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82 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Upper esophageal dysfunction may also contribute to GERD. The CPM has been implicated in
the development of Zenker diverticulum, which is
formed by the protrusion of the posterior hypopharyngeal mucosa between fibers of the inferior con-
FIGURE 3 –10. Patient with significant edema at the level of
the larynx and vocal folds.
strictor and CPMs. Figure 3–11 shows x-ray images
of the UES prior to and following the surgery for
Zenker diverticulum.
The surgery to close the Zenker pouch may be
done endoscopically or through an open surgical
A B
FIGURE 3–11. This barium esophagram allows easy delineation of the dilated esophagus. A. The Zenker diver-
ticulum prior to surgery. B. The same esophageal segment following successful surgery.
3. SWALLOWING DISORDERS ARISING FROM NEUROLOGICAL DISORDERS AND OTHER DISEASES 83
procedure. The barium esophagram before surgery
allows easy delineation of the dilated esophagus.
Figures 3–11A and B show before and after photos of surgery for Zenker diverticulum. When the
barium esophagram shows no evidence of Zenker
diverticulum, the tight CPM may be relaxed temporarily with injection of botulinum toxin.
47
The role of the SLP must be coordinated with the
surgeon as the type of surgery will impact the
postoperative treatment. This is discussed in
Chapter 4.
Laryngopharyngeal Reflux Disease. Laryngo-
pharyngeal reflux disease (LPRD) is actually an
inflammatory disease of the larynx, but it originates
in the stomach like other reflux disorders. Acid from
the stomach rises up to the level of the larynx and
targets the laryngeal tissues to cause a number of
disorders such as hoarseness, vocal process granulomas, and coughing. Reflux of acid into the hypopharynx is a common and potentially debilitating
disease. A healthy person complaining of hoarseness, throat clearing, and excess phlegm in the
throat is typically describing the common symptoms
of LPRD. In more severe cases, the symptoms might
also include excessive coughing, occasional choking of liquids or foods, and globus. It differs from
GERD in that it is an upright disease, occurring in
the daytime and presenting with the common symptoms noted earlier and usually without the specific
complaint of heartburn. GERD, on the other hand,
usually results in complaints of heartburn, abdominal pain, and regurgitation.
The most common symptoms of LPRD have
been identified by Belafsky et al.
48
From a list of
symptoms, they developed the Reflux Symptom
Index (see Appendix 1), a patient self-assessment
questionnaire of the severity of common symptoms
of reflux. Heartburn and regurgitation, the classic symptoms of GERD, are unusual symptoms in
patients with LPRD, occurring in as few as 10% of
patients with LPRD symptoms, according to Belafsky et al.
48
Although the reasons for this are not
completely understood, most investigators suspect
that it relates to the lack of acid-clearing mechanisms in the laryngopharynx.
The physical exam findings of LPRD have also
been quantified by Belafsky et al
49
and are referred
to as the Reflux Finding Score (RFS; see Appendix 2). A clinician determines the RFS after the TFL
examination. A score of 9 or greater is significant
and strongly suggests LPRD. Rarely are the signs of
LPRD seen in isolation, meaning it would be very
unusual for a patient to have only a pseudosulcus
vocalis as the sole manifestation of LPRD. Typically,
the patient with LPRD has multiple laryngeal indicators. Edema of the larynx, not erythema, is the
clinical hallmark of LPRD.
Traditionally, the diagnosis of LPR is made by
a combination of patient history, physical examination of the larynx, and diagnostic instrumental
testing. The test may consist of a 24-hour pH test
or an in-office sensory test that takes minutes to
perform and may be much more appealing to a
patient.
50
Table 3–8 summarizes the salient differences between GERD and LPRD, as reported by
Levy and Young.
46
Barrett esophagus (sometimes referred to as
Barrett metaplasia) is a compensatory change in the
esophageal mucosa from squamous to specialized
intestinal epithelium, and it occurs in up to 15% of
patients with atypical presentations of GERD. This
disease often presents as a swallowing problem with
nonspecific complaints of heartburn and dyspepsia.
