Download 2003 Jun. Vol.15 No.1 - USF Health

CONTINUING MEDICAL EDUCATION
MEDICAL STAFF
The Center for Swallowing Disorders has continued active
participation in graduate medical education by lectures at
regional, national and international meetings and by contributions to the medical literature.
Director . . . . . . . . . . . . . . . . . . . . . . H. Worth Boyce, Jr., M.D.
Professor of Medicine
Hugh F. Culverhouse Chair in Esophagology
Lecture Presentations by CSD Staff
Patient Care . . . . . . . . . . . . . . . . . . . . Janet L. Jones, B.A., CGC
Coordinator
Instructor of Medicine
December 5-7, 2002: Joy McCann Culverhouse Center for
Swallowing Disorders 4 th Annual Postgraduate Course,
Esophagology for Clinicians: Esophageal Disorders: From A to Z for
2003: 1) Endoscopic Esophageal Anatomy: The Basis for
Endoscopic Diagnosis, 2) Botulinum Toxin Type A Injection –
Indications, Locating the LES and Details of Technique and 3)
Uncommon, Complex, High Risk Strictures. Boardwalk Inn, Walt
Disney World, FL (Boyce)
December 5-7, 2002: Joy McCann Culverhouse Center for
Swallowing Disorders 4 th Annual Postgraduate Course,
Esophagology for Clinicians: Esophageal Disorders: From A to Z for
2003: Esophageal EUS Basics and Benign Disorders and Diagnosis
and Medical Therapy of Esophageal Sequelae of GERD. Boardwalk
Inn, Walt Disney World, FL (Johnson)
January 20-21, 2003: 13 th Endoscopy Masters’ Forum:
Endoscopic Surgery by Flexible Endoscopy: Advanced
Technique/Technologies and Future Trends. Orlando, FL (Boyce)
February 22, 2003: Mayo Clinic in Scottsdale Winter
Gastroenterology Meeting: Esophageal Gastroenterology Linked
to Endoscopy & Hepatology. Strictures: 1) Using Classification to
Guide Therapy; 2) Endoscopic Anatomy of the LES and BOTOX
Injection: Who, When, How? Scottsdale, AZ (Boyce)
March 21-22, 2003: Walter Reed Gastroenterology Symposium:
Rings, Webs, and Things: Diagnostic Clues and Caveats for
Therapy. McLean, VA (Boyce)
March 29, 2003: University of South Florida College of
Medicine. Update on GERD & Common Swallowing Disorders
For Primary Care. Clearwater, FL (Boyce, Johnson, Jones)
Contributions To Medical Literature
Boyce HW: Barrett esophagus: Endoscopic findings and what to
biopsy. J Clin Gastro (accepted for publication 2003).
Bloomston, M, Fraiji E, Boyce HW, Gonzalvo A, Johnson MC,
Rosemurgy A: Preoperative Intervention Does Not Affect
Esophageal Muscle Histology or Patient Outcomes in Patients
Undergoing Laparoscopic Heller Myotomy. Jnl Gastrointest Surg
2003;7(2):181-190.
Joy McCann Culverhouse
Center for Swallowing Disorders
University of South Florida
University of South Florida Health Sciences Center
12901 Bruce B. Downs Blvd., MDC Box 72
Tampa, FL 33612
Medical Staff . . . . . . . . . . . . . . . . . . . . .Milton C. Johnson, M.D.
Associate Professor of Medicine
Assistant Patient Care . . . . . . . . . . . . . . . . Betsy J. Lamoy, R.N.
Coordinator
VOLUME 15
JUNE 2003
Office Manager . . . . . . . . . . . . . . . . . . . . . . . Candace K. Harley
DIRECTOR’S FORUM
Administrative Secretary . . . . . . . . . . . . . . . . . Natalie A. Ralyea
ACHALASIA
Appointment Secretary . . . . . . . . . . . . . . . . . . . Jennifer C. Rust
Speech Pathology Consultants for
Oropharyngeal Swallowing Disorders
Speech Pathology . . . . . . Joy E. Gaziano, M.A., CCC/SLP
Linda Stachowiak, M.S., CCC/SLP
Things To Remember
OFFICE HOURS: 8:00 a.m. ‘til 4:30 p.m. Monday through Friday.
Telephone hours: 8:00 a.m. ‘til 5:00 p.m.
Also, our emergency telephone number for after hours is (813) 974-2201
BILLING: Payment for services rendered is due at the time of your
visit. Please be prepared to pay any co-payments due at the time of your
visit to the Center.
Patients who have problems with their physician or facility fee bills
should contact Gayle Stephens, Financial Specialist, at the University of
South Florida Medical Clinics at (813) 974-3575 between the hours of
9:00 a.m. and 4:00 p.m. Monday through Thursday.
For those patients who are from out-of-town, a new toll-free number has
been added for you to call with billing questions. The number is 1-888873-3627. This number is for calls originating in Florida and is only for
billing questions and help with insurance authorizations.
