Surgical Management of UES Procedures

Surgical Management Overview

• Surgical intervention is considered when therapy fails to yield satisfactory results.
• Most surgeries target the larynx or upper esophageal sphincter (UES).

UES Surgical Procedures

• Cricopharyngeal Myotomy:

  • Involves cutting the cricopharyngeus muscle to remove obstruction at the UES.
  • Aims to enhance bolus flow.

• Botox Injection:

  • Botulinum toxin is injected into the UES.
  • Effectively alleviates outlet obstruction, improving bolus passage.

• Dilatation:

  • Mechanical widening of the UES to eliminate constriction.
  • Facilitates better bolus flow by correcting strictures.

Velopharyngeal Surgery

• Pharyngeal Flap Surgery:
  • Tissue from the pharynx is surgically attached to the soft palate.
  • Intent is to reduce velopharyngeal insufficiency, aiding in speech clarity.

Laryngeal Surgical Interventions

• Total Laryngectomy:

  • Complete surgical removal of the larynx.
  • Primarily performed to prevent aspiration.

• Tracheostomy:

  • Surgical incision made below the vocal folds with a tube inserted.
  • Procedure secures the airway and minimizes the risk of aspiration.

• Vocal Fold Medialization:

  • A surgery aimed at improving glottic closure by repositioning or augmenting the vocal folds.
  • Enhances the approximation of vocal folds for better voice quality.

Surgical Management Overview

• Surgical intervention is considered when therapy fails to yield satisfactory results.
• Most surgeries target the larynx or upper esophageal sphincter (UES).

UES Surgical Procedures

• Cricopharyngeal Myotomy:

  • Involves cutting the cricopharyngeus muscle to remove obstruction at the UES.
  • Aims to enhance bolus flow.

• Botox Injection:

  • Botulinum toxin is injected into the UES.
  • Effectively alleviates outlet obstruction, improving bolus passage.

• Dilatation:

  • Mechanical widening of the UES to eliminate constriction.
  • Facilitates better bolus flow by correcting strictures.

Velopharyngeal Surgery

• Pharyngeal Flap Surgery:
  • Tissue from the pharynx is surgically attached to the soft palate.
  • Intent is to reduce velopharyngeal insufficiency, aiding in speech clarity.

Laryngeal Surgical Interventions

• Total Laryngectomy:

  • Complete surgical removal of the larynx.
  • Primarily performed to prevent aspiration.

• Tracheostomy:

  • Surgical incision made below the vocal folds with a tube inserted.
  • Procedure secures the airway and minimizes the risk of aspiration.

• Vocal Fold Medialization:

  • A surgery aimed at improving glottic closure by repositioning or augmenting the vocal folds.
  • Enhances the approximation of vocal folds for better voice quality.

Surgical Management Overview

• Surgical intervention is considered when therapy fails to yield satisfactory results.
• Most surgeries target the larynx or upper esophageal sphincter (UES).

UES Surgical Procedures

• Cricopharyngeal Myotomy:

  • Involves cutting the cricopharyngeus muscle to remove obstruction at the UES.
  • Aims to enhance bolus flow.

• Botox Injection:

  • Botulinum toxin is injected into the UES.
  • Effectively alleviates outlet obstruction, improving bolus passage.

• Dilatation:

  • Mechanical widening of the UES to eliminate constriction.
  • Facilitates better bolus flow by correcting strictures.

Velopharyngeal Surgery

• Pharyngeal Flap Surgery:
  • Tissue from the pharynx is surgically attached to the soft palate.
  • Intent is to reduce velopharyngeal insufficiency, aiding in speech clarity.

Laryngeal Surgical Interventions

• Total Laryngectomy:

  • Complete surgical removal of the larynx.
  • Primarily performed to prevent aspiration.

• Tracheostomy:

  • Surgical incision made below the vocal folds with a tube inserted.
  • Procedure secures the airway and minimizes the risk of aspiration.

• Vocal Fold Medialization:

  • A surgery aimed at improving glottic closure by repositioning or augmenting the vocal folds.
  • Enhances the approximation of vocal folds for better voice quality.

Surgical Management Overview

• Surgical intervention is considered when therapy fails to yield satisfactory results.
• Most surgeries target the larynx or upper esophageal sphincter (UES).

UES Surgical Procedures

• Cricopharyngeal Myotomy:

  • Involves cutting the cricopharyngeus muscle to remove obstruction at the UES.
  • Aims to enhance bolus flow.

• Botox Injection:

  • Botulinum toxin is injected into the UES.
  • Effectively alleviates outlet obstruction, improving bolus passage.

• Dilatation:

  • Mechanical widening of the UES to eliminate constriction.
  • Facilitates better bolus flow by correcting strictures.

Velopharyngeal Surgery

• Pharyngeal Flap Surgery:
  • Tissue from the pharynx is surgically attached to the soft palate.
  • Intent is to reduce velopharyngeal insufficiency, aiding in speech clarity.

Laryngeal Surgical Interventions

• Total Laryngectomy:

  • Complete surgical removal of the larynx.
  • Primarily performed to prevent aspiration.

