Swallowing Disorders

What Are the Symptoms of a Swallowing Disorder?

• Pain while swallowing (odynophagia)
• The sensation of food or liquids getting stuck in your throat or chest
• Coughing while eating or drinking
• Feeling like liquids or solids are “going down the wrong pipe”
• Drooling or liquids running down your chin while drinking
• Regurgitation of food or liquids back up into your mouth or out of your nose
• Frequent heartburn or indigestion
• Unexpected weight loss
• Needing to cut food into smaller pieces
• Taking longer during meal time due to difficulty eating/drinking
• Avoiding certain foods because of trouble swallowing

These are just some of the symptoms someone experiencing dysphagia may have, as there are many different types of swallowing disorders with various symptoms. If you have been experiencing one or more of the above symptoms daily for more than 2-4 weeks, or think you may have other frequent symptoms of dysphagia, you should make an appointment with a specialist.

What Causes a Swallowing Disorder?

Swallowing is a complex process and there are many different medical conditions that can disrupt this process. Dysphagia can be best understood if broken down into two subsections: oropharyngeal dysphagia and esophageal dysphagia.

Oropharyngeal Dysphagia and Its Causes

Oropharyngeal dysphagia is best described as difficulty with timing the movement of food and liquids from your mouth to your throat and upper esophagus when you begin your swallow. If you have oropharyngeal dysphagia, you may experience choking, gagging, or coughing when swallowing. You may have the sensation of liquids and/or solids “going down the wrong pipe” (going into the airway) or going up into the nose. You may also experience the sensation of foods or liquids getting stuck in your throat. Frequent episodes of liquids/solids going into the airway may lead to aspiration pneumonia. Some (but definitely not all) of the causes of oropharyngeal dysphagia are:

• Neurological disorders: Neurological disorders such as multiple sclerosis, muscular dystrophy, Parkinson’s disease, and amyotrophic lateral sclerosis can weaken the swallowing musculature, making oropharyngeal dysphagia a concern.
• Neurological damage: Sudden neurological damage, such as a stroke or brain or spinal cord injury can affect your body’s ability to coordinate the swallow, leading to oropharyngeal dysphagia.
• Cancer and tumors: Depending on their location, some types of cancer and tumors can lead to oropharyngeal dysphagia.
• Radiation: Following radiation for some cancers, specifically those that are supraglottic (i.e. pharyngeal cancer, tonsillar cancer, base of tongue cancer), you may experience oropharyngeal dysphagia, because the radiation frequently causes stiffness to the swallowing musculature.
• Age: As you get older, you may experience a weakening of the swallowing musculature, which for some people can lead to difficulty maintaining appropriate timing of swallowing.
• Muscle Tension Dysphagia: For some people, tension in the throat and with the extrinsic laryngeal muscles can lead to difficulty swallowing or a constant lump in the throat sensation. This is due to the tension and recruitment constantly being placed on the muscles meant for swallowing which can make it difficult for the swallowing mechanism to function normally.

Esophageal Dysphagia and Its Causes

Esophageal dysphagia is best described as difficulty passing food or liquids from the bottom of your throat, through the esophagus (a long narrow tube that connects your throat to your stomach), and down to the stomach.  Some (but not all) of the causes of esophageal dysphagia are:

• Achalasia: When your lower esophageal muscle (sphincter) doesn’t relax properly to let food enter your stomach, it may cause you to bring food back up into your throat.
• Esophageal dysmotility: Once you swallow, the food moves through the esophagus through a series of well-timed contractions.  Sometimes, these become irregular or even absent. The food may not move through the esophagus correctly and the foods or liquids hang out in the esophagus for prolonged periods of time, resulting in the sensation of pressure in the chest or food sticking in the throat.
• Cricopharyngeal muscle dysfunction/CP bar: The cricopharyngeus is the muscle that serves as the entryway into the esophagus.  This muscle must relax enough for food to pass through when you swallow.  Sometimes, this muscle remains tight during swallowing, or cannot relax enough to allow all of your food to pass through.  You may feel like some foods stick in your throat, or are very difficult to swallow.
• Esophageal Stricture: A narrowed esophagus (stricture) can trap large pieces of food. Tumors or scar tissue, often caused by gastroesophageal reflux disease (GERD), can cause narrowing.
• Esophageal Tumor: If an esophageal tumor is present, swallowing tends to become progressively more difficult.
• Foreign Bodies: Sometimes food or another object can partially block your throat or esophagus (though this is rare). Older adults with dentures and people who have difficulty chewing their food may be more likely to have a piece of food become lodged in the throat or the esophagus.
• Esophageal Ring: A thin area of narrowing in the lower esophagus that can intermittently cause difficulty swallowing solid foods.
• Gastroesophageal Reflux Disease (GERD): Damage to the esophageal tissues from stomach acid backing up into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus.
• Eosinophilic Esophagitis: This condition is caused by an overpopulation of cells called eosinophils in the esophagus and can cause effortful swallowing.
• Radiation Therapy: This type of cancer treatment can lead to inflammation and scarring of the esophagus causing difficulty for passage of food and liquids through the esophagus.
• Zenker’s Diverticulum: An esophageal pouch that develops in the upper esophagus can cause debilitating dysphagia and regurgitation of food. When patients attempt to swallow, food can get caught in zenker’s diverticulum rather than heading down into the stomach

