Swallowing Disorders

If you experience frequent problems moving food or liquid from your mouth to your stomach, you may have dysphagia, which is a term for difficulty swallowing. Dysphagia may also be accompanied by pain when swallowing.

Occasional difficulty swallowing, which may occur when you eat or drink too quickly, is not cause for concern. However, persistent dysphagia may indicate a serious medical condition requiring treatment. Dysphagia can occur at any age but is more common in older adults.

Swallowing Disorders We Treat

Our specialists are skilled in treating the full range of swallowing disorders, including:

• Zenker’s diverticulum
• Eosinophilic esophagitis
• Esophageal stricture
• Cricopharyngeal dysfunction
• Radiation induced dysphagia 
• Neurologic dysphagia

Symptoms of a Swallowing Disorder

Swallowing disorders can involve a range of symptoms, including:

• Pain while swallowing (odynophagia)
• Inability to swallow
• Sensation of food getting stuck in your throat or chest
• Drooling
• Regurgitation (bringing food back up)
• Frequent heartburn
• Food or stomach acid which backs up into your throat
• Unexpected weight loss
• Coughing or gagging when swallowing
• Needing to cut food into smaller pieces
• Avoiding certain foods because of trouble swallowing

If you have experienced difficulty swallowing liquids or solids daily for more than two to four weeks, you should make an appointment with a specialist.

Causes of Swallowing Disorders

Several conditions can interfere with the process of swallowing. Most of the time, dysphagia can be identified as esophageal dysphagia or oropharyngeal dysphagia.

Causes of Esophageal Dysphagia

Esophageal dysphagia refers to the sensation of food sticking in the base of your throat or in your chest after you’ve started to swallow. Some 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 down the esophagus through a series of well-timed contractions. Sometimes, these contractions become irregular or stop, causing a sensation of pressure in the chest or food sticking in the throat.
• 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 esophagus.
• Esophageal ring: A thin area of narrowing in the lower esophagus that can intermittently cause difficulty swallowing solid foods.
• Cricopharyngeal muscle dysfunction: The cricopharyngeus is the muscle that serves as the entryway to the esophagus. This must relax enough for food to pass through when you swallow. Sometimes, this muscle remains tight. You may feel like some foods stick in your throat or are very difficult to swallow.
• 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 make swallowing difficult.
• Radiation therapy: This type of cancer treatment can lead to inflammation and scarring of the esophagus.
• Zenker’s diverticulum: This is an esophageal pouch that develops in the upper esophagus and can cause debilitating dysphagia and regurgitation of food. When patients attempt to swallow, food can get caught in the Zenker’s diverticulum rather than progressing to the stomach.

Causes of Oropharyngeal Dysphagia

Oropharyngeal dysphagia involves difficulty with movement of food and liquids from your mouth to your throat and esophagus when you start to swallow. If you have oropharyngeal dysphagia, you may experience choking, gagging, or coughing when swallowing. You may have the sensation of liquids or solids “going down the wrong pipe” (going into the airway) or going up the nose. Frequent episodes of liquids or solids going into the airway may lead to pneumonia. Some (but 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 muscles, 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 cause oropharyngeal dysphagia.
• Radiation/Chemotherapy: Following treatment for some cancers (such as pharyngeal cancer, tonsil cancer, and base of tongue cancer), you may experience oropharyngeal dysphagia, Chemotherapy and radiation therapy can cause stiffness to the swallowing muscles, making it more difficult to swallow. 
• Age: As you get older, you may experience a weakening of the swallowing muscles, which for some people can lead to difficulty swallowing.

