Other Swallowing Treatments

Abstract

In addition to several methods of swallowing exercise widely used to improve swallowing function, the alternative treatment by using assistive device and surgical intervention are viable options to achieve the treatment outcome, for safety and for improved quality of life. The common devices and surgical techniques commonly used in our practice are described in this chapter.

Appendix

1.1 UES Myotomy Combined with Laryngeal Suspension

Physiologically, three main factors are involved in opening the esophageal inlet and allowing a bolus through the UES: relaxation of the UES, pharyngeal peristaltic contraction, and hyolaryngeal elevation . UES myotomy alone is adequate for patients with good pharyngeal contraction. Otherwise, the addition of laryngeal suspension is helpful to compensate for functional swallowing deficiency by achieving the same laryngeal position as occurs during the normal swallowing action.

1.1.1 Indications

• 1. Failure of a thorough, conservative rehabilitation program, usually lasting >6 months

• 2. Long-standing history of severe chronic aspiration and recurrent pneumonia (>6 months after onset)

• 3. Evidence of severe aspiration due to impaired laryngeal elevation , inadequacy of pharyngeal constrictor activity, and/or incoordination and insufficient opening of the esophageal inlet (UES)

1.1.2 Contraindications

• 1. Overt gastroesophageal regurgitation secondary to a permanently opened esophageal inlet , which eradicates the protective mechanism of the UES against regurgitation and augments the risk of aspiration of gastric contents

• 2. Cognitive impairment including dementia , mental problems, and inability to follow commands

• 3. Moderate to severe trunk ataxia

• 4. Poor general condition

1.1.3 Surgical Procedure

• 1. UES myotomy

• 2. Laryngeal suspension surgery. The effect of laryngeal suspension is increased elevation of the larynx . This procedure can be performed using several techniques [15]:

  • Type 1: Thyrohyoid fixation approach. This procedure is the simplest technique with which to facilitate upward movement of the larynx by about one vertebral height.

  • Type 2: Hyoid–mandible fixation approach. This method is indicated in dysphagic patients with pooling of residue in the vallecula and inadequate epiglottic inversion , which influences laryngeal closure .

  • Type 3: Thyrohyoid–mandible complex fixation approach. The thyrohyoid complex is suspended from the mandible , and the infrahyoid muscles are resected. The mandible , hyoid bone , thyroid cartilage , and/or cricoid cartilage are connected by a wire or thread. This procedure is appropriate in patients with UES opening deficits secondary to impaired hyolaryngeal anterior excursion.

  • Type 4: Thyroid–mandible fixation approach. This procedure is always performed concurrently with myotomy and is beneficial for patients with severe dysphagia and concurrent suprahyoid muscle weakness. After the operation, the patient must be trained to swallow using a specific swallowing pattern (head extension and neck flexion ) to augment the opening of the UES entrance (chin jut ) during direct swallowing training (Figs. 8.3 and 8.4).

Fig. 8.4

VE and VF images of a widely opening esophageal inlet (UES) following laryngeal suspension and myotomy

If oral intake is possible without aspiration by 1–2 months postoperatively, the tracheotomy tube can be removed. Additionally, the functions of mastication and tongue movement (which importantly contribute to bolus formation and propulsion) and the presence of pharyngeal residue (which increases the risk of aspiration) should be assessed to determine the patient’s eating ability and most appropriate bolus type.

Caution: Respiratory difficulty may occur due to excessive suspension of the laryngeal complex.