Question
Are there any successful dysphagia treatments to address epiglottic dysmotility?
Answer
First for the observed problem. Any speech-language pathologist who does much fluoroscopy has seen the patient with an epiglottis that does not move, or does not move much, during the swallow. I presume that is what our reader is asking about how can we get that epiglottis to move more?
Before we can answer the question, we need to clarify some terms.. The epiglottis is a cartilage, not a muscle, and therefore does not have the power to move on its own. The term 'dysmotility' means inability to move spontaneously, or an impairment in the ability to move spontaneously. The work 'mobile' is nearly like motile, but has a broader definition: it refers to the ability to move or be moved (passively) from one place to another. Thus, if we use a term to refer to the epiglottis that is not moving, we need to talk about its dysmobility or immobility, not dysmotility. Unfortunately, his term is not the best one to describe the problem, either, because it places the blame on the epiglottis, when the problem may be with the ligaments and muscles attached to the epiglottis. During swallowing, the epiglottis is moved passively by the force of muscles that are attached to it -pulling the tip posteriorly so that it assumes a horizontal tilt and bending the tip down (the 'downfolding' motion). The primary attachments at the tip and sides of the epiglottis are to the hyoid bone while the base of the epiglottis, referred to as the petiolus, attaches to the thyroid cartilage ligament. As the hyoid and thyroid cartilage elevate during the swallow, they move the epiglottis to a horizontal and then inverted position, covering the arytenoids and vocal folds. The base of tongue then presses against the lingual surface of the epiglottis, helping to squeeze out the contents of the valleculae.
Sometimes, the epiglottis is to blame for its immobility. In old age, the cartilage can become partly calcified, and then it is not as mobile as it was in its younger days. After radiation therapy, the epiglottis can be edematous or friable and not be as mobile as it used to be. Sometimes, the epiglottis is very mobile, and the muscles are strong, but a cervical oesteophyte impinges into the pharyngeal airspace, making the passage much more narrow. The epiglottis may have difficulty inverting completely in this constricted space. So mechanical or anatomical problems can impede the movement of the epiglottis and it is very important to consider these reasons when viewing incomplete epiglottal movement. In the majority of cases, however, the reason for the reduced epiglottic movement is inadequate hyolaryngeal elevation, with reduced traction and pulley forces exerted on the epiglottis.
In answer to the question about what treatment should be prescribed for an 'immobile epiglottis', we must first determine the cause. If it is an anatomical change, the best treatment may be to find the head and neck position that allows fullest passage of the bolus during swallowing. If the cause is neurologic, then strengthening exercises may be the answer. Two exercises known to promote better hyolaryngeal elevation are Shaker's exercise (1, 2) and the Mendelsohn maneuver (3). If the patient has a neurologic problem such as ALS, however, exercises are contraindicated and postural changes are the best strategy.
A recent article on epiglottic dysfunction is one by Garon BR, Huang Z, Hommeyer S, et al., ''Epiglottic dysfunction: abnormal epiglottic movement patterns''. Dysphagia 17: 57-68, 2002. It has references to many other excellent studies.
Susan E Langmore PhD, CCC-SLP
References
1. Shaker R, Kern M, Ardan E, et al. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. Am J Physiol. 272, G1518-G1522, 1997.
2. Shaker R, Easterling C, Kern M, et al., Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122, 1314-21, 2002.
3. Kahrilas PJ, Logemann JA, Krugler C, Flanagan E. Volitional augmentation of upper esophageal sphincter opening during swallowing. Am J Physiol, 260:G450-G456, 1991.
Susan E. Langmore, PhD., CCC-SLP is currently an Associate Clinical Professor in the Department of Neurology and Otolaryngology at the University of California at San Francisco. She is an ASHA fellow who has vast clinical, research, and administrative experience in various medical settings. Dr. Langmore is best known for her pioneering efforts for the development of the FEES procedure, which uses flexible laryngoscopy to evaluate oropharyngeal dysphagia. This procedure is now one the standard assessment procedures for pharyngeal dysphagia. She has also conducted important research concerning aspiration pneumonia. Dr. Langmore is the author of more than 20 articles on dysphagia and one textbook on this subject. She is a member of the Inaugural Specialty Board in Swallowing and Swallowing Disorders. In her current practice, she primarily sees patients with neurologic disorders, head and neck cancer, and pulmonary dysfunction and she is actively involved with the ALS Clinic and the Memory and Aging Clinic at UCSF.