• Tracheostomy:

  • Surgical incision made below the vocal folds with a tube inserted.
  • Procedure secures the airway and minimizes the risk of aspiration.

• Vocal Fold Medialization:

  • A surgery aimed at improving glottic closure by repositioning or augmenting the vocal folds.
  • Enhances the approximation of vocal folds for better voice quality.

Pharmacological Management

• Capsaicin: Ingredient derived from hot peppers; enhances the release of substance P, leading to improved pharyngeal sensory functions.
• Cholinesterase Inhibitors: Commonly found in medications for Alzheimer’s disease and Myasthenia Gravis; these drugs inhibit the breakdown of acetylcholine, thereby enhancing involuntary muscle function from the pharynx to the larynx.

Enteral Feeding/Tubefeed Management

• Indications for Tube Feeding: Used when there is an inability to obtain adequate nutrition orally and when airway protection is compromised during swallowing.

• Types of Feeding Tubes:

  • Nasogastric Tube (NGT):

    • Insertion is easy and quick.
    • Typically lasts around 1 month.
    • Requires infrequent replacements.
    • Higher patient discomfort due to invasiveness.
    • Common issues include mucosa scarring, arytenoid swelling, infections, tube obstruction, and displacement.

  • Percutaneous Endoscopic Gastrostomy (PEG):

    • Requires a surgical procedure for insertion; more invasive.
    • Designed for longer-term use, functioning for up to 9 months or more.
    • Patient discomfort is lower compared to NGT.

• Therapeutic Interventions: Aimed at enhancing tolerance for various food and liquid consistencies until tube feeding is no longer necessary.

Pharmacological Management

• Capsaicin: Ingredient derived from hot peppers; enhances the release of substance P, leading to improved pharyngeal sensory functions.
• Cholinesterase Inhibitors: Commonly found in medications for Alzheimer’s disease and Myasthenia Gravis; these drugs inhibit the breakdown of acetylcholine, thereby enhancing involuntary muscle function from the pharynx to the larynx.

Enteral Feeding/Tubefeed Management

• Indications for Tube Feeding: Used when there is an inability to obtain adequate nutrition orally and when airway protection is compromised during swallowing.

• Types of Feeding Tubes:

  • Nasogastric Tube (NGT):

    • Insertion is easy and quick.
    • Typically lasts around 1 month.
    • Requires infrequent replacements.
    • Higher patient discomfort due to invasiveness.
    • Common issues include mucosa scarring, arytenoid swelling, infections, tube obstruction, and displacement.

  • Percutaneous Endoscopic Gastrostomy (PEG):

    • Requires a surgical procedure for insertion; more invasive.
    • Designed for longer-term use, functioning for up to 9 months or more.
    • Patient discomfort is lower compared to NGT.

• Therapeutic Interventions: Aimed at enhancing tolerance for various food and liquid consistencies until tube feeding is no longer necessary.

Behavioral Management

• Focuses on modifying various components to improve swallowing and reduce aspiration risks.
• Four main areas of modification include diet, patient posture, swallowing techniques, and structure through rehabilitation exercises.

Bolus Modification

• Involves changing the consistency or texture of foods and liquids to enhance safety during swallowing.
• Follow International Dysphagia Diet Standardisation Initiative (IDDSI) levels to guide modifications.
• Changes can include altering the size or taste of boluses to suit patient needs.
• Aims to reduce aspiration events, such as coughing during eating and drinking.
• Current research indicates limited benefits beyond aspiration reduction, showing little improvement in fluid intake or decreased risk of aspiration pneumonia.

Compensatory Strategies in Dysphagia

• Compensatory strategies involve posture adjustments, swallowing maneuvers, and sensory enhancements.
• These strategies serve as "quick fixes" but do not rehabilitate swallowing structure or physiology.
• Effectiveness is evaluated through instrumental assessments.

Issues in Swallowing Phases and Corresponding Strategies

• Poor Bolus Awareness

  • Utilize verbal reminders to enhance awareness, such as announcing the food type and amount.
  • Improve sensory input through enhanced taste or aroma.

• Anterior Leakage

  • Adjust bolus placement for better control, keeping it more medial in the mouth.
  • Employ tools like straws or syringes for more effective delivery.

• Oral Residue

  • Perform finger sweeps or lingual sweeps to clear remaining food debris from the mouth.

• Nasal Regurgitation

  • Reduce the size of the bolus to minimize risk.
  • Encourage effortful swallowing and cueing to increase awareness during the swallowing process.

• Vallecular Residue

  • Solutions include throat clearing, suctioning, and effortful or cued swallowing to clear residue.

• Pyriform Sinus Residue (often seen with liquids)

  • Encourage volitional coughing, effortful swallowing, and cued swallowing to eliminate residue.

• Penetration

  • Use techniques such as the supraglottic swallow and intentional coughing.
  • Implement cued swallowing to ensure safe swallowing.

• Aspiration

  • Monitor vocal quality as a sign of aspiration risk.
  • Utilize the supraglottic swallow and cued swallowing for safer swallowing.

• Pharyngeal Regurgitation

  • Decrease bolus size to lower the risk of regurgitation.
  • Use cyclic ingestion strategy: alternate between solids and liquids during meals.

