The indirect approach to addressing dysphagia during the pharyngeal stage is useful because it does not pose the risk of aspiration, but indirect training must still be conducted safely by knowing the indications and methods and implementing risk management measures. In this module, we look at the significance of tube swallowing exercises and balloon therapy and methods for performing each.
Explanation
Tube swallowing exercises are designed to improve triggering of the swallowing reflex and the speed and distance of laryngeal elevation by repeated swallowing of a tube. These exercises can also be expected to improve coordination between tongue movements to transport food and swallowing movements. They are indicated for patients who have problems with triggering the swallowing reflex or with coordination of swallowing movements when direct training is not feasible due to high risk of aspiration. Tube swallowing may not be feasible for patients with a strong gag or cough reflex.
Explanation
Insert a feeding tube about 12-16 Fr in size through the mouth. We can sometimes insert the tube through the nose if oral insertion fails due to gagging but use a narrower 12 Fr tube in that case. Once the tip passes the esophageal orifice9 by about 20 cm, the tube is withdrawn and advanced in synchrony with swallowing movements, but it's not withdrawn so far that the tip slips out of the esophageal entrance into the pharynx. When performing tube swallowing exercise to improve transport in the oral stage, position the tube on top of the tongue and instruct patients to propel the tube toward the pharynx with their tongue and swallow. We manually insert the tube in the first session and aim for patients to gradually become able to swallow on their own.
Explanation
If strong gagging occurs when the tube is inserted in the mouth, instruct patients to first lick the tube with their tongue to gradually become accustomed to the stimulus. If they still can't do the exercise, don't force them to do it. Confirming safe insertion of the catheter into the esophagus by videofluoroscopy or videoendoscopy in the first session, and marking the proper length at the corner of the mouth when the catheter tip reaches the esophageal orifice makes it easier to perform this exercise at the bedside. Intermittent tube feeding and balloon dilation produce the same effects.
Explanation
Balloon dilatation (balloon therapy) is a technique for improving transport of the food bolus into the pharynx by mechanical dilatation of the esophageal orifice (upper esophageal sphincter: UES) using a balloon catheter. It is indicated for patients with conditions that cause insufficient opening of the esophageal orifice, such as bulbar palsy or cricopharyngeal dysphagia.
Explanation
Whether balloon therapy is indicated is determined on a patient-to-patient basis during initial videofluoroscopic examination of swallowing. For patients in the acute stage of bulbar palsy, we perform it only after early symptoms such as dizziness and vomiting have resolved. Prerequisites for eligibility are no local inflammation, no external compression of swallowing structures (eg. by a tumor), and good general condition. Other criteria are: (1) UES obstruction (2) lack of improvement with compensatory methods, and (3) tolerance of balloon therapy.
Explanation
Symptoms of pharyngeal stage impairment such as insufficient UES opening, reduced pharyngeal constriction, insufficient laryngeal elevation, and insufficient triggering of the swallowing reflex are identified on videofluoroscopy.
We need to pay particular attention to whether there is retention of bolus in the piriform sinus and the side of pharyngeal transit.
Retention of saliva may be observed on endoscopic evaluation of swallowing, and movement of the vocal cords or arytenoid region and laterality in pharyngeal constriction are also evaluated by endoscopy. Compensatory methods may be effective in patients with pharyngeal retention or laterality in pharyngeal transport. Food is directed to the transiting side by having the patient lie on their side while swallowing or do a one-sided swallow. If these methods do not produce the desired effect, try balloon dilation and evaluate its effectiveness and tolerability. This therapy poses risks of shock and damage to pharyngeal tissue by the vagal response, so the first session should be performed by a physician or with a physician in attendance.
Explanation
We can also insert the tube with patients in a seated position if it is possible, but it is easiest to insert when the bed is reclined in the range of 30-60° to relax their neck. Their neck should be flexed slightly anteriorly, and blood oxygen saturation should be measured using a saturation monitor to watch for changes in respiratory status. Any sputum or saliva retained in the mouth or pharynx is removed by self-clearing or suctioning. Before tube insertion, stimulate the oral cavity to become moistened by ice massage and promote dry swallowing. Moisten the catheter with ice water to allow for smoother insertion.
Explanation
Insert the tube at the left side of the pharynx with patients having turned their face to the right. Insert the catheter diagonally downward from the right side of the mouth aiming for the left side of the pharynx. Once the tip reaches the UES after advancing about 16-18 cm, lightly push the catheter as they swallow to advance it into the esophagus. If they can make sounds, we can confirm whether the catheter has reached the esophagus by asking them to make a sound.
