Dysphagia

Dinesh Chhetri, Karuna Dewan

• Publisher: Elsevier
• Year: 2018
• ISBN:
  9780323569361
• Topic: Medicine
• Subtopic: Ear, Nose & Throat Medicine

Get a quick, expert overview of the many aspects of the evaluation and management of dysphagia from a team of experts in the field, led by otolaryngologists Drs. Dinesh K. Chhetri at UCLA's David Geffen School of Medicine and Karuna Dewan at Stanford University. This practical resource presents a focused summary of today's current knowledge on anatomy and physiology of swallowing, assessment of swallowing, and treatment of dysphagia. It's an easy-to-read, one-stop resource for staying up to date in this high-demand area.

• Features up-to-date information on assessment of swallowing, including the physical exam, FEES, TNE, MBSS, Barium Esophagram, and HRM.
• Offers current coverage of dysphagia treatment, including Neurologic Dysphagia; Chemoradiation-induced Dysphagia; Epiglottic Dysfunction; Cervical Osteophytes; Glottic Insufficiency; Cricopharyngeal Achalasia; Zenker's Diverticulum; Dysphagia After Laryngectomy; Esophageal Dysphagia; Eosinophilic Esophagitis; and Swallowing Therapy.
• Discusses future directions in dysphagia treatment.
• Consolidates today's available information on this timely topic into one convenient resource.

Section III

Treatment of Dysphagia

Outline

Chapter 13. Developing the Optimal Treatment Strategy for Dysphagia

Chapter 14. Neurologic Dysphagia

Chapter 15. Chemoradiation-Induced Dysphagia

Chapter 16. Epiglottic Dysfunction

Chapter 17. Cervical Osteophytes

Chapter 18. Glottic Insufficiency

Chapter 19. Cricopharyngeal Dysphagia

Chapter 20. Zenker’s Diverticulum

Chapter 21. Dysphagia Following Laryngectomy

Chapter 22. Esophageal Dysphagia

Chapter 23. Eosinophilic Esophagitis

Chapter 24. Swallowing Therapy

Chapter 25. Future Directions in Dysphagia Treatment

Chapter 13

Developing the Optimal Treatment Strategy for Dysphagia

Dinesh K. Chhetri, MD

Abstract

Contemporary management of oropharyngeal dysphagia is a multidisciplinary effort. The optimal dysphagia treatment is developed if the otolaryngologist and the speech and language pathologist who are dedicated dysphagia specialists work closely together. A consensus treatment plan is then developed. Significant obstructions to bolus flow generally require surgical intervention. Other disorders require careful planning before surgical or swallow therapy is recommended. In addition, the timing of treatments should be considered. A systematic approach to dysphagia management generally ensures all relevant issues have been covered before treatment is recommended and leads to the best possible outcome.

Keywords

Dysphagia surgery; Dysphagia treatment; Medical decision making; Swallow therapy

Introduction

Contemporary management of oropharyngeal dysphagia is a multidisciplinary effort. The otolaryngologist and the speech language pathologist (SLP) must play central roles in evaluation and co-management of dysphagia. Other specialties such as gastroenterology and general surgery also play significant roles, especially for esophageal dysphagia. The optimal treatment can be developed and offered to the patient only after a thorough assessment of swallowing dysfunction via targeted history, physical exam, instrumental exams of swallowing, and consideration of relevant comorbid medical conditions and cognitive functioning of the patient. Treatment decisions may be primary surgery, primary swallow therapy, or both. Sometimes, observation and routine surveillance is an acceptable treatment approach. A collaborative multidisciplinary approach for the assessment and treatment of dysphagia will lead to better medical decisions and superior swallowing outcomes.