Moreover, there is evidence that the condition predisposes one to esophageal adenocarcinoma, cancer
of the lower esophagus, which is rapidly increasing in the Western world. Treatment is by medication for GERD and diet modification. Since this
metaplastic condition may evolve into esophageal
TABLE 3–8. Symptoms of Gastroesophageal Reflux
(GERD) and Laryngopharyngeal Reflux Disease (LPRD)
Esophageal (GERD) Laryngopharyngeal (LPRD)
Heartburn
Acid regurgitation
Water brash
Dysphagia
Odynophagia
Esophageal spasm
Nighttime cough
Pharyngitis
Laryngitis
Hoarseness
Globus
Daytime cough/throat clearing
Shortness of breath
Air hunger
Pulmonary aspiration
84 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
cancer, routine endoscopic follow-up examinations
are recommended for patients identified with Barrett esophagus.
Burns
Esophageal burns come from injection of caustic
substances, gasses, or hot liquids that are swallowed
too quickly. Esophageal burns may be as high as
the CPM and lead to scarring or strictures in the
esophagus resulting in food not going into the stomach or feeling “stuck” in the esophagus. Emergency
treatment includes prednisolone or other corticoste-
51.
roids.
that are treated with esophageal stenting or with
balloon dilation.
chronic stage when there is a need to manage diet
consistencies in order to reduce the effects of food
lodging or the feeling of food lodged in the esophagus. Instrumental examination of the esophagus is
necessary to identify the cause of the problem. Careful case history should always precede the instrumental exam.
Many burns result in esophageal strictures
52
The role of the SLP comes at the
virus. Esophagitis, however, is a major cause of
morbidity in individuals with impaired immunity
caused by human immunodeficiency virus infection, chemotherapy, or solid organ or bone marrow
transplantation.
Eosinophilic Esophagitis
Eosinophilic esophagitis is an inflammation that
builds up in a type of white blood cell in the esophagus. This buildup results in an inflammation that is
often thought to be a reaction to foods, allergens,
or acid reflux.
58
Damage through inflammation in
the esophagus can lead to difficulty swallowing or
cause food to get caught when you swallow. Eosinophilic esophagitis has been identified only recently
but now is considered a chronic immune disease
of the digestive system. Symptoms include chest or
abdominal pain, possible vomiting in children, discomfort in swallowing, and regurgitation of foods
or liquids.
Chagas Disease
INFECTIOUS DISEASES
Oral Cavity/Oropharynx
Bacterial infections of the oropharynx that result
in dysphagia include tonsillitis, pharyngitis, and
abscesses that may be associated with primary
mucosal or lymphoid inflammation that causes pain
and odynophagia. Candidiasis may also involve the
oral cavity and the oropharynx in both immunocompetent and immunocompromised individuals.
It is more common, however, in the latter group of
patients and in those who require prolonged treatment with antibiotics.
Esophagitis
Primary esophageal infections are unusual in the
general population. When they arise, these are
typically due to candidiasis or herpes simplex
Chagas disease is a parasitic infectious disease that
leads to achalasia. Chagas disease, endemic in the
Amazon basin, is caused by Trypanosoma cruzi, a
parasite. It can lead to achalasia that, in severe cases,
results in megaesophagus due to the destruction of
the parasympathetic innervation.
Do you ever ask your patients where they went
on vacation? Maybe you should. If they travel
to Florida or the tropics, they may get bug bites
from a bug that carries the Trypanosoma cruzi
parasite. This can lead to problems that at first
seem like GERD but in fact may be the start of
achalasia.
Deep Neck Infections
Deep neck infections are typically the result of polymicrobial infections. In addition to symptoms of the
primary infection site, patients may present with
3. SWALLOWING DISORDERS ARISING FROM NEUROLOGICAL DISORDERS AND OTHER DISEASES 85
dysphagia, odynophagia, drooling, fever, chills, neck
stiffness, and swelling. Treatment includes empirical
therapy with broad-spectrum agents, airway protection, and often, surgical intervention.
Laryngeal Infections
Adult epiglottitis may cause life-threatening supraglottic edema that can progress to a delay in diagnosis and treatment. Common symptoms of supraglottic
infection include a sore throat that is out of proportion to the findings of a pharyngeal examination,
dysphagia, odynophagia, and dysarthria. Epiglottitis
is diagnosed via endoscopic examination.