HAS YOUR INSURANCE COMPANY OR PRIMARY CARE
PHYSICIAN CHANGED? With an ever changing medical insurance market (shopping for the best contract, companies merging, others
closing their doors, etc), you may have changed insurance company. If
you changed your insurance company you may have a new primary care
physician. Maybe you have moved and had to choose a new doctor closer
to your home. Regardless of the circumstances we would very much
appreciate your contacting our office to let us know, (813) 974-3374.
This will not only insure we can obtain the necessary authorizations/
pre-certifications and that your medical bills go to the right insurance
company but it will help us make sure your medical records are forwarded
to the right doctors. Thank you for helping us keep the records straight.
NON-Profit Organization
U.S. Postage
PAID
Tampa, FL
Permit No. 1632
NUMBER 1
H. Worth Boyce, M.D.
Professor of Medicine and Director
The term chalasia means to loosen or relax. This condition is seen
Endoscopy reveals a large esophagus with retained food and fluid.
in newborns, especially premature infants who regurgitate after
However, if the patient is properly prepared before this exam by
most feedings for the first several months of life. At about four
two days of clear fluids, only a small amount of liquid content is
months of age the lower esophageal sphincter (valve) begins to
found. A clean esophagus is essential at the time any treatment is
close normally between swallows and the regurgitation from the
performed. The endoscope passes into the stomach through the
stomach is prevented. The opposite is true for achalasia that occurs
closed lower esophageal sphincter with mild to moderate resistance.
at any age between childhood and the ninth decade having an equal
The diagnosis of achalasia is best confirmed by performing an
frequency between males and females. Achalasia is a disorder
esophageal manometry (motility) study which confirms the loss
characterized by a loss of peristalsis (propulsive muscle contractions
of peristalsis in response to swallows and usually an elevated
or movement) in the esophagus and failure of the lower esophageal
pressure in the lower esophageal sphincter which typically relaxes
sphincter to relax and allow emptying of the esophagus.
incompletely or not at all after a liquid swallow taken during the
The cause of achalasia is unknown (idiopathic). There is a loss of
manometry study.
nerve cells in the Auerbach plexus between the two muscle layers
Once the diagnosis is established, a decision regarding therapy is in
of the esophageal wall and in the lower esophageal sphincter. This
order. Some patients with early achalasia and mild symptoms may
defect results in the loss of peristalsis, which is needed to push food
elect to delay treatment or try medical (drug) treatment. Such
into the stomach, and the failure of the lower esophageal sphincter
treatment with calcium channel blocker drugs may help by
to relax and allow food to enter the stomach. These changes result
transiently relaxing the closed sphincter but this response is usually
in failure of esophageal emptying and retention of solid and liquid
short-lived and not reliable for long-term use.
foods in the esophagus. Over time the esophagus enlarges and
Ultimately most patients opt for some form of treatment. None
holds more and more contents. Regurgitation (return of
of the treatments available will improve the peristalsis in the
esophageal contents into the throat and mouth) occurs as a conseesophagus. All are designed to weaken the lower esophageal
quence of both overflow and abnormal esophageal contractions.
sphincter. The standard medical treatment option is dilation of
Failure of emptying into the stomach, regurgitation and, in some, a
the tight sphincter with balloon dilators, available in diameters of
fear of eating, all may lead to weight loss. Patients learn to improve
30, 35 and 40 mm. These instruments are intended to over-stretch
esophageal emptying by eating slowly and swallowing extra fluids
the sphincter to the point that the muscle fibers lose their ability to
which serve to flush esophageal contents into the stomach. The
contract tightly and thereby allow the esophagus to empty more
problems with esophageal emptying and regurgitation can cause
efficiently. This form of therapy provides good to excellent
considerable embarrassment in social settings. Regurgitation,
improvement in from 70 to 90% of patients depending on the size
especially at night when the patient is recumbent, can result in
of balloon used. The main risk of this treatment is perforation or
aspiration of fluid into the lungs causing bronchitis
full-thickness tear of the esophagus that occurs
and pneumonia. Another aggravating factor is sialin 2 to 5% of patients. If this occurs a surgical
orrhea, which is the production of large amounts of
operation usually is needed to close the tear. At
saliva in response to the esophageal obstruction.
the same operation a myotomy or muscle
Patients notice the sialorrhea as a large amount of
splitting operation to treat the achalasia is
“foamy mucus” requiring frequent swallows or
usually performed to provide definitive treatment.
expectoration to keep the hypopharynx free from
In past years, when balloon dilations had failed
this bothersome fluid (see article herein).
on two occasions, an operation called a Heller
The diagnosis of achalasia should be first suspected
myotomy (surgical cutting of the sphincter
after the physician takes a complete history. A
muscle) was recommended. This surgical
barium swallow (esophagram) reveals a dilated
procedure gave good or excellent results when
esophagus with a large amount of retained barium
performed by an experienced surgeon but
and usually some food particles. The esophagus at
required an incision through the chest wall
the lower sphincter is tapered to show a narrow
column of barium likened to the shape of a bird Figure 1. Barium esophagram of typical appearance of a dilated esophagus and a tight lower esophageal sphincter
(arrows). Barium enters the stomach slowly by gravity depending on the level of pressure in the sphincter.
beak (Figure 1).
