Swallowing Disorders

Normal Swallow

The normal swallowing mechanism can be divided into four stages:  preparatory, oral, pharyngeal and esophageal. The first two phases are under the control of the person swallowing (voluntary); the latter two phases are reflexively triggered once the food reaches the throat (involuntary).

  1. Preparatory Phase
    Food is placed into the mouth. A food bolus is formed by chewing and moistened with saliva.  The bolus is kept in the mouth and prepared for swallowing.
  2. Oral Phase
    The food bolus is moved from the mouth to the back of the throat (Pharynx).  The uvula and soft palate elevate to keep the food out of the nose and the back of the tongue pushes the food back into the pharynx. 
  3. Pharyngeal Phase
    The food bolus in the pharynx triggers the swallowing reflex. The bolus of food is squeezed into the esophagus from the pharynx.  Breathing stops during this part of swallowing, with the voice box (larynx) closing in order to prevent food from entering the airway (aspiration).

    At the junction of the throat (pharynx) and esophagus, there are bands of muscle fibers (cricopharyngeal muscle) that create a one way valve.The cricopharyngeal muscle relaxes to allow the food to pass and tightens to keep the esophageal contents from returning back into the throat. This one way valve made of the cricopharyngeal muscle is also known as the upper esophageal sphincter.
  4. Esophageal Phase
    The food bolus moves through the esophagus into the stomach. At the junction of the esophagus and stomach, there are bands of muscle fibers that create a one way valve (upper esophageal sphincter).The muscles relaxes to allow the food to pass and tighten to keep the stomach contents from returning back into the esophagus.
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Dysphagia (Difficulty Swallowing)

A problem involving any of the phases of swallowing can result in Dysphagia. Swallowing is the interplay between two separate but related functions, airway protection and bolus transport. Airway protection is the ability to prevent food from entering the trachea (aspiration) while eating. Bolus transports is the transit of food from the mouth into the stomach. All swallowing disorders alter either one or both of these functions. Various diseases, conditions, or surgical interventions can result in swallowing problems.

Symptoms

The symptoms of Dysphagia vary depending on the anatomic location of the pathology. Symptoms include:

  • Inability to swallow
  • Coughing during or right after eating or drinking
  • Regurgitation of food after eating
  • Wet sounding voice
  • Increased effort or time needed to chew or swallow
  • Food or liquid leaking from the mouth
  • Food or liquid getting stuck in the mouth, throat or chest
  • Recurring pneumonia or chest congestion after eating
  • Weight loss or dehydration from not being able to eat enough

Causes

  • Acid Reflux
    The reflux of acid into the esophagus or the throat can lead to inflammation resulting in Dysphagia.
  • Cricopharyngeal Muscle Dysfunction
    Disorders of the cricopharyngeal muscle lead to malfunction of the upper esophageal sphincter. This results in difficulty passing food from the throat into the esophagus.
  • Foreign Material
    Objects such as fishbone or pills can get stuck in the throat or esophagus resulting in obstruction or difficulty swallowing.
  • Infectious
    Various bacterial, viral and fungal infections can lead to inflammation resulting in Dysphagia.
  • Medications
    Dysphagia can occur secondary to the use of medications. Sedatives can lead to difficulty swallowing, especially in the elderly. In addition, many medications cause a dry mouth (xerostomia), which can interfere with the oral preparatory phase of swallowing.
  • Neurologic Disorders
    Neurologic disorders such as stokes or Parkinson's disease may lead to weakness of the swallowing muscles or lack of coordination of the swallowing mechanism.
  • Trauma
    Trauma to the mouth, throat or esophagus may lead to Dysphagia. Injury from burns or surgeries in the area may lead to scarring or decreased movement resulting in difficulty swallowing.
  • Tumors
    Both benign and malignant tumors can lead to difficulty swallowing. Lesions in the mouth, back of the tongue, throat, voice box, esophagus, thyroid, spine and neck can interfere with swallowing. The tumors can involve the anatomical area responsible for a phase of swallowing, obstruct movement of the muscles, or may cause compression from the outside, thus leading to Dysphagia.   
  • Vocal Cord Paralysis
    Immobility of the vocal cord alters the swallowing mechanism and may lead to the passage of food into the windpipe (trachea), resulting in aspiration.
  • Zenker's Diverticulum
    Zenker's Diverticulum is an out-pouching of a weakened area in the lower throat that collects food and interferes with swallowing.