Diagnosing a Swallowing Disorder

If you are having difficulty swallowing, your doctor will ask about your symptoms and may perform or refer you for two or more of the following tests:

• Flexible laryngoscopy: This test is used to view the structures of the larynx (throat). A small flexible camera is passed through the nasal passage, through the nasopharynx (the connection between the nose and throat), and down into the throat. A topical anesthetic is used for maximum comfort during the examination. The exam takes around one to two minutes and is not painful.
• Transnasal esophagoscopy (TNE): Similar to the flexible laryngoscopy, a TNE is a camera that passes through your nose. It is slightly larger and longer than the laryngoscope and can see the inside of the esophagus to the stomach. This test can be done in the office without sedation. After the nose and throat are numbed, the patient swallows the camera without discomfort. The exam takes around 10 minutes.
• Modified barium swallow study (MBS): This test is used to view your swallowing safety and efficiency. You will be asked to swallow substances mixed with barium, such as liquids of various viscosities, pudding and a graham cracker. Barium is a whitish substance that allows the substances foods to light up under an X-ray so the examiner can determine how these substances move through your mouth, pharynx, and esophagus. This exam also allows us to determine the physiology of one’s impairment, which is helpful in treatment planning.
• Flexible endoscopic evaluation of swallowing (FEES): FEES allows the examiner to see food and liquid as it passes through the throat. In order to view the swallow, a flexible laryngoscopy is performed. While visualizing the throat using the camera, the patient eats and drinks various foods and liquids mixed with food-safe dye. This allows the examiner to determine if/where foods are sticking in the throat and if they are going down the wrong way(being aspirated).  This exam can be performed in the office and does not involve radiation exposure. In contrast to the MBS, which does involve a small amount of radiation exposure, this test cannot be used to evaluate the oral and esophageal phases, cannot view the precise moment of aspiration and is more limited in determining the physiology of one’s swallowing impairment.
• Esophageal manometry: This test shows whether your esophagus is working correctly. It 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) containing sensors is passed through your nose, esophagus, and 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.

Treatments for Swallowing Disorders

Treatment plans may vary depending on the type and severity of dysphagia you are experiencing. The most important things your doctor will consider when determining treatment are nourishment and risk of pneumonia or other pulmonary infections. Treatments for dysphagia may include:

• Dysphagia therapy: A speech and language pathologist provide exercises and strategies to help strengthen the swallowing muscles and re-coordinate the timing of your swallow.
• Diet modifications: Various diet modifications may be recommended, such as thickening liquids or eating purees. These diets are highly individualized.
• Esophageal dilation: If you have a tight esophageal sphincter or an esophageal stricter, your doctor may perform a procedure to stretch or dilate the esophagus.
• Medical management: Some mild cases of dysphagia can be caused by gastroesophageal reflux disease (GERD), and these can be treated with reflux medications.
• Office procedures: Both esophageal dilations, as well as biopsies, can be done in the office using a transnasal esophagoscope, a flexible camera that passes through your nose and down the esophagus to the stomach. For patients wishing to avoid anesthesia or an operating room procedure, many diagnostic biopsies and upper esophageal dilations can be done in the office.
• Feeding tube: In severe cases, a swallowing disorder can lead to an inability to eat or drink enough to maintain proper nutrition. In these cases, a feeding tube is placed.
• Botox injection: If you have cricopharyngeal muscle dysfunction, in which the muscle will not relax enough to let food pass into the esophagus or let air pass into the throat (no-burp syndrome), Botox can be injected to prevent the muscle contraction. This can be done in the office or operating room.
• Surgery: Minimally invasive surgical techniques such as an endoscopic cricopharyngeal dilation, chemodenervation (Botox), myotomy, or Zenker's divericulectomy can be performed in an outpatient surgical procedure. More extensive, open procedures are possible in the operating room and may require an overnight stay.  

Complications of a Swallowing Disorder

Dysphagia can be frustrating because it takes the joy out of eating and drinking. It can also lead to more severe complications such as malnutrition, weight loss, and dehydration. In addition, if you are aspirating (having liquids or solids enter the airway while swallowing), respiratory problems can develop, such as pneumonia, bronchitis, or other upper respiratory infections.