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REVIEWS

Therapeutic intervention in
oropharyngeal dysphagia
Rosemary Martino1,2* and Timothy McCulloch3*
Abstract | Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies,
and even considered part of the normal ageing process. Early and accurate identification
provides the opportunity for early implementation of dysphagia treatments. This Review
describes the current state of the evidence related to dysphagia therapies — focusing on
treatments most clinically utilized and of current interest to researchers. Despite successes in
select studies, the level of evidence to support the efficacy of these treatments remains limited.
Heterogeneity exists across studies in both how interventions are administered and how their
therapeutic value is assessed, thereby making it difficult to establish external validation. Future
work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to
account for influences from pre-morbid patient characteristics as these factors have potential to
increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and
psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology
that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or
instrumental assessments, and the existing needs and supports of patients.

This Review discusses the evidence for oropharyngeal sources related to unique therapies within each category.
dysphagia treatments in adult patients regardless of aetio­ Our primary sources herein are published systematic
1
Departments of Speech logy. By definition, high-level evidence includes only reviews — some focused on select patient aetiologies and
Language Pathology, properly conducted systematic reviews and/or original others on particular therapy types. Limitations of avail­
Rehabilitation Sciences randomized controlled trials (RCTs). However, other able high-quality evidence and clinical experience might
Institute, and Otolaryngology- study designs (including cohort or case–control studies preclude meaningful exchange about even commonly per­
Head and Neck Surgery,
University of Toronto,
and occasional case reports) have been used to address formed clinical interventions. However, some therapies are
160–500 University Avenue, the merits of dysphagia management and thus, in our discussed in detail owing to their common use, available
Ontario M5G 1V7, Canada. opinion, have value in understanding the overall thera­ high-quality published evidence and relative importance.
2
Krembil Research peutic benefit of dysphagia interventions. Furthermore,
Institute, University Health
defining a therapeutic benefit needs to go beyond simply Evidence-based medicine
Network, 399 Bathurst Street
(MP 11–331), Toronto, confirming improvement in swallow physiology or a pos­ Early proponents of evidence-based medicine estab­
Ontario M5T 2S8, Canada. itive shift along on a clinical rating scale. Benefit should lished a hierarchy of best evidence that continues to be
3
Division of Otolaryngology- also include supporting a patient’s understanding of their supported1 (FIG. 1). Only a few dysphagia therapy trials
Head and Neck Surgery, swallow limit­ations, providing counselling on risk accept­ are RCTs, which is an unfortunate reality given that cause
Department of Surgery,
School of Medicine and Public
ance within varying management choices and supporting and effect is most accurately shown in a hypothesis-driven
Health, University of patients’ emotional barriers, psychological barriers and randomization study. A nonrandomized experimental
Wisconsin, 600 Highland rehabilitation expectations. Therapeutic value, we sub­ design — even a high-quality observational study — can
Avenue, Madison, mit, needs to be proven both within a controlled clinical at best only show a strong correlation between treatment
Wisconsin 53792, USA.
­environment and within the context of everyday life. and outcome. Fortunately, however, strong correlations
*Both authors contributed Various treatments for oropharyngeal dysphagia have that are collectively reported from several independent
equally to this work.
been introduced and studied over the years. With few and properly run observational studies can in fact provide
Correspondence to R.M. 
exceptions, these available treatments can be categorized convincing evidence for therapeutic value2. Whenever
rosemary.martino@
utoronto.ca into the following themes: compensatory; behavioural possible, this Review highlights evidence from either
exercise; neurostimulation; and surgical. We touch on individ­ual RCTs or series of nonrandomized studies
doi:10.1038/nrgastro.2016.127
Published online 14 Sep 2016; each of these approaches individually, but do not provide with similar objectives to demonstrate the best available
corrected online 27 Sep 2016 a comprehensive systematic evaluation of the primary ­support for dysphagia therapies.

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Key points Compensatory treatments



Compensatory treatments aim to modify the swallow
• Strong supportive evidence of effectiveness is not available for many dysphagia action as it is being executed so as to effectively and
treatments so clinicians need to use best available evidence to support therapy choice efficiently direct the bolus toward the oesophagus, thus
• Unlike compensatory strategies, behavioural exercise therapies offer the opportunity preventing airway entry or residue from remaining in
for long-term, and perhaps even permanent, improvements in the rehabilitation of the oropharynx. Commonly used compensatory strat­
the oropharyngeal swallow egies include postural modifications, such as the chin
• The elements of feedback, education and patient compliance are critical in our design tuck and/or head rotation. By design, these modifica­
of exercise therapies, and made even more so with exercises that patients tions are only effective if they accompany each swallow.
independently execute over time
Considering that an average meal requires several hun­
• Evidence-based practice is only meritorious if it actually benefits both the patients’ dred swallows, patients who depend on such strategies
swallow physiology and health
are at high risk of fatigue, diminished mealtime enjoy­
• Therapy must be tailored to an individual recognizing the person’s disease, limits, ment, and eventually even reduced nutritional intake.
attitudes, support systems and comorbidities
Yet, in our experience, these treatments are prescribed
frequently and can be ingrained into a patient’s swallow
behaviour to ensure a safe swallow.
In addition to study design, this Review also To date, only one high-level RCT has assessed com­
emphasizes the importance of study quality. Experts pensatory therapies (TABLE 1). Specifically, this multi-site
in evidence-­based medicine have clearly demonstrated study compared the benefit of chin tuck versus thickened
that all levels of study design, from RCTs to observa­ liquid to reduce immediate aspiration of thin liquids
tional studies, are equally vulnerable to flawed conduct 3. (as identified on videofluoroscopic examination)9, and
If present, these flaws can seriously threaten a study’s the long-term incidence of pneumonia during a cumula­
internal validity, resulting in an inaccurate estimate of tive 3-month follow‑up period11. Three patient popu­
treatment benefit 4. Reporting guidelines are now avail­ lations were included: patients with Parkinson disease,
able, such as the Consolidated Standards of Reporting patients with dementia, and patients with Parkinson
Trials (CONSORT)5, that offer easy to follow check­ disease and dementia. The first of this two-part study 9
lists for researchers to ensure these essential treatment was initiated in 1989 and in its introduction described
study design details are followed and reported in their the chin tuck strategy as already “commonly used”
published papers. In this narrative review, we use the — a statement demonstrating that clinicians are willing
CONSORT guidelines to present our critique of the dys­ to adopt treatment strategies even without established
phagia treatment literature. Accordingly, we define strong evidence of effectiveness.
strong evidence of treatment efficacy as that derived This study enrolled >700 patients over 7 years, clearly
from studies high in both design and quality. showcasing the enormous efforts that this and other
RCTs require. This study rightly recognized that patients
Treatments with dementia have the greatest opportunity for success
Finding high-level, high-quality evidence to support with a relatively simple therapeutic technique to ensure
clinical practices in dysphagia therapy is difficult. low cognitive burden, such as the chin tuck. The impor­
The earliest systematic reviews of dysphagia treat­ tance of aligning the therapy to the patient in this way
ments were published between 2008–2009, targeting should not be underemphasized, as the value of any clin­
dysphagia second­ary to neurological causes6,7, head ical intervention only exists when it can easily integrate
and neck ­cancer 8 and mixed aetiologies9. One such into a patient’s life beyond the clinic setting. In the end,
review addressing the available evidence for com­ the chin tuck posture was not identified in this study
pensatory treatments noted that only two published as the best strategy for aspiration prevention. Instead,
articles addressed these treatments under controlled the thickened liquid consistency (for example, honey
conditions, and all other studies were case series 7. was better than nectar) proved a more effective therapy
In that review, the evidence for dysphagia treatment for airway safety 9. Interestingly, patients themselves pre­
was declared to be in its infancy. A flurry of system­ ferred the chin tuck posture to either of the thickened
atic reviews have also sought to update this evidence, liquids — an important finding as therapeutic benefit for
and sadly they too have reached this same conclusion. long-term outcomes such as pulmonary or nutritional
Despite herculean efforts to find value, research on dys­ health can only be actualized if there is uptake by patients
phagia therapy remains at an impasse. We draw from in their everyday practice.
these published reviews and select original papers to The use of the chin tuck has gained support from
discuss the best available evidence and suggest ways in basic research where it has been shown to change
which we need to redirect our research efforts. Even ­anatomic structural orientations around the larynx,
in the face of limited evidence, Speyer et al. concluded primar­ily narrowing the angle between the epiglottis and
that the literature supports the observation that most the anterior tracheal wall and the width of the airway
interventions have a positive therapy outcome10. We entrance12. The posture does not seem to substantially
would agree that the collective intelligence and integ­ change pressure events during the swallow 13,14.
rity of clinicians who provide care for patients with The second part of the RCT compared the long-
dysphagia is guided by many positive experiences term benefit to pulmonary health after 3 months of
with their treatments. either the chin tuck posture or fluid intake restricted to

