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Speech Pathologist Practice Patterns for Evaluation and Management of Suspected Cricopharyngeal Dysfunction

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Abstract

Speech pathologists are often the first professionals to identify signs of a cricopharyngeal (CP) dysfunction and make recommendations for further care. There are many care options for patients with CP dysfunction, but it is unclear how certain interventions are used in practice. A paper-based survey employing two clinical cases involving suspected CP dysfunction (Case 1 with adequate pharyngeal strength and Case 2 with coexisting pharyngeal weakness) was sent to members of American Speech-Language Hearing Association’s Special Interest Group 13. Respondents ranked the order of management approaches (swallowing therapy, further evaluation, and referral to another medical professional) and selected specific interventions under each approach that they would recommend for each case. Completed surveys from 206 respondents were entered into analysis. The majority of the respondents recommended swallowing therapy as a first approach for each case (Case 1: 64 %; Case 2: 88 %). The most prevalent swallowing exercises recommended were the Shaker (73 %), effortful swallow (62 %), and Mendelsohn maneuver (53 %) for Case 1 and effortful swallow (92 %), Shaker (84 %), and tongue-hold swallow (73 %) for Case 2. 76 % of respondents recommended a referral for Case 1, while 38 % recommended the same for Case 2. Respondents with access to more types of evaluative tools were more likely to recommend further evaluation, and those with access to only videofluoroscopy were less likely to recommend further evaluation. However, the high degree of variability in recommendations reflects the need for best practice guidelines for patients with signs of CP dysfunction.

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Acknowledgments

This study was supported by National Institutes of Health grant number R21 DC011130A from the National Institute on Deafness and Other Communicative Disorders and by the Diane M. Bless Chair in Otolaryngology at University of Wisconsin-Madison. The authors acknowledge Department of Surgery biostatistician Glen Leverson, Ph.D., for his assistance with statistical analysis.

Conflict of interest

The authors declare that they have no conflict of interest associated with this article.

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Authors and Affiliations

  1. Division of Otolaryngology – Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792-7375, USA

    Corinne A. Jones, Molly A. Knigge & Timothy M. McCulloch

  2. Clinical Science Center – H4, 600 Highland Ave., Madison, WI, 53792-7375, USA

    Timothy M. McCulloch

Authors
  1. Corinne A. Jones
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  2. Molly A. Knigge
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  3. Timothy M. McCulloch
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Corresponding author

Correspondence to Timothy M. McCulloch.

Appendix: Transcript of Survey

Appendix: Transcript of Survey

Case #1: You saw an 81-year-old female with complaints of food sticking in her throat and needing a long time to eat meals. She is eating a diet consisting of soft solids and thin liquids. She has no history of recent pneumonia and has had a gradual weight loss of 15 lb. over 5 years. She is cognitively intact, has no significant neurological history, and has no history of gastroesophageal reflux. A VFSS revealed a swallow pattern characterized by:

  • Functional oral phase

  • Adequate tongue base to posterior pharyngeal wall retraction and bolus propulsion

  • Timely pharyngeal swallow trigger for age

  • Reduced hyolaryngeal excursion

  • Narrow UES opening with a CP prominence needing multiple swallows to clear bolus

  • Stasis in the valleculae and pyriform sinuses

  • Penetration of thin liquid to the vocal folds without a cough response

  • No aspiration events

Neither postural changes (e.g., head turn, chin tuck) nor swallow maneuvers (e.g., Mendelsohn) reduced the degree of stasis or penetration or the amount of material that cleared through the UES on the initial swallow.

Case #2: You saw a 70-year-old male who is 1-year status post a fall that resulted in a right subdural hematoma and has been discharged from a rehab facility for 2 months. An oral mechanism exam revealed decreased lingual range of motion and strength (though his speech is intelligible), but no other significant findings. He is currently NPO, expectorating saliva/secretions instead of swallowing, and is getting nutrition/hydration via PEG tube. He is cognitively intact and hoping to return to an oral diet soon. A VFSS revealed a swallow pattern characterized by:

  • Functional oral phase

  • Dilated pharynx with poor tongue base propulsion and reduced pharyngeal constriction

  • Delay of pharyngeal swallow to the valleculae with thin liquids

  • Reduced hyolaryngeal excursion

  • Narrow UES opening needing multiple swallows to clear bolus

  • Stasis in the pyriform sinuses

  • Aspiration of thin liquid from stasis in the pyriform sinus without a cough response

A left head turn mildly improved the amount of material that cleared through the UES on the initial swallow but did not reduce the degree of stasis or aspiration.

After each case, respondents were given the following options:

Given the resources currently at your disposal, please indicate your primary and subsequent management approach(es) (e.g., 1, 2, etc.) and mark the specific interventions you would pursue under each approach.

  • Swallowing therapy

    • Oral motor exercises (range-of-motion and/or resistance)

    • Supraglottic and/or super-supraglottic swallow

    • Vocal fold adduction exercises

    • Falsetto exercise

    • Effortful swallow

    • Masako maneuver (tongue-hold swallow)

    • Mendelsohn maneuver

    • Shaker (head lift) exercise

    • Therapy with external device (e.g., IOPI)

    • Biofeedback therapy (e.g., submental surface EMG)

    • Thermal-tactile stimulation

    • Neuromuscular Electrical Stimulation (NMES)

  • Further evaluation

    • FEES

    • Conventional manometry (1–6 pressure transducers)

    • High-resolution manometry (20+ pressure transducers)

    • Intraluminal impedance

    • EMG

    • EGG

  • Consult physician for surgical management

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Jones, C.A., Knigge, M.A. & McCulloch, T.M. Speech Pathologist Practice Patterns for Evaluation and Management of Suspected Cricopharyngeal Dysfunction. Dysphagia 29, 332–339 (2014). https://doi.org/10.1007/s00455-013-9513-6

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  • DOI: https://doi.org/10.1007/s00455-013-9513-6

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