Dysphagia, or difficulty swallowing, has many causes. Although most patients with dysphagia complain of discomfort and annoyance, dysphagia can have grave consequences such as aspiration, malnutrition, and death. The swallowing mechanism is among the most complex in the body. With more than 20 muscle groups and 4 cranial nerves involved in the process, all of which are coordinated in a stepwise manner in less than 10 seconds, it is surprising that more people do not have dysphagia. The primary goals for evaluation are diagnosing the cause, securing a safe airway free from aspiration, and initiating treatment. Cervical dysphagia has traditionally been a “black box” for both otolaryngologists (ENT) and gastroenterologists often requiring multiple tests and close collaboration.
Though at times difficult to diagnose, the cause of most swallowing disorders can be found and treated. At the very least, a safe airway without aspiration must be secured.
- Lump in Throat
- Throat Clearing
- Food Sticks
- Regurgitation of undigested food
- Mucous (Phlegm)
- Cough at Meals
- Recurrent Pneumonia
- Wet, gurgly voice
The diagnosis of dysphagia can be difficult since there are numerous systems involved in a normal swallow. The patient’s history helps to pinpoint the location and timing of the swallowing problem. The diagnostic testing, aided by an explosion of new technology in the last decade, helps to find the cause:
- TNE. Trans-Nasal Esophagoscopy is an office based non-sedated esophagoscopy with topical anesthesia that takes 2-3 minutes to perform. The esophagus can be completely visualized, allowing for a functional examination and biopsy if needed.
- FEES. Fiberoptic Endoscopic Evaluation of Swallowing provides direct visualization of the laryngopharynx while the patient swallows food and liquids. Aspiration events can be identified, as well as any associated sensory deficits.
- pH Testing. New ambulatory 24 Hour Nasopharyngeal pH testing allows for simple, painless recording of laryngopharyngeal reflux episodes.
- Manometry. This procedure measures pressure in the pharynx and esophagus.
- MBS. Modified Barium Swallow is a radiographic exam that visualizes the oral and pharyngeal phases of swallowing, as well as identifying possible esophageal involvement in the swallowing disorder.
Treatment is guided by the cause:
- Medical therapy for reflux, allergy, and secretion management includes proton pump inhibitors, anti-allergy medications, anti-cholinergics, botulinum toxin injections, and pro-motility drugs.
- Surgical therapy can include esophageal dilations, endoscopic laser-assisted cricopharyngeal myotomy, and endoscopic Zenker’s diverticulectomy.
Management involves the use of compensatory strategies that are designed to change the environment or behavior of the patient to facilitate intake. Examples include dietary recommendations regarding consistencies of liquids and food, positioning, and swallow techniques (e.g. head turn, chin tuck).
Treatment involves an individual therapy plan to change swallow physiology. Examples are oral motor exercises, Shaker exercises and electrical stimulation.