Surgical Treatments for Swallowing Disorders
Surgery is usually a last resort reserved for patients with swallowing disorders that do not respond to swallowing therapy. Surgical procedures are customized to the patient's needs and, in general, are aimed at improving the patient's existing swallowing function as much as possible. These procedures can be categorized as follows:
- procedures that improve the closure of different valves within the swallowing mechanism, such as the soft palate and vocal cords
- surgeries used to open valves that are too tight, such as the upper esophageal sphincter, a “muscle-valve” between the throat (pharynx) and foodpipe (esophagus)
- surgeries to correct mechanical obstruction, such as a narrowing, or tumors
- surgeries that separate the esophagus from the airway
- surgeries that can aid the patient in sustaining his or her weight and/or nutritional balance (gastrostomy tube placement)
Although the physicians of the Swallowing Disorders Center do not perform gastrostomies, if one is needed, they can refer you to an appropriate physician.
The most common surgeries recommended for patients with specific swallowing disorders include:
Medialization of the Vocal Cord
Medialization refers to the process of moving a paralyzed vocal cord closer to the middle, so that the other vocal cord can close the gap between them and protect the trachea (windpipe). Surgeons can use any of the following techniques to achieve this purpose.
vocal fold (cord) injection
This is the least invasive technique, but it is less accurate than other procedures that involve traditional surgery (incision). The vocal cord can be injected with permanent and/or temporary materials to add bulk to the tissues of the vocal fold and/or move it closer to the middle. The injection can be done through the mouth or through the skin of the neck.
laryngeal framework surgery
This type of surgery includes procedures in which an implant is used to add bulk and/or move the vocal cord closer to the middle. Some patients require placement of a stitch be placed at the joint of the vocal cord to correct the position of the joint. Although it involves an external incision, to create a window in the larynx (voicebox), the effect of this surgery is very reliable and the improvement is immediate.
Pharyngoesophageal Dilatation
Stenosis of the pharynx and upper esophagus (narrowing of the throat) most commonly results from radiation therapy to the head and neck (with or without chemotherapy). Stenosis may also occur following surgery for tumors of the upper aerodigestive tract (voice box or food passage of the throat). This narrowing may cause patients to experience difficulty swallowing solids and/or liquids. Pharyngoesophageal dilatation involves passing an inflatable balloon or bougie (long, flexible rubber cylinder) through the mouth into the throat to strech the narrowed area.
Cricopharyngeal Myotomy
The cricopharyngeus muscle is located at the level of the lower neck. This muscle works like a valve to prevent the swallowing of air when we breathe and to prevent food from coming back up into the throat after it has been swallowed into the esophagus. The muscle is usually tight but relaxes to let food go down. In a variety of conditions, such as a spasm or achalasia, the muscle fails to relax, stopping the passage of food from the throat into the esophagus. In this case, the muscle may be cut to allow the free passage of food.
Surgery for Zenker's Diverticulum
A Zenker's viverticulum is an outpouching in the pharynx (throat) that develops due to failure of relaxation in the upper esophageal sphincter during swallowing. Food may collect in this outpouching causing regurgitation of food following meals or even aspiration (food spilling over from the pouch into the windpipe). A Zenker's diverticulum may be treated by making an incision in the neck and either removing the pouch or securing the pouch so that it drains into the esophagus more effectively. During this "open approach," a cricopharyngeal myotomy (see above) is also usually performed. Alternatively, many Zenker's diverticula are amendable with endoscopic surgical treatment (through the mouth, without incisions in the neck). The endoscopic procedure involves looking through the mouth with a telescope and dividing the common wall separating the pouch from the esophagus.
Palatopexy
A palatopexy is recommended for those patients whose soft palate is paralyzed, causing food to backflow into the nose. This procedure affixes the soft palate (the tissue that hangs at the back of the throat) to the back wall of the throat, using permanent stitches.
Laryngo-Tracheal Separation
In the extreme event in which a patient continues to aspirate (that is, food continues to go into the windpipe), leading to repeated pneumonias, the foodway (esophagus) can be completely separated from the airway (trachea or windpipe). This is a last resort, reserved for patients who have suffered catastrophic strokes and those presenting with advanced stages of neurologic diseases, such as multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), or Parkinson’s disease.