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only thickened liquids11. Across all patients, the overall


incidence of pneumonia was ~10% regardless of thera­ 1 SR Highest
peutic arm, which is lower than the anticipated 40% for
this patient cohort 15. By the 3‑month mark, no single RCT
2
intervention could be identified as superior. However,
Cohort study
the secondary outcomes of dehydration and urinary
tract infections were more frequent in patients treated 3
Case control
with thickened liquids. These findings emphasize the
importance of careful surveillance of study partici­ 4
Case series
pants, as well as patients in clinics, as interventions
designed to improve one outcome can unintentionally 5 Opinion of experts Lowest
worsen another.
This extensive multi-site longitudinal RCT empha­ Mechanistic or physiological plausibility
sizes the difficultly in answering even the simple clin­
ical question of therapeutic value for one compensatory Figure 1 | Level of evidence pyramid for evidence-based
Nature Reviews | Gastroenterology & Hepatology
technique. Understanding that at this time the chin tuck medicine. At the top of this hierarchical pyramid are
systematic reviews (SR) of homogenous randomized
is the only isolated compensatory strategy assessed over
controlled trials (RCT). Next in line are individual
time using rigorous high-level evidence, clinicians are high-quality RCTs or nonrandomized experimental studies
required to use judgments based on case series (level 4) with dramatic effects, followed by single nonrandomized
evidence to determine the potential value of other com­ controlled cohort or longitudinal studies. Further down
pensatory techniques with little to no knowledge about this evidence hierarchy are case–control and case series
any possible collateral harmful effects. or historically controlled studies. Finally, at the bottom
Unlike the chin tuck posture, head rotation affects are studies of mechanism or physiological plausibility.
pharyngeal swallowing pressures by raising pressure
toward the rotation and diminishing pressure opposite
the rotation14,16. The rotation also affects upper oesoph­ without accompanying food. Clearly, current behavioural
ageal sphincter (UES) function by diminishing resting ­therapies align with the principles of neuroplasticity 20.
pressure and opening pressure, and producing a delay Behavioural exercises target different physiological
in closure, with the effect of directing the bolus away effects depending on the aetiology causing the dyspha­
from the direction of rotation. A preliminary clinical gia. For example, in patients with stable or ameliorating
article evaluating head rotation in patients with lateral aetiologies, such as stroke or trauma, the therapeutic
medullary syndrome identified this population as a goal is early and complete recovery of range, strength
potential patient subgroup who could benefit from this and timing of physiological movements. However, for
­manoeuvre, especially those with unilateral pharyngeal patients with aetiologies that are progressive, such as
weakness and UES opening impairment 17. Parkinson disease, the goal is instead to maintain the
In their practice, clinicians often use a combination current swallow status for longer than would have
of simple interventions such as head postures (chin tuck other­wise been possible. We suggest that these are crit­
and head rotations) with thickened liquids to address ical aspects to consider when evaluating benefit from
aspiration risk as assessed by contrast barium swallow. behavioural therapies.
In most cases, the recommendation is made after evalu­
ating the effect of single or combined interventions on Therapies with food. The behavioural therapies that clin­
one or two viewed swallows. Even without a large body icians commonly administer with food include effortful
of literature to support these individual recommenda­ swallow and supraglottic swallow. Both are designed to
tions, there is merit supporting the direct clinical obser­ facilitate efficient propulsion of the bolus, with the added
vation of improvement. Maintaining an oral diet is benefit of a safe airway. In addition, the super-­supraglottic
critical to the psychological well-being of most patients. and Mendelsohn strategies aim to maximize airway
protection during swallowing 6,12. Studies in this area
Behavioural exercise and retraining are sorely lacking and, of those available, no high-level
Unlike postural therapies or modifications in diet, evidence exists for gains in swallow ability with thera­
behavioural exercise therapies might have other bene­ pies that include food (TABLE 1). One randomized study
fits such as the opportunity for long-term change in assessed the value of the Mendelsohn manoeuvre during
the central control of swallow via neuroplasticity. These food intake, but was not sufficiently powered to identify
therapies specific­ally target motor rehabilitation of the benefit (only 18 patients with stroke were included in
oropharyngeal swallow. The physiology of a normal the study)21. The only other available evidence is limited
swallow is a complex series of rapid movements execu­ by case series design22,23, assessment in individuals with
ted by >30 ­muscles18 and requires exact coordination unimpaired swallows24, or following complex therapeutic
with respir­atory and phonatory systems19. Behavioural programs tested only in observational studies that are not
therapies are designed to target these movements either easily reproduced25,26. Given the conceptual backing from
in isolation or in combination. Unlike compensa­ principles of neuroplasticity, we make a call for future
tory strategies that by definition are applied with food research to assess the value of exercise therapies executed
intake, behavioural therapies can be executed with or during food intake activities.