(thoracotomy). Currently a modification of the Heller myotomy,
called a laparoscopic myotomy, can be performed using the laparoscope
and
accessory instruments through several small incisions in the
abdominal wall. As more experience has been gained this
procedure has become the preferred technique when the surgical
approach is elected. Current long-term improvement is being
confirmed in over 80% of cases. If the sphincter muscle is rendered
too weak by myotomy, there is a risk for acid in the stomach to
reflux into the esophagus and cause esophagitis or a stricture.
Surgeons may attempt to reduce this risk by performing an
antireflux operation at the time of the myotomy. Even if this
problem occurs the acid reflux can be adequately treated by acid
suppressing drugs.
Another treatment for achalasia used for the past 10 years is the
injection of a bacterial toxin, clostridium botulinum toxin-A
(Botox) into the esophageal sphincter. The botulinum toxin
prevents the release of a chemical (acetylcholine) from the nerves
in the lower esophageal sphincter resulting in relaxation and
reduction of the high sphincter pressure. Botox is injected through
a small needle passed through the endoscope. The procedure is
performed as an outpatient procedure and requires about 10
minutes to complete. This effect prevents the muscle from
contracting which leads to increased emptying and improvement
of the patient’s swallowing and regurgitation in about 80% of cases.
This technique fails in 10 to 15% of patients. Its only significant
drawback is its limited duration of relief. The good effects are
gradually lost over a 6 to 12 month period (some patients have
good symptom relief for 12 to 18 months and a few even longer) as
new nerve endings sprout and regrow with a return of the high
sphincter pressure. Complications are very rare and in those who
respond swallowing is greatly improved within several days.
We have been using Botox injection for achalasia since 1993. This
treatment is most useful in patients who are ill with other medical
problems, those who refuse other
forms of therapy, as an urgent temporizing therapy for students in
the middle of a school year and those who are malnourished or
otherwise not candidates for surgery.
During the past 10 years we have had the opportunity to evaluate
514 patients with achalasia. Initial therapy has included pneumatic
dilation or Botox injection in the majority. Laparoscopic myotomy
has been effective in those not satisfied with or who fail medical
treatments. This surgical option may be most appropriate as initial
therapy in younger individuals since it produces the best long-term
symptom relief.
SIALORRHEA:
AN OFTEN UNRECOGNIZED SIGN OF ESOPHAGEAL DISEASE
Michael R. Bakheet, M.D.
Sialorrhea or ptyalism is an excessive salivary flow leading to a
common patient complaint of, “I have a lot of foamy mucus in my
mouth!” Sialorrhea occurs with conditions that promote an
increase in saliva secretion and/ or disturb its passage through the
esophagus into the stomach. Within the oral cavity, three major
salivary glands (parotid, submandibular, and sublingual) as well as
several minor glands produce more than a quart of saliva each day.
Consequently, the esophagus is continually bathed by a stream of
saliva as it passes into the stomach.
Esophageal conditions that promote sialorrhea are grouped into
two broad categories: mechanically stimulated salivation due to an
esophageal obstruction and chemically stimulated salivation due
to esophageal inflammation. Ultimately, the function of such
heightened salivary flow, via the esophago- salivary reflex, is to
flush out the impacted object or to neutralize the offending agent.
Variables such as salivary volume, viscosity, chemical makeup, and
acidity (increased flow is associated with a more alkaline or higher
pH saliva) are adjusted by the body in the resultant product based
presumably on the offending condition or agent.
Saliva contains over 65 different substances. The major ones
include a lubricating glycoprotein (mucin) for food bolus passage,
digestive enzymes (amylase and lipase) for preliminary starch and
fat digestion and antimicrobial agents (lysosomal enzymes and IgA
antibody) as well as several electrolytes (for example: hydrogen,
potassium and sodium). Collectively, these products work in
concert to support the digestive process, promote oral hygiene,
participate in taste conduction, and protect the esophageal
epithelium from noxious agents.
Sialorrhea has significant implications due to its incessant nature,
as well as its potential for several complications. At a minimum,
laryngeal penetration (fluid enters only the larynx above the vocal
cords) and aspiration of saliva below the vocal cords into the
trachea (wind pipe) will lead to hoarseness, cough and a choking
sensation. Aspiration is most prevalent in patients that have
difficulty with the passage of saliva through the pharynx or
esophagus due to oropharyngeal dysmotility, advanced obstruction
(progressive cancer or stricture formation) or an esophageal
neuromotor disorder, such as achalasia. Thus, the retained salivary
pool accumulates in the lower pharynx and/ or esophagus and may
eventually enter the larynx, trachea, bronchi, and ultimately the
lung. Aspiration may lead to bronchitis and pneumonia as well as
chronic cough. When aspiration volume is high, the resulting
decreased oxygenation (hypoxia) may lead to rapid heart rate
(tachycardia), chest pain, cyanosis, an altered mental state, and
even respiratory failure. The risk of aspiration is greatest in
patients with associated oropharyngeal dysmotility, extremes of age
(elderly/ pediatric) or the severely debilitated patient. These
persons may not sense the aspirated saliva (silent aspiration), fail
to clear the saliva by coughing and thereby develop pneumonia.
