Fig. 8.1
Intermittent oral self-catheterization. Two locations of the catheter tip are possible depending on the patient’s condition
The recommended feeding speed is usually 150–200 ml/h when placing the catheter tip in the stomach to prevent vomiting [4]. If the catheter tip is placed along the esophageal route, the feeding speed can be higher due to physiological enteric mobility, which is triggered following esophageal peristalsis . The patient should be instructed to intentionally swallow saliva during tube feeding to promote esophageal peristalsis and prevent gastroesophageal regurgitation .
Intermittent oral catheterization can be a method of swallowing treatment. Swallowing is more likely to be triggered with tube than saliva swallowing. Therefore, swallowing the tube at every feeding (three times/day) intermittently provides the increase of swallowing frequency. Additionally, it helps to prevent the decrease of sensation, which is caused by long-term tube placement. The social benefits of intermittent oral catheterization include the aesthetic appearance without tube.
8.1.2 Dental Prostheses
In addition to oral hygiene care , dentists are responsible for prosthetic management of swallowing disorders, i.e., oral prosthodontics. A dental prosthesis is an intraoral prosthesis used to restore (reconstruct) intraoral defects and thus improve morphological swallowing function. It acts as an auxiliary device for treatment of oral functional abnormalities primarily related to postoperative oral cancer, maxillofacial trauma, or neurologic/motor deficits with tongue paralysis. Various types of oral prostheses are designed to improve the oral stage of swallowing, such as the palatal augmentation prosthesis , palatal lift prosthesis , and lingual augmentation prosthesis [5–8]. The advantages of these prostheses include improved chewing , accommodation for bolus formation and control in the mouth , a decreased tongue–palate distance, and increased propulsive pressure for bolus transit . Like other swallowing treatments, the efficacy of prostheses can be determined by VF study, ensuring the best functional outcome.
The palatal augmentation prosthesis is one of the most common oral prostheses used in dysphagic patients with tongue movement disorders caused by postoperative tongue resection due to cancer, amyotrophic lateral sclerosis, stroke , and other conditions (Fig. 8.2). The morphological mechanism of the palatal augmentation prosthesis involves a decrease in the volume of the oral cavity by establishment of a lower palatal vault level; thus, less tongue bulk and motility are required to transport the bolus to the posterior oral cavity, and the tongue–palate contact pressure increases to propel the bolus into the oropharynx . The effectiveness of the palatal augmentation prosthesis for swallowing is provided by the improvement in the tongue pressure and tongue base pressure, which leads to [9–11]:
A shortened oral transit time
A shortened pharyngeal transit time
Facilitation of contact between the base of the tongue and posterior pharyngeal wall
Improved articulation
Fig. 8.2
Palatal augmentation prosthesis : the most common oral prosthesis for enhancing swallowing ability
8.2 Surgical Treatment
Severe dysphagia with intractable aspiration is a life-threatening medical condition. Surgical intervention should be considered if extensive swallowing rehabilitation has failed. At FHUR, otolaryngologists collaborate with a transdisciplinary swallowing team and play a major role in the specific reconstructive surgery performed for such patients: a particular combination of bilateral cricopharyngeal myotomy (or UES myotomy ) and laryngeal suspension.
Various surgical procedures have been described to treat chronic aspiration and recurrent pneumonia in patients with severe dysphagia (e.g., total laryngectomy , laryngeal closure , and laryngeal diversion ) [12, 13]. Most procedures involve the creation of a permanent tracheostoma and result in loss of normal phonation . UES myotomy and laryngeal suspension were alternatively developed for preservation of normal phonation and respiration without a permanent tracheostomy , as described in the next section. The goal of this surgery is to prevent life-threatening aspiration [13–16] with preservation of a functional larynx and facilitation of oral nutrition ; this procedure is not used to normalize the swallowing function (Appendix “UES Myotomy Combined with Laryngeal Suspension”).
Temporary tracheostomy is routinely performed in the postoperative period to protect the airway in case of airway compromise and the need for intubation . A narrower laryngeal entrance caused by laryngeal suspension and/or edema could result in dyspnea . Tracheostomy is also important to ensure the safety of performing swallowing exercises . It is imperative to ensure that the patients and their families understand that several months of postoperative dysphagia rehabilitation is necessary to augment oropharyngeal muscle strengthening and perform exercises for the new swallowing pattern.
The specific postoperative training exercise for the new swallow pattern is a combination of head extension and neck flexion for opening the UES (chin jut ).
Patients must learn to perform this posture performance on the right time when the bolus reaches the pharynx . While giving visual feedback to patients, VE is often utilized to ensure that patients achieve an accurate sense of the degrees and timing of head extension and neck flexion . Simultaneously extending the head and flexing the neck moves the mandible and larynx anterosuperiorly, which consequently opens the esophageal inlet (Fig. 8.3).