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In the past 5  years alone, studies from North these patients often succumb, not to their disease, but
America27–29, the UK30–32, Europe33,34 and globally 35 have to aspir­ation pneumo­nia related to dysphagia15. Yet, the
systematically searched the literature for therapeutic overall conclusion from these comprehensive systematic
value of behavioural exercises. The focus has mainly reviews is discouraging. Their collective findings iden­
been on two aetiologies — head and neck cancer and tify no high-level or high-quality evidence to support
Parkinson disease. In the head and neck cancer popu­ clinically relevant b
­ enefit to swallow physiology from
lation, this interest is spurred by increasing awareness behavioural exercises.
of collateral damage to the swallow mechanism from Despite the current lack of evidence, some findings
well-intentioned cancer treatments, including both sur­ give promise for the future. For example, although bene­
gical ablation36 and organ-sparing treatments of radi­ fits from device-guided jaw opening resistance exercises
ation and/or chemo­radiation therapy, affecting many have been inconsistent 39–41, findings from a better-­
patients acutely 37 and even years later 38. In the Parkinson powered randomized study identified patient compli­
disease population, there is even more urgency because ance as a potential confounder 41. In this study, patients

Table 1 | Compensatory, behavioural and neurostimulation therapies for oropharyngeal dysphagia


Intervention Level of evidence Intended therapeutic value Refs
Compensatory treatment
Bolus volume Case series Increase intraoral sensory awareness of the bolus to facilitate 137
bolus clearance
Chin tuck RCTs and case series Widens the valleculae and narrows the aditus laryngis, reducing 9,11,138,139
penetration depth into the larynx and trachea
Head rotation Case series Redirects the bolus to the contralateral unimpaired pyriform sinus 17
Supraglottic Case series Coordinates respiration with the swallow such that swallowing 23,140
occurs in the early expiratory phase
Combination of above Case series and Any or all of the above 6–8,10,12,31,
systematic reviews 141–145
Behavioural exercise and retraining
Tongue exercises RCTs and case series Increase lingual strength and/or range of movement 146,147
Effortful swallow Case series Increase lingual driving pressures 148
Masako (tongue-hold) Mechanism Strengthen the posterior pharyngeal wall 24
Jaw exercises RCTs and case series Increase mandibular range and/or strength during mastication 39–41,149–156
Super-supraglottic Case series Prolong and increase force of laryngeal adduction 23
Mendelsohn RCTs and systematic Strengthen supra-hyoid muscles via prolonged laryngeal 6,21,28
reviews elevation and laryngeal adduction
Shaker head lift RCTs Strengthen anterior neck muscles thereby increase opening of UES 46,157
Expiratory muscle strength training RCTs, case series and Strengthen expiratory and suprahyoid muscles 34,45,158
(EMST) systematic reviews
Lee Silverman voice treatment (LVST) Case series Strengthen laryngeal adduction via controlled increased vocal 159
intensity
McNeill Protocol (combination of Case–control and See effortful swallow above 25,26
effortful swallow, bolus modifications, case series
biofeedback, stimulation)
Biofeedback RCTs and case series Sensory motor re‑education 44,160–164
Combination of at least two of the RCTs, case series and Any or all of the above 8,10,12,22,23,27,
above (with or without compensatory systematic reviews 31–33,35,47–53,
and/or texture interventions) 141,165–168
Neurostimulation
Peripheral electrical RCTs, case series and Neural swallow pathway 27,28,34,58,61,
systematic reviews 62,169–178
Peripheral electrical combined with RCTs, case series and Neural swallow pathway 27,31,179–185
exercises systematic reviews
Peripheral nonelectrical RCTs, case series and Neural swallow pathway 7,34,174,170,
systematic reviews 186–191
Central RCTs and systematic Neural swallow pathway 60,192–198
reviews
RCT, randomized controlled trial; UES, upper oesophageal sphincter.

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who reported more home practice were also those with therapies  (P <0.003). The evidence from this one
the greatest gain regardless of assistive device. Similarly, well-conducted RCT in patients with acute stroke sup­
other work focused on suprahyoid42 and respiratory 43 ports the therapeutic value of individualized swallowing
exercises report a benefit when patients are provided protocols with intensive surveillance. The limitation of
with biofeedback to their exercise movements. Another this study is its generalization to the clinical setting as
study has shown improved physiological gains in patients the individualized protocol is challenging to replicate.
who received education about their swallow 44. These Furthermore, it is difficult to disambiguate the complex
findings suggest that feedback and/or education might protocol to identify the responsible therapeutic variable
have a potentiation effect to improve patient compliance that caused the positive outcome. Although mixed ther­
when combined with exercise therapies. At the very least, apy protocols are well intended and firmly grounded to
patients who can track their efforts during exercise will the impaired mechanism, establishing their therapeutic
probably be more engaged. The elements of feedback, value with external validation in the clinical setting is
education and compliance, we posit, are critical in the near impossible.
design of exercise therapies. Their role is even more Likewise, RCTs of mixed behavioural treatment
important when the exercises are independently executed protocols in patients with head and neck cancer pres­
over time and without clinical supervision. ent with the same limitation. Specifically, three studies
assessed the benefit of a series of oral and laryngeal exer­
Therapies without food. Having no reliance on food cises administered during 49,50 or after 51 chemoradiation
eliminates the risk of aspiration, enabling more active therapy. Depending on the timing of these exercises,
engagement of the muscles involved in respiration45 and their purpose was either to maintain muscle function or
the supralaryngeal area46. This advantage is of course restore it to premorbid levels. All three trials reported
tempered by the opinion of those who remain uncer­ benefit from behavioural exercises. Their protocols
tain, as previously mentioned, that gain following iso­ included a mixed series of exercises and thus were not
lated exercises will generalize to effective physiological designed to identify the most effective exercise. Similar
improvements during everyday consumption of food to the studies in stroke, the heterogeneity of these exercise
and liquid. Collective evidence to date does not disprove protocols makes them difficult to replicate.
these naysayers. Beyond being difficult to reproduce, the available
evidence for mixed exercise protocols is further limited
Mixed protocols with or without food. In contrast to the by poor outcome selection. This factor is well demon­
few high-level studies focused on individual behavioural strated in two nonrandomized dysphagia studies52,53 that
therapies, several high-level studies have used combin­ assessed quality of life in patients with head and neck
ations of behavioural therapies — some with food47,48 cancer receiving mixed behavioural therapies versus no
and others without 49–51. therapy (as was standard in their facility). The authors
The most notable early RCTs that assessed the bene­ report a statistically significant improvement in quality
fit of behavioural dysphagia therapy were those with the of life scores in the experimental arm versus the control
stroke population — one in the rehabilitation setting 48 arm following even 2 weeks of therapy (P <0.0002 and
and the other in the acute setting 47 (TABLE 1). Both stud­ P <0.01). However, despite laudable efforts to select a
ies targeted a mixed therapeutic approach including a psycho­metrically sound tool (in both studies the MDADI
combination of behavioural exercises, compensatory (MD Anderson Dysphagia Inventory) was used)54, qual­
strategies and texture modifications, all customized to ity of life alone is not an accurate measure of physiologi­
the individual physiological impairment of each study cal swallow improvement. Research in patients who have
participant. Thus, the experimental variable for these dysphagia secondary to cancer 55, and even other aetiolo­
RCTs was not the therapies themselves but instead the gies56, has shown that patients’ self-reporting of swallow
number of patient visits that the treating clinician made impairment is grossly under-reported. Furthermore,
to monitor, adjust and reinforce the customized thera­ gains in quality of life, unless properly controlled with a
pies. Participants in the control arm received speech and sham group or equivalent, are vulnerable to response bias
language pathology visits as needed (typical of standard (also known as the placebo effect), which if present will
care) and those in the experimental arms received sched­ overestimate any finding of treatment benefit5.
uled visits according to a pre-set time (for example, daily In summary, in this section we have highlighted sev­
versus weekly). The important health outcomes of mor­ eral limitations to the current evidence for behavioural
tality and pneumonia were assessed in both studies and dysphagia therapies. The main weaknesses of this body
provide opportunity for comparison. of work relate to the following: insufficient sample sizes;
The rehabilitation trial reported no deaths and few combinations of therapies that cannot be easily replicated;
pneumonia events with no difference across arms. not accounting for patient compliance; and selection of
Unfortunately, this study was underpowered to detect outcomes that do not comprehensively and meaning­
differences in health status from varying treatment fully measure benefit. We urge researchers to consider
intensities. The acute trial, on the other hand, was larger these points in their designs of future work to avoid these
and more robust 47. It reported a statistically signifi­ same pitfalls.
cant increase in chest infections in patients receiving Given that the evidence is not yet established, we
the lowest intensity therapy (usual care) compared urge clinicians who continue to prescribe behavioural
with patients receiving either of the more intensive exercises to do so responsibly. To maximize their benefit,