Developing the Optimal Treatment Plan Together

The optimal dysphagia treatment is developed if the otolaryngologist and SLP with dedicated clinical focus on dysphagia work closely together. Ideally, both should convene a face-to-face meeting and review the core triad of instrumental swallow assessments for dysphagia: flexible endoscopic evaluation of swallowing (FEES), modified barium swallow study (MBSS), and transnasal esophagoscopy (TNE). At the minimum, there should be open channels of communication between the two to co-manage the patient. At our institution, we convene weekly meetings to go over all swallow studies. This collaborative effort has many benefits. For the otolaryngologist, it is very useful to review the MBSS personally with the SLP to correlate and corroborate the anatomic and swallowing dysfunction seen on FEES, especially for surgical planning. An indepth discussion of swallowing evaluations, and the pros and cons of the different treatment options is discussed. The face-to-face discussion also benefits the SLP, as it brings out in discussion the physician's assessment and plans as well as what MBSS images, interpretations, and reporting is needed to facilitate those treatment decisions. The SLP can also view the endoscopic images to more fully understand the patient's anatomy and swallow function and provide input about how a surgical intervention may impact swallow function or swallow therapy. The approach also improves the coordination of care. For example, a decision can be made for a staged treatment approach, with surgery followed by swallow therapy or vice versa. Most importantly, the patient benefits from better treatment decisions and swallowing outcomes that result when cases are discussed and the patient's dysphagia complaints and swallow dysfunction are clarified prior to treatment. This collaboration also allows the swallow team to speak with a single voice, which may improve the patient's understanding of the problem and plans for managing dysphagia.

The dysphagia history is first discussed during the case reviews. A key question to consider is how the medical history may be expected to relate to the patient's swallowing problems. For example, is there a history of chronic neurologic disease, chemoradiation therapy, head and neck surgery, or other acute exacerbating factors such as recent stroke? What is the patient's age? This may be an important consideration since some elderly individuals have multiple medical conditions and reduced functional reserve. Generally, older patients in their 80s and 90s poorly tolerate acute worsening of swallow function and its complications. How long has the patient had a swallowing problem? The time since the onset of dysphagia is particularly important in dysphagia from chemoradiation therapy for head and neck cancer. We also consider the patient's description of the swallowing problems as well as medical conditions that may have a bearing on treatment considerations, such as dementia. Next, the swallow studies are reviewed. FEES provides anatomic details of swallowing apparatus and severity of pharyngeal residue as well as penetration/aspiration. MBSS allows a closer review of all phases of swallowing. The pharyngeal phase of swallowing is quick and lasts about a second, thus reviewing the study in real time often misses the relevant swallow events. Thus, frame-by-frame analysis of the pharyngeal phase of the swallow is performed to fully discern the anatomic and physiologic details of swallow dysfunction. Commercially available video software capable of pausing/advancing/rewinding each frame is needed for this task. After the MBSS review, other tests that may have been obtained—TNE, esophagram, high-resolution esophageal manometry—are discussed. We find it particularly useful to document the severity and details of the following findings in making treatment decisions: presence or absence of (1) pharyngeal weakness, (2) epiglottic dysfunction, (3) penetration, (4) aspiration, (5) upper esophageal sphincter (UES) dysfunction, (6) findings of an esophageal screen on MBSS, if performed, and (7) overall impression of the swallow dysfunction and the contributing factors.

A consensus treatment plan is then developed. First, an overall impression of the key factors that explains the swallow dysfunction should be made. For example, a patient with long-standing dysphagia from radiation therapy or neurodegenerative disease may have had an acute worsening of swallowing after a recent surgical procedure even if the surgery was not in the head and neck region. In such cases, one could anticipate that the swallow dysfunction may be improved at least to baseline before the latest exacerbation in swallowing. The overall treatment plan is documented, including recommendations for (1) currently safe diet, (2) surgical intervention(s), and/or (3) swallow therapy. If both surgery and swallow therapy are recommended, the timing of either should be decided, as well as the swallow therapy technique(s) that may be most effective. For example, if surgery could worsen penetration/aspiration, then it makes sense to train the patient in the supraglottic or super-supraglottic swallow technique to protect the airway prior to surgery. On the other hand, if significant obstructions to swallowing are present, then those obstructions should be removed prior to swallow therapy (assuming that treating the obstruction will not increase the risk of aspiration—each patient must be viewed as a unique case). Finally, potential barriers to improving swallow function should be considered and documented. Such considerations include the length of time from chemoradiation therapy, whether the pharynx is insensate, the cogniti...