Other consequences of sialorrhea, albeit less detrimental, include
social stigmas as the patient may have profound drooling or
hypopharyngeal pooling requiring the need to regularly evacuate
the oral cavity by spitting or wiping the corner of the mouth with a
tissue to achieve relief. When sialorrhea is severe, patients
typically will have to carry a tissue or “spit cup” at all times. This
creates a disturbing, major social incapacity. Nocturnal sialorrhea
can cause chronic sleep disturbance, as the patient has to regularly
wake up to “clear my throat.” This will lead to daytime fatigue, and
somnolence. For those with intact oropharyngeal function, there
will be a need to swallow often to clear the extra saliva. Each
swallow delivers air into the gastrointestinal tract. Increased
swallowing frequency may lead to symptomatic air swallowing
(aerophagia) with resultant gas bloating, flatus, and pain.
Any swallowed object that is retained within the esophagus
will stimulate local mechanoreceptors (mechanical/ physical
receptors) leading to increased salivation. Impacted foreign bodies
(bones, coins, dentures, etc.) typically present in a characteristic
combination of painful swallowing (odonophagia) and sialorrhea.
A sufficiently prolonged impacted object can lead to scar tissue
deposition and stricture formation. Ultimately, such scarring
will lead to a decrease in lumen diameter and further promotion of
sialorrhea.
Neoplasms (malignant or benign tumors) that grow into the
esophageal lumen will reduce the normal esophageal diameter
causing a blockage. Similar to an impacted foreign object, such a
growth in the esophageal wall will lead to sialorrhea.
Webs, rings and strictures narrow the esophageal lumen producing
prolonged eating times and food retention. Sialorrhea is typically
noticed by the patient only after there is an acute blockage or
impaction of food into one of these narrowed areas.
Achalasia, is a pathologic condition that is defined by an absence
of esophageal peristalsis or motility in the lower two thirds of the
esophagus. Often, there is an excessively tight (hypertensive)
lower esophageal sphincter causing food retention associated
esophageal enlargement (megaesophagus) and chest pain. Food
and saliva passage into the stomach is prevented leading to retrograde flow or regurgitation of saliva. The saliva or “foamy mucus”
floats atop the retained food, typically appearing as the first
substance to be regurgitated. Sialorrhea and its problems are a
consistent occurrence in patients with achalasia.
Similar to mechanically stimulated sialorrhea, inflammatory irritation (due to chemical ingestion, local viral infection, etc.) of the
inner esophageal wall layers (mucosa and submucosa) will result in
an increase of salivary flow. Local chemoreceptors (chemical
receptors) enhance salivary secretion rate when stimulated. These
receptors also have the capability to detect heat (thermoreceptors)
or chemical concentrations (osmoreceptors).
Gastroesophageal reflux, the most common cause of chemical
irritation to the esophagus elicits water brash, a characteristic
reflux- related variation of sialorrhea that has a typically bitter
frothy quality detected in the patient’s mouth. It occurs as a reflex
to provide protection of the esophageal mucosa from acid injury.
Ingestion of corrosive substances (lye, acid, bleach, etc.) will
irritate the mucosa and induce hypersalivation. Additionally, the
tissue damage can lead to stricture formation and a narrowing of
the lumen which may synergistically add to the sialorrhea.
Other forms of mucosal injury may be due to esophageal viral
infection (herpes simplex virus esophagitis) leading to the
irritation and reflex salivation. Pill impaction, particularly with
vitamin C, non steroidal anti- inflammatory drugs (aspirin,
acetaminophen, ibuprophen, etc.) potassium chloride, quinidine
gluconate, fosamax and other drugs that can impact, cause
irritation, inflammation and possible stricture formation.
Clinically, the patient experiences dysphagia and sialorrhea that
may appear hours to weeks after pill ingestion depending on the
type and degree of injury.
Assessment of the abnormally salivating patient should begin with
a thorough history and complete physical examination. Therapy
for esophageal-related sialorrhea must be directed at treating the
underlying disorder. Swallowed objects that become impacted
should be promptly removed during an endoscopic exam.
Esophageal obstruction by strictures can be treated with dilation
and cancer obstruction by surgery or placement of an esophageal
stent. Achalasia is managed medically by pneumatic dilation or
with intrasphincteric botulinum toxin (Botox A) injection and
surgically by laparoscopic myotomy. Therapy for reflux esophagitis
is best done by prescribing proton pump inhibitors (PPI) and by
laparoscopic antireflux surgery in severe cases.
Direct therapy on the salivary glands may be used to reduce saliva
production in severe cases. These include drugs, radiation therapy,
Botox injection, and surgery.
In conclusion, sialorrhea or enhanced salivary flow, is not only a
relentless annoyance, but can also lead to serious complications.
More importantly, excessive saliva may be indicative of a serious
esophageal disease. Only by identifying and treating the underlying cause can the patient regain the qualities of physical and social
life and potential complications be prevented.
