Swallowing Disorders: Causes, Diagnosis, and Treatment

Introduction:

Swallowing refers to muscular movements controlling the mouth, the back of the throat (pharynx), and the food tube (esophagus). Swallowing occurs involuntarily without even thinking about it. Yet it is a complex and vital function, as it is very important for eating and social interaction. Swallowing happens in three phases.

• Oral (mouth): Chewing the food along with saliva.

• Pharyngeal (throat): Pushing the food from the mouth to the esophagus.

• Esophageal (food pipe): Sequential passing of food into the stomach without backflow.

What Is Meant by Swallowing Difficulty?

The medical term used for difficulty in swallowing is dysphagia. A patient may also complain of trouble in moving food through the mouth, pharynx, and food pipe. Sometimes, the patient might pinpoint the level of sticking of food. If it is said to be above the suprasternal notch, then the site of obstruction is the oropharynx. Pointing to the level of the chest might indicate food pipe obstruction. The condition is more common in the elderly.

What Are the Types of Swallowing Disorders?

There are two terms that explain the problems with swallowing,

Dysphagia: A sense of discomfort with choking or coughing during swallowing.

Odynophagia: Pain during swallowing.

Often both the conditions are presented together and addressed as dysphagia.

What Are the Symptoms of Swallowing Disorder?

Associated symptoms relevant to dysphagia are:

• Pain.

• Weight loss.

• Presence of a mass in the neck.

• Change in voice.

• Regurgitation of foods.

• Aspiration of food.

What Are the Causes of Swallowing Disorders?

Dysphagia can be due to mechanical reasons or due to abnormalities in the muscles controlling the action of swallowing.

1. Mechanical Causes:

• Obstruction to the movement of the bolus of food (chewed food with saliva).

• Foreign bodies.

• Tumors.

• Webs or rings in the food pipe.

• Narrowing of the passage in the food pipe following cancerous growth or due to ingestion of acids or alkalis.

• Sometimes compression of the food pipe can occur from outside as in cervical spondylitis, a thyroid mass, or a mass in the chest.

2. Abnormalities of Muscles Controlling Swallowing Can Lead To Trouble Swallowing:

• Paralysis of tongue muscles.

• Paralysis of muscles of the pharynx (due to stroke).

• Neurological disorders like myasthenia gravis.

• Muscle disorders.

• Disorders of muscles or nerves of the food pipe like achalasia.

• Cerebral palsy.

• Alzheimer's disease.

How Swallowing Disorders Are Diagnosed?

Diagnosis of swallowing problems is suspected from history. Difficulty in swallowing solids can indicate mechanical while liquid can indicate neurological disorders.

Initial consultation with a family doctor and referral to an ENT (ear, nose, throat) specialist might be needed. The ENT doctor starts with the examination of the inside of the throat and then proceeds with an indirect laryngoscopic examination of the throat. This test involves placing a mirror inside the mouth after pulling your tongue and holding it with cotton. The patient is asked to breathe/say 'Aaa' or 'Eee' for visualization of the food pipe area. This test usually is well tolerated by most patients after proper explanation and reassurance before the test.

Investigations relevant to dysphagia are barium swallow (a type of X-ray test), and endoscopic examination of the food pipe if mechanical causes are suspected.

Endoscopy:

An endoscopy is a procedure to visualize the upper digestive tract using a tiny camera with a light inserted through the mouth into the esophagus.

In endoscopy,

• Sedation or anesthesia is given.

• The endoscope is inserted.

• The physician may look for any abnormalities in the pharynx (back throat), esophagus (food pipe), and stomach.

• Ulcers, narrowing of the esophageal opening, and tumors can be evaluated in endoscopy.

• A piece of the diseased tissue can be removed (biopsy) for further microscopical evaluation.

Barium Esophagram:

Swallowing disorders can be assessed well in barium esophagram. The structure and the function of the gastrointestinal tract can be better viewed. Barium is a radiocontrast material used to highlight the body parts in the radiograph.

In barium esophagram,

• The patient under investigation is given liquid barium to swallow as a whole and X-rays are passed to get the images.

• Barium washes and covers the lining of the food tract and makes it clear for visualization.

• The sequence of X-rays can be performed to assess the swallowing pattern.

Esophageal Manometry:

Pressure is usually generated inside the esophagus during swallowing. The changes in the pressure can be measured in esophageal manometry.

In esophageal manometry,

• A tube is inserted through the mouth or nose.

• The tube has multiple attached pressure sensors that record the muscle activity during swallowing.

• Water or food can be given to trigger the action and the real-time movement can be measured.

• Esophageal manometry gives information about the ability of the esophageal muscles and the sphincter that controls the bolus movement.

pH Testing:

The acidic pH in the lower esophagus is checked to evaluate the acid reflux symptoms like heartburn and irritation during swallowing. A ph sensor chip is introduced into the digestive tract and left in place for two days, that records the data and transmits the information.

How Swallowing Disorders Are Treated?

The treatment of swallowing problems depends on the cause. Sometimes, they go away on their own, while at other times, treatment by a specialist may be necessary. Meanwhile, it is good to follow some lifestyle modifications like eating soft food, chewing very little food at a time, taking syrup or crushed forms of medication, etc.

The treatment option includes,

• Medication to treat muscular and neurological dysfunction.

• Artificial saliva can be used to prevent dryness.

• Dilation to broaden the constricted esophagus.

• Stent placement in the esophagus to retain the dilation.

• Surgery may be needed to remove tumors.

Conclusion:

The swallowing disorder can deprive the person of getting proper nutrition and energy. The patient should understand the underlying cause of swallowing problems and try to avoid the triggering factors. Lifestyle modifications and exercises can help in most cases. When swallowing difficulties are not addressed properly, it may lead to complications like severe cough, dehydration, malnutrition, and pulmonary complications.