Residency · Residency · Otolaryngology
Dysphagia: Otolaryngologic Assessment and Management
Overview
Dysphagia is a common problem encountered by otolaryngologists, with causes ranging from neurologic disorders to structural abnormalities of the pharynx and esophagus. The otolaryngologist is uniquely positioned to evaluate the pharyngeal phase of swallowing through flexible endoscopic evaluation of swallowing (FEES) and to manage specific structural causes including cricopharyngeal dysfunction and Zenker diverticulum. A multidisciplinary approach involving speech-language pathology, gastroenterology, and neurology optimizes patient outcomes.
Normal Swallowing Physiology
Phases
Oral preparatory phase: mastication, bolus formation, voluntary control. Oral propulsive phase: tongue propels bolus posteriorly; triggers the pharyngeal swallow. Pharyngeal phase: reflexive; palatal elevation (nasopharyngeal closure), pharyngeal constriction, laryngeal elevation and closure (epiglottic deflection, vocal fold adduction, arytenoid tilting), upper esophageal sphincter (UES) opening. Esophageal phase: peristalsis carries bolus to the stomach; lower esophageal sphincter relaxation.
Upper Esophageal Sphincter (Cricopharyngeus)
Cricopharyngeus muscle: primary component of the UES. Tonic contraction at rest; relaxes during swallowing. Opening requires: CP relaxation, hyolaryngeal elevation (pulling open), bolus pressure. Dysfunction leads to dysphagia, aspiration, and Zenker diverticulum formation.
Etiologies of Dysphagia
Oropharyngeal (Transfer) Dysphagia
Neurologic: stroke (most common), Parkinson disease, multiple sclerosis, ALS, myasthenia gravis, brainstem tumors. Structural: head and neck cancer (tumor or post-treatment), Zenker diverticulum, cervical osteophytes, cricopharyngeal bar, webs. Muscular: inclusion body myositis, polymyositis, muscular dystrophy. Iatrogenic: post-surgical (skull base, neck), post-radiation fibrosis, medication-related.
Esophageal Dysphagia
Stricture, eosinophilic esophagitis, malignancy, motility disorders (achalasia), extrinsic compression. Primarily managed by gastroenterology.
Evaluation
History
Onset, duration, progression. Solids vs. liquids vs. both (solids only suggests structural; liquids suggest neurologic). Localization of "sticking" sensation. Coughing/choking with meals, wet/gurgly voice, recurrent pneumonia. Weight loss, dietary modifications. History of stroke, neurologic disease, head and neck cancer, radiation.
Clinical Swallowing Assessment
Cranial nerve examination (V, VII, IX, X, XII). Oral cavity examination: dentition, tongue mobility, palatal elevation. Cervical auscultation during swallowing, Trial swallows of various consistencies. Limitations: cannot directly assess aspiration; clinical assessment misses silent aspiration in 40-50%.
| Assessment Tool | Modality | Phases Assessed | Key Advantages | Key Limitations |
|---|---|---|---|---|
| FEES | Endoscopic | Pharyngeal | Portable, no radiation, repeatable, bedside | Whiteout during swallow, no oral/esophageal phase |
| MBSS (Videofluoroscopy) | Fluoroscopic | Oral, pharyngeal, esophageal | All phases visualized, aspiration timing | Radiation, requires suite, brief |
| FEESST | Endoscopic + sensory | Pharyngeal + sensation | Quantifies sensory threshold | Requires specialized equipment |
| Esophageal manometry | Pressure transducer | Esophageal/UES | Objective motility assessment | Invasive, patient discomfort |
Flexible Endoscopic Evaluation of Swallowing (FEES)
Gold standard office-based assessment by otolaryngologists. Flexible laryngoscope positioned above the epiglottis. Assesses: secretion management, pharyngeal anatomy, bolus transit, penetration/aspiration, pharyngeal residue, laryngeal sensation. Green-dyed food/liquid boluses of various consistencies (thin liquid, nectar-thick, puree, solid). Advantages: portable (bedside, ICU), no radiation, repeatable, directly visualizes anatomy, can assess sensation (FEESST). Limitations: whiteout during swallow (cannot visualize the moment of maximal pharyngeal contraction), does not assess oral or esophageal phases. Penetration-Aspiration Scale (Rosenbek): 1 (no penetration) to 8 (silent aspiration).
Modified Barium Swallow Study (MBSS/Videofluoroscopy)
Fluoroscopic evaluation with barium-impregnated boluses. Gold standard for assessing all phases of swallowing (oral, pharyngeal, esophageal). Visualizes: oral control, tongue base retraction, epiglottic deflection, hyoid excursion, pharyngeal constriction, UES opening, aspiration timing (before, during, after swallow). Advantages: visualizes oral and esophageal phases, identifies aspiration timing, assesses efficacy of compensatory strategies in real time. Limitations: radiation exposure, requires fluoroscopy suite, brief assessment.
Additional Studies
Barium esophagogram: esophageal stricture, diverticulum, motility disorders. Esophagogastroduodenoscopy (EGD): mucosal assessment, biopsy, dilation. Esophageal manometry: motility disorders (achalasia, UES dysfunction). FEESST: FEES with sensory testing; air pulse delivered to aryepiglottic fold to elicit laryngeal adductor reflex; quantifies laryngopharyngeal sensory threshold.
Cricopharyngeal Dysfunction
Pathophysiology
Failure of the cricopharyngeus muscle to relax during swallowing. May be due to fibrosis, neurologic impairment, or primary muscle disorder. Results in pharyngeal residue, overflow aspiration, and potentially Zenker diverticulum.
Diagnosis
MBSS: cricopharyngeal bar (posterior indentation at C5-C6 level), poor UES opening, pharyngeal residue. FEES: pooling in pyriform sinuses, overflow aspiration. Manometry: elevated UES resting pressure, incomplete relaxation.