5TH ANNUAL POSTGRADUATE COURSE
Esophageal and Gastric Disorders
December 4-6, 2003
Location: Boardwalk Inn, Walt Disney World,
Orlando, FL
For further information contact: University of South Florida Office of
Continuing Professional Education, P.O. Box 550610, Tampa, FL 33655-0610 Or
Fax to: (813) 974-3217
(thoracotomy). Currently a modification of the Heller myotomy,
called a laparoscopic myotomy, can be performed using the laparoscope
and
accessory instruments through several small incisions in the
abdominal wall. As more experience has been gained this
procedure has become the preferred technique when the surgical
approach is elected. Current long-term improvement is being
confirmed in over 80% of cases. If the sphincter muscle is rendered
too weak by myotomy, there is a risk for acid in the stomach to
reflux into the esophagus and cause esophagitis or a stricture.
Surgeons may attempt to reduce this risk by performing an
antireflux operation at the time of the myotomy. Even if this
problem occurs the acid reflux can be adequately treated by acid
suppressing drugs.
Another treatment for achalasia used for the past 10 years is the
injection of a bacterial toxin, clostridium botulinum toxin-A
(Botox) into the esophageal sphincter. The botulinum toxin
prevents the release of a chemical (acetylcholine) from the nerves
in the lower esophageal sphincter resulting in relaxation and
reduction of the high sphincter pressure. Botox is injected through
a small needle passed through the endoscope. The procedure is
performed as an outpatient procedure and requires about 10
minutes to complete. This effect prevents the muscle from
contracting which leads to increased emptying and improvement
of the patient’s swallowing and regurgitation in about 80% of cases.
This technique fails in 10 to 15% of patients. Its only significant
drawback is its limited duration of relief. The good effects are
gradually lost over a 6 to 12 month period (some patients have
good symptom relief for 12 to 18 months and a few even longer) as
new nerve endings sprout and regrow with a return of the high
sphincter pressure. Complications are very rare and in those who
respond swallowing is greatly improved within several days.
We have been using Botox injection for achalasia since 1993. This
treatment is most useful in patients who are ill with other medical
problems, those who refuse other
forms of therapy, as an urgent temporizing therapy for students in
the middle of a school year and those who are malnourished or
otherwise not candidates for surgery.
During the past 10 years we have had the opportunity to evaluate
514 patients with achalasia. Initial therapy has included pneumatic
dilation or Botox injection in the majority. Laparoscopic myotomy
has been effective in those not satisfied with or who fail medical
treatments. This surgical option may be most appropriate as initial
therapy in younger individuals since it produces the best long-term
symptom relief.
SIALORRHEA:
AN OFTEN UNRECOGNIZED SIGN OF ESOPHAGEAL DISEASE
Michael R. Bakheet, M.D.
Sialorrhea or ptyalism is an excessive salivary flow leading to a
common patient complaint of, “I have a lot of foamy mucus in my
mouth!” Sialorrhea occurs with conditions that promote an
increase in saliva secretion and/ or disturb its passage through the
esophagus into the stomach. Within the oral cavity, three major
salivary glands (parotid, submandibular, and sublingual) as well as
several minor glands produce more than a quart of saliva each day.
Consequently, the esophagus is continually bathed by a stream of
saliva as it passes into the stomach.
Esophageal conditions that promote sialorrhea are grouped into
two broad categories: mechanically stimulated salivation due to an
esophageal obstruction and chemically stimulated salivation due
to esophageal inflammation. Ultimately, the function of such
heightened salivary flow, via the esophago- salivary reflex, is to
flush out the impacted object or to neutralize the offending agent.
Variables such as salivary volume, viscosity, chemical makeup, and
acidity (increased flow is associated with a more alkaline or higher
pH saliva) are adjusted by the body in the resultant product based
presumably on the offending condition or agent.
Saliva contains over 65 different substances. The major ones
include a lubricating glycoprotein (mucin) for food bolus passage,
digestive enzymes (amylase and lipase) for preliminary starch and
fat digestion and antimicrobial agents (lysosomal enzymes and IgA
antibody) as well as several electrolytes (for example: hydrogen,
potassium and sodium). Collectively, these products work in
concert to support the digestive process, promote oral hygiene,
participate in taste conduction, and protect the esophageal
epithelium from noxious agents.
Sialorrhea has significant implications due to its incessant nature,
as well as its potential for several complications. At a minimum,
laryngeal penetration (fluid enters only the larynx above the vocal
cords) and aspiration of saliva below the vocal cords into the
trachea (wind pipe) will lead to hoarseness, cough and a choking
sensation. Aspiration is most prevalent in patients that have
difficulty with the passage of saliva through the pharynx or
esophagus due to oropharyngeal dysmotility, advanced obstruction
(progressive cancer or stricture formation) or an esophageal
neuromotor disorder, such as achalasia. Thus, the retained salivary
pool accumulates in the lower pharynx and/ or esophagus and may
eventually enter the larynx, trachea, bronchi, and ultimately the
lung. Aspiration may lead to bronchitis and pneumonia as well as
chronic cough. When aspiration volume is high, the resulting
decreased oxygenation (hypoxia) may lead to rapid heart rate
(tachycardia), chest pain, cyanosis, an altered mental state, and
even respiratory failure. The risk of aspiration is greatest in
patients with associated oropharyngeal dysmotility, extremes of age
(elderly/ pediatric) or the severely debilitated patient. These
persons may not sense the aspirated saliva (silent aspiration), fail
to clear the saliva by coughing and thereby develop pneumonia.
