Dysphagia

Overview and Facts about Dysphagia

Dysphagia is the medical term used to describe difficulty swallowing. There are two main types of dysphagia: oropharyngeal dysphagia and esophageal dysphagia.

Oropharyngeal dysphagia includes preparing food in the mouth, initiating the swallow process and passing the food from the mouth through the throat (or pharynx) and into the esophagus.

Esophageal dysphagia is difficulty passing food down through the esophagus and into the stomach.

Signs and Symptoms of Dysphagia

The most common signs of dysphagia include:

• Aspiration pneumonia
• Change in voice or being hoarse
• Coughing or choking with swallowing
• Difficulty initiating swallowing
• Drooling
• Heartburn
• Nasal regurgitation
• Sensation of food being stuck in the throat or chest
• Weight loss

Causes and Risk Factors of Dysphagia

Oropharyngeal dysphagia can be caused by muscular disorders, throat tumors and cancers, or neurologic conditions that interfere with the nerves controlling the muscles of the mouth, back of the throat, and upper esophageal sphincter (the muscle at the top end of the swallowing tube).

These disorders and conditions include:

• Benign masses or tumors of the throat
• Brain tumor
• Cancer of the mouth, throat and larynx
• Cerebral palsy
• Dementia
• Multiple sclerosis
• Parkinson’s disease
• Radiation treatment to the head or neck
• Spinal cord injury
• Stroke
• Traumatic brain injury
• Zenker’s diverticulum - a rare condition affecting older people in which a large sack develops in the upper part of the esophagus

Esophageal dysphagia is caused by an obstruction in the throat or the narrowing of the esophagus due to:

• Achalasia
• Eosinophilic esophagitis
• Esophageal cancer
• Esophageal eysmotility - poor coordination of the esophageal muscles
• Esophageal webs or strictures
• Gastroesophageal reflux disease (GERD)
• Radiation treatment to the head or neck

Tests and Diagnosis of Dysphagia

When a patient is being evaluated for dysphagia, several medical professionals, including a specialist in otolaryngology (ENT) will perform a series of tests. These tests will help pinpoint the cause of the difficulty swallowing and determine whether the patient has oropharyngeal or esophageal dysphagia. Potential tests include:

• Video swallow study (Modified barium swallow): a speech pathologist watches swallowing occur under x-ray when foods and liquids coated with barium (a white, pasty material) are given. The speech pathologist monitors, records and evaluates how different consistencies of swallowed material is processed from the mouth to the beginning of the esophagus.
• Flexible laryngoscopy: a flexible scope is inserted through the nose to look at the throat, pharynx and larynx. This study gives basic information regarding the form and function of the throat structures.
• Esophagram: an x-ray evaluation of the esophagus is performed after swallowing liquid barium in the radiology department by a radiologist. It is used to evaluate abnormalities in the contour of the esophagus as well as how the muscles of the esophagus move ingested materials into the stomach. Esophageal manometry determine the strength and coordination of the muscles of the esophagus.
• pH and impedance testing: these tests detect reflux activity and categorizes reflux episodes as being acidic or nonacidic.
• Fiberoptic endoscopic evaluation of swallowing (FEES): performed either by a laryngologist or speech pathologist, this test involves swallowing foods and liquids of different consistencies while flexible laryngoscopy is being performed. The exam visualizes the swallowed foods or liquids to determine if they are entering the airway (aspiration) and is used to examine motor and sensory functions of swallowing.
• Transnasal esophagoscopy (TNE): a flexible scope with a camera is inserted through an anesthetized nose and fed through the throat, into the esophagus and to the stomach. This screening tool is useful in evaluating the esophagus in patients with acid reflux, throat pain and swallowing symptoms.
• Esophageal Manometry: a small catheter is inserted into the esophagus in our gastroenterology department to measure the strength and coordination of the muscle contractions of the esophagus. This gives important information regarding the functioning of the esophagus.
• Esophagogastroduodenoscopy (EGD): this is performed by gastroenterologists under sedation to thoroughly evaluate the esophagus and stomach.

Treatment and Care of Dysphagia

The treatment your specialist recommends will be determined by the diagnosis along with a patient’s individual needs, circumstances, symptoms and other more. Treatments can vary and include medications, swallowing therapy, endoscopic or other “open” surgical procedures.

Treatment options can include:

• Swallowing therapy: swallowing therapy can be thought of as physical therapy for the throat. Similar to physical therapy that involves the exercising and strengthening of arms or legs, swallowing therapy strengthens and trains throat muscles, and gives strategies to promote a safe swallow. The therapies are usually weekly and can last from 4-8 sessions, sometimes more if needed.
• Zenker’s diverticulum: if a Zenker’s diverticulum is causing symptoms, surgical treatment may be recommended. Surgery consists of severing the tight cricopharyngeal muscle (CPM) and either removing or altering the pouch. The procedure can be performed either endoscopically (through the mouth) or transcervically (through an incision in the neck). With the endoscopic approach, the esophagus and diverticulum are visualizled through a special tube through the mouth. The wall between these two structures is divided thereby simultaneously severing the CPM and opening the diverticulum directly into the esophagus. With the transcervical approach, a skin incision is made in the neck. The CPM is severed and the diverticulum is removed.
• Cricopharyngeal myotomy: the cricopharyngeal muscle (CPM) is severed when its dysfunction is proven to cause swallowing problems. The procedure can be performed either endoscopically (through the mouth) or transcervically (through an incision in the neck). With the endoscopic approach, the CPM is visualized through a special tube through the mouth in the operating room and cut with a laser. With the transcervical approach, a skin incision is made in the neck and the CPM is severed.
• Conservation surgery for throat cancer: endoscopic laser resections as well as open approaches are used to remove cancers while attempting to preserve voice and swallowing function. Comprehensive treatment of these cancers is often done along with medical oncologists and radiation oncologists.