esophageal stricture is nasal regurgitation that occurs after the swallow. This is related to ineffective bolus passage through a narrowed area, with pooling or backflow of material in a retrograde manner through the nasopharynx after the swallow is complete and velopharyngeal closure has relaxed. Strictures are managed medically or surgically by dilating the constricted area. This may need to be repeated multiple times and at regular intervals, because the tissues frequently scar back to their prior position. It is important that patients are counseled to push oral intake after dilations, especially trying denser consistencies to stretch the dilated area. Occasionally, strictures are not amenable to conservative management and require surgical excision with reconstruction. Dietary modifications can be helpful in these cases, including alternating liquids and solids while eating.
Pseudoepiglottis or a pseudodiverticulum may form and be additional complications to efficient swallowing. These abnormal pseudo-structures develop as a result of surgical healing along with scar development. Pseudodiverticulum appears as a pharyngeal pouch, while a pseudoepiglottis develops at the base of tongue area. mimicking the appearance of an epiglottis. Due to lack of muscular presence, a pseudoepiglottis serves as an impediment to bolus passage. Depending on the size and location, these may collect significant amounts of food while the patient is eating. Similar to patients with a Zenker’s diverticulum, individuals will frequently complain of regurgitating undigested food or sensing the material for prolonged periods of time after eating and halitosis (Oursin, Pitzer, Fournier, Bongartz, & Steinbrich, 1999). Because these anatomic structures develop above the level of the pharygoesophageal segment, they also are subject to inadvertent vibration during tracheo-esophageal speech because the airflow may vibrate through the collected material and distort sound production. Management depends on the severity of symptoms produced. For minor complaints, patients may benefit from washing foods through with liquids, changes in head posture as observed on a videofluoroscopy for effectiveness, and increasing the effort of swallowing. More significant problems occasionally are managed surgically.
Pharyngo-esophageal (P-E) problems may present as both swallowing and alaryngeal speech difficulties. Coordination of P-E segment relaxation for the passage of a bolus while swallowing, or in reverse to allow air passage while speaking, is vital. Problems with the UES or P-E segment are suspected when patients evidence transient difficulties with denser consistencies of food. Thickening or prominence arising from the posterior pharyngeal wall can be seen on radiographic study assisting in confirmation of this phenomenon (Crary & Glowasky, 1996). In addition, a potential stricture may be seen, but then be noted to open, demonstrating the transient nature of a spasm. Further diagnostic measures may be employed, including esophageal manometry to measure the various pressures within the esophagus and pharynx during swallowing. Treatment of P-E problems varies depending on the severity of dysphagia experienced. In some minor case, this is only an inconvenience, and patients tolerate occasional difficulties without further intervention. More significant problems can be managed with Botox injections or surgical myotomy. The injection of Botox typically is delivered bilaterally to multiple sites along the pharyngoesophageal area with guidance from an EMG signal. Confirmation of location is made when an active signal reduces during swallowing. In normal subjects, the signal should be very active at rest, as the muscles contract to maintain a closed sphincter, and significantly diminish during swallowing to allow relaxation of the sphincter and bolus passage.
Xerostomia (dryness) is a persistent aggravating problem that many patients experience. Xerostomia can affect lubrication of the bolus, making drier and more crumbly foods difficult to manage (Gaziano, 2002). Xerostomia also may interfere with the reflux barrier and increase symptomatic gastroesophageal reflux disease (Sullivan & Hartig, 2001). Xerostomia typically is the reaction of the mucosa and salivary glands to radiation exposure, reducing fluid production. This, in turn, changes the characteristically thin and watery saliva to scant, thick, and viscous.