Other consequences of sialorrhea, albeit less detrimental, include
social stigmas as the patient may have profound drooling or
hypopharyngeal pooling requiring the need to regularly evacuate
the oral cavity by spitting or wiping the corner of the mouth with a
tissue to achieve relief. When sialorrhea is severe, patients
typically will have to carry a tissue or “spit cup” at all times. This
creates a disturbing, major social incapacity. Nocturnal sialorrhea
can cause chronic sleep disturbance, as the patient has to regularly
wake up to “clear my throat.” This will lead to daytime fatigue, and
somnolence. For those with intact oropharyngeal function, there
will be a need to swallow often to clear the extra saliva. Each
swallow delivers air into the gastrointestinal tract. Increased
swallowing frequency may lead to symptomatic air swallowing
(aerophagia) with resultant gas bloating, flatus, and pain.
Any swallowed object that is retained within the esophagus
will stimulate local mechanoreceptors (mechanical/ physical
receptors) leading to increased salivation. Impacted foreign bodies
(bones, coins, dentures, etc.) typically present in a characteristic
combination of painful swallowing (odonophagia) and sialorrhea.
A sufficiently prolonged impacted object can lead to scar tissue
deposition and stricture formation. Ultimately, such scarring
will lead to a decrease in lumen diameter and further promotion of
sialorrhea.
Neoplasms (malignant or benign tumors) that grow into the
esophageal lumen will reduce the normal esophageal diameter
causing a blockage. Similar to an impacted foreign object, such a
growth in the esophageal wall will lead to sialorrhea.
Webs, rings and strictures narrow the esophageal lumen producing
prolonged eating times and food retention. Sialorrhea is typically
noticed by the patient only after there is an acute blockage or
impaction of food into one of these narrowed areas.
Achalasia, is a pathologic condition that is defined by an absence
of esophageal peristalsis or motility in the lower two thirds of the
esophagus. Often, there is an excessively tight (hypertensive)
lower esophageal sphincter causing food retention associated
esophageal enlargement (megaesophagus) and chest pain. Food
and saliva passage into the stomach is prevented leading to retrograde flow or regurgitation of saliva. The saliva or “foamy mucus”
floats atop the retained food, typically appearing as the first
substance to be regurgitated. Sialorrhea and its problems are a
consistent occurrence in patients with achalasia.
Similar to mechanically stimulated sialorrhea, inflammatory irritation (due to chemical ingestion, local viral infection, etc.) of the
inner esophageal wall layers (mucosa and submucosa) will result in
an increase of salivary flow. Local chemoreceptors (chemical
receptors) enhance salivary secretion rate when stimulated. These
receptors also have the capability to detect heat (thermoreceptors)
or chemical concentrations (osmoreceptors).
Gastroesophageal reflux, the most common cause of chemical
irritation to the esophagus elicits water brash, a characteristic
reflux- related variation of sialorrhea that has a typically bitter
frothy quality detected in the patient’s mouth. It occurs as a reflex
to provide protection of the esophageal mucosa from acid injury.
Ingestion of corrosive substances (lye, acid, bleach, etc.) will
irritate the mucosa and induce hypersalivation. Additionally, the
tissue damage can lead to stricture formation and a narrowing of
the lumen which may synergistically add to the sialorrhea.
Other forms of mucosal injury may be due to esophageal viral
infection (herpes simplex virus esophagitis) leading to the
irritation and reflex salivation. Pill impaction, particularly with
vitamin C, non steroidal anti- inflammatory drugs (aspirin,
acetaminophen, ibuprophen, etc.) potassium chloride, quinidine
gluconate, fosamax and other drugs that can impact, cause
irritation, inflammation and possible stricture formation.
Clinically, the patient experiences dysphagia and sialorrhea that
may appear hours to weeks after pill ingestion depending on the
type and degree of injury.
Assessment of the abnormally salivating patient should begin with
a thorough history and complete physical examination. Therapy
for esophageal-related sialorrhea must be directed at treating the
underlying disorder. Swallowed objects that become impacted
should be promptly removed during an endoscopic exam.
Esophageal obstruction by strictures can be treated with dilation
and cancer obstruction by surgery or placement of an esophageal
stent. Achalasia is managed medically by pneumatic dilation or
with intrasphincteric botulinum toxin (Botox A) injection and
surgically by laparoscopic myotomy. Therapy for reflux esophagitis
is best done by prescribing proton pump inhibitors (PPI) and by
laparoscopic antireflux surgery in severe cases.
Direct therapy on the salivary glands may be used to reduce saliva
production in severe cases. These include drugs, radiation therapy,
Botox injection, and surgery.
In conclusion, sialorrhea or enhanced salivary flow, is not only a
relentless annoyance, but can also lead to serious complications.
More importantly, excessive saliva may be indicative of a serious
esophageal disease. Only by identifying and treating the underlying cause can the patient regain the qualities of physical and social
life and potential complications be prevented.