How Is a Swallowing Disorder Diagnosed?

If you are having difficulty swallowing or experiencing one or more of the symptoms described above on a regular basis, you should have a swallow evaluation. Your physician will probably refer you to a speech-language pathologist who specializes in dysphagia or to a gastroenterologist to perform one of the following examinations:

Flexible endoscopic evaluation of swallowing (FEES): FEES is an instrumental examination of swallowing that allows the examiner to view food and liquid as it passes through the throat. In order to view the swallow, a small flexible scope is placed into your nose and passed through the nasopharynx into your throat. It is not painful and is very well tolerated. While visualizing the throat through the laryngoscope, a variety of foods and liquids are consumed. In this examination, no radiation exposure is necessary. In contrast to the MBSS, which does involve a small amount of radiation exposure, this test cannot be used to evaluate the oral and esophageal phases and cannot view the precise moment of aspiration.  Therefore, this test is appropriate for many, but not all dysphagia complaints, but can be very beneficial for some and limit radiation exposure. Your physician and speech-language pathologist will determine which type of test is best for you based on your complaints and any previous testing.

Modified barium swallow study (MBSS): This test is used to view your swallowing process from the mouth down to the esophagus. You will be asked to swallow a variety of substances such as liquid, applesauce, and a graham cracker that will be coated in barium. Barium is a whitish paste that allows the foods and liquids to light up under X-ray so the examiner can determine how these substances are moving through your mouth, pharynx, and esophagus.

Esophageal manometry: This test is used to show whether your esophagus is contracting properly. The esophagus is a long, muscular tube that connects the throat to the stomach. Esophageal manometry measures the rhythmic muscle contractions that occur in your esophagus when you swallow. It also measures the coordination and force exerted by the muscles of your esophagus. During this test, a thin, flexible tube (catheter) that contains sensors is passed through your nose, down your esophagus, and into your stomach. Your throat and nose will be numbed for this test. During the test, you will be asked to take small sips of water, and swallow on command.

How Do You Treat a Swallowing Disorder?

Depending on the type and severity of dysphagia that you are experiencing, treatments can vary greatly. First and foremost, treatment must ensure that you are getting enough nutrition and are decreasing your risk for aspiration pneumonia or other pulmonary disease. Your dysphagia team will also take into consideration your quality of life and the impact that eating has on your happiness. Treatments for dysphagia may include (but are not limited to):

• Dysphagia therapy: Exercises and strategies are provided by a speech and language pathologist who specializes in dysphagia to help strengthen the muscles of swallowing, re-coordinate the timing of your swallow, and encourage a safe and effective swallow.
• Diet modifications: Various diet modifications may be recommended depending on your specific type of dysphagia. These may include thickening liquids, eating purees, etc. This is highly individualized and a thorough examination should be performed first prior to altering a diet.
• Esophageal Dilation: If you have a tight esophageal sphincter or an esophageal stricture, your doctor may perform a procedure to stretch or dilate the esophagus.
• Medical management: Some mild dysphagia can be caused by gastroesophageal reflux disease (GERD) and these can be treated with reflux medications. You should not assume your problem is just due to reflux without proper evaluation first.
• Feeding Tube: In most severe cases, a swallowing disorder can lead to an inability to eat or drink completely or not enough to maintain proper nutrition. In these cases, a feeding tube may be placed.
• Botox Injection: If you have cricopharyngeal muscle dysfunction where the muscle will not relax enough to let food pass into the esophagus, Botox can be injected to essentially inhibit the muscle contraction.

Surgery: For some disorders, surgical techniques such as cricopharyngeal myotomy for Zenker’s diverticulectomy may be necessary to resolve the dysphagia.