Management of Dysphagia Requires a Team Approach

A healthy pharyngeal pressure would be over 100 mmHg, but this patient ranged from 20 mmHG to 45-50 mmHg in the study. Manometry helped confirm where the obstruction might be-in this case at the cricopharyngeal bar, Dr. Stachler said.

Without manometry, there are other ways to determine pharyngeal strength. If you’re just doing endoscopy and you don’t see a whiteout, then that’s significant. It tells you that the pharynx is not contracting around your scope fully, said Dr. Amin. Another way would be to get the patient to say eeee vigorously. This brings in the side walls of the pharynx and can permit a sense of the pharyngeal closure.

The pharynx is critical to swallowing, said Dr. Postma. It is probably even more important than the tongue, in light of the fact that people with total glossectomy can be trained to swallow when a bolus is introduced in the oropharynx. However, from a clinical point of view, lingual problems are easier to deal with than pharyngeal problems.

Managing the pharynx is a very difficult thing from a behavioral point of view. It’s not accessible easily for manipulation. There are electrical stimulation techniques you can try to stimulate pharyngeal contractions. You can attempt various bolus manipulations and head adjustments, Dr. Postma said.

The patient ended up getting a Botox injection to the cricopharyngeous, using a combination of manometry and EMG. His eating assessment improved from 68 to 48, but still had residual dysphagia.

Sometimes tongue strengthening can help these patients. The tongue is the chief piston that prepares the food and pushes it back. If you can achieve stronger movement, perhaps you can compensate somewhat for pharyngeal difficulties, Dr. Dworkin said. He sometimes sends patients home with simple devices made from tongue depressors that can be used for tongue strengthening exercises.

New Technologies, Better Diagnosis and Treatment

The cases show how newer technologies are helping otolaryngologists, Dr. Postma said. Transnasal esophagoscopy (with improved optics) allows for great visualization. High-resolution manometry allows otolaryngologists to directly measure and time the contractions of the throat, esophagus, and its valves.

We can also do a great deal of intervention in the clinic with balloon dilations, Botox injections into the valves of the esophagus, and electrical stimulation of the throat muscles to improve swallowing, he said.

©2007 The Triological Society