5TH ANNUAL POSTGRADUATE COURSE
Esophageal and Gastric Disorders
December 4-6, 2003
Location: Boardwalk Inn, Walt Disney World,
Orlando, FL
For further information contact: University of South Florida Office of
Continuing Professional Education, P.O. Box 550610, Tampa, FL 33655-0610 Or
Fax to: (813) 974-3217
CONTINUING MEDICAL EDUCATION
MEDICAL STAFF
The Center for Swallowing Disorders has continued active
participation in graduate medical education by lectures at
regional, national and international meetings and by contributions to the medical literature.
Director . . . . . . . . . . . . . . . . . . . . . . H. Worth Boyce, Jr., M.D.
Professor of Medicine
Hugh F. Culverhouse Chair in Esophagology
Lecture Presentations by CSD Staff
Patient Care . . . . . . . . . . . . . . . . . . . . Janet L. Jones, B.A., CGC
Coordinator
Instructor of Medicine
December 5-7, 2002: Joy McCann Culverhouse Center for
Swallowing Disorders 4 th Annual Postgraduate Course,
Esophagology for Clinicians: Esophageal Disorders: From A to Z for
2003: 1) Endoscopic Esophageal Anatomy: The Basis for
Endoscopic Diagnosis, 2) Botulinum Toxin Type A Injection –
Indications, Locating the LES and Details of Technique and 3)
Uncommon, Complex, High Risk Strictures. Boardwalk Inn, Walt
Disney World, FL (Boyce)
December 5-7, 2002: Joy McCann Culverhouse Center for
Swallowing Disorders 4 th Annual Postgraduate Course,
Esophagology for Clinicians: Esophageal Disorders: From A to Z for
2003: Esophageal EUS Basics and Benign Disorders and Diagnosis
and Medical Therapy of Esophageal Sequelae of GERD. Boardwalk
Inn, Walt Disney World, FL (Johnson)
January 20-21, 2003: 13 th Endoscopy Masters’ Forum:
Endoscopic Surgery by Flexible Endoscopy: Advanced
Technique/Technologies and Future Trends. Orlando, FL (Boyce)
February 22, 2003: Mayo Clinic in Scottsdale Winter
Gastroenterology Meeting: Esophageal Gastroenterology Linked
to Endoscopy & Hepatology. Strictures: 1) Using Classification to
Guide Therapy; 2) Endoscopic Anatomy of the LES and BOTOX
Injection: Who, When, How? Scottsdale, AZ (Boyce)
March 21-22, 2003: Walter Reed Gastroenterology Symposium:
Rings, Webs, and Things: Diagnostic Clues and Caveats for
Therapy. McLean, VA (Boyce)
March 29, 2003: University of South Florida College of
Medicine. Update on GERD & Common Swallowing Disorders
For Primary Care. Clearwater, FL (Boyce, Johnson, Jones)
Contributions To Medical Literature
Boyce HW: Barrett esophagus: Endoscopic findings and what to
biopsy. J Clin Gastro (accepted for publication 2003).
Bloomston, M, Fraiji E, Boyce HW, Gonzalvo A, Johnson MC,
Rosemurgy A: Preoperative Intervention Does Not Affect
Esophageal Muscle Histology or Patient Outcomes in Patients
Undergoing Laparoscopic Heller Myotomy. Jnl Gastrointest Surg
2003;7(2):181-190.
Joy McCann Culverhouse
Center for Swallowing Disorders
University of South Florida
University of South Florida Health Sciences Center
12901 Bruce B. Downs Blvd., MDC Box 72
Tampa, FL 33612
Medical Staff . . . . . . . . . . . . . . . . . . . . .Milton C. Johnson, M.D.
Associate Professor of Medicine
Assistant Patient Care . . . . . . . . . . . . . . . . Betsy J. Lamoy, R.N.
Coordinator
VOLUME 15
JUNE 2003
Office Manager . . . . . . . . . . . . . . . . . . . . . . . Candace K. Harley
DIRECTOR’S FORUM
Administrative Secretary . . . . . . . . . . . . . . . . . Natalie A. Ralyea
ACHALASIA
Appointment Secretary . . . . . . . . . . . . . . . . . . . Jennifer C. Rust
Speech Pathology Consultants for
Oropharyngeal Swallowing Disorders
Speech Pathology . . . . . . Joy E. Gaziano, M.A., CCC/SLP
Linda Stachowiak, M.S., CCC/SLP
Things To Remember
OFFICE HOURS: 8:00 a.m. ‘til 4:30 p.m. Monday through Friday.
Telephone hours: 8:00 a.m. ‘til 5:00 p.m.
Also, our emergency telephone number for after hours is (813) 974-2201
BILLING: Payment for services rendered is due at the time of your
visit. Please be prepared to pay any co-payments due at the time of your
visit to the Center.
Patients who have problems with their physician or facility fee bills
should contact Gayle Stephens, Financial Specialist, at the University of
South Florida Medical Clinics at (813) 974-3575 between the hours of
9:00 a.m. and 4:00 p.m. Monday through Thursday.
For those patients who are from out-of-town, a new toll-free number has
been added for you to call with billing questions. The number is 1-888873-3627. This number is for calls originating in Florida and is only for
billing questions and help with insurance authorizations.