Lyme Disease
Lyme disease is a bacterial infection caused by a bite
from an infected tick. It usually shows up with a red
rash at the point of the bite. Once bitten, the patient
should seek help early. The infection may spread to
other parts of the body and may lead to severe paralytic conditions. When not treated early, fever, rash
and even paralysis and swollen joints may occur.
As it progresses, muscles tighten, patients may have
joint pains, and fatigue is a common symptom. Dysphagia may occur due to stiffness, chewing fatigue,
and joint inflammation.
Diagnostic Tip: When patients complain of swallowing fatigue, difficulty with chewing, and food
not “going down,” consider Lyme disease. Always
check to see if they have been walking out in
heavy wooded areas or around wild deer.
MEDICATIONS AND SWALLOWING DISORDERS
prescribed, affect swallowing, impairing consciousness, coordination, motor and sensitivity functions,
and the lubrication of the upper aerodigestive tract
(Table 3–9).
New medications continue to be introduced, and
the SLP should be aware that many patients
may be given a newer medication than listed
here or they may be given a generic medication
that is similar to one that is listed here.
Analgesics
Salicylates (aspirin) and nonsteroidal anti-inflammatory agents cause ulceration of the mouth, throat
burning, mucosal hemorrhage, glossitis, and dry
mouth.
Antibiotics
Side effects such as glossitis, stomatitis, and esoph-
agitis have been described for penicillin, erythro-
mycin, chloramphenicol, and the tetracyclines. Sulfa
can cause a reaction similar to Stevens-Johnson syndrome, resulting in extensive mucosal ulceration
and glossitis. Aminoglycosides can increase parkinsonian symptoms of weakness.
Antituberculosis medications, such as isoniazid,
rifampin, ethambutol, and cycloserine, can cause
confusion, disorientation, and dysarthria. Antiviral
agents, such as acyclovir, amantadine, ganciclovir,
and vidarabine, can indirectly cause dysphagia with
confusion, asthenia, and lingual facial dyskinesia.
Amantadine can cause severe xerostomia and xerophonia in some patients. Zidovudine (AZT), an antiviral drug, causes dysphagia in approximately 5% to
10% of patients and tongue edema in 5% of patients.
Chloroquine (Plaquenil), mostly used for treating
malaria, can cause stomatitis.
The effects of medications are influenced by sex,
age, body size, metabolic status, individual biological response, and concurrent use of other medications. A variety of medications, including those
obtained over the counter and those medically
Antihistamines
Antihistamines (H1-receptor antagonists) are commonly used to treat allergies. However, because of
86 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
TABLE 3–9. Common Medications Affecting Swallowing
Product Category Examples Common Indications Possible Effects
Neuroleptics
Antidepressants Elavil (tricyclic)
Gabapentin
Amitriptyline
Mirtazapine
Remeron
Lexapro
Effexor
Zoloft
Celexa
Wellbutrin
Paxil
Prozac
Cymbalta
Relief of endogenous
depression
Drying of mucosa,
drowsiness
Possible weight gain
Antipsychotics Haldol
Thorazine
Management of patients
with chronic psychosis
Clozapine
Risperidone
Sedatives
Barbiturates Phenobarbital
Treatment of insomnia CNS depressant
Nembutal
Antihistamines Cold and cough
preparations
Diuretics Lasix
Hydrochlorothiazide
Spironolactone
Relief of nasal congestion
and cough
Treatment of edema (eg,
associated with congestive
heart failure)
Aldosterone
Mucosal
anesthetics
Hurricaine
Benzocaine
Topical anesthetic used to
aid passage of fiberoptic
nasopharyngoscopes,
control of dental pain
Anticholinergics Cogentin
Atrovent
Bronchodilator
Help to open the lungs
Oxivent
Spireva
a
Adapted and modified from Perlman and Schulze-Delrieu.
Tardive dyskinesia
(drowsiness causing
decompensation of patients
with cognitive deficits)
Drying mucosa, sedative
effects
Signs of chronic dehydration
(dryness of mouth, thirst,
weakness, drowsiness)
Suppresses gag and cough
reflex
Dry mouth and reduced
appetite
24
3. SWALLOWING DISORDERS ARISING FROM NEUROLOGICAL DISORDERS AND OTHER DISEASES 87
their anticholinergic side effects, this class of medications commonly exerts a drying effect on the
aerodigestive tract mucosa, causing difficulty in gastrointestinal motility during the swallowing process.
