patients with an inadequate deglutitive glottal closure mechanism, such as seen in patients with Parkinson’s disease or amyotrophic lateral sclerosis, the deglutitive airway closure could be augmented by injection of a non‐absorbable material such as Teflon [32, 83, 84] into the lateral thyroarytenoid muscle. These injections will result in bulk formation at the injection site and displace the true cord in a fixed position toward the midline, facilitating glottal closure during swallowing, since the adduction of the functioning cord will result in contact of the two cords and closure of the introitus of the trachea. Teflon injection into the cords has also been successfully used to prevent aspiration in patients with various types of vocal cord paralysis, due to dysfunction of the recurrent laryngeal and/or superior laryngeal nerve as a result of various central nervous system, surgical, or inflammatory disorders [85, 86].
Swallowing and postural techniques
Swallowing maneuvers and exercises
The majority of OPD patients require specialized rehabilitation of their swallowing functions. Swallow therapy is performed with the aid of videofluoroscopy and, more recently, unsedated transnasal videoendoscopy. The therapy requires a cooperative patient with intact cognition. Swallow therapies (Table 3.3) are time‐consuming and must be tailored to each individual patient and their specific oropharyngeal abnormalities. At times, attempts at various techniques and maneuvers are required until an efficient and safe swallow is achieved. Swallowing maneuvers are used to improve bolus transfer and airway safety. In our practice, we find that they are more effective than postural techniques.
Multiple swallows
The target population is patients with post‐deglutitive residue, poor pharyngeal peristalsis, and posterior tongue thrust. The patient follows the swallow of each bite with two or three additional dry swallows. The desired effect is the enhancement of pharyngeal closure and elimination of post‐deglutitive pharyngeal residue.
Supraglottic swallow
The target population is patients with intra‐deglutitive aspiration. When ready to swallow, the patient takes a deep breath, holds it, and then swallows while bearing down, followed by a cough [87]. The desired effect is to close the airway completely by adducting the vocal cords and arytenoids and approximating the adducted arytenoids to the base of the epiglottis in order to prevent aspiration. The subsequent cough expels any contents that potentially may have penetrated the airway.
Mendelsohn’s maneuver
The target population is patients with abnormal pharyngeal transit and post‐deglutitive aspiration. The patient is instructed to generate a sustained laryngeal and hyoid bone elevation following the swallow [88]. The desired effect is to prolong UES opening and thus enhance pharyngeal emptying.
Table 3.3 Postural techniques and swallowing maneuvers and exercises.
| Desired effect | |
| Postural changes Chin tuck Tilting head to stronger side Head rotation to affected side Chin up | Positions bolus anteriorly and narrows airway entrance Gravitational forces direct bolus to stronger side Takes advantage of stronger muscles on unaffected side to improve pharyngeal transfer Improves posterior movement of the bolus |
| Swallowing maneuvers Multiple swallows Supraglottic swallow Effortful swallow Mendelsohn’s maneuver | Residue is cleared with repeated effort Closes the true vocal cords and arytenoids and approximate the adducted arytenoids to the base of the epiglottis in order to prevent aspiration. The subsequent cough expels any contents that potentially may have penetrated the airway Increases posterior tongue thrust Prolongs upper esophageal sphincter (UES) opening and laryngeal elevation, thus improving pharyngeal clearance |
| Strengthening exercises Shaker exercise Swallowing Against Laryngeal Restriction | Increases cross‐sectional area of UES opening Improves pharyngeal clearance and reduces/eliminates post‐deglutitive aspiration Increases maximum UES opening, superior and anterior laryngeal excursion, posterior pharyngeal wall thickness, and deglutitive pharyngeal contractile integral Reduces/eliminates post‐deglutitive aspiration |
Shaker exercise
The target population is patients with abnormal UES function who present with post‐swallow pharyngeal residue and aspiration. An isotonic and isometric head‐raising exercise regimen in the supine position is performed three times a day for a six‐week period [89, 90]. The desired effect is an increase in the cross‐sectional area of the UES opening by strengthening the traction forces of the suprahyoid muscles responsible for UES opening, thus improving pharyngeal clearance and eliminating aspiration.
Swallowing against laryngeal restriction
Repetitive swallowing against a resistive load induced by restricting anterosuperior excursion of the larynx has been shown to induce fatigue in pharyngeal peristalsis, which has the potential to strengthen the pharyngeal contractile function [91]. A recent study evaluating the biochemical effect of a novel resistance exercise program incorporating Swallowing Against Laryngeal Restriction (SALR) on pharyngeal phase swallowing in the healthy elderly demonstrated swallow resistance exercise, but not the sham exercise; resulted in a significant increase in maximum UES opening, superior and anterior laryngeal excursion, posterior pharyngeal wall thickness, and deglutitive pharyngeal contractile integral [92]. These findings provide optimism for developing an exercise‐based swallow health maintenance program for the elderly that may prevent development of OPD. Further studies will be necessary to determine the effect of this exercise program in an OPD population.
Postural techniques
Postural changes employ altered angles and/or gravitational forces to allow safe passage of the bolus and therefore reduce or eliminate aspiration. Chin tuck, chin up, head rotation to the affected side, and tilting of the head to the stronger side are examples of postural techniques (see Table 3.3). Abnormalities of oropharyngeal transit are often overlapping, and rehabilitation of the swallowing mechanism often requires the use of a number of the swallowing maneuvers and postural techniques. Abnormalities of UES opening, which usually present with increased pharyngeal residue and post‐deglutitive aspiration, respond to maneuvers that improve transphincteric transit, and a single approach, e.g. Mendelsohn’s maneuver, Shaker exercise, may suffice.
Cost‐effectiveness
There is data to support the use of swallowing measures [93]. Large, randomized, controlled trials are needed to establish the cost‐effectiveness of these interventions and their method of delivery [94]. For example, a randomized controlled trial found that limited patient and family instruction regarding the use of diet modification and swallowing techniques was just as effective in decreasing the incidence of complications, as was intervention by a therapist to control diet consistency and provide daily rehearsal of compensatory swallowing techniques [95]. For this reason, the frequency of scheduled therapy sessions with healthcare professionals should be re‐evaluated, and increased family participation should be encouraged.
Pharmacologic treatment
To date, no specific pharmacologic treatment is available for enhancement of general oropharyngeal swallowing function. Withdrawal of certain pharmacologic agents, such as antihistamines,