Explanation
In intermittent dilatation using a spherical balloon, insert the tip of the catheter up to the esophagus (about 25 cm), inflate the balloon using about 5 cc of air injected through a syringe, and withdraw the catheter until it meets resistance (positioned at the inferior end of the cricopharyngeal area). After that, temporarily deflate the balloon using the syringe, withdraw the catheter a few millimeters, and then inflate the balloon again until it meets resistance to gradually dilate the cricopharyngeal area. After about 20 s of dilatation, deflate the balloon and withdraw the catheter again 5 mm. Repeat this until the tube is completely removed.
Explanation
This technique allows for dilatation of the esophageal orifice over time by adjusting the balloon diameter. However, the spherical shape of the balloon causes it to slip out of position easily, so we need to become familiar with the technique. Graduated markings on the catheter make slippage less likely. Longer duration of dilatation is necessary in areas with strong resistance.
Explanation
When using the synchronized swallowing/withdrawal technique or the simple withdrawal technique with a spherical balloon, insert the catheter into the esophagus, inflate the balloon with 4 to 5 cc of air, and withdraw the catheter as patient swallows. When withdrawing the catheter, pull it toward the target side of the pharynx, with the neck rotated toward the opposite side. In the simple withdrawal technique, just withdraw the balloon when it is difficult to synchronize withdrawal and swallowing.
This technique is simple and easy for patients to perform by themselves, even for patients with mildly reduced hand function. It helps with laryngeal elevation while also synchronizing the timing of laryngeal elevation and UES opening. However, several repetitions are needed to see any effect if the dilatation time in a single repetition is short. As therapy sessions continue, be sure to check whether the volume of air used is producing sufficient dilatation in order to ensure application of some resistance.
Explanation
In balloon swallowing with a spherical balloon, inflate the balloon with 3 to 4 cc of air before insertion. Insert the catheter through the mouth, and once it hits resistance, instruct patients to swallow while lightly pushing on the catheter. This method poses no risk of aspiration and can be used for swallowing practice, but this is difficult to do unless therapy has progressed to the extent that balloon dilatation is possible.
Explanation
In sustained dilatation using a cylindrical balloon (double balloon, 14 or 16 Fr), insert the catheter up to the esophagus and confirm balloon placement with videofluoroscopy. Then inflate the inner balloon (for stabilization) with about 2 to 3 mL of air and pull up to the area of stricture (UES). In patients with insufficient opening of the esophageal orifice, the balloon is anchored there. Next, inflate the outer balloon (for dilatation) with 10 to 20 mL of air to dilate the area of stricture. This method is commonly used with patients in whom the spherical balloon tends to slip due to high cricopharyngeal resting pressure or who are not seeing sufficient effects with other methods. Cylindrical balloons enable sustained dilatation and slip less often but are more expensive than spherical balloons.
Explanation
A balloon dilation program generally consists of thrice-daily sessions of about 20 min each. Dilation is effective when performed before eating or intermittent oral catheterization because it facilitates pharyngeal transport of food and tube insertion. Method selection varies by patient. The intermittent dilatation and tube withdrawal methods are used for almost all patients, and the swallowing and sustained dilatation methods are used for certain patients. The volume of air used to inflate the spherical balloon should first be set at 4 mL (diameter of about 1.5 cm) and then gradually increased to a maximum of about 10 mL (diameter of 2.3 cm). Dilatation of the side with more severe impairment of transit is prioritized, but both the left and right sides of the cricopharyngeal area are targeted. A physician, speech-language-hearing therapist, or nurse should perform the balloon therapy for a while after starting the program, and they should gradually instruct the patient, a family member, or a caregiver in the technique. When to stop balloon dilation should be determined by the degree of improvement in pharyngeal transport.
References
- Siagusa H: "Direct" "Indirect" swallowing exercise: Swallowing rehabilitation using feeding-tube. JOHNS 101:102-1021, 1998
- Fujitani J: Indirect exercise. Swallowing Handbook for doctors and dentists. Honda T, Mizojiri G Eds. Ishiyaku Publisher, Tokyo, 2000, 116-121.
- Sumiya N et al. Second stage of Dysphagia. Intermittent dilation by balloon catheter. General Rehabilitation 20 (6): 513-516, 1992
- Hojo K et al: Balloon catheter treatment methods for cricopharyngeal dysphagia. The Japanese Journal of Dysphagia Rehabilitation 1:45-56, 1997
- Hojo K, Fujishima I, Ohno T, Uematsu H: Research into the effectiveness how well the balloon dilation method causes the desired outcome for cricopharyngeal dysphagia at the chronic stage in cerebrovascular disease. Japanese Journal of Speech, Language, and Hearing Research 3: 105-115, 2006
- Onogi K et al: Immediate effectiveness of balloon dilation therapy for patients with dysphagia due to cricopharyngeal dysfunction. Jpn J Compr Rehabil Sci 5: 93-96, 2014
