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Swallowing Disorders

What are swallowing disorders? 

Swallowing is a complex process in which many muscles and nerves that work together to receive food into the mouth, prepare it and move it from the mouth, to the throat, down the esophagus and into the stomach.  This happens in three stages: the oral phase, the pharyngeal phase and the esophageal phase.  Dysphagia or “difficulty swallowing” is a symptom that can range from the feeling of a simple lump in the throat with no identifiable swallowing impairment, to the experience of severe swallowing impairment.  

Swallowing dysfunction can involve any of the stages of swallowing. It may diagnosed by a physician, such as an otolaryngologist, and a specialized speech-language pathologist. Swallowing dysfunction can have concerning health consequences, including weight loss, dehydration and choking. Swallowing dysfunction can also lead to secretions, food or liquid entering the lungs, placing a person at risk for developing pneumonia or other respiratory complications. 

Swallowing dysfunction requires a multidisciplinary approach to care, as it can arise from a wide variety of causes including, but not limited to:   

  • Gastroesophageal reflux disease
  • Normal aging
  • Dysfunction of the upper esophageal sphincter (e.g. cricopharyngeal bars or webs, Zenkers diverticulum)
  • Cancer or surgery of the head/neck (e.g. tumor, radiation/chemotherapy side effects or after surgical interventions to head, neck, cervical spine)
  • Neurological causes such as stroke, amyotrophic lateral sclerosis (ALS), Parkinson's disease, Alzheimer's dementia or other neuromuscular or neurogenerative disorders 
  • Traumatic causes such as head or spine injury 
  • Infectious, autoimmune and inflammatory causes (e.g. viral conditions, rheumatologic disorders, myositis, acid reflux)
  • Structural abnormalities (e.g. diverticula, esophageal stricture and tumors)
  • Medication induced abnormalities (e.g. from antipsychotics, muscle relaxants, anticholinergic)

Signs of potential swallowing dysfunction are numerous. These include but are not limited to the following:

  • Loss of saliva, food or liquids from the mouth
  • Difficulty chewing and controlling liquid or food in the mouth
  • Prolonged time to complete a meal
  • Food or meal refusal
  • Pain upon swallowing
  • Coughing and/or throat clearing before, during or after swallowing
  • Gurgly voice after food or liquid intake
  • Sensation of food sticking in the throat or chest
  • Regurgitation of food or liquid after meals
  • Inability to eat specific food types
  • Extra effort needed to chew and swallow
  • Weight loss
  • Frequent pneumonia or upper respiratory infections of unknown cause 

Diagnosis and Treatment

Weill Cornell Medicine’s highly-trained multidisciplinary team of otolaryngologists and specialized medical speech-language pathologists provide a unique comprehensive approach to the evaluation and treatment of swallowing disorders by providing advanced diagnostic and imaging techniques to evaluate of all the stages of the swallowing process.  Based on the exams, the team may recommend additional medical and surgical interventions with the otolaryngologist or other specialized physician or suggest therapeutic and rehabilitative techniques with the speech-language pathologist. 

 

Diagnostic Procedures 

Office laryngoscopy:

Office laryngoscopy is the gold-standard evaluation of the larynx and the pharynx, and one of the most commonly performed procedures in otolaryngology. Office laryngoscopy is a key component of the diagnostic armamentarium, as it can uncover important etiologies of swallowing dysfunction, such as laryngeal injuries (e.g., vocal fold paralysis, subglottic stenosis), malignancies, and laryngopharyngeal reflux. It is often combined with flexible endoscopic evaluation of swallowing (FEES). 

Transnasal esophagoscopy: 

The transnasal esophagoscope allows to perform unsedated esophageal exams and procedures. Controlled studies have demonstrated the equivalent diagnostic accuracy and image quality of TNE with conventional peroral endoscopy.

Flexible Endoscopic Evaluation of Swallowing (FEES):

A small flexible endoscope with a video camera is inserted through the nose down the throat to allow the speech-language pathologist and physician to observe pharyngeal swallowing anatomy and function as liquids and foods of various consistencies are swallowed. FEES can be used to identify aspiration (food or liquid entering the airway) and residue left over in the throat.  Speech pathologists may trial strategies during the evaluation to improve swallow safety or efficiency. FEES can also serve as a valuable biofeedback for educating patients about the nature of their swallowing problem and can be used to teach patients various swallowing techniques. 

Fluoroscopic studies

Fluoroscopy is a foundational component of diagnostic evaluation of swallowing dysfunction, both in the inpatient and the outpatient setting. It involves the use of radiography and barium to evaluate the anatomy and function of swallow.