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clinicians will need to maintain frequent contact, prov­ for NMES therapy is still not well defined. In addition,
ide education, ensure adherence to treatment plans and an RCT utilizing NMES therapy combined with a stand­
adjust those plans according to changing swallow status ard traditional therapy in patients with head and neck
and patient needs. Patients need to understand that due cancer with post-treatment dysphagia failed to identify
to uncertainty with the evidence, these active therapies any added value with the addition of NMES63. Future
are suggested based on physiological and mechanistic research will need to identify which patient variables
logic and hence might or might not produce a benefit to show a positive response to NMES therapy so that it can
their swallow. Not explaining this factor to patients can be ­appropriately utilized with the most suited patients64.
give them false hope or, even worse, a sense of failure if A meta-analysis by Scutt et al.62 showed that patients
despite their ardent commitment to these therapeutic with stroke receiving PES had marked gains in swal­
protocols they are left with no gains. Informed decision-­ low function and safety compared to similar patients
making is a basic right for patients with dysphagia that with either sham or reduced stimulation intensity.
clinicians are obligated to provide. Although not statistically significant, patients in the PES
­experimental arm also had reduced length of hospital stay.
Neurostimulation Pisegna and colleagues60 assessed the benefits from
Neurostimulation therapies administer sensory stimuli to central stimuli, namely rTMS and tDCS, in patients with
effect lasting changes in target neural networks. Specific stroke. Their findings identified no clear difference in
to swallowing, stimuli are delivered in one of three ways: efficacy between these central stimuli techniques, but
peripherally to various oral and pharyngeal structures, do suggest that excitatory stimulation is most effective
centrally to the brain, or by pairing both peripheral and when applied to the unaffected hemisphere. They pro­
central stimuli. To date, peripheral swallowing stimuli pose that, given the bilateral representation of swallow­
have been one of the following: electrical — applied ing, the neuroplasticity of the unaffected hemisphere
directly on the anterior neck and suprahyoid area (known has the greatest potential to facilitate swallow recovery.
as neuromuscular electrical stimulation or NMES) or on Their findings also suggest, albeit with less convinc­
the pharyngeal mucosa (known as pharyngeal electrical ing evidence, that inhibitory stimuli to the unaffected
stimulation or PES); tactile — cold touch or air-puffs hemi­sphere might improve the swallow. They suggest
directed to the oropharynx; or gustatory — delivered this downregulation of the unaffected hemisphere might
with boluses of varying tastes and temperatures. Central decrease transcallosal inhibition to the affected hemi­
stimuli targeting swallowing have included repetitive sphere and, therefore, enable neuroplastic recovery of
transcranial magnetic stimulation (rTMS) or transcranial the affected hemisphere. Future research will need to
direct current stimulation (tDCS). validate this differential hemispheric advantage and
Conceptually, these therapies are based on the same determine whether it is excitatory or inhibitory stimuli
principles of neuroplasticity that are the foundation for that produce the greatest benefit to swallow recovery.
behavioural therapies. However, unlike behavioural Many clinicians consider neurostimulation to be
therapies that require patients to actively execute a ‘noninvasive’; however, because it targets the nervous
motor response, these sensory stimuli are administered system we are in support of those who suggest a caution­
passively 57. Considering that aetiologies that cause dys­ ary approach60. In our opinion, clinical implementation
phagia often affect cognition, this feature gives neuro­ needs to await findings from future trials showing that
stimulation therapies an important advantage over the benefits of neurostimulation therapies outweigh any
behavioural therapies. possible adverse effects.
Although based on sound theoretical backing, neuro­
stimulation therapies have not yet become part of main­ Surgical management
stream clinical practice. High-level evidence supporting Evidence for the surgical management of dysphagia is
and guiding their uptake is currently lacking. As noted at best supported by case series reports, strengthened by
in systematic reviews31,58–62, this line of research has sev­ systematic reviews that combine their findings (TABLE 2).
eral small-scale trials conducted by independent inter­ To date, no studies have compared alternative forms of
national groups. However, even studies with similar surgical treatments, or surgery versus a behavioural treat­
neurostimulation techniques do not apply them with ment and/or control group. Surgical interventions for the
the same dosage, or measure their benefit with the same most part target a single swallow-related problem. This
targeted swallow­ing outcomes59. Despite these varying approach enables analysis of benefit to the swallow with
study designs, meta-analyses have been conducted for the even pre or post case series designs. According to the
three most studied neurostimulation therapies: NMES61, Strengthening the Reporting of Observational Studies in
PES62 and central brain stimulation60. These analyses, Epidemiology (STROBE) guidelines65, bias can be sub­
although clearly breaching requirements to pool data, stantially reduced in these observational studies provided
offer i­ mportant considerations for future research. researchers declare confounding patient variables and
Tan and colleagues61 identify that NMES seems to be capture outcomes using psychometrically sound proto­
most effective when combined with behavioural thera­ cols. Although limited by design, surgical case studies
pies, and overall is least effective in patients with stroke. targeting swallowing management provide a valuable
From this finding, the speculation is that NMES has the contribution to the body of evidence related to therapeu­
potential to ‘boost’ gains from behavioural therapies in tic benefit. To date, surgical management of dysphagia in
select patients but not others. However, patient selection adults has focused mainly on the UES and larynx.

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Table 2 | Surgical interventions for oropharyngeal dysphagia


Surgical intervention Level of evidence Intended therapeutic value Refs
Cricopharyngeal myotomy Case series, Improve bolus flow and eliminate UES outlet 67,74,76,
systematic reviews obstruction 77,79,81
Cricopharyngeal botulinum Case series, Improve bolus flow and eliminate UES outlet 83,85,
toxin injection systematic reviews obstruction 86,199
UES dilatation Case series, Improve bolus flow and eliminate UES outlet 88,89
systematic reviews obstruction
Vocal fold medialization Case series, Improve glottic closure during swallow 103,107,
systematic reviews 109–111
Endoscopic Zenker repair Case series, Improve bolus flow, eliminate UES outlet obstruction 90,95–99,
systematic reviews and bolus retention in diverticulum pouch 102
Transcervical Zenker repair Case series, Improve bolus flow, eliminate UES outlet obstruction 95,97
systematic reviews and bolus retention in diverticulum pouch
Laryngeal suspension Case series Protect the airway and decrease chronic aspiration 80,116–119
Tracheoesophageal diversion Case series Prevent aspiration 124,126
Laryngectomy Case series Prevent aspiration 125
UES, upper oesophageal sphincter.

