Condition: Swallowing Disorders

Dysphagia is a term that describes the inability, or reduction in the ability to swallow. It is a very common symptom affecting around 22% of adults over 50, and nearly all adults over the age of 80.

Depending on the cause, the degree of dysphagia may vary from being subtle and short-lived to more profound and permanent. In extreme cases, this results in the inability to ingest food or fluid via the mouth with a risk of feed going down the voice box (or larynx) and windpipe (or trachea), causing repeated life-threatening chest infections called aspiration pneumonias.

Consultant Gastroenterologist, Dr Rami Sweis, provides an overview of swallowing disorders, common symptoms, and how the condition can be investigated in a healthcare setting.

New dysphagia requires a careful assessment to make an accurate diagnosis as there may be many causes. The most important thing however, is to exclude a cancerous growth in the swallowing apparatus or on the nerves that supply them.

Please seek medical attention if there is a progressive history of difficulty swallowing solids, weight loss, pain when swallowing, a constant neck or ear pain or new neck lump that you can feel. These symptoms may indicate an underlying malignancy.

Because the swallowing mechanism is a complex intricate coordination of nerve and muscle groups within the tongue, throat (or pharynx) and gullet (or oesophagus), dysphagia is also a common feature of neurological disorders. In the early stages, conditions like Parkinson’s disease or Multiple Sclerosis are more likely to cause difficulty in swallowing liquids in comparison to solids.

Other relatively common causes of dysphagia include a thickening in the valve muscle (called the cricopharyngeus) that separates the throat musculature from that of the gullet. This is called cricopharyngeal hypertrophy and may be caused or exacerbated by untreated heartburn (otherwise called gastro oesophageal reflux or GORD). If very severe, cricopharyngeal hypertrophy may additionally lead to an outpouching of the throat lining above it through a small muscular defect, creating a “pharyngeal pouch”. (picture) Food material may get trapped in this pharyngeal pouch and may characteristically be regurgitated into the mouth a little while later. There is an associated risk of food spilling into the airway and lungs from the pouch to cause pneumonia, particularly in elderly people.

Untreated GORD and other inflammatory and degenerative conditions of the oesophagus can cause scarring called a stricture (a narrowing). Stricturing is also a particularly troublesome long-term complication of radiotherapy that can occur years after treatment.

External compression from surrounding structures such as a bony outgrowth from the spinal column or a very enlarged thyroid gland may also cause dysphagia.

Assessment consists of a careful history including the completion of validated questionnaires designed to identify specific difficulties that might have otherwise been ignored, but will affect further management.

A neurological examination will be performed with a full head and neck examination including mouth, tongue, tonsils and an endoscopic assessment of the tongue base, pharynx and larynx.

Specialist assessments may be undertaken including instrumental swallow assessments such as a video swallow or a flexible endoscopic evaluation of swallow (FEES). These are complementary tests designed to assess how food and fluid pass around the larynx and also demonstrate any discoordination of the swallowing muscles from tongue to upper oesophagus.

The assessments may provide you with feedback on any strategies and compensatory manoeuvres that you may be taught to compensate for the dysphagia.

Transnasal (through the nose) oesophagoscopy (TNO) with a high-resolution camera that allows super slow-motion video playback is useful to exclude malignancy in the upper swallowing apparatus including the oesophagus. It is very well tolerated under local anaesthesia and any suspicious areas may be biopsied.

If the dysphagia is thought to arise from the oesophagus or stomach and there is no obvious lesion seen on the above examinations, you may be referred to our gastroenterology colleagues.

A barium swallow and/ or a CT scan of the neck and chest and sometimes an MRI scan of the brain may be used to identify any blockage, growths or neurological conditions that may cause dysphagia.

Occasionally, despite negative findings on the above clinical and cross-sectional imaging studies and if you remain symptomatic, your clinician may counsel you about performing an examination of your upper airway and digestive tract under general anaesthesia during which time any suspicious areas will be biopsied.