Other side effects include sedation, disturbed coordination, and gastric distress. CNS effects include
ataxia, incoordination, convulsions, dystonia, and
bruxism, which can lead to poor oral intake.
Antimuscarinics, Anticholinergics,
and Antispasmodics
Antimuscarinics and antispasmodics, used for a variety of reasons, such as bradycardia, excessive oral
secretions, motion sickness, and diarrhea, diminish
the production of saliva and mucus. Salivary secretion is particularly sensitive to inhibition by antimuscarinic agents, which can completely abolish
the copious water secretions induced by the parasympathetic system. The mouth becomes dry, and
swallowing and talking become difficult.
Prokinetic agents improve motility and speed
gastric emptying. The 2 major drugs in this category
are metoclopramide (Reglan) and cisapride (Propulsid); however, the latter is no longer available
in the United States. The former is associated with
greater antihistamine-like side effects and must be
taken carefully to avoid confounding the swallowing disorder.
Mucolytic Agents
Mucolytic agents can be used to counter the effects
of drying agents such as antihistamines. However,
no medications, including mucolytic agents, are
a substitute for adequate hydration, and indeed,
these medications are dependent on adequate water
intake.
Antineoplastic Agents
These agents affect swallowing mainly through the
mechanism of inflammation, sloughing, and occasionally causing infection of the aerodigestive tract
mucosa. This effect results in mucositis, stomatitis,
pharyngitis, esophagitis, and esophageal ulceration.
Common antineoplastic agents are cisplatin and
tamoxifen, both used in chemotherapy protocols to
treat cancer in various organs.
Vitamins
An overdose of vitamin A causes hypervitaminosis, a
condition that includes dermatological, gastric, skeletal, and cerebral and optic nerve edema. Fissures of
the lips, dry mouth, and abdominal discomfort can
result. A similar stomatitis can result with vitaminE
overdose.
Neurological Medications
Anticonvulsants
Phenobarbital is a sedative and anticonvulsant with
side effects similar to the tricyclic antidepressants:
dry mouth, sweating, hypotension, and tremor. Phenytoin’s (Dilantin) adverse effects include CNS signs
such as ataxia, slurred speech, incoordination, and
dystonia. Carbamazepine (Tegretol) is an anticonvulsant used primarily for seizures. Digestive symptoms
can also be serious, such as glossitis, stomatitis, and
dryness of the mouth.
Anti-Parkinson Disease Agents
Levodopa may improve all symptoms of Parkinson
disease, including swallowing, but it can cause gastrointestinal discomfort, dyskinesia, and oral dryness.
Antihypertensives
Almost all of the antihypertensive agents have some
degree of parasympathetic effects and thus dry the
mucous membranes. Hydration is the first step to
improve swallowing when taking these medications.
Antipsychotics
Antipsychotic medications primarily work by dopamine antagonism. Commonly used drugs in this class
include haloperidol (Haldol), aripiprazole lauroxil,
chlorpromazine (Thorazine), thioridazine (Mellaril),
88 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
and prochlorperazine (Compazine). These medications can have anticholinergic effects, such as dry
mouth, nasal congestion, and hypotension. Patients
receiving long-term antipsychotic medications will
develop tardive dyskinesia, with symptoms ranging
from tongue restlessness, disfiguring choreiform,
and/or athetoid movements, leading to significant
swallowing and feeding problems.
Life-threatening dysphagia can occur after prolonged neuroleptic therapy. Neuroleptic drugs can
induce extrapyramidal symptoms such as dystonia,
akathisia, and tardive dyskinesia. Contrast radiography has revealed poor contractions in the upper
esophagus, a hypertonic esophageal sphincter, and
hypokinesia of the pharyngeal muscles.
Anxiolytics
Significant dysphagia can result from chronic use
of benzodiazepines. Reported effects include hypopharyngeal retention, cricopharyngeal incoordination, aspiration, and drooling. Benzodiazepines can
inhibit discharges from interneurons in the nucleus
of the tractus solitarius or nucleus ambiguous, both
of which are critical to the pharyngeal phase of
swallowing.
problem who is also being treated for an autoimmune disease.
