SpeechPathology.comPhone: 800-242-5183

New master brand. Same great company. Introducing continued! Read Our Story

Signature Healthcare

Treatment for Epiglottic Dysmotility

Susan Langmore, Ph.D,CCC-SLP

May 26, 2003

Share:

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.

Related Courses

Risk Factors for Aspiration Pneumonia -Who Gets Sick?
Presented by Angela Mansolillo, M.A., CCC-SLP, BCS-S
Video

Presenter

Angela Mansolillo, M.A., CCC-SLP, BCS-S
Course: #6180 1 Hour
  'Such a wealth of information that can be easily applied to working in multiple settings, especially am SLP new to IP'   Read Reviews
Aspiration pneumonia is an important and dangerous consequence of dysphagia but every patient with swallowing impairment does not necessarily develop pneumonia. Dysphagia clinicians must consider a number of factors that potentially increase the risk of pneumonia in our patients with swallowing disorders. This course will review the evidence base in the areas of aspiration and aspiration pneumonia and assist in answering the question “Who Gets Sick?”
Tongue Elevation Intervention in Pediatric Feeding Disorders
Presented by Jennifer Dahms, M.S., CCC-SLP, BCS-S
Video

Presenter

Jennifer Dahms, M.S., CCC-SLP, BCS-S
Course: #6182 1 Hour
  'Good comprehensive overview of assessment and treatment of lingual elevation'   Read Reviews
Tongue elevation is critical for managing solid foods and for swallowing. There are many types of deviations in tongue functioning in regards to elevation that can impact safe and efficient feeding. It is critical that feeding therapists be able to identify the functional limitations in tongue elevation and understand which particular techniques will be beneficial for remediation.

Please note: This course is also offered in a series titled "Improving Oral-Motor Functioning in Pediatric Feeding Disorders", course 6240, which is offered for .6 CEUs. By completing this course, you will NOT be eligible to complete course 6240 for credit.

Tongue Lateralization Intervention in Pediatric Feeding Disorders
Presented by Jennifer Dahms, M.S., CCC-SLP, BCS-S
Video

Presenter

Jennifer Dahms, M.S., CCC-SLP, BCS-S
Course: #6183 1 Hour
  'I enjoyed the videos for a visual representation of the treatment techniques!'   Read Reviews
Tongue lateralization is critical for managing solid foods for chewing. There are many types of deviations in functioning in regards to tongue lateralization that can impact safe and efficient feeding. It is critical that feeding therapists be able to identify the functional limitations in tongue lateralization and understand which particular techniques will be beneficial for remediation.

Please note: This course is also offered in a series titled "Improving Oral-Motor Functioning in Pediatric Feeding Disorders", course 6240, which is offered for .6 CEUs. By completing this course, you will NOT be eligible to complete course 6240 for credit.

Documenting to Demonstrate Skilled Service and Focus on Function
Presented by Nancy B. Swigert, MA, CCC-SLP, BCS-S
Video

Presenter

Nancy B. Swigert, MA, CCC-SLP, BCS-S
Course: #6227 1 Hour
  'Very good information, although dated now, I believe is still relevant in today's speech language pathology work environment'   Read Reviews
In this changing health care environment, the SLP should work closely with the patient in establishing goals that focus on function and aim to achieve the desired, measurable outcome. Medicare guidelines stipulate that services must be provided at a level of complexity requiring the services of a speech-language pathologist. Even when Medicare guidelines are followed in the provision of services, the documentation sometimes does not demonstrate the focus on function or that a skilled service was provided. This course will address how to write measurable, functional goals and provide tips on how to accurately document skilled services.
Chewing and Biting Intervention in Pediatric Feeding Disorders
Presented by Jennifer Dahms, M.S., CCC-SLP, BCS-S
Video

Presenter

Jennifer Dahms, M.S., CCC-SLP, BCS-S
Course: #6184 1 Hour
  'This course was interesting and easy to follow'   Read Reviews
Biting and chewing skills are critical for managing solid foods. There are many types of deviations in regards to biting and chewing skills that can impact safe and efficient feeding. It is critical that feeding therapists be able to identify the functional limitations in biting and chewing and understand which particular techniques will be beneficial for remediation.

Please note: This course is also offered in a series titled "Improving Oral-Motor Functioning in Pediatric Feeding Disorders", course 6240, which is offered for .6 CEUs. By completing this course, you will NOT be eligible to complete course 6240 for credit.