Surgical management of the UES toxin might only address a minor portion of the over­
Many patients with dysphagia begin their work‑up all pathophysiology 73. These patients are numerous and
with videofluoroscopy that reveals incomplete opening their clinical histories diverse; thus, the clinical care plan
of the UES segment, a cricopharyngeal bar, or residual requires a detailed analysis of the individual patient’s his­
contrast in the pharynx after the swallow (FIG. 2). The tory, diagnostic studies, disease state and expected clin­
presence of a cricopharyngeal impression on swallow ical trajectory. Applying the same surgical management
study is not evidence of pharyngeal dysfunction, as the approach to the entire patient group is not appropriate
relationship between UES activity, the pharynx and the and predicting the added value of a surgical intervention
oesophagus are equally as important66–68. The finding of a is very difficult.
cricopharyngeal bar in a patient with dysphagia raises the Evidence for the effectiveness of cricopharyngeal sur­
therapeutic question of whether an intervention directed gical interventions in clinic populations was reviewed in
at this radiologic manifestation of dysphagia is w
­ arranted. 2016 by Kocdor et al.74 This systematic review included
Factors that might be important when electing to inter­ 32 articles, including articles on botulinum toxin injec­
vene with surgery at the level of the cricopharyngeus tions without myotomy, and dilation procedures without
include the extent of the apparent obstruction, the known myotomy. Success rates were similar across treatments
disease state most likely producing the failed relaxation, (69% for botulinum toxin injection, 73% for dilation and
and the state of the pharynx and oral cavity, as adequate 78% for myotomy)74. In general, complication rates were
pharyngeal clearance pressure is a predictor of a successful low in all groups (<7%). The myotomy group did show
clinical outcome after myotomy 66,69. the highest rate of complications, but when comparing
The management of cricopharyngeal dysfunction an endoscopic myotomy to the standard open neck
without Zenker’s diverticulum is controversial. Treatment approach, it seems that the complication rates can be
options include myotomy, dilatation and chemical decreased to 2% without affecting treatment success, as
denerv­ation with botulinum toxin. Determining the this subset of patients has a patient-weighted average of
source of pathology is difficult, particularly when a prom­ success 84% of the time74.
inent ‘non-relaxing’ cricopharyngeal bar with associated
pharyn­geal residue is identified on videofluoroscopy. The UES dysfunction and cricopharyngeal myotomy.
critical issue to address is whether there is inadequate Several diagnostic tools are available for swallow special­
bolus propulsion due to tongue and pharyngeal weak­ ists to distinguish UES dysfunction from other causes of
ness, or increased resistance due to failed UES relaxation dysphagia, including videofluoroscopic swallow studies,
in the face of normal tongue and pharyngeal muscular standard pharyngeal manometry, and high-resolution
activity. Complete opening of the UES is more compli­ pharyngeal manometry. To date, most prior studies have
cated than simple quiescence of baseline cricopharyngeal only used videofluoroscopy to compare pretreatment
muscle activity. Sufficient opening can depend on hyo­ and post-treatment swallow function and have also
laryngeal elevation, bolus propulsion forces, pharyngeal focused primarily on changes following cricopharyngeal
clearance forces and low surface resistance70–72. myotomy. Conclusions gathered via videofluoroscopy
The diverse aetiologies leading to UES dysfunction suggest that myotomy improves pharyngeal constriction
are usually coupled with pharyngeal or oesophageal and pharyngoesophageal sphincter opening, but does
pathology that complicates management. Treating the not substantially reduce stasis or aspiration68,75. These
UES directly with dilatation, myotomy, or botulinum findings were thought to be due to persistent pharyngeal

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a b due to iatrogenic nerve injury 77,79. The manometric


findings of impaired UES opening and the absence of
a discernible underlying cause appeared to best predict
success of myotomy in the Mason et al. study 79. However,
this study did exclude patients with severe pharyngeal
motility dysfunction on manometry. Myotomy is less
reliable in patients after stroke and with myopathic dis­
ease, which can not only impact UES relaxation but also
affect opening due to weakened hyolaryngeal elevation
and pharyngeal bolus propulsion. Myotomy might also
fail in patients treated with radiation therapy owing to
similar issues caused by fibrosis and muscle weakness77.
The choice of which patients should undergo myo­
tomy will always be a complex clinical decision, as there
are risks to the procedure and in many cases a pos­
Figure 2 | Barium contrast image of a cricopharyngeal bar. a | Before treatment. itive outcome cannot be assured. This threat should be
Nature Reviews | Gastroenterology & Hepatology
b | After dilation and botulinum toxin injection. weighed against the risk the patient is left with if ­swallow
does not improve. Many patients require substantial
diet modifications and have penetration and/or aspir­
weakness that is not addressed with a myo­tomy. St Guily ation on swallowing evaluation before under­going myo­
et al.76 reported that myotomy was success­ful when tomy 79 — a successful intervention markedly improves
standard manometry revealed normal and even dimin­ this situation80. Myotomy might even improve swallow
ished pressure, but failed in the aperistaltic pharynx. function and quality of life during certain stages of
However, some evidence suggests that patients might amyotrophic lateral sclerosis81,82. Regardless of the dis­
find benefit even in the face of weak constrictor activ­ ease state, patients often endorse easier swallowing after
ity 77. Data from a case series with healthy controls using UES interventions even when objective data are lack­
standard pharyngeal manometry and videofluoroscopy ing. Notably, in almost all cases, patients have received
identified changes in intrabolus pressures after myo­ ­combined surgical and nonsurgical therapy.
tomy, indicating improved bolus flow, at least in patients
with intact bolus driving forces67. The authors report that UES dysfunction and botulinum toxin injection. The
the measurement of intrabolus pressures with mano­ first use of botulinum toxin for UES dysfunction was
metry should be able to identify patients who could reported by Schneider et al. in 1994 (REF. 83). The use of
benefit from myotomy and/or dilatation67. However, the botulinum toxin is often described as chemical myotomy
data remain limited with regard to objective measure­ and is effective at producing weakness in the targeted
ments of pharyngeal and UES pressure abnormalities muscle. Because the UES is a complex fibromuscular
that would warrant a UES intervention. In addition, system that can develop increased muscle tone, appro­
no manometric guidelines exist to quantify successful priately placed and dosed botulinum toxin will decrease
surgical management of UES dysfunction. There are no the symptoms of, and risks associated with, incomplete
studies using pharyngeal high-resolution manometry UES opening 84. Most cases of dysphagia are multi­
as a complement to videofluoroscopy in the analysis factorial and the specific contribution of the UES is often
of surgical interventions in general. In 2002, Bammer questionable. UES relaxation and opening rely on several
et al. suggested that the use of a gradient pressure across factors — botulinum toxin addresses only the abnormal
the UES would be the best single pressure measure to muscular activity within the UES; unlike with myotomy
identify patients who would benefit from myotomy 78. and dilatation, inflammation and fibrosis within the
However, no clinical data support this hypothesis. UES are not affected by this treatment. Documenting
No standard exists for measuring a surgically success­ the ­status of vocal fold motion and pharyngeal strength
ful outcome. Almost all studies rely on a patient symptom is also important as poorly directed injections and dif­
report, augmented by diet choices and changes in aspir­ fusion of botulinum toxin can lead to laryngeal paralysis
ation patterns on videofluoroscopy to create a composite and pharyngeal weakness85.
measure in order to stratify patient outcomes as successes The ideal patient for botulinum toxin injection is
or failures75,78. Manometry does enable measurement of similar to that described by Kelly 66 for cricopharyngeal
UES baseline pressures, which after a successful myo­ myotomy. The patient should have adequate hyolaryn­
tomy will drop to near zero indicating complete surgi­ geal elevation and tongue and/or pharyngeal propulsion.
cal disruption of the UES contractile force77. Identifying The patient should also be medically and neurologically
the patient population that will or will not benefit from stable, or improving. Additionally, the UES dysfunction
myotomy remains unresolved. In the review by Kocdor should be myogenic at its root cause with no or limited
et al. looking at standard clinical practice, it seems that fibrosis or connective tissue changes, such as fatty infil­
most patients selected for surgery receive some benefit 74. tration or inflammation. Including a dilation procedure
Certain groups seem to have an increased probability of with the injection can be useful as many patients will
benefit, including patients with idiopathic cause, patients have a fibrotic component within the UES connective
with myogenic disease and patients with UES dysfunction tissue along with failure of muscle fibre relaxation.