Management
Botulinum toxin injection: injected into the cricopharyngeus (transcervical or endoscopic); temporary effect (3-6 months); useful as diagnostic/therapeutic trial. Cricopharyngeal myotomy: surgical division of the CP muscle. Endoscopic (transoral): CO2 laser or stapler-assisted; increasingly preferred. Open (transcervical): left-sided neck approach; muscle fibers divided over 2-3 cm. Dilation: balloon dilation of the UES; temporary relief.
Zenker Diverticulum
Pathophysiology
Pulsion diverticulum through Killian dehiscence (weak area between the oblique fibers of the inferior constrictor and the transverse fibers of the cricopharyngeus). Posterior pharyngeal wall herniation above a dysfunctional cricopharyngeus. Mucosa and submucosa only (false diverticulum), Predominantly affects elderly males.
Clinical Features
Progressive dysphagia, regurgitation of undigested food, Halitosis, gurgling in the throat, Aspiration pneumonia, Palpable neck mass (large diverticulum), Weight loss in advanced cases.
Management
Endoscopic stapler-assisted diverticulotomy (Dohlman procedure): most common approach; GIA stapler divides the common wall (septum) between the diverticulum and the esophagus, simultaneously cutting and stapling; quick, effective, short hospital stay. Endoscopic laser or cautery septotomy: CO2 laser or electrocautery to divide the septum; may require staged procedures for large diverticula. Open transcervical diverticulectomy: excision of the diverticulum sac + cricopharyngeal myotomy; definitive but higher morbidity; reserved for very large diverticula or failed endoscopic approaches. Diverticulopexy: suture fixation of the sac in an inverted position + myotomy; avoids mucosal closure. All approaches should include cricopharyngeal myotomy to address the underlying pathology.
Complications
Mediastinitis (perforation): rare but life-threatening. Recurrence: 5-15% (more common with endoscopic approaches for large diverticula). Recurrent laryngeal nerve injury (open approach), Fistula.
<image>Flexible endoscopic evaluation of swallowing (FEES) setup and findings. Panel A: Position of the flexible laryngoscope above the epiglottis with a view of the laryngeal inlet, base of tongue, valleculae, and pyriform sinuses. Panel B: Normal swallow showing green-dyed bolus passing through the pharynx without residue. Panel C: Abnormal findings showing green-dyed residue pooling in the pyriform sinuses and valleculae after swallow. Panel D: Aspiration with green-dyed material visible below the vocal folds in the subglottis. Labels indicate anatomical landmarks and severity using the Penetration-Aspiration Scale.</image>
<image>Zenker diverticulum anatomy and surgical approaches. Panel A: Sagittal view showing the diverticulum herniating posteriorly through Killian dehiscence between the inferior constrictor and cricopharyngeus muscles, with the common wall (septum) between the diverticulum and esophageal lumen. Panel B: Endoscopic view showing the septum between the diverticulum (posterior) and esophageal lumen (anterior) with the GIA stapler positioned across the septum. Panel C: Endoscopic stapler-assisted diverticulotomy with the stapler dividing the septum and creating a common cavity. Panel D: Open transcervical approach showing the diverticulum sac exposed and mobilized, with the cricopharyngeus muscle identified for myotomy.</image>
<image>Modified barium swallow findings in cricopharyngeal dysfunction. Lateral fluoroscopic views during swallowing showing: Panel A: Normal UES opening with the cricopharyngeus relaxed and barium passing freely into the esophagus. Panel B: Cricopharyngeal bar with posterior indentation at the C5-C6 level narrowing the barium column. Panel C: Significant pharyngeal residue in the pyriform sinuses and valleculae after swallow due to poor UES opening. Panel D: Zenker diverticulum seen as a posterior outpouching above the cricopharyngeus filled with barium. Labels indicate the hyoid bone, epiglottis, cricopharyngeus muscle, and barium column.</image>
Clinical Pearls
Silent aspiration occurs in up to 50% of aspirating patients and cannot be detected by clinical swallowing assessment alone; instrumental evaluation (FEES or MBSS) is essential for accurate diagnosis. FEES is the ideal bedside assessment tool for ICU and medically complex patients; it is portable, avoids radiation, and can be repeated to track progress. Always perform cricopharyngeal myotomy when surgically addressing Zenker diverticulum; failure to address the underlying CP dysfunction leads to recurrence. Botulinum toxin injection into the cricopharyngeus serves as both a diagnostic and therapeutic tool; a positive response predicts success with definitive myotomy. Post-radiation dysphagia is multifactorial (fibrosis of the pharyngeal constrictors, base of tongue, UES) and is often progressive; early and ongoing swallowing therapy during and after radiation is critical for prevention. The endoscopic stapler-assisted approach for Zenker diverticulum has largely replaced open surgery, offering comparable outcomes with reduced morbidity and shorter hospital stay.
References
- Langmore SE, Schatz K, Olsen N. "Fiberoptic endoscopic examination of swallowing safety: a new procedure." Dysphagia. 1988;2(4):216-219.
- Aviv JE, Kim T, Thomson JE, Sunshine S, Kaplan S, Close LG. "Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in healthy controls." Dysphagia. 2000;15(2):87-92.
- Verdonck J, Morton RP. "Systematic review on treatment of Zenker's diverticulum." Eur Arch Otorhinolaryngol. 2015;272(11):3095-3107.
- Kocdor P, Siegel ER, Tulunay-Ugur OE. "Cricopharyngeal dysfunction: a systematic review comparing outcomes of dilatation, botulinum toxin injection, and myotomy." Laryngoscope. 2016;126(1):135-141.
