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Swallowing

(415) 885-7700

Conditions We Treat

Cricopharyngeal Hypertrophy or Cricopharyngeal Bar

Hypertrophy refers to the increase in volume of an organ or tissue in the body, which can sometimes have a detrimental effect. Cricopharyngeal Hypertrophy refers to hypertrophy of the cricopharyngeus muscle, which serves as the upper esophageal sphincter and plays a key role in swallowing. During a normal swallow, the cricopharyngeus muscle relaxes and allows the food to pass into the esophagus. However, when this muscle is enlarged it can sometimes act like a “bar” and block the food from passing down the esophagus smoothly.

Symptoms

Patients with Cricopharyngeal Hypertrophy can present with difficulty swallowing (especially solids) and a feeling that food may be stuck in the throat. There are many other disorders that may present in a similar fashion warranting thorough evaluation.

Evaluation

A comprehensive evaluation by a laryngologist is essential to evaluating for Cricopharyngeal Hypertrophy. A videoflouroscopic swallow study (VFSS) performed by a speech pathologist is the best way to evaluate for a Cricopharyngeal bar. In addition to this, a barium swallow, esophagoscopy or Flexible Endoscopic Evaluation of Swallowing (FEES) can provide useful information.

Treatment

Treatment of this condition can involve only dietary modifications, although this will not cure the condition. For those with significant symptoms, Botox can be used to weaken the muscle to allow the food bolus to pass more easily. The Botox lasts for 3-6 months and can also be used to determine if a patient would benefit from surgery on the Cricopharyngeal muscle. A cricopharyngeal myotomy is a procedure in which the muscle is cut, which allows the sphincter to relax and the food to pass through. This can be done either with an open approach or in a minimally invasive fashion using a surgical laser.

Oropharyngeal Dysphagia

Oropharyngeal Dysphagia is the term used to describe difficulty swallowing involving muscles in the mouth and throat.

Symptoms

Patients with oropharyngeal dysphagia may experience coughing or choking when eating and/or drinking, a wet or gurgly sounding voice, drooling, food or liquid spilling from mouth, pocketing or holding contents in mouth, difficulty moving food from mouth to throat, food or liquid coming out of the nose, food getting stuck in the throat, and/or lengthy meal times.

The above symptoms can lead to inadequate nutritional intake and weight loss, avoidance of foods, social isolation, and aspiration pneumonia. Individuals with neurovascular disease, neurodegenerative conditions, autoimmune disorders, head & neck tumors, or advanced age are at increased risk of having dysphagia.

Evaluation

Evaluation is completed by a laryngologist and speech pathologist (SLP) with expertise in swallowing. The swallowing evaluations are used to assess swallowing function to identify specific deficits, determine risk of penetration and aspiration (food/liquid entering the voicebox or airway), explore strategies for safe eating and drinking, and to identify goals for swallowing rehabilitation. This may include:

Clinical Swallowing Evaluation Measurements

A variety of instrumental assessment tools to measure tongue, lip, and cheek strength, as well as neck, jaw, and tongue range of motion.

  • Videofluoroscopic Swallow Studies (VFSS): A dynamic video x-ray procedure involving eating and drinking different textures and consistencies of barium – a digestible radiopaque contrast.
  • Flexible Endoscopic Evaluations of Swallowing (FEES): A flexible endoscope with a camera is passed through the nose to the back of the throat after which an individual is then taken through various speaking and swallowing tasks.
  • Static Endoscopic Evaluations of Swallowing (SEES): A rigid endoscope is placed into the mouth, using an angled camera lens to view the throat before and after eating and drinking. Frequently this is performed in conjunction with a laryngostroboscopic examination, which is used to assess vocal cord vibration during voicing.

Treatment

Following instrumental evaluations, our interdisciplinary MD and SLP team work with the patient to identify the most suitable swallowing rehabilitation plan. These plans may include surgical, medical, and exercise-based management interventions. Should an exercise-based intervention approach be selected, the SLPs will work to develop an individualized rehabilitation regimen to optimize gains for each patient. An exercise-based therapy regimen may include:

  • Biofeedback training is the process of using technology to gain greater understanding of muscle movements. The SLPs at UCSF are trained in using real-time visual feedback as needed to teach the patient what their body is doing during a variety of different swallowing exercises.
  • Myofascial Release and Peri-Laryngeal Massage is the manual manipulation of muscles and skin in the front and side of the neck. This may be performed by the SLP and taught to the patient for treatment of connective tissue and muscle hypomobility.
  • Cervical and mandibular range of motion exercises are stretches of the neck and jaw. Following surgery and radiation therapy, the neck and jaw can become stiff, therefore range of motion exercises are instructed and performed in order to maintain functional movement in these areas for speech and swallowing.
  • Respiratory muscle strength training is the use of an exercise device with the purpose of increasing breathing and coughing strength. It is used to maximize coughing productivity in order to clear any food or liquid that may have entered the lungs while eating and drinking.
  • Evidence-based practice swallowing rehabilitation exercises uses principles of neuromuscular rehabilitation and highest levels of research to prevent decline in swallow function, and/or improve current swallowing status. These exercises are like “going to the gym for the throat.”

Zenker’s Diverticulum

A diverticulum is an outpunching of a hollow structure within the body. A Zenker’s diverticulum is a diverticulum of the pharynx just above the cricopharyngeus muscle (which is the upper sphincter of the esophagus or food tube). In medical terms, this is a “false diverticulum”, meaning that not all layers of the esophageal wall are involved. This disorder tends to present in older adults and although there has never been a clear cause identified, acid reflux is thought to play a role in its development.

Symptoms

Patients with a Zenker’s diverticulum typically report dysphagia (difficulty swallowing), regurgitation of undigested food, cough and halitosis (bad breath). Along with these symptoms, a diverticulum can put some patients at a greater risk of aspiration of food contents, which in turn can lead to severe pneumonias (lung infections).

Evaluation

An evaluation by a laryngologist is essential to evaluating a Zenker’s diverticulum. For imaging studies, a barium swallow is the gold standard of diagnosis. A barium swallow is series of radiographs (x-rays of the swallow) used to examine the upper gastrointestinal system and will generally show the diverticulum. These can also be discovered with an upper GI endoscopy and CT with oral contrast, and/or on a videoflouroscopic swallow study (VFSS), which is a swallowing test administered by a Speech Pathologist. If you have any imaging, please be sure to bring this in to your evaluation.

Treatment

Treatment can vary from observation alone to surgical intervention, which depends largely on the quality-of-life impact to the patient. For small and asymptomatic diverticulum pouches, keeping a close eye on the patient over time is often appropriate. This may sometimes involve dietary modifications to avoid certain foods. For some with larger pouches, a discussion of surgical intervention is warranted. The traditional approach to a diverticulum is through an open approach through the neck wherein the diverticulum is resected and the cricopharyngeus muscle is incised. In recent years, however, more and more cases have been able to be treated through an endoscopic approach (through the mouth without external incisions). Depending on the size of the diverticulum and circumstances of the patient, either a stapler or laser can be used with this method.