Diagnostic Studies

In addition to a detailed history of the problem and a thorough physical examination, further testing is occasionally necessary to diagnose the source of Dysphagia. Based on the findings, a variety of studies may be recommended:

  • Laryngoscopy
    The throat (pharynx) and voice box (larynx) are visualized with a thin, flexible endoscope that is passed via the nose. Laryngoscopy shows a magnified view of the laryngeal structures and their movement.
  • Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)
    Flexible endoscopic evaluation of swallowing with sensory testing evaluates swallowing under direct visualization. A thin, flexible endoscope is passed via the nose, allowing a magnified view of the laryngeal structures and movement. The area is then observed while the patient is eating. In addition, the throat's ability to sense food is evaluated.  The sensation of food is important since it leads to the protection of the airway and thus prevention of transit of food into the windpipe (aspiration).  
  • Video Swallow Study
    The patient swallows a variety of liquids and foods mixed with barium, as X-rays of the mouth and throat are taken.  These images show how food passes from the mouth through the throat and into the esophagus.  The study may help diagnose passage of food into the windpipe (aspiration) or other abnormalities of swallowing.
  • Barium Esophagogram
    The patient swallows a variety of liquids and foods mixed with barium, as X-rays of the esophagus are taken.  These images show how food passes from the throat through the esophagus and into the stomach.
  • pH Probe Monitoring
    Sensors placed in various parts of the esophagus measure the level of acidity.
  • Esophageal Manometry
    Sensors placed in the esophagus record pressure changes and muscle contractions.

Treatment

Treatment depends on the cause, symptoms, and type of the swallowing problem. Patients are often treated by a team of specialists including an ENT physician, speech pathologist and neurologist.  Treatment options include swallow therapy, dietary changes, medications, and surgery.

Surgeries of the throat and esophagus are usually performed through the mouth. There is rarely a need for external skin incisions.

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Zenker's Diverticulum

Zenker's Diverticulum is the development of a pouch (diverticulum) in the wall of the lower throat.   It usually occurs in people over age 50. The pouch slowly fills with food with every swallow. Once the pouch is filled, it may spill into the throat, causing coughing and spitting up of food swallowed many hours earlier. The filled pouch may also press on the upper esophagus, making it difficult for food to pass.

The exact cause of developing a Zenker's Diverticulum is not known. It is thought that weakness in the muscle of the throat, dysfunction of the cricopharyngeal muscle (upper esophageal sphincter) and poor swallowing coordination lead its development. For this reason, it is uniformly accepted that division of the Cricopharyngeal muscle is necessary for successful surgical treatment of Zenker's Diverticulum.

There are three surgical methods of treating Zenker's Diverticulum. The endoscopic surgical option is used the majority of the time. The open neck approaches are only utilized when the endoscopic technique is not possible.

  • Endoscopic Zenker's Diverticulum Surgery
    In this surgery, the wall separating the pouch and the esophagus is divided endoscopically.   Surgery is done under general anesthesia, via a laryngoscope, an instrument inserted through the mouth to view the wall separating the esophagus and the diverticulum. Using a laser or a stapling device, the common wall between the pouch and esophagus, which includes the cricopharyngeal muscle, is divided.  This approach eliminates the pouch by making it part of the upper esophagus.  

    Recovery after an endoscopic excision of Zenker's Diverticulum is fast and easy. Patients often go home the same day or the day following surgery. They can drink liquids after the surgery and are usually able to return to a normal and solid diet in approximately a week.
  • Diverticulectomy
    Diverticulectomy involves an operation requiring an incision on the neck in order to access the diverticulum. Open neck techniques are used only when the endoscopic approach is not possible. In this technique, the pouch is identified and removed.   In addition, the cricopharyngeal muscle is divided.

    Patients are often observed in the hospital for three to four days and start a liquid diet three days after surgery. They are usually able to return to a normal and solid diet in approximately a week.
  • Diverticulopexy
    Diverticulopexy involves an operation requiring an incision on the neck in order to access the diverticulum. Open neck techniques are used only when the endoscopic approach is not possible. The pouch is isolated and tacked upside-down so that the mouth of the pouch is in a dependent position. In addition, the cricopharyngeal muscle is divided. Diverticulopexy is less invasive than Diverticulectomy.

    Patients often go home in a few days. They can drink liquids after the surgery and are usually able to return to a normal and solid diet in approximately a week.
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Mani H Zadeh, MD, FACS Like us on Facebook:

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Mani H. Zadeh, M.D., F.A.C.S.
2080 Century Park East
Suite 1700
Los Angeles, CA 90067
Tel: (310) 201-0717
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Email: info@ZadehMD.com

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