Conferencia magistral oropharyngeal disorders: diagnosis and treatment

In summary, the management of oropharyngeal dysphagia often involves a polydisciplinary evaluation, the aims of which are to identify and characterize oropharyngeal dysphagia as well as identify the underlying cause whenever possible. A specific diagnosis of the underlying cause of neurogenic dysphagia is rarely made on the basis of videoradiographic or manometric observations because observed patterns of oral, laryngeal, pharyngeal and cricopharyngeal dysfunction can exist in a range of neurogenic disorders. Finding the underlying cause of oropharyngeal dysphagia often requires the clinical team to think broadly, owing to the wide array of diagnostic possibilities. Special emphasis should be placed on detecting treatable underlying systemic conditions such as thyrotoxicosis, myopathy, myasthenia, and neoplasms. While seeking evidence for a systemic disorder, the second aim of clinical evaluation is to identify surgically (or endoscopically) treatable structural abnormalities. Careful radiographic and/or endoscopic examination of the oropharynx and proximal esophagus is aimed at detecting signs of neoplasm, infection, strictures, or diverticuli, each of which implies a specific therapy. After important etiologic abnormalities have been sought, functional abnormalities of the oropharyngeal swallow should be defined. Characterization of the temporal disruption of the swallow coordination and identification of the underlying mechanism leading to that dysfunction requires a videofluoroscopic or cineradiographic examination. In some instances, especially with suspected UES dysfunction, concurrent use of pharyngeal manometry with videofluoroscopy can allow further delineation of the underlying pathology and direct treatment. From this point onwards, management decisions will be applicable to those patients in whom a structural surgically treatable abnormality has been excluded. When considering further treatment strategies, the clinician must first establish whether institution of non-oral (e.g. gastrostomy) feeding is indicated. This will depend on establishing the likelihood that the patient will be able to sustain adequate nutrition safely via the oral route and on the unproven, but reasonable, premise that non-oral feeding is likely to reduce the risk of aspiration pneumonia. This decision is made in conjunction with the speech language pathologist who can, on the basis of videofluoroscopic analysis of therapeutic maneuvers, estimate the likelihood that such maneuvers will reduce the risks of oral feeding and enhance the efficiency of the swallow. The natural history and prognosis of the underlying cause for dysphagia, as well as the patient's cognitive ability, will also influence the choice between oral and non-oral feeding. Introduction of appropriate dietary modification and specific swallow therapy by the speech language pathologist is appropriate at this point. The choices among therapies will be directed by the videofluoroscopic findings and the individual patient's ability to comprehend and cooperate with the various strategies. This process will frequently involve a subsequent videofluoroscopic examination to assess progress and the advisability of ongoing swallow therapy and ascertain whether alternatives should be considered. The place of cricopharyngeal myotomy, and other procedures such as laryngeal suspension, in this class of patient remains controversial. The clinician can predict an overall response rate from myotomy of around 60%, but, at present, cannot predict the likelihood of response in an individual patient with certainty. Until further well designed studies in clearly defined subsets of patients are conducted, the decision about myotomy will remain empirical after informing the patient of the risk and possible, but unproven, benefit.