Compensatory Strategies in Dysphagia

• Compensatory strategies involve posture adjustments, swallowing maneuvers, and sensory enhancements.
• These strategies serve as "quick fixes" but do not rehabilitate swallowing structure or physiology.
• Effectiveness is evaluated through instrumental assessments.

Issues in Swallowing Phases and Corresponding Strategies

• Poor Bolus Awareness

  • Utilize verbal reminders to enhance awareness, such as announcing the food type and amount.
  • Improve sensory input through enhanced taste or aroma.

• Anterior Leakage

  • Adjust bolus placement for better control, keeping it more medial in the mouth.
  • Employ tools like straws or syringes for more effective delivery.

• Oral Residue

  • Perform finger sweeps or lingual sweeps to clear remaining food debris from the mouth.

• Nasal Regurgitation

  • Reduce the size of the bolus to minimize risk.
  • Encourage effortful swallowing and cueing to increase awareness during the swallowing process.

• Vallecular Residue

  • Solutions include throat clearing, suctioning, and effortful or cued swallowing to clear residue.

• Pyriform Sinus Residue (often seen with liquids)

  • Encourage volitional coughing, effortful swallowing, and cued swallowing to eliminate residue.

• Penetration

  • Use techniques such as the supraglottic swallow and intentional coughing.
  • Implement cued swallowing to ensure safe swallowing.

• Aspiration

  • Monitor vocal quality as a sign of aspiration risk.
  • Utilize the supraglottic swallow and cued swallowing for safer swallowing.

• Pharyngeal Regurgitation

  • Decrease bolus size to lower the risk of regurgitation.
  • Use cyclic ingestion strategy: alternate between solids and liquids during meals.

Feeding Process and Pediatric Concerns

• Mealtime duration exceeding 30 minutes is common, with typical meals taking 30 to 40 minutes.
• Disruptive and stressful feeding environments can lead to behavioral issues such as crying or restlessness during meals.
• Lack of weight gain over the past 2 to 3 months may indicate the child is underweight and not building muscle mass effectively.
• A limited food repertoire is characterized by the child repetitively eating only select foods, indicating a lack of dietary variety.
• Food refusal includes a child's rejection of certain or unfamiliar foods, potentially limiting nutritional intake.
• Age-inappropriate food choices can occur, such as a 6-year-old child only consuming rice porridge (lugaw), raising concerns for developmental nutrition.

Primary Factors in Therapy Intervention

• Motor skills are crucial in feeding, requiring coordination of multiple muscle groups involved in the process.
• Behavioral aspects should be assessed, including any history of forced feeding or trauma that may impact a child's willingness to eat.
• Sensory considerations play a role in feeding difficulties, necessitating an understanding of how sensory sensitivities may affect food acceptance.

Feeding Process and Pediatric Concerns

• Mealtime duration exceeding 30 minutes is common, with typical meals taking 30 to 40 minutes.
• Disruptive and stressful feeding environments can lead to behavioral issues such as crying or restlessness during meals.
• Lack of weight gain over the past 2 to 3 months may indicate the child is underweight and not building muscle mass effectively.
• A limited food repertoire is characterized by the child repetitively eating only select foods, indicating a lack of dietary variety.
• Food refusal includes a child's rejection of certain or unfamiliar foods, potentially limiting nutritional intake.
• Age-inappropriate food choices can occur, such as a 6-year-old child only consuming rice porridge (lugaw), raising concerns for developmental nutrition.

Primary Factors in Therapy Intervention

• Motor skills are crucial in feeding, requiring coordination of multiple muscle groups involved in the process.
• Behavioral aspects should be assessed, including any history of forced feeding or trauma that may impact a child's willingness to eat.
• Sensory considerations play a role in feeding difficulties, necessitating an understanding of how sensory sensitivities may affect food acceptance.

Feeding Process and Pediatric Concerns

• Mealtime duration exceeding 30 minutes is common, with typical meals taking 30 to 40 minutes.
• Disruptive and stressful feeding environments can lead to behavioral issues such as crying or restlessness during meals.
• Lack of weight gain over the past 2 to 3 months may indicate the child is underweight and not building muscle mass effectively.
• A limited food repertoire is characterized by the child repetitively eating only select foods, indicating a lack of dietary variety.
• Food refusal includes a child's rejection of certain or unfamiliar foods, potentially limiting nutritional intake.
• Age-inappropriate food choices can occur, such as a 6-year-old child only consuming rice porridge (lugaw), raising concerns for developmental nutrition.

Primary Factors in Therapy Intervention

• Motor skills are crucial in feeding, requiring coordination of multiple muscle groups involved in the process.
• Behavioral aspects should be assessed, including any history of forced feeding or trauma that may impact a child's willingness to eat.
• Sensory considerations play a role in feeding difficulties, necessitating an understanding of how sensory sensitivities may affect food acceptance.

This quiz covers the surgical management techniques for treating disorders of the upper esophageal sphincter (UES) and velopharynx, including procedures like myotomy, botox injections, and pharyngeal flap surgery. Understand the intended effects and implications of each surgical intervention.