November 29, 2012 by
Presenter: Peter Belafsky, MD, PhD, MPH
Professor and Director of Voice & Swallowing Center at UC Davis Medical Center
Dr. Belafsky’s primary clinical interests are the comprehensive diagnosis and management of voice, swallowing, and airway disorders. As Medical Director of the Voice and Swallowing Center at UC Davis, Dr. Belafsky treats a wide array of laryngeal and esophageal disorders. These disorders include but are not limited to vocal fold paralysis and paresis, vocal fold dysfunction, laryngopharyngeal reflux, chronic cough, and dysphagia caused by stroke, ALS, Zenker’s diverticulum, esophageal motility disorders, Parkinson’s disease, and swallowing problems suffered as a consequence of the treatment of head and neck cancer. Dr. Belafsky has pioneered minimally invasive treatments of voice and swallowing disorders. Minimally invasive in-office procedures performed by Dr. Belafsky at the Center include unsedated treatment of laryngeal polyps, leukoplakia, and papillomas, subglottic, tracheal, and esophageal strictures, and office-based vocal fold medialization. Dr. Belafsky’s primary research focus is the development of an artificial swallowing mechanism. He has created a medical device that can manually control the upper esophageal sphincter and is working on a comprehensive swallow propulsion system. He is also pursuing his interest in bloodless surgery through the use of radio frequency probes and non-contact lasers.
- CASE: 82 yo male presented with the chief complaint of solid food dysphagia and moderate dysphonia. He reported a 15lb weight loss over the past 18 months and 1 episode of pneumonia requiring hospitalization 5 months previous.
- PMHx: Hypertension, hypercholesterolemia, Parkinson’s disease
- PSurgHx: Inguinal hernia repair, rotator cuff repair
- ALLERGIES: None
- MEDS: Lipitor, Cardizem
- SOCIAL HISTORY: Retired Air Force Colonel, served in Vietnam War. No tobacco or illicit drug use. Social ETOH. Lives at home with his wife of 49 years. 3 children and 7 grand children. Good familial support.
- REVIEW OF SYMPTOMS: Solid food dysphagia, Hypertension, urinary frequency, weight loss, mild resting tremor, dysphonia
- PHYSICAL EXAM: Comprehensive head and neck examination unremarkable. Mild upper extremity resting tremor and mild bradykinesia. Oral motor examination unremarkable. Moderate breathy dysphonia.
- FEES: moderate laryngeal edema with underlying vocal fold atrophy, posterior commissure hypertrophy, mild arytenoid hyperemia. Pharyngeal strength and sensation appeared intact. There was significant post-swallow regurgitation with puree with no evidence of penetration or aspiration during the swallow.
- MBSE: Videofluoroscopic swallow study revealed evidence of a moderately obstructing cricopharyngeus muscle bar and an early Zenker Diverticulum. There was delayed pharyngeal transit time but no evidence of penetration or aspiration.
- TREATMENT RECOMMENDATIONS:
- Swallowing and voice therapy. Swallow for life program with iSwallow. EMST. LSVT. (Feel free to add to this).
- The patient was offered a cricopharyngeus muscle myotomy and a medialization laryngoplasty or an injection medialization of the vocal folds and a CP botulinum toxin injection. Because of his advanced age the patient desired an injection medialization and a CP botulinum toxin injection.
- WATCH MEDIALIZATION (0.4cc of calcium hydrozylapatite injected into each true vocal fold)
- WATCH BOTOX INJECTION (60 units of botulinum toxin injected into the cricopharyngeus muscle)
- OUTCOME: Post-therapy and Postoperatively the patient reported a significant improvement in voice and swallowing function. Repeat videofluoroscopy revealed improved bolus transit through the pharyngoesophageal segment with near complete resolution of the Zenker’s Diverticulum.
- FOLLOW-UP: He will be monitored closely for a progression of his dysphagia when the botulinum toxin wears off in 6-9 months. He will continue with his Swallow for Life Program.