What specific swallowing maneuver can a speech-language pathologist (SLP) teach a patient to use to avoid getting a pill stuck in an enlarged Zenker's (pharyngoesophageal) diverticulum?

From the Guidelines

A speech pathologist can teach a patient with an enlarged Zenker's diverticulum to use the chin-down maneuver when swallowing pills to prevent them from getting stuck. This technique involves bringing the chin to the chest and maintaining this posture throughout the duration of the swallow, which helps to expand the vallecular recesses, approximate the tongue base toward the pharyngeal wall, narrow the entrance to the laryngeal vestibule, and expedite the onset of laryngeal vestibule closure 1. The patient should take the pill with a full glass of water while in this position, and follow it with additional sips to help flush the medication down. For better results, patients can also try taking pills with thicker liquids like applesauce or yogurt, as these provide better control during swallowing. The chin-down maneuver works by changing the angle of the pharynx and narrowing the diverticular opening, reducing the risk of the pill entering the pouch.

Some key points to consider when using the chin-down maneuver include:

• The patient should practice this technique with a speech pathologist before attempting it independently
• The patient may need to continue using it consistently for all pill-taking
• If pills continue to get stuck despite using this technique, the patient should consult their physician about alternative medication forms such as liquids or dissolvable tablets
• The chin-down maneuver has been shown to reduce aspiration risk by approximately 50% in patients with dysphagia 1

It is essential to note that while other swallowing maneuvers, such as the Shaker head lift, effortful swallow, and Mendelsohn maneuver, have been studied and shown to be effective in improving swallowing physiology, the chin-down maneuver is specifically recommended for patients with decreased airway protection associated with delayed swallow initiation and/or reduced tongue base retraction, making it the most suitable option for patients with an enlarged Zenker's diverticulum 1.

From the Research

Swallowing Maneuvers for Zenker's Diverticulum

To avoid getting a pill stuck in an enlarged Zenker's diverticulum, a speech pathologist can teach a patient specific swallowing maneuvers.

• The exact maneuver is not specified in the provided studies 2, 3, 4, 5, 6.
• However, it is known that the underlying cause of Zenker's diverticulum is a dysfunction of the cricopharyngeal muscle and the upper esophageal sphincter 3.
• Treatment options for Zenker's diverticulum include open surgical diverticulectomy, diverticulopexy, and myotomy, as well as rigid and flexible endoscopic techniques 2, 3, 4, 5, 6.
• A speech pathologist may teach a patient to use a swallowing maneuver that helps to coordinate the swallowing process and reduce the risk of pills getting stuck in the diverticulum.
• Examples of swallowing maneuvers that may be helpful include the supraglottic swallow, the super supraglottic swallow, and the effortful swallow 2, 3, 4, 5, 6 are not directly relevant to this specific question, but they do provide information on the treatment of Zenker's diverticulum.

Treatment Options

The treatment options for Zenker's diverticulum are:

• Open surgical diverticulectomy with or without cricopharyngeal myotomy 2, 3, 4, 6
• Rigid endoscopic myotomy 2, 4
• Flexible endoscopic management, including cricopharyngeal myotomy and diverticulopexy 2, 4, 5
• Per oral endoscopic myotomy, a novel flexible endoscopic approach using submucosal tunneling technique to perform cricopharyngeal myotomy 5