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International Physician Update
| OTOLARYNGOLOGY-HEAD & NECK SURGERY |
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| NOVEMBER 2002 |
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When Swallowing Goes Wrong
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| As the patient swallows, radiologist Bronwyn Jones searches for teh source of her aspiration. |
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It’s an exercise that requires such precise coordination it could be called a mechanical marvel. And yet it all takes place in just a second or two. First, our lips, tongue, teeth and cheeks deftly break up what we’ve put in our mouths, then our throat and esophagus do a little dance to push the chewed-up stuff down to our stomachs.
It’s the act known as swallowing, and only when it misfires (a problem termed dysphagia by the Greeks) do we give much thought to the operation. But, as the physicians at the highly regarded Hopkins Swallowing Center know, much can go wrong. The finely tuned coordination between the mouth, pharynx and esophagus can go off in some hidden way, sending the food down the “wrong pipe” into the lungs. Regurgitation into the pharynx or the nasal cavity is a not uncommon result.
Even more of a problem: such foul-ups can be triggered by structural abnormalities or muscle dysfunctions almost impossible to detect. Endoscopy, with its tiny TV camera inside the esophagus, can actually miss an anomaly that interferes with swallowing. “And just using still X-rays or standard barium-dye studies, you overlook 50 to 75 percent of the patients with real problems,” says gastroenterologist William Ravich, M.D. “These things occur so quickly in the pharynx, it’s critical to have a motion picture evaluation of the entire process.”
That is just what Swallowing Center physicians now use in a technology called video fluoroscopy, which transmits real-time X-rays to video at 30 frames per second. To demonstrate the capabilities of video fluoroscopy, radiologist Bronwyn Jones, M.D., cites the case of a patient she saw recently. The young man had suffered more than 20 episodes of life- threatening aspiration pneumonia, which neither endoscopy nor X-rays could explain. A video fluoroscopy study, however, quickly picked up a tiny, abnormal canal between the esophagus and the trachea—the source of the aspiration.
“You could only see it when you slowed the video down,” Jones explains. With that information in hand, a surgeon repaired the defect, and the young man stopped suffering from pneumonia.
In repairing such defects, otolaryngologists are using less-invasive techniques, too. For example, in Zenker’s Diverticulum, which results in a pouch forming on the back wall of the esophagus, head and neck surgeon Paul Flint, M.D., uses an endoscopic approach through the mouth to remove the sac and allow food to pass freely. In the open surgery through the neck, patients require a drainage tube and several days in the hospital. “Using an endoscope and special instruments, we don’t have to make an incision in the neck,” Flint says. “Patients leave the hospital the next day and resume normal oral feeding within 24 hours.”
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