Understanding the Difficulties of Swallowing

Many clinicians find dysphagia challenging to treat, but the UPMC Swallow Disorders Center is trying to change that. Dr. Sandra Stinnett, Director of the Center, talked about this and more in the Eye & Ear Foundation’s December 14th webinar entitled, “It’s a Hard Pill to Swallow: Understanding the Difficulties of Swallowing from the Physician’s Perspective.”

Dysphagia is just a fancy way of saying “difficulty with swallowing,” and has to do with the abnormalities that impact swallowing from the mouth all the way to the stomach. Swallowing is a quality-of-life issue that impacts on many levels, as much of our culture revolves around food. “It is one of the most intricate and fascinating phenomena of the human body,” Dr. Stinnett said. Much of it is involuntary.

Physiology of Deglutition (the action or process of swallowing)

  • Solids/liquids pass from mouth to stomach
    • 1/3rd mouth to throat
    • 2/3rd by the esophagus
  • Brain – central swallowing centers
    • Floor of 4th ventricle, medulla, cortex, vomiting, and respiratory centers
  • Swallow 580 times daily
    • Oro-pharyngeal phase (voluntary phase)
    • Esophageal phase (involuntary)

Esophageal Phase

  • Food propelled through esophagus by involuntary wave of contraction
    • Relaxation at the upper esophageal sphincter (gatekeeper)
      • Cricopharyngeus muscle
    • Primary peristaltic wave initiated by swallowing
      • 2 to 4 cm/s – reaches distal esophagus about 9 seconds

Swallowing Deficits

Swallowing deficits can either be structural – mechanical or obstructive – or functional – neurologic or muscular.

Oropharyngeal – difficulty initiating swallowing

Functional – sensation of difficulty swallowing with no neuromuscular/anatomical abnormality

Esophageal – difficulty passing food down the esophagus

Neuromuscular – damage to nerve or brain

Signs and Symptoms

Many people manifest their symptoms in the throat.

  • Pain and difficulty swallowing
  • Sensation of food getting stuck into throat
  • Coughing or gagging
  • Nasal regurgitation
  • Dysarthria (slurred speech)
  • Nasal speech
  • Heart burning
  • Acid brash or food in throat
  • Unintentional weight loss

Mechanical/Obstructive vs Neuromuscular

Mechanical/Obstructive can result from esophagitis, GERD, infections/inflammatory, medications, radiation, caustic injury, stricture, diverticulum, external compression, UES disorders, or a foreign body.

Neuromuscular swallowing difficulties can result from acahalasia, spasm, autoimmune, oculopharyngeal, myopathy, CVA, multiple sclerosis, or myasthenia gravis.

Working up the “Goose”

  • Eating Assessment Tool – 10 (EAT-10)
  • Reflux Severity Index (RSI)
  • Flexible laryngoscopy
    • Pharyngeal Squeeze Manueuver
  • Flexible Endoscopic Evaluation of Swallow (FEES)
    • Penetration Assessment Scale (PAS)
  • Sensory testing
    • Laryngeal Adductor Reflex (LAR)
  • Transnasal esophagoscopy (TNE)
    • Guided Observation of Swallow in the Esophagus (GOOSE)
  • High Resolution Manometry

How it Started and How it’s Going

What once took weeks to schedule a procedure can now be done in the clinic, which can be a one-stop shop in treating and diagnosing the patient. This is also cost effective and saves time. TNE is an example of a procedure that’s accurate, tolerated, and involves less stress.

Why Should We Care About Dysphagia?

Because it matters to quality of life. Patients are not always aware of some interventions that exist. A number of papers are coming out to address swallowing issues and there are trials implementing therapy and interventions. Studies are just scratching the surface, however. More has to be done and made standard care, Dr. Stinnett said.

Awake/Office-Based Procedures

  • Challenging anatomy
  • Unable to tolerate general anesthesia
  • Patient preference
  • Can diagnose and treat
  • Less “down time” for patient
  • More procedures by surgeon

Future Implications

  • UPMC Swallow Disorders Center to provide multidisciplinary dysphagia care
    • Solid SLPStrong relationship with GI and Thoracic
    • Neurology, Neurosurgery, Rheumatology
  • Paucity of data regarding dysphagia in ENT
    • Interventions
    • Office based
    • Disparities
  • Locoregional, national, and international collaborations
    • Standardization of protocols
    • Courses for clinicians
    • Multi-institutional research initiatives
    • Prospective study

The A-Team

Tamara Wincko, MS, CCC, SLP, Director of SDC

Sandra Stinnett, MD, MS, Director of SDC

Jonas T. Johnson, MD, Director of Survivorship

As Dr. Stinnett said, they are in the right place, positioned to make a difference.