium swallow study (esophagram) provides a view of the movement of liquid from the mouth to the stomach. It is ordered when the clinician suspects there may be an issue with the phase of the swallowing mechanism involving the esophagus (the tube that connects the throat to the stomach)
The Modified Barium Swallow Study (Videoesophagram)
Is performed by a speech pathologist and radiologist to view the movement of food/liquid from the mouth to the esophagus.
5. Endoscopic Treatment of Zenker’s Diverticulum and Cricopharyngeal Muscle Spasm
A Zenker’s diverticulum is a pouch that forms with its opening just above the entrance to the esophagus. It develops due to a tight upper esophageal sphincter that makes it difficult for food to pass from the throat into the esophagus. As a result, some of the food pushes through a weak area in the back wall of the throat and eventually creates a pocket. The pocket can grow and become more of a trap for food and pills. Patients who have a Zenker’s diverticulum may not only have difficulty swallowing due to the tight upper esophageal sphincter but may also periodically have food come back up on them. If this occurs while they are lying down, the food may be aspirated (fall into the lungs) and cause pneumonia. Patients with a Zenker’s may also complain of a cough and bad breath. Zenker’s diverticulum is usually found in elderly patients but can occur in middle-aged patients as well. The diagnosis is confirmed with a barium swallow (esophagram).
Traditionally, treatment for Zenker’s diverticulum required an incision in the neck and retraction of important structures. These days the majority of these cases may be performed endoscopically (through the mouth). Endoscopic treatment typically results in a much faster recovery. Patients are often eating that evening or the morning after surgery.
Cricopharyngeal Spasm (Upper Esophageal Sphincter Dysfunction)
The cricopharyngeus muscle makes up the upper sphincter of the esophagus. It relaxes to allow food to pass into the esophagus. If it is too tight, either due to a neuromuscular issue or to scarring, swallowing becomes difficult. In some cases, a Zenker’s diverticulum might form. In the case of scarring, often dilation of the sphincter is required. This is typically performed endoscopically (through the mouth). If it is a neuromuscular problem, this is termed cricopharyngeal spasm. Procedures can be performed to relax the muscle.
The diagnosis of cricopharyngeal spasm as the main cause of swallowing problem can be difficult as many factors can affect the swallowing mechanism. Typically, the diagnosis is suggested by a modified barium swallow study. Often, manometry is obtained to confirm the diagnosis. Manometry uses a probe to measure the strength of contractions throughout the esophagus. If cricopharyngeal spasm is strongly suspected a number of options are available. Swallow therapy may be useful as a first measure. If this is not sufficient, often a trial of botulinum toxin injection into the sphincter is performed. This is typically performed in the operating room, endoscopically. If this is successful and the problem recurs, additional injections may be performed, or the muscle may be cut during a procedure termed cricopharyngeal myotomy. Traditionally, this was performed through an incision in the neck, but today, in many cases, it may be performed endoscopically. The procedure is not without risk, and a full discussion is required with the surgeon.