Dr David Vokes: Swallowing Disorders, Problems and Conditions Treated

Swallowing is the process by which food and fluid is transported from the mouth to the stomach. Swallowing is a complex activity that is divided into three stages: the oral (mouth), pharyngeal (throat) and oesophageal phases.

Dysphagia is the medical term for difficulty swallowing, and includes aspiration, which defined as the unwanted passage of swallowed material into the lower airway, inferior to the vocal folds. Aspiration is a serious problem, because aspiration may result in life threatening respiratory complications, such as laryngospasm, bronchospasm, tracheobronchitis and pneumonia.

Dysphagia is a very important symptom to recognise because it raises significant issues for the person who has the difficulty swallowing: nutrition and hydration, safety (aspiration may lead to respiratory complications such as pneumonia), psychological wellbeing, and the possibility of cancer.

A multidisciplinary team approach for the evaluation and treatment of people with a swallowing disorder is recommended, as there are many possible causes and several complementary approaches to treatment. The team may include clinicians from Otorhinolaryngology, Speech Language Therapy, Radiology, Nutrition, Neurology, Gastroenterology, General Surgery, Physiotherapy and Rehabilitation Medicine.

Most swallowing disorders are treated without surgery, but there are some disorders of swallowing that are treated with surgery by a Laryngologist.

For more information about specific swallowing disorders please click on a link below:

Cricopharyngeal Dysfunction & Pharyngeal Pouch (Zenker’s Diverticulum)

The cricopharyngeus muscle is the muscle at the junction between the throat and the oesophagus (the tube that connects the throat to the stomach). When the cricopharyngeus does not open fully during swallowing, sticking of food in the bottom of the throat may result. This is called cricopharyngeal dysfunction. Cricopharyngeal dysfunction may also be associated with a pouch or hernia from the bottom part of the throat, referred to as either a pharyngeal pouch or a Zenker’s Diverticulum.

Cricopharyngeal dysfunction may be treated with a dilation (and a Botulinum Toxin injection), but the definitive procedure to treat cricopharyngeal dysfunction is a cricopharyngeal myotomy, a procedure in which the cricopharyngeus muscle is cut.

A cricopharyngeal myotomy is performed in one of two ways: either through the mouth using a laser or stapler to cut the muscle (Endoscopic Cricopharyngeal Myotomy), or via an external incision in the neck (External or Open Cricopharyngeal Myotomy). Both procedures are performed under general anaesthetic in the operating room and require two days in hospital after the surgery.

Pharyngeal/Oesophageal Scarring

A narrowing in the throat or oesophagus may cause difficulty swallowing, especially swallowing solid fluid. This narrowing may be caused by scar tissue in the throat or oesophagus.

This narrowing may be treated with dilation (stretching) to enlarge the passage for food and fluid. This is performed via the mouth using a pharyngoscope or oesophagoscope under general anaesthetic in the operating room. The area of narrowing is dilated (stretched) using a balloon dilator.

Retrograde Cricopharyngeal Dysfunction

Retrograde cricopharyngeal dysfunction (RCPD) is a disorder of the swallowing mechanism that has only been defined recently, in 2019. The key symptom reported by people with this condition is that they are unable to belch/burp. This causes a number of other symptoms, including chest discomfort, abdominal discomfort and abdominal bloating.

Retrograde cricopharyngeal dysfunction occurs because the cricopharyngeus muscle, the muscle at the junction between the throat and the oesophagus (the tube that connects the throat to the stomach), does not relax properly to allow release of the air that comes up into the oesophagus (from the stomach) into the throat, and then to the outside world. Interestingly, people with RCPD do not report difficulty with swallowing their food (ie. food does not stick as it passes through the cricopharyngeus from the throat into the oesophagus).

The treatment of RCPD is injection of Botulinum Toxin into the cricopharyngeus muscle to relax it. Although the effect of Botulinum Toxin is only temporary (usually 3-4 months), most people with RCPD only require one treatment with Botulinum toxin. It is thought this is because the period of muscle relaxation allows the body to reset the activity of the muscle, restoring its normal function. If the symptoms of RCPD return, either further Botulinum Toxin, or surgery to cut the cricopharyngeus muscle (a cricopharyngeal myotomy), may be required.

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