HAS YOUR INSURANCE COMPANY OR PRIMARY CARE
PHYSICIAN CHANGED? With an ever changing medical insurance market (shopping for the best contract, companies merging, others
closing their doors, etc), you may have changed insurance company. If
you changed your insurance company you may have a new primary care
physician. Maybe you have moved and had to choose a new doctor closer
to your home. Regardless of the circumstances we would very much
appreciate your contacting our office to let us know, (813) 974-3374.
This will not only insure we can obtain the necessary authorizations/
pre-certifications and that your medical bills go to the right insurance
company but it will help us make sure your medical records are forwarded
to the right doctors. Thank you for helping us keep the records straight.
NON-Profit Organization
U.S. Postage
PAID
Tampa, FL
Permit No. 1632
NUMBER 1
H. Worth Boyce, M.D.
Professor of Medicine and Director
The term chalasia means to loosen or relax. This condition is seen
Endoscopy reveals a large esophagus with retained food and fluid.
in newborns, especially premature infants who regurgitate after
However, if the patient is properly prepared before this exam by
most feedings for the first several months of life. At about four
two days of clear fluids, only a small amount of liquid content is
months of age the lower esophageal sphincter (valve) begins to
found. A clean esophagus is essential at the time any treatment is
close normally between swallows and the regurgitation from the
performed. The endoscope passes into the stomach through the
stomach is prevented. The opposite is true for achalasia that occurs
closed lower esophageal sphincter with mild to moderate resistance.
at any age between childhood and the ninth decade having an equal
The diagnosis of achalasia is best confirmed by performing an
frequency between males and females. Achalasia is a disorder
esophageal manometry (motility) study which confirms the loss
characterized by a loss of peristalsis (propulsive muscle contractions
of peristalsis in response to swallows and usually an elevated
or movement) in the esophagus and failure of the lower esophageal
pressure in the lower esophageal sphincter which typically relaxes
sphincter to relax and allow emptying of the esophagus.
incompletely or not at all after a liquid swallow taken during the
The cause of achalasia is unknown (idiopathic). There is a loss of
manometry study.
nerve cells in the Auerbach plexus between the two muscle layers
Once the diagnosis is established, a decision regarding therapy is in
of the esophageal wall and in the lower esophageal sphincter. This
order. Some patients with early achalasia and mild symptoms may
defect results in the loss of peristalsis, which is needed to push food
elect to delay treatment or try medical (drug) treatment. Such
into the stomach, and the failure of the lower esophageal sphincter
treatment with calcium channel blocker drugs may help by
to relax and allow food to enter the stomach. These changes result
transiently relaxing the closed sphincter but this response is usually
in failure of esophageal emptying and retention of solid and liquid
short-lived and not reliable for long-term use.
foods in the esophagus. Over time the esophagus enlarges and
Ultimately most patients opt for some form of treatment. None
holds more and more contents. Regurgitation (return of
of the treatments available will improve the peristalsis in the
esophageal contents into the throat and mouth) occurs as a conseesophagus. All are designed to weaken the lower esophageal
quence of both overflow and abnormal esophageal contractions.
sphincter. The standard medical treatment option is dilation of
Failure of emptying into the stomach, regurgitation and, in some, a
the tight sphincter with balloon dilators, available in diameters of
fear of eating, all may lead to weight loss. Patients learn to improve
30, 35 and 40 mm. These instruments are intended to over-stretch
esophageal emptying by eating slowly and swallowing extra fluids
the sphincter to the point that the muscle fibers lose their ability to
which serve to flush esophageal contents into the stomach. The
contract tightly and thereby allow the esophagus to empty more
problems with esophageal emptying and regurgitation can cause
efficiently. This form of therapy provides good to excellent
considerable embarrassment in social settings. Regurgitation,
improvement in from 70 to 90% of patients depending on the size
especially at night when the patient is recumbent, can result in
of balloon used. The main risk of this treatment is perforation or
aspiration of fluid into the lungs causing bronchitis
full-thickness tear of the esophagus that occurs
and pneumonia. Another aggravating factor is sialin 2 to 5% of patients. If this occurs a surgical
orrhea, which is the production of large amounts of
operation usually is needed to close the tear. At
saliva in response to the esophageal obstruction.
the same operation a myotomy or muscle
Patients notice the sialorrhea as a large amount of
splitting operation to treat the achalasia is
“foamy mucus” requiring frequent swallows or
usually performed to provide definitive treatment.
expectoration to keep the hypopharynx free from
In past years, when balloon dilations had failed
this bothersome fluid (see article herein).
on two occasions, an operation called a Heller
The diagnosis of achalasia should be first suspected
myotomy (surgical cutting of the sphincter
after the physician takes a complete history. A
muscle) was recommended. This surgical
barium swallow (esophagram) reveals a dilated
procedure gave good or excellent results when
esophagus with a large amount of retained barium
performed by an experienced surgeon but
and usually some food particles. The esophagus at
required an incision through the chest wall
the lower sphincter is tapered to show a narrow
column of barium likened to the shape of a bird Figure 1. Barium esophagram of typical appearance of a dilated esophagus and a tight lower esophageal sphincter
(arrows). Barium enters the stomach slowly by gravity depending on the level of pressure in the sphincter.
beak (Figure 1).