The diagnosis and treatment of swallowing disorders in patients with autoimmune disorders and
diseases are complex and commonly limited by
their primary condition or by the other treatments
or medications that they may be receiving. A rheumatologist generally manages patients with autoimmune disorders; however, when a patient reports a
swallowing problem, the patient is usually referred
to an otolaryngologist. The otolaryngologist usually includes an SLP in the treatment plan as management of the swallowing problem may involve
diet modification, swallowing therapy, and/or voice
therapy.
The immune system functions to protect the
body from foreign substances. Autoimmune conditions often result in dryness, inability to swallow
certain types of foods, symptoms of reflux disease,
and lack of taste. The role of the SLP is to work with
the team to manage safe swallowing, support the
need to be alert to conditions that have a negative
effect on swallowing, such as rapid eating and poor
bolus preparation, and assure patients that with the
correct diet, they can remain healthy.
53
Since reflux
and dysmotility are common conditions of patients
with autoimmune diseases, dietary support should
always be part of the treatment plan.
AUTOIMMUNE DISORDERS AND DISEASES
Autoimmune Diseases
Autoimmune diseases are characterized by the production of antibodies that react with host tissue or
immune effector T cells that react to self-peptides.
Autoimmune diseases may affect swallowing by
causing intrinsic obstruction, external compression,
abnormal motility, or inadequate lubrication. Diagnosis of autoimmune diseases is usually via a blood
test and biopsy. The biopsy may be of the salivary
gland in the case of Sjögren syndrome. Other autoimmune diseases are diagnosed through radiological testing, or serology, electromyogram, or muscle
biopsy. Proper evaluation by the swallowing team
is essential to manage the patient with a swallowing
Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic, relapsing
inflammatory arthritis, usually affecting multiple
diarthrodial joints with a varying degree of systemic
involvement. The female-to-male ratio is 3:1.
RA is associated with xerostomia, temporomandibular joint (TMJ) syndrome, a decrease in the
amplitude of the peristaltic pressure complex in the
proximal, striated part of the esophagus, as well as
from cervical spine arthritic disease, all of which
cause or contribute to swallowing problems.
54
Rheumatic laryngeal involvement can result in cricoarytenoid joint fixation. Objective functional testing is
necessary to determine the contributions of the oral
phase and pharyngeal phase to the swallowing disorder. Patients may benefit from a modified barium
swallow to identify the oral phase components amenable to therapeutic exercises.
3. SWALLOWING DISORDERS ARISING FROM NEUROLOGICAL DISORDERS AND OTHER DISEASES 89
Patients with RA have more problems with solid
food than with liquids. Treatment of the dysphagia is
focused on dietary management, reducing the need
to chew and providing textures that can be easily swallowed. Patients may benefit from increased
hydration and artificial saliva and/or pilocarpine for
the xerostomia. TMJ dysfunction (ie, trismus, mastication problems) is treated with nonsteroidal antiinflammatory agents and exercises with mechanical
devices.
54
Laryngeal closure exercises may also be
useful. These are further described in Chapter 7.
Sjögren Syndrome
Sjögren syndrome includes dryness in the eyes,
salivary and lacrimal glands, and mouth.
55
Xerostomia, oral pain, glossodynia, and dysgeusia are
prominent features of the syndromes. Patients also
report symptoms of reflux disease (GERD). A patient
experiences the inability of the esophagus to clear
gastric refluxate, and the bicarbonate antacid effect
of saliva is diminished.
55
The majority of treatment focuses on managing
the symptoms. Treatment of xerostomia is often palliative and includes saliva preparations, pilocarpine,
antacids, and H2-blockers. Diet modification to a
mixed thickened and slippery combination of foods
is also helpful as is stimulation with sialagogues.
The disease is often refractory to standard therapy
using corticosteroids.
Giant Cell Arteritis
Giant cell arteritis, also known as temporal arteritis, is an inflammatory disorder affecting large and
medium-size vessels. The arteries that originate from
the arch of the aorta are the most affected. Pharyngeal, tongue, or jaw claudication may occur when
the ascending pharyngeal, lingual, deep temporal,
or mesenteric arteries are affected. Systemic corticosteroids often resolve these all within 1 to 2 weeks.
Mixed Connective-Tissue Disease
Mixed connective-tissue disease (MCTD) is characterized by clinical findings that may be found in
PSS, systemic lupus erythematous, and polymyositis/dermatomyositis. Similarly, the swallowing disorders described under each of these disorders can
be part of MCTD.
