Flexible Endoscopic Evaluation of Swallowing (FEES)

An esophagogram or esophogram, is a study performed in a radiology suite with a radiologist. The patient is asked to swallow a thick liquid. X-rays are used to evaluate how the food is swallowed examining for abnormalities including areas of narrowing or strictures.

A modified barium swallow study is commonly performed-with a speech pathologist and a physician in tandem. Similar to an esophogram, it is performed in a radiology suite. In a modified barium swallow study, a patient is asked to swallow foods and liquids of

different consistencies. X-rays evaluate how successfully food is swallowed and whether aspiration occurs. Speech pathologists can use this as a time to test treatment strategies and use the X-ray to help determine how successful they are.

A Functional endoscopic evaluation of swallowing (FEES) is performed using a flexible laryngoscope. A laryngoscope is passed through a patient’s nose and the images are visualized on a monitor. The patient is asked to swallow foods of different consistencies (applesauce, peaches, and crackers). The process of swallowing is recorded and closely analyzed for any signs of penetration or aspiration.

Minimally invasive surgery

Minimally invasive surgery has developed over the last ten years in laryngology. Today patients are able to undergo numerous procedures and procedures awake that in the past would have required a patient to be asleep.

These include:

Vocal cord injections
Laser surgery
Esophagoscopy
Bronchoscopy
Tracheo-esophageal puncture placement after laryngectomy
Esophageal dilation
Airway dilation

Laser Surgery

Lasers have been used to treat conditions of the throat for the past 40 years. Lasers provide benefits in allowing for accurate surgery to occur, oftentimes making procedures quicker and minimally invasive

Patients with conditions such as papilloma, scar, granuloma and select patients with airway stenosis can be treated with lasers in the office. Treatment is performed without an IV or general anesthesia, meaning patients can drive themselves to and from work, and return to work on the same day.

Most laser surgery is performed through the nose, although surgery through the mouth has been described as well. Lidocaine, or a local anesthetic, is used to numb the nose, mouth and throat. An endoscope is placed through a patient nose. A channel within the endoscope is used to transmit a laser fiber to the level of the vocal folds or trachea (wherever the laser energy is needed). Laser energy is applied with the patient seated.

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Dilation of the throat or esophagus

Difficulty swallowing can be a result of scar or narrowing of the throat or esophagus. The area of narrowing can sometimes be dilated or stretched.

Dilation of the esophagus can be performed in the operating room or in the office. In the office treatment is performed without an IV or general anesthesia, meaning patients can drive themselves to and from work, and return to work on the same day.

Lidocaine, or a local anesthetic, is used to numb the nose, mouth and throat. An endoscope is placed through a patient nose to identify the area of narrowing. A balloon is placed through the nose and through the area of narrowing. Water is used to fill the balloon which stretches the narrowing.

In the operating room, a similar procedure is performed through the mouth.

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Cancer of the throat

Throat Cancer is a wide term that can mean many things. The term throat cancer may refer to cancers of the

Tonsil
Tongue
Larynx or voice box
Hypopharynx
Esophagus

All of these cancers may be related to tobacco and alcohol use. The effect of alcohol and tobacco may be long lasting – in other words even if an individual quit smoking years ago the risk of developing cancer is still higher.

Most throat cancers are squamous cell cancer . This describes the type of cells that overgrow.

The tonsils are located in the back portion of the mouth or oropharynx. Tonsils play a role in the immune system. Cancers of the tonsil may present with

Sore throat
Asymmetric tonsillar mass
Neck mass
Ear pain
Dysphagia

Tonsillar cancer may be related to certain strains of human papilloma virus as well.

Tonsillar cancer may be treated with

Surgery
Radiation therapy
Chemotherapy

Depending on the extent of the cancer, tonsil cancer can be treated:

Through the mouth using a laser

Spread in the neck may be treated with a neck dissection

Radiation therapy and chemotherapy may also be used to treat this disease.

Management of the originating site, or primary tumor
Management of areas of spread, or lymph nodes

Evaluation for any cancer of the head and neck involves determination of:

Original site, or primary
Regional spread, or lymph nodes
Distant spread, or metastasis

This determination is made with a thorough history and physical examination. Physical examination may involve:

Flexible laryngoscopy,
Esophagoscopy
Bronchoscopy
X-rays including CT Scans, MRIs and PET scan

Once the extent of the lesion is determined the physician can determine the best treatment plan.

Most head and neck cancers are treated with either:

Surgery
Radiation therapy
Chemotherapy

Cancer of the larynx or voice box can cause a number of symptoms from hoarseness to ear pain. Cancers are classified on the subsite.

Laryngeal cancer is most commonly glottic cancer or supraglottic cancer. Cancers of the subglottis occur, albiet relatively uncommonly.

Glottic cancer, or vocal fold cancer, principally causes hoarseness.

Vocal fold cancer can also cause

ear pain
cough
swallowing problems
neck mass

Glottic cancer spreads to lymph nodes much less than other cancers. As such treatment can foucs on the primary site.

Glottic cancer is staged:

Glottis
T1
Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.
T1a
Tumor limited to one vocal cord.
T1b
Tumor involves both vocal cords.
T2
Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility.
T3
Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.
T4a
Moderately advanced local disease.
Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
T4b
Very advanced local disease.
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

Treatment for glottic cancer is a balance between preservation of voice and elimination of cancer. For earlier stage cancers, T1, T2 and possibly T3 cancer. special voice preservation surgeries may be performed, in which the normal anatomy is retained.

Partial laryngectomy means removal of part of the voice box. Partial laryngectomy performed from the outside, removes a vocal fold, or portions of both vocal fold depending on extent of the lesion.
Some partial laryngectomies recreate the vocal fold muscle or other local tissue.

Endoscopic partial laryngectomy may be performed through the mouth removing the diseased tissue using a laser. Endoscopic techniques disturb less of the normal anatomy, possibly preserving functions of swallowing and voice production. Tracheotomy tubes may not be necessary with this surgery.

Total laryngectomy, removal of the voice box, is reserved for advanced cancers. A total laryngectomy is performed in the operating room – the larynx is removed, the throat is opened and recreated, and the trachea is attached to the skin to create a permanent stoma. After total laryngectomy a patient permanently breathes through the neck stoma and not through the mouth or nose. Total laryngectomy removes the voice box, meaning an individual must rely on artificial means of speech. Despite removal of the voice box, patients are able to phonate or make sound and have very understandable speech.

During a total laryngectomy the surgeon removes the voice box, opening the neck to create a new throat. Patients are fed through a feeding tube temporarily while the new throat heals.

Voice rehabilitation after total laryngectomy.

• Esophageal speech – Air is forced from the belly through the esophagus or eating tube. This causes the throat tissues to vibrate similar to vocal fold vibrating. This sound is transmitted to the mouth and the tongue and lips forms this into words and sentences.
• Electrolarynx A hand held external device is placed against the skin. This vibrates, similar to the vocal folds vibrating. This sound is transmitted through the skin, and formed by the mouth/tongue and formed into words and sentences.