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The temporary nature of botulinum toxin has value in to the mucosa, thus an external approach will fail to
patients with high probability of spontaneous improve­ address the primary issue unless the area is completely
ment, and as an intervention when the role of UES dys­ opened and repaired. In a report by Agarwalla et al.87,
function is questionable, as it has been shown to be an the mean number of dilations for a radiation-induced
effective treatment with no major adverse effects for stricture was three, although some required up to eight
patients with isolated UES dysfunction and in patients with patency defined as a 14 mm lumen. Using this serial
with complex dysphagia associated with bolus retention dilatation technique the clinical success rate was 83%87.
and aspiration83,86. Mechanical dilation can be completed under s­ edation
Injection methods include electromyography-­ with balloon dilators, or with serial tapered bougie dila­
guided transcutaneous injection, transoral flexible tors using a wire guide or direct visualization88. The use of
oesophagoscopy-­guided transmucosal injection, and two balloon dilators at the level of the UES was reported
rigid oesophagoscopy-guided direct injection83. The as an attempt to improve dilation outcomes and account
botulinum toxin dose in the literature also varies widely, for the kidney shape of the UES89. However, e­ vidence that
from 5 to 100 units75,82. The most common technique is this approach improved o ­ utcomes is limited.
a transoral approach with a direct view of the abnor­
mal cricopharyngeal muscle bar. Direct visualization Surgical management of Zenker diverticulum
enables precision with the injection and the opportu­ Zenker diverticulum is a surgically managed dis­order, with
nity to perform either a balloon or semi-rigid serial strong support in the literature that all cases be directed
dilatation. This method is our preferred technique as it to surgical care as the first line of treatment 90,91. Zenker
enables precise injection into the muscle and an oppor­ diverticulum is a pharyngeal outpouching ­superior and
tunity to evaluate the surrounding tissues for mucosal posterior to the cricopharyngeus muscle, within a weak­
scar bands and fibrosis within the muscle or soft tissues. ness at the inferior border of the ­inferior pharyn­geal con­
In the systematic review by Kocdor et al.74, twelve ­articles strictor muscle in an area known as Killian’s ­triangle. The
containing 148 patients were reviewed noting a 69% cricopharyngeus ­muscle is the primary ­muscle implicated
patient-weighted success rate, with a complication rate in the formation of Zenker ­diverticulum and the key to
of only 4%74. This success rate for botulinum toxin was successful surgical intervention.
less than for myotomy (78%), but no study performed a Abnormal cricopharyngeal relaxation coupled with
direct comparison. Botulinum toxin could be offered to a natural weakness inferior to the pharyngeal constric­
patients who might be concerned about risks of an open tor muscles and secondarily elevated swallow pressures
procedure or as a test to determine if weakening the is believed to produce this diverticulum and its symp­
UES would improve swallow before myotomy. Success toms. The diverticulum develops slowly over several
of botu­linum toxin often leads to myotomy in patients years as repeated swallows dilate the non-muscular sac
seeking permanent benefit 82. owing to the elevated bolus pressures above an incom­
pletely relaxed UES92. The average age of diagnosis is
UES dysfunction and mechanical dilation. Mechanical ~70 years and it is rarely seen <50 years93. Manometric
dilation seems to have a success rate (73%) somewhere studies have shown that, with ageing, bolus transit time
between that for myotomy and botulinum toxin 74. increases, the normal UES pressure drop is delayed, and
Dilation of the UES might be most useful in patients the minimum UES opening pressure increases to a sub­
with known fibrosis within the region, which is most stantial positive value94. Increased fibro-adipose tissue
commonly found after radiation therapy but would also replacement and fibre degeneration in the cricopharyn­
include patients with traumatic injury or peptic stric­ geus of patients with Zenker diverticulum suggests that
ture. Although this procedure often requires repetition, structural changes in the muscle contribute to its failed
it does reduce the risk associated with attempting an complete relaxation69.
open neck operation on a patient following radiation. Although many patients do not aspirate, lose weight,
Stricture, in nearly all cases, is isolated to or extends or substantially modify their diet until the diverticulum
reaches a moderate size, the pathology is already present
and not reversible without surgical intervention. Early
a b intervention prevents the late effects of Zenker diverticu­
lum (such as aspiration pneumonia, complete obstruc­
tion and large, difficult-to‑treat diverticular pouches),
enables surgery on a healthier patient, and improves
E swallow function even if only subtle ­d isturbances
are present.
U Treatment in all cases should include a cricopharyn­
geal myotomy using either an open or endoscopic
transmucosal approach, with or without removal of the
D
diverticulum itself (FIG. 3). The current trend is to treat
most patients transorally using a CO2 laser or stapling
Figure 3 | Endoscopic view of Zenker diverticulum. a | Before treatment. techniques92. Results from either technique are reported
Nature Reviews
b | After CO2 laser myotomy, with diverticulum | Gastroenterology
opened into & Hepatology
oesophageal lumen. to be quite good, and the risks are similar 95–97. The data
D, posterior diverticulum; E, oesophageal lumen; U, upper oesophageal muscle. for selecting a transoral laser approach when possible