Esophageal motility is severely affected, and the
majority of patients have little or no peristalsis, or
they have low-amplitude peristalsis contributing to
GERD. Heartburn and dysphagia are present in up
to 50% of the patients with MCTD. The treatment of
GERD in these patients may reduce the dysphagia.
Crohn Disease
Crohn disease produces lesions throughout the
digestive tract that vary in appearance, often resembling aphthous ulcers (small white pimples in the
oral cavity) or cheilitis. Dysphagia is the most common presenting symptom of esophageal Crohn
disease.
Epidermolysis Bullosa
Epidermolysis bullosa is a rare disorder characterized by blistering of the mucosal lining, often elicited by minimal trauma. It has a variable onset and
no racial or gender predilection. The oral cavity,
pharynx, larynx, and esophagus may be severely
affected, resulting in severe dysphagia. Pharyngeal and esophageal webs and/or scarring may be
severe, necessitating a gastrostomy or jejunostomy.
Myositis
Polymyositis and dermatomyositis are characterized by inflammation of the skeletal muscle. Thus,
muscles of the pharynx are often affected, while the
esophageal smooth muscle is spared. Endoscopic
evaluation of swallowing with TFL may reveal prominence of the CPM, decreased epiglottis tilt, and moderate to severe residue in the pharynx, which fails
to pass into the esophageal inlet even with multiple
swallows. Two-thirds of these patients have demonstrable delayed esophageal transit. Polymyositis and
dermatomyositis are treated with corticosteroids.
Pemphigus Vulgaris
Pemphigus vulgaris is a rare, chronic intraepidermal
bullous disease. Blisters most commonly develop on
the soft palate but can occur anywhere on the oral
90 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
cavity. Painful ulcerations that can become infected
follow the ruptured blisters. Ulcerations heal by secondary intention, often leading to scarring. Distal
involvement of the pharynx, larynx, and esophagus
is possible and may account for the dysphagia noted
by some patients.
Ocular Cicatricial Pemphigoid
Ocular cicatricial pemphigoid is a chronic blistering disease that affects the oral mucosa in almost all
cases. Typical lesions are characterized by erosion
of the gingiva and buccal mucosa that usually are
not as painful as those associated with pemphigus
vulgaris. As the targeted proteins are found in the
basement-membrane zone, the lesions heal with
submucosal scarring. Treatment of ocular cicatricial
pemphigoid is primarily with corticosteroids.
Sarcoidosis
Sarcoidosis is a chronic systemic disorder presumed
to have an autoimmune pathogenesis. Sarcoidosis
may cause laryngeal lesions, extrinsic compression
of the esophagus by mediastinal adenopathy, and
esophageal dysmotility due to myopathy, infiltration
of Auerbach plexus, or granulomatous infiltration
of the esophageal wall, which may produce long
esophageal strictures.
The dysphagia can be minimized by adequate
chewing and by reducing the bolus size. Esophageal
motility can be improved by medications such as
prokinetic agents.
Systemic Lupus Erythematous
Systemic lupus erythematous is an inflammatory
disorder that is associated with a variety of autoantibodies against many different tissue components.
The vast majority of patients with systemic lupus
erythematous do not experience dysphagia and
have normal esophageal transit studies. Dysphagia
and/or chest pain is most often attributed to esophageal dysmotility associated with LES insufficiency
and thus GERD.
Wegener Granulomatosis
Wegener granulomatosis is characterized by a
granulomatous arteritis involving the upper and
lower respiratory tracts, a progressive glomerulonephritis, and extra respiratory symptoms attributable
to systemic small-vessel arteritis. Wegener granulomatosis often affects the hard and soft palate and
may lead to extensive ulceration, oronasal fistulas,
and velopharyngeal insufficiency.
Scleroderma
Systemic sclerosis (scleroderma) is a disorder
characterized by progressive fibrosis and vascular changes in the small blood vessels.
common and the earliest symptom in people with
PSS is Raynaud disease, characterized by pallor and
sweating of the fingers or hands that progresses to
cyanosis and pain.
