In addition to its connection to reflux disease, aspiration can also occur with swallowing disorders, and members of the USC Thoracic-Foregut Group have done extensive research and clinical work in this area. The Swallowing Center at USC University Hospital has a particular focus on oropharyngeal dysphagia, which is a problem in swallowing of the upper end of the esophagus. Cedric G. Bremner, M.D., co-director with Dr. DeMeester of the USC University Hospital Swallowing Center, notes that "Oropharyngeal dysphagia is poorly understood by the average practitioner, and ignorance in this area may lead to inappropriate treatment with no relief of disabling symptoms."

Dr. Bremner, professor of Clinical Surgery and director of Clinical Research, Department of Surgery, explained that oropharyngeal dysphagia can have its origins in the central nervous system, for example, following a stroke. It can also be a muscular disorder, which may simply be attributed to the aging process or other diseases affecting muscles. In either case, the problem can often be linked to the cricopharyngeal muscle. "This is a little ring muscle in the neck on top of the esophagus that is closed all the time," Dr. Bremner points out.

"When you swallow, it opens and closes in a split second -just enough time to allow the food to drop down into the esophagus. At the same time, the glottis closes over the airway so the food does not get aspirated into the wind pipe." This mechanism requires split-second timing. A neurological disorder can cause the failure of the cricopharyngeal muscle to relax adequately or in a coordinated manner, resulting in food backup which is then aspirated into the lungs.

Cricopharyngeal Myotomy

Dr. Bremner notes that many of these patients are helped considerably by surgically dividing the cricopharyngeal muscle. This procedure, called a cricopharyngeal myotomy, involves cutting the muscle to render it incompetent. Thus, when the individual swallows, the small muscle is completely relaxed, allowing food to pass through. While cricopharyngeal myotomy is not a new concept, what has been of tremendous value in the last few years is the technological ability to measure more accurately the pressure events that occur in the cricopharyngeal area. With our new manometry techniques, we can conduct a detailed cricopharyngeal study to determine before the procedure if myotomy will be beneficial.

For many patients, cricopharyngeal myotomy can significantly enhance quality of life. Some patients who have difficulty swallowing are fed through a Percutaneous Endoscopic Gastrostomy (PEG) tube to avoid choking on food. "In actuality," says Dr. Bremner, "some of these patients can benefit from a cricopharyngeal myotomy, after which we are able to take out the PEG tube."

He cited the recent case of an 81- year-old male patient who had been prescribed a PEG tube. A member of his family, who was a physician, contacted Dr. Bremner and set up an appointment for testing to determine if the patient would be a candidate for the myotomy. Tests indicated the myotomy could solve the problem, and the man underwent the procedure. Today he is swallowing normally, and does not require the PEG tube. "It is important to inform both physicians and patients that this option exists for patients who are having difficulty in swallowing," Dr. Bremner says. "The myotomy allows patients like this man to continue eating food, which is a quality of life issue." In some cases the myotomy can be performed in a minimally invasive fashion using a technique pioneered by Rodney J. Mason, M.D., Ph.D., or using a trans-oral approach.

The Swallowing Center at USC University Hospital takes a multidisciplinary approach to swallowing disorders. The team is comprised of gastroenterologists, neurologists, radiologists, surgeons and swallowing therapists. Patients who are not candidates for surgery may benefit from the expertise of our swallowing therapist, who- through various exercises- helps patients relearn the swallowing process, which in turn gives them more confidence.