Swallowing Problems - Dysphagia

Normal swallowing function achieves two goals: transporting food from the mouth to the stomach and protecting the airway. There are 3 phases of swallowing: oral (mouth), pharyngeal (throat), and esophageal.

During the "oral" phase, food is chewed, mixed with saliva, and pushed to the back of the mouth. This part of swallowing is voluntary.

Once the food enters the pharynx (throat), swallowing becomes involuntary, stimulated by reflexes. At this point, normal swallowing propels the food downward towards the esophagus, and prevents

food from going up behind the nose or into the lungs. If food enters the airway and goes into the lungs, this is called "aspiration" and may result in pneumonia and serious illness.

Once the food is in the esophagus it is propelled downwards to the stomach.

Normal swallowing requires the coordinated action and communication of the brain, brainstem, nerves, and muscles. Impairment of normal swallowing results in "dysphagia" or swallowing problems, and may result in aspiration.

• Poor fitting dentures
• Dry mouth
• Acid reflux
• Neurologic disease, such as stroke, Parkinson's disease, Alzheimers, and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)
• Vocal fold paralysis
• Infection
• Strictures
• Tumors
• Surgery

• Esophageal motility problems
• Cricopharyngeal spasm (The cricopharyngeus muscle is the upper esophageal sphincter. If this is too "tight" food will have difficulty passing through, resulting in dysphagia).
• Zenkers diverticulum (Zenkers diverticulum is a pouch which forms above a chronically "tight" cricopharyngeal muscle. Undigested food is retained in the pouch and often regurgitated by patients).
• Medications
• Aging

Anyone with difficulty or pain with swallowing, unexpected weight loss, history of aspiration pneumonia, or choking with eating should have a swallowing evaluation. People at high risk for "silent

aspiration" (aspiration of food into the lungs without any obvious signs, such as coughing), such as the elderly, stroke patients, and other debilitated patients should be evaluated.

When you come for a swallowing evaluation a complete head and neck examination will be performed. The physician may look at your throat and larynx (voice box) with a mirror or a small flexible scope. Your physician then may recommend additional testing.

At Lakeshore ENT, we offer two important tests for the evaluation of dysphagia. These include:

Flexible Evaluation of Swallowing with Sensory Testing (FEESST)

This test is an alternative to the videoesophagram (modified barium swallow) and is useful for testing both the motor and sensory components of swallowing. It is performed by Dr. Adam Rubin and one of our speech language pathologists.

A flexible scope is passed gently through your nose. Small puffs of air will be used to test laryngeal sensation and the laryngeal reflex, which is critical for protection of the airway. We will proceed to have you

swallow foods of different consistencies that are stained with a green dye. We then watch the food pass from the mouth into the esophagus, to see where it may be held up and to make sure it does not enter the larynx.

The advantages to FEESST are that we are able to directly visualize swallowing without the use of x-rays, try different therapeutic maneuvers during the examination, and provide immediate results and recommendations. There is no radiation exposure and you do not need to swallow any barium.

Transnasal Esophagoscopy

Some patients with dysphagia require an endoscopy of the esophagus. Traditionally, this has been performed either under general anesthesia or sedation. Transnasal esophagoscopy is a short procedure (often only 5 - 10 minutes) requiring only topical anesthesia. The procedure does not carry the additional risks of sedation. Patients may return to work the same day.

Depending on what we find with the swallowing study, a number of recommendations may be made. We may have you avoid foods of certain consistencies. We may teach you physical maneuvers to assist with your swallowing. If reflux plays a large role in your swallowing difficulties, we may place you on medication and make additional dietary recommendations.

Some problems, such as cricopharyngeal spasm may be treated with injections of BOTOX® in the office.

Others, such as Zenkers diverticulum or a stricture may require surgery. We can usually perform this surgery endoscopically, without any incisions in the neck.

If a patient is at high risk for silent aspiration, we may recommend a feeding tube to be placed in the stomach. There are a number of other surgeries which attempt to prevent food and saliva from entering the airway. These are typically reserved for patients at high risk of aspirating their own saliva.