Dysphagia, which is the second most common
symptom of this disorder, is usually first noticed
while swallowing solids. Dysphagia is most often
due to poor motility through the inferior two-thirds
of the esophagus. The process starts affecting the
Auerbach plexus, which coordinates the smooth
muscles. This is followed by a myopathy, which is
then followed by fibrosis and strictures secondary
to the effects of GER.
56
The most
ANTERIOR CERVICAL SPINE DISORDERS
Dysphagia may follow anterior cervical spine surgery as both a short-term and long-term side effect
depending on the exact type and technique of the
surgery. This surgery is done for patients who have
undergone some type of trauma, such as spinal cord
compression, or for other conditions, such as arthritis. The swallowing disorders following anterior cervical spine surgery (ACSS) involve treatment when
there is neck pain resulting from the surgery and
from such conditions as herniated disks in the neck.
Prior to the surgery, the patient often reports neck
pain and numbness in the hands and/or feet. The
surgical preference for treating these conditions is
an anterior approach to the spinal cord to avoid further damage to the spinal cord. Surgeons approach
3. SWALLOWING DISORDERS ARISING FROM NEUROLOGICAL DISORDERS AND OTHER DISEASES 91
the spinal cord anteriorly, using a cervical incision
to mobilize the laryngotracheal complex away from
the great vessels of the neck to reach the prevertebral space to allow inspection and repair of the
cervical spine.
Treating Postoperative Anterior
Cervical Spine Surgery
Postoperative dysphagia is found in almost all
patients who undergo ACSS.
most common risk factors for dysphagia after ACSS.
Other preconditions may exist that also slow progress or limit swallowing after surgery. In 2018, Li
58
etal
showed that the major risk factors for dysphagia in a group of 158 patients after ACSS were
being 60 years and older, being female, having an
internal fixation with titanium plate/titanium mesh,
TABLE 3–10. Risk Factors for Dysphagia Following Anterior
Cervical Spine Surgery (Compiled from Several Reports)
• Age: 60 and older
• Female
• Intraoperative retraction of the esophagus
• Esophageal injury prior to or during the surgery
• Endotracheal intubation
• Preexisting pain that remains following surgery
• Surgical duration — longer surgery associated with
dysphagia
• Mid-level surgery — surgery may range from C2 to C7
• Revision surgery
• Blood loss
• Post-op hematoma formation
• Soft tissue swelling
• Anterior cervical plate thickness — related to females
more than males
• Graft-related problems (ie, protrusions)
• Infection either during surgery or recovery
• Adhesion formation — scarring may limit pharyngeal or
laryngeal movements
• Nerve injuries — recurrent laryngeal nerve, superior
laryngeal nerve, glossopharyngeal nerve
57
Table 3–10 lists the
having the narrowest esophageal distance before
internal fixation of less than 5 mm, and having 3
operative segments.
In many clinics, a presurgical evaluation by the
SLP is now common for patients undergoing
cervical spine surgery. That evaluation should
include a discussion of the importance of
sampling the feeling of swallowing liquids,
then puree materials, and finally food when
the surgery site is healed. Small bites and sips
should be emphasized.
The dysphagia is often of short duration, but
it can persist beyond 1 year in as many as 23% of
patients.
59
A report by Hart et al60 found that dysphagia was the most frequent complication of surgical
spinal surgery, accounting for 46% of the postoperative complications. Many of the complications
reported were minor; however, PEG feeding was
required in 15% of patients. Long-term vocal fold
paralysis, such as that shown in Figure 3–12 requiring
surgical correction, was found in 7% of the patients.
CP dilation/myotomy is not uncommon because of
the shared space with the surgical hardware.
There are several possible etiologies for dysphagia following ACSS in addition to vocal fold paralysis
or partial paralysis. These are shown in Table3–11.
First, the patient may have dysphagia preoperatively, which may worsen after the surgery. Thus,
many surgeons are now seeing the need for assessment of the swallow function prior to ACSS. Second,
because of postoperative swelling, the patient may
become more aware of symptoms immediately after
the surgery, leading to fear of swallowing/choking.
Additionally, neurological damage may result from
direct trauma or retraction trauma to the recurrent
laryngeal nerve, superior laryngeal nerve, or glossopharyngeal nerve, depending on the height range
of the surgery.
A major complication is airway edema, reducing
sensation and the ability to manage the bolus in
the oral or oropharyngeal stage of swallowing.
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