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are relatively compelling — with low-risk and high A large variety of safe injectable materials exist that
success rates being reported repeatedly over multiple can last from weeks (hyaluronic acid gels) to months
decades98–101. Evidence suggests that the level of success (micronized particulate acellular human dermis) to
is best predicted by the ease and extent of exposure of years (calcium hydroxyapatite paste)108. Radiologic,
the diverticulum and the cricopharyngeal mucosal clinical, and fluoroscopic studies support early inter­
impression, with better exposure predicting a better vention86,87. Decreasing aspir­ation by improving glottic
long-term outcome102. closure enables clinicians to maintain swallowing during
In a systematic review 95, 70 studies with almost 3,000 therapy, thus broadening the options within the rehabil­
patients were identified to address the safety and effi­ itation protocols109,110. Beyond the early interventions,
cacy of the available surgical procedures. Both open and restoration of glottic function can include more invasive
endoscopic approaches seemed to have low complication procedures (medial­ization thyroplasty, arytenoid adduc­
rates and comparatively high success rates. However, tion and laryngeal re‑­innervation) with the intention
endoscopic approaches were associated with frequent to extend the benefits of adequate closure beyond that
difficulties with exposure, and there was a higher long- which is expected from injection techniques108,111. These
term failure rate with endoscopic stapling compared to open procedures can be coupled with cricopharyn­
open cricopharyngeal myotomy. Importantly, patients in geal myotomy to improve swallow function in patients
all treatment groups reported high satisfaction. Surgeons with combined laryngeal and pharyngeal dysfunction
should take an individualized approach, recognizing that ­secondary to cranial nerve or CNS pathology 112,113.
when an endoscopic approach is feasible, complication
rates are slightly lower than open approaches and laser Pharyngeal muscle reduction procedures
techniques have higher long-term success rates com­ The idea of pharyngeal muscle reduction to improve
pared to stapling. They also noted that all patients are swallowing in patients with pharyngeal weakness was
candidates for open approaches and a successful open first put forward in 1995 (REF. 114). The concept is not
approach seems to have the lowest recurrence rate. Thus, dissimilar to cardiac and pulmonary tissue reductions
it would be favourable for young patients, patients with — cardiac function is improved when nonfunctioning
a small diverticulum, and patients in whom endoscopic tissues are removed, allowing for more effective cardiac
exposure has failed. contractions, as a noncontractile segment dissipates
pressure generation115. Similarly, if a patient develops
Vocal fold paralysis and dysphagia a segment of noncontracting tissue in the pharynx
The majority of patients will have new onset of dys­phagia due to muscular paresis after cranial nerve injury or
symptoms with both solids and liquids when a vocal fold stroke, eliminating that segment of muscle is theoret­
paralysis occurs103. The role vocal fold paraly­sis has in ically bene­ficial, enabling the intact muscle to create
dysphagia is complicated but necessary to evaluate and a more effective contractile force. Limited literature
treat when encountered. The cause of the paralysis, the exists to support this concept and in almost all cases
patient’s medical condition at the time of the paralysis, it is performed in combination with a procedure to
and the involvement of additional ­muscular dysfunc­ address glottic insufficiency (type I thyroplasty) and a
tion and sensory loss all come into play when prioritiz­ cricopharyngeal myotomy 114.
ing an intervention. High index of suspicion based on
medical and surgical history (for example, new-onset Laryngohyoid suspension
brainstem stroke, recent cardiac surgery, known media­ Surgical suspension of the larynx and hyoid can augment
stinal or skull base mass) combined with examination bolus passage into the oesophagus80. This procedure is
findings showing voice change, weak cough, and cough occasionally performed to treat patients with stroke-­
with liquid swallow, as well as aspir­ation on video­ related or multifocal dysphagia; however, most of the
fluoroscopy, should all lead to concern for a possible literature is related to the management of dys­phagia
vocal fold immobility. associated with cancer surgery 116. The procedure is an
This suspicion can be easily confirmed with endo­ essential part of laryngeal cancer procedures in which
scopic examination of swallow, flexible laryngoscopy, supraglottic and tongue base tissues are removed
or videostroboscopy. The flexible examination enables (supraglottic laryngectomy and extended supraglottic
some direct assessment of sensory problems by touch­ laryn­gectomy), and when anterior glottic structures
ing and air puff techniques on surrounding mucosal are removed (supracricoid laryngectomy)117–119. The
surfaces104,105 and indirect assessment by watching the method of laryngeal suspension differs depending
patient’s laryngeal responses to mucus and salivary flow. on the retention of superior epiglottic tissue (crico­
Many patients with vocal fold paralysis will have both a hyoidoepiglottopexy or cricohyopexy). In all cases, the
sensory and motor deficit 106. retained laryngeal structures are suspended antero-­
Confirming the presence of a glottic closure issue has inferior to the retained hyoid bone, the arytenoid cartil­
great value because of the ease and benefit of early inter­ ages are sutured in a forward position, the trachea is
vention; a minimally invasive vocal fold medialization released from below, and in most cases a cricopharyn­
procedure can restore the physiologic benefit of active geal myotomy is completed. With this complex s­ urgery,
glottic closure, including decreased aspiration risk with early aspiration risk is common but improves with
thin liquids (although aspiration risk might not be totally time and swallowing therapy 118,119. If the suspension
eliminated) and improved voice and effective cough107. fails or is incomplete, aspiration is guaranteed and

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only resolves by surgically correcting the suspension. treatment is swallow pathophysiology. The success of
Laryngeal suspension is also useful after glossectomy these therapies is most frequently judged from changes
and pharyngeal resections120,121. identified during videofluoroscopic contrast barium,
flexible direct endoscopic swallow studies, or high reso­
Aspiration prevention surgeries lution manometry. Given that any compromise in swal­
Preventing aspiration can be accomplished with sur­ low physiology reduces swallow safety and efficiency,
geries designed to separate the airway from the path of we ­support the importance of physiological outcomes.
the bolus. These approaches do not address the cause However, the patient perspective is also critical and
of the dysphagia but once the aspiration risk is elimin­ needs to be considered when judging the value of dys­
ated the patient might have additional therapy options, phagia treatments. Patients place importance on psycho­
which could include swallowing food and liquids that logical issues related to dysphagia130. Acutely ill patients
would not have been possible before the surgery. Some of report swallowing-related anxiety and fear of dying,
these techniques are reversible if the patient’s condition whereas patients with chronic dysphagia report feelings
improves enough to enable safe swallowing. All these of embarrassment, depression, isolation and abandon­
procedures require a tracheotomy or creation of tracheal ment131. Thankfully, important aspects of the psychologi­
stoma. Some approaches close the supraglottic larynx at cal issues experienced by patients with chronic dysphagia
the level of the arytenoids and epiglottis using valved are alleviated by compensatory strategies taught to them
glottis stents, which prevent most aspirations and retain by clinicians. These strategies increase their ability to
some voice but still require a tracheotomy for airway control their swallow and thereby to return to eating
safety 122,123. Most of these techniques exclude the use of with family and friends. Furthermore, patients acknow­
the larynx for voicing. ledge that these strategies serve to increase the safety of
Finally, two procedures can eliminate aspiration com­ their oral intake and reduce the risk of pneumonia and
pletely: tracheoesophageal diversion and narrow-field mal­nutrition130 — biomedical outcomes important to
laryngectomy 124–126. In both cases, swallowed material clin­icians. This work proves that, although patient per­
cannot enter the airway even if a portion of the bolus ception is related to that of the clinician, it is clearly dis­
is retained in the pharynx as the connection between tinct. A comprehensive evaluation of therapeutic value
the pharyngoesophageal tissues and the trachea and needs to address both.
lung is eliminated. These two procedures are used Another important consideration for both researchers
almost exclusively in patients with severe chronic aspir­ and clinicians is the degree to which patients adhere to
ation, for example after cancer therapy, or in patients assigned therapeutic protocols, as poor compliance neg­
with extensive neurologic dysfunction. Laryngectomy atively influences treatment benefit. This effect might be
is most commonly performed in patients who aspir­ less of a problem with comparative trials designed to have
ate substantially after organ-preserving treatments of equivalent patient burden across treatment study arms.
laryngeal cancer, which can include partial laryngec­ However, less rigorous study designs cannot adjust for
tomies and radiation therapy treatment protocols127. noncompliance. Furthermore, even with efforts to con­
Laryngectomy does have a role in other patients with trol for compliance, some patients might report more
chronic aspiration and additional clinically significant than actual therapeutic adherence thereby nullifying
co‑morbid illness128. Clinicians might in fact be under­ study findings132. Generally, com­pliance relates to adher­
using these techniques owing to an emphasis on retain­ ence to a therapeutic practice or maintenance of a plan,
ing vocal communication. It is important to weigh the and is greatest in people who prioritize their health133.
risks of chronic aspiration on long-term lung function, Pharmacological trials have identified other factors that
repeated pneumonias and potential death against modi­ also have a positive influence on compliance in the clin­
fied communication. Importantly, with these techniques ical setting, namely the following: tracking the therapeu­
patients retain the ability to eat at least some foods and tic activity; educating the patient about the therapy and its
might experience a true increase in length and quality purpose; and continued supervision by clinicians during
of life. Tracheoesophageal diversion was designed with the treatment period134. Perhaps these factors generalize
the potential for reversal once a patient’s dysphagia to increase compliance with dysphagia treatments. If so,
improved, such as in stroke recovery. This procedure clinicians will need to provide education that is meaning­
is less common today, in an era of early percutaneous ful to patients and foster an understanding on how the
gastro­stomy tube placement and patient transfer to intervention will be helpful to them. Certainly, all patients
chronic care facilities. are unique and they will have varying levels of concern
about their swallowing problems, which might in turn
Model to measure therapeutic benefit influence their motivation toward therapy. This factor
Many of the dysphagia interventions described in this might explain why patients are especially non­compliant
Review arose from clinical observations and were envi­ with prophylactic dysphagia treatments prescribed before
sioned to address a single specific clinical problem. there is any appreciation of the impending possible swal­
Clearly, the clinician perspective motivated their design. lowing problems42. Only by evaluating and monitoring
Broadly speaking, clinician perception is biased toward for poor compliance can clin­icians and researchers
biomedical issues129, and clinicians with expertise in mitigate to reduce it, and m ­ aximize benefit from those
dysphagia are no exception130. Unsurprisingly then, the swallow­ing interventions that are ­particularly dependent
speci­fic clinical problem targeted most often in dysphagia on active patient participation.

