What is the best treatment approach for an elderly female patient with cervical fusion at levels C3-C5-C6, experiencing intermittent laryngitis, dysphagia, and xerostomia?

Post-Cervical Fusion Dysphagia and Laryngitis Management

This elderly patient with C3-C5-C6 fusion presenting with intermittent laryngitis, dysphagia, and xerostomia requires immediate instrumental swallowing evaluation with videofluoroscopy or FEES to assess for hardware-related mechanical complications, followed by ENT evaluation to rule out hardware migration or esophageal adhesions. 1, 2, 3

Immediate Diagnostic Priorities

Rule Out Hardware-Related Complications First

• Obtain lateral cervical spine X-rays immediately to verify hardware position, as screw or plate migration can cause esophageal erosion, dysphagia, and laryngitis even years after surgery 4, 5
• Hardware migration into the esophagus has been documented up to 10 years post-operatively, presenting with chronic laryngitis and dysphagia as the primary symptoms 4, 5
• One case series found that 48% of patients had radiographic swallowing abnormalities pre-operatively (often asymptomatic), but 67% of those with normal pre-operative studies developed post-operative dysfunction 3

Obtain Instrumental Swallowing Assessment

• Videofluoroscopic swallow study (modified barium swallow) is the gold standard for evaluating post-surgical dysphagia, as it visualizes all swallowing phases and identifies specific biomechanical impairments 1, 2
• Clinical examination alone is insufficient—up to 55% of dysphagic patients have silent aspiration without protective cough reflex 1, 2
• FEES (fiberoptic endoscopic evaluation of swallowing) is an alternative that provides direct visualization of pharyngeal structures and can be performed at bedside 1, 2

Consider CT Neck with Oral Contrast

• CT with IV contrast better defines anatomic structures and can identify retropharyngeal fluid collections, abscesses, or hardware displacement compressing the esophagus 1
• Oral contrast administered immediately before examination facilitates interpretation of esophageal integrity and anatomy 1

Most Likely Etiologies in This Patient

Esophageal Adhesions to Hardware (Most Common)

• Extensive adhesions attaching the esophagus to the prevertebral fascia and anterior cervical spine around the periphery of cervical plates are the primary operative finding in patients with persistent post-ACDF dysphagia 6
• These adhesions cause mechanical restriction of esophageal movement during swallowing 6
• Multilevel fusion (as in this C3-C5-C6 case) increases risk due to greater soft tissue swelling and more extensive surgical dissection 3

Hardware Migration or Prominence

• Anteriorly prominent hardware can cause chronic mechanical irritation of the posterior pharyngeal wall and esophagus, leading to inflammation, laryngitis, and dysphagia 4, 5
• Screw migration into esophageal submucosa can occur without frank perforation, causing dysphagia that worsens with swallowing as the hardware rotates 5

Recurrent Laryngeal Nerve Injury

• Vocal cord paresis occurs in a subset of post-ACDF patients and contributes to both dysphonia (laryngitis symptoms) and aspiration risk 3
• This can be transient or permanent and requires direct laryngoscopy for diagnosis 3

Retropharyngeal Infection/Abscess

• Delayed retropharyngeal abscess can occur years after ACDF, presenting with dysphagia but potentially without fever or elevated inflammatory markers 7
• MRI is the imaging modality of choice if infection is suspected despite normal labs 7

Treatment Algorithm Based on Findings

If Hardware Migration or Prominence Confirmed

• Surgical removal of anterior cervical plate and adhesiolysis improves dysphagia in 55% of patients to complete resolution and 32% to mild symptoms only 6
• Average time from initial surgery to revision for dysphagia is 18 months, but symptoms can persist for years 6
• Transcervical retrieval of migrated hardware with adhesiolysis typically results in resolution of dysphagia within 1 week 5

If Adhesions Without Hardware Issues

• Surgical adhesiolysis with or without hardware removal remains the definitive treatment 6
• Conservative management with swallowing therapy alone has limited efficacy when mechanical adhesions are the primary problem 6

If Functional Dysphagia Without Structural Cause

• Implement compensatory strategies: chin-down posture during swallowing reduces aspiration by changing biomechanics and pressure generation 1
• Dietary modifications based on videofluoroscopy findings: thickened liquids reduce aspiration compared to thin liquids in most patients 1
• Progressive swallowing exercises (Shaker exercises, effortful swallow, Mendelsohn maneuver) strengthen cervical and pharyngeal musculature 1

Address Xerostomia Specifically

• Severe xerostomia exacerbates dysphagia by reducing bolus lubrication and increasing aspiration risk 1
• Review medications for anticholinergic effects (common culprits in elderly patients) 1
• Prescribe saliva substitutes and consider pilocarpine if no contraindications exist
• Ensure adequate hydration and oral care to reduce pneumonia risk from aspiration 1

Critical Management Pitfalls to Avoid

• Do not attribute symptoms to "normal post-surgical changes" without imaging verification of hardware position, as late migration can occur years after surgery and cause life-threatening complications 4, 5
• Do not rely on bedside swallowing evaluation alone in elderly post-surgical patients, as silent aspiration is common and clinical signs are unreliable 1, 2
• Do not delay instrumental assessment while continuing dietary modifications that are clearly failing, as this prolongs malnutrition and aspiration risk 2
• Do not assume current speech therapy is adequate without objective data showing what specific impairments need targeting 2
• Do not dismiss chronic laryngitis as unrelated—it may be the primary presenting symptom of hardware erosion into the posterior pharynx 4, 5

Multidisciplinary Coordination Required

• ENT consultation for direct laryngoscopy to assess vocal cord function and visualize posterior pharyngeal wall for hardware prominence 3, 5
• Speech-language pathologist for instrumental swallowing assessment and rehabilitation program 1, 2
• Spine surgeon for evaluation of hardware position and consideration of revision surgery if indicated 6, 5
• Registered dietitian for nutritional assessment and supplementation if oral intake is inadequate 1, 2