Dysphagia is difficulty swallowing. It is a very common problem that is present in many diseases and can cause life-threatening problems such as aspiration pneumonias.
Diagnosis of dysphagia
The diagnosis of dysphagia is based on various tests, some of them clinical, others endoscopic (such as swallowing videoendoscopy) and others functional or radiological (such as videofluoroscopy). The etiopathogenic diagnosis that can be obtained with these tests is key to propose an adequate treatment.
Treatment of dysphagia
The treatment of dysphagia is mainly dietary and rehabilitative, although on some occasions we can perform more invasive procedures that seek to improve the efficiency of swallowing, such as the treatment of certain sphincters or the improvement of glottic closure; a thyroplasty in case of laryngeal paralysis or exceptional measures aimed at avoiding possible aspirations (by means of laryngeal exclusion or separation of the airway from the digestive tract). Other procedures treat specific processes, such as Zenker’s diverticulum. Finally, a gastrostomy may sometimes be required to facilitate prolonged enteral nutrition.
Some patients, especially those with certain neurodegenerative disorders, may have excessive tonic contraction of the cricopharyngeus muscle, a fundamental component of the upper esophageal sphincter. This contraction, called cricopharyngeal bar, can be treated by a procedure called cricopharyngeal myotomy, which can be performed by an external cervicotomy approach with a series of risks and possible complications, and which has been classically indicated in cases with a marked increase of contracture of the mentioned sphincter that causes a closure of the passage of the alimentary bolus increasing the resistances to such passage.
The old open surgery procedures have been replaced by endoscopic techniques with laser or mechanical instruments, as well as in certain occasions, if the fibrotic origin of the cricopharyngeal closure is ruled out, botulinum toxin type A can be infiltrated in the cricopharyngeal muscle, causing a neuromuscular block and a relaxation for some months of said contracture and improving swallowing in the cases in which said contracture is the cause of the swallowing alteration. Its effect is reversible and it may be necessary to repeat the infiltrations.
Care must be taken in the localization of the injection because it can spread to other muscle groups causing pharyngolaryngeal paralysis, which can aggravate the patient’s condition.
Consequences of sustained cricopharyngeal contracture
A consequence of a sustained cricopharyngeal contracture is the production of a diverticulum by herniation of the pharyngeal mucosa through the triangle of Lainert, which can form a pocket where food accumulates.
The treatment of the diverticulum was classically performed by the same approach of myotomy, but currently there are other endoscopic techniques such as laser myotomy or with mechanical self-suture systems, such as those used in abdominal surgery.
It is used in patients with primary cricopharyngeal contracture, sometimes as a diagnostic and prognostic test before indicating a myotomy.
Sometimes there is an incompetence of the glottic sphincter, in vocal cords, either by paralysis or other neuromuscular alteration at that level; in these cases, in addition to the rehabilitation of phonation itself, it may require medializing treatments of the glottis (which may be surgical, by placing a prosthesis) or infiltration techniques of various substances (hydroxyapatite gel, collagen, autologous fat, etc.), which can be practiced endoscopically, transoral or percutaneous.
The result of infiltration tends to be temporary, whereas thyroplasty has a more permanent result. It is sometimes associated with an arytenoid adduction procedure to increase closure at the posterior glottic level.
Finally, in cases of failure of all treatments, airway exclusion techniques can be performed by laryngeal exclusion techniques, endoscopic closure of the supraglottis (currently in some centers it can be performed by transoral robotic surgery) or, as a last resort, a total laryngectomy.
For more information consult your ENT specialist.