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therefore one intervention will not generalize to all its


General category
of aetiology possible causes. Another reason might lie in the hetero­
History
geneity of the interventions assessed, of which few have
Neurological been tested in isolation. Despite the countless stud­
Education ies, these varied therapy protocols make it difficult to
Emotional
Mechanical determine which aspects are potentially most effective.
Diagnostics
support In addition, there is inconsistency with how therapeutic
Iatrogenic value is measured — some studies measure physiological
Compliance benefit whereas others capture the patient perspective.
Systemic
All of these factors limit comparison of findings across
Therapy studies, which is a necessary prerequisite to establish
Psychological
external validation.
To get out of this standstill, some researchers and
Figure 4 | A comprehensive model depicting factors
Nature
that affect Reviewsbenefit
therapeutic | Gastroenterology & Hepatology
for oropharyngeal
clinicians have called for larger studies whereas others,
dysphagia. invoking the principles of evidence-based medicine,
have called for more RCTs. We support these changes
but argue that they are not enough. Additional changes
Despite critical gaps in the existing research for dys­ that are important include the following: establish suf­
phagia treatments, we advocate that clinicians continue ficiently powered samples sizes (not necessarily large);
to use best available information and clinical experi­ detail an explicit study design that specifically minimizes
ence to treat patients. Provided that clinicians disclose risk of bias and that can be replicated by others135; and
to patients the basis for their recommendations, we trust utilize outcomes that are validated, meaningful and
that a therapeutic plan even without strong evidence is sensitive to clinically important change representing
better than no clinical intervention. At a minimum, what is considered important to both the clinician and
clin­icians should use the clinical opportunity to educate the patient.
patients and their families about the importance of safe Fortunately, dysphagia therapies continue to be
swallowing, and the potential risks of repeated aspiration, explored. In the case of behavioural therapies, the focus
malnutrition and dehydration. From the work described is now on refining these exercises according to anatomi­
herein, we know that even this conservative educational cal, neural and physiological findings from basic, animal
approach will be of value to the patient and, in turn, will and human science. These discoveries hold promise that
facilitate improved c­ ompliance — a ­necessary basis for soon they will unveil the true value of swallow rehabil­
any successful intervention. itation. In the meantime, behavioural swallow thera­
Therapy planning for dysphagia needs to begin pies can be part of clinician-guided sessions, at times
with a good understanding of the swallow anatomy accompanied by devices that increase effort or provide
and physiology. Swallowing disorders are now known meaningful feedback. Alternatively, these therapies can
to be a sequelae of a variety of medical conditions and be executed as home exercise programs. It is important
perhaps even represent a condition associated with the to discover what elements make each of these scenarios
later phases of the normal ageing process. Thus, as our more effective to ultimately increase the likelihood of
understanding of swallow therapy could be described success in swallow recovery.
as in its infancy, so too is our understanding of much We are optimistic that over time as the standard­
of the underlying pathophysiology of dysphagia. Very ized CONSORT reporting guidelines are increasingly
few causes of dysphagia are fully understood. Future implemented by journals, improved critical appraisal
work needs to address the neuropathological causes of in the peer-review process will in turn motivate a shift
dysphagia according to medical aetiology, and delineate toward high-quality, innovative dysphagia treatment
the influence of important premorbid patient character­ research. Therapeutic innovations need proper scrutiny
istics that not only increase the risk of dysphagia but also at a peer-review level before they are introduced into
aspiration, malnutrition and psychological burden on the clinical setting and certainly before entering the
patients. To achieve this, dysphagia therapies need to market­place. Clinicians need an opportunity to critically
be planned according to the aetiology that is at its root, appraise these innovative therapies. To do so properly,
modified to accommodate the resulting impairments in they need to evaluate its applicability to their practice
swallow physiology captured from comprehensive clin­ setting and make decisions about which patients are
ical and/or instrumental assessments, and customized most likely to benefit.
to support the needs of the individual patients and their As Sackett et al.136 write, “Good [clinicians] use
carers (FIG. 4). both individual clinical expertise and the best available
external evidence, and neither alone is enough. Without
Conclusions clinical expertise, practice risks becoming tyrannised
More than two decades of research has yet to yield a by evidence, for even excellent external evidence may
single therapeutic intervention with consistent value to be inapplicable to or inappropriate for an individ­
recovery of the swallow physiology. Part of the reason ual patient. Without current best evidence, practice
might be that dysphagia is itself a sequelae of diverse risks becoming rapidly out of date, to the detriment
aetiologies influenced by several patient variables; of patients”.

676 | NOVEMBER 2016 | VOLUME 13 www.nature.com/nrgastro


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CORRECTION

ERRATUM

Therapeutic intervention in oropharyngeal dysphagia


Rosemary Martino & Timothy McCulloch
Nature Reviews Gastroenterology & Hepatology doi:10.1038/nrgastro.2016.127
In the version of this article orginally published online, there was an error in the title. The error has been corrected for the
HTML and PDF versions of the article.

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