Medical and surgical management will usually be directed at the underlying diagnosis as well as encompassing dietary and lifestyle modifications to improve exacerbating factors such as dry-mouth or GORD.

Complex dysphagia requires collaborative work with a speech and swallow therapist. We will develop an individualised programme of exercises designed to help your swallow, aiming to divert food away from the airway in an aspirating larynx, strengthen the tongue musculature and the external muscles that surround the throat and provide strategies to clear food and fluid that may have entered the larynx.

Surgical procedures to improve swallow may be recommended after careful assessment as outlined above and will vary depending on the abnormalities found, but here are some examples.

If there is an abnormality in the larynx that predisposes to aspiration, such as a vocal cord palsy, this could be corrected by injection of an artificial tissue substance into the larynx to help temporarily move or “medialise” the vocal cord. A permanent medialisation could be performed using a non-dissolving implant. This will improve voice and cough and the ability to clear away food debris that may have soiled the airway.

A thickened upper oesophagus sphincter or ring of muscle in the cricopharyngeus segment may be relaxed by injection of botulinum toxin through the mouth under a short general anaesthetic and the area gently dilated with a balloon. If this is effective then a more permanent solution may be offered: either a minimally invasive laser division of the muscle through the mouth (endoscopic) or division of the muscle through an external neck incision.

A pharyngeal pouch may be similarly addressed via an endoscopic (through the mouth) stapling or laser procedure, although very large ones can only be treated through a neck incision.

Pharyngeal and upper oesophageal strictures including those caused by radiotherapy may be gently dilated with a balloon, following the injection of botulinum toxin. Depending on the cause, this procedure may need to be repeated.

Other less commonly employed larynx suspension type procedures are designed to fix the voice box skeleton to the mandible and/ or hyoid bone. This raises it against the base of tongue. Food is then more likely to flow over a partially closed and therefore protected larynx. The suspension may also stretch open the cricopharyngeal muscle segment allowing smoother transit of food into the oesophagus.

Globus Pharyngeus.

This term isn’t a diagnosis but is commonly used to describe the sensation of a lump or a foreign body or pressure in the throat.

The sensation may be exacerbated when you swallow your own saliva. In the majority of people, particularly if there are no other associated symptoms the cause is benign, however for peace of mind it is important that you are fully examined by an experienced ENT surgeon with a specialist interest in laryngology or Head and Neck surgery. This is in order exclude the rare possibility of a cancer in the throat, back of tongue or the upper gullet. An endoscopic examination of the swallowing apparatus including the gullet is a vital component. This can often be performed in the outpatient clinic.

If there are any concerning features in your history or examination, additional tests such as a CT, MRI and/ or dynamic X-ray swallowing studies may be required to help with the diagnosis.

Assuming malignancy has been excluded, the cause of globus sensation is usually multifactorial but probably originates from irritation of the muscular wall of the lower throat/ upper gullet (oesophagus). Conditions like gastro oesophageal acid reflux (GORD) and oesophageal dysmotility; irritants such as cigarette smoke, pollution or cleaning chemicals and inflammatory fluid drip from the back of the nose are common culprits that may amalgamate to cause a globus sensation. Nasal blockage and consequent mouth breathing tend to dry the throat, particularly during sleep. Some medications can cause a dry mouth or cough and may contribute. Sometimes an external lump that partially compresses the upper gullet, such as from an enlarged thyroid or a bony growth in the spine may cause a globus type symptom.

There is often an initial trigger event such as infection, or injury to the throat or neck. Globus sensation is often a sequel of an acute psychologically stressful situation and it is important that this be addressed in conjunction with any physical ailments.

For most patients, symptoms may resolve following a thorough clinical examination, an empirical course of anti-reflux treatment and lifestyle changes, including hydration and a healthy anti-reflux diet. If dynamic X ray studies of the swallow demonstrate some motility problems, medicines that help coordinate contraction may be helpful (prokinetics or neuromodulators). If all of these measures fail to alleviate symptoms you may be referred to a gastroenterologist to confirm GORD and exclude and treat other oesophageal and gastric pathology.