    1. Videofluoroscopic Swallow Study (VFSS), also known as Modified Barium Swallow (MBS): 

This exam is completed in a Radiology suite by the speech-language pathologist in conjunction with a radiologist. The patient swallows various consistencies of barium contrast while a real-time video x-ray is used to visualize the swallowing function from the mouth to the stomach.  VFSS can be used to identify aspiration (food or liquid entering the airway) and residue left over in the mouth or throat.  Speech-language pathologists may trial strategies during the evaluation to improve swallow safety or efficiency. 

    2. Esophagram:

The comprehensive videofluoroscopic esophagram protocol allows for evaluation of structural and motility disorders of the esophagus. Like the modified barium swallow, it is performed in the radiology suite.

High-Resolution Esophageal Manometry with Impedance (HRM)

A manometer catheter is passed through the nose and throat and then swallowed into the esophagus. The catheter remains in place for several minutes while the patient swallows various volumes of salt water. The manometer has 36 sensors that measure pressures in the throat and esophagus to evaluate esophageal motor function.  

High-Resolution Pharyngeal Manometry:

The same catheter used in esophageal manometry is used to assess pharyngeal function, including strength and coordination of swallow. This approach also provides an opportunity for biofeedback during swallow therapy with a speech pathologist.

Ambulatory pH testing

Gastro-esophageal reflux disease is a common cause of dysphagia, and ambulatory pH testing is a central diagnostic instrument in a dysphagia practice. The indications for pH testing in patients with dysphagia include the diagnosis of GERD as possible etiology of dysphagia, (2) the investigation of dysphagia symptoms refractory to reflux treatment when reflux has been identified as the cause of dysphagia. We offer catheter-based pH monitoring at our clinic. The pH catheter is placed through the nose in the fasting patient, at the completion of the manometry study.

Treatment 

Swallowing Therapy

The speech-language pathologist specializes in the evaluation and treatment of the oral or pharyngeal phases of swallowing and can provide you with a customized diet consistency plan with specific swallowing strategies, new techniques, and/or an individualized therapy plan that may involve strengthening or improving the coordination of the oral-pharyngeal swallowing muscles.  

Swallowing rehabilitation at Weill Cornell Medicine by the speech-language pathologist is provided in the clinic, or is also available via telehealth to appropriate candidates. The speech-language pathologist will incorporate various techniques that are tailored to each individual’s specific swallowing impairment(s). These advanced techniques may include but are not limited to:  

  • Individualized exercise-based therapy program 
  • Biofeedback therapy with FEES or pharyngeal HRM
  • Respiratory muscle strengthening training with including use of EMST-75/EMST-150 or The Breather devices. 
  • Assessment of tongue and lip strength and tongue strengthening therapy with an oral manometer- Iowa Oral Performance Instrument (IOPI). 
  • Prophylactic head and neck swallowing exercise program for patients before, during and after head and neck cancer treatment. 

Office dilation of the esophagus using balloons

Endoscopic alloon dilation of the esophagus has been demonstrated to be as safe and effective. The balloon dilators allow visualization of the area being stretched, simultaneous use of two balloons and unsedated procedures. Indications for office-based transnasal esophageal balloon dilation include cricopharyngeus muscle dysfunction and post-radiation stricture.

 

Office Botulinum toxin injections

Botulinum toxin (Botox) causes temporary muscle paralysis via chemical denervation. In the clinic, Botox may be injected (1) in the cricopharyngeus muscle for patients with laryngectomies experiencing dysphagia related to cricopharyngeus muscle dysfunction, (2) in the lower esophageal sphincter for the treatment of achalasia or hypertensive sphincter.

 

Office injection laryngoplasty 

For patients with one paralyzed vocal fold or atrophy of the vocal folds, dysphagia symptoms and function may be improved with injection augmentation of the affected vocal fold with fillers. Cough function may also gain efficiency with the same intervention, facilitating airway clearance.  

 

Office injection pharyngoplasty

Injection pharyngoplasty may be offered to patients with soft palate dysfunction and nasal regurgitation. The procedure involves injection of a filler into the posterior pharynx to add bulk and reduce the gap with the soft palate.

 

Surgical interventions

Surgical interventions include cricopharyngeal myotomy and myectomy, thyroplasty, adduction arytenopexy, hypopharyngoplasty, laryngohyoid suspension, tubed supraglottoplasty, and are discussed on a case-by-case basis.

Sean Parker Institute for the Voice Weill Cornell Medical College 240 E 59th Street New York, NY 10022 Map it