Voice and swallow are interwoven, Dr. Sandra Stinnett, laryngologist and Director of the UPMC Swallowing Disorders Center, said in the Eye & Ear Foundation’s August 27th webinar, “Bridging the Gap Between Voice and Swallow.” She likened it to an interstate highway, because it is that complex.
Anatomy and Physiology of Voice and Swallowing
Swallowing is the passage of bolus of food/liquid from the oral cavity to the stomach via the pharynx and esophagus, while passing over the laryngeal vestibule. In other words, it basically goes over the voice box mechanism.
Phonation is the sound produced by the passage of air over the vocal folds to produce voice. The larynx’s primary function is to protect the airway followed by producing voice.
Swallowing is partly reflex and partly voluntary control. There are three phases:
- Oral – prepatory -> voluntary
- Pharyngeal – reflex
- Esophageal -> involuntary
The oral phase only takes one-to-two seconds, and involves the jaw, chewing, and sealed lips. The pharyngeal phase is when food touches the trigger point – in only one second. The process is as follows:
- Closure of the nasopharynx and oropharynx
- Closure of the larynx
- Vestibular closure – AE and IA muscles contract
- False folds approximate
- Vocal folds adduct
- Epiglottis covers larynx
- Hyolaryngeal elevation
- Opening of Upper esophageal sphincter (UES)
The esophageal phase takes 10-15 seconds and is when the UES closes and peristalsis takes food down to the stomach.
Dysphonia
Dysphonia is an abnormal change in the way a person’s voice sounds. It has many causes:
- Trauma
- Irritants/toxins: reflux, tobacco
- Infections: laryngitis
- Neurologic: Parkinsons, paralysis, dystonia (inability to control movements), presbylarynx (thinning of the vocal folds)
- Tumors/masses: cancer, benign masses
Videostrobolaryngoscopy
This is a fancy way to describe a camera used to look at the voice box. “It allows us to see places that most clinicians can’t see,” Dr. Stinnett said. Usually, it is employed in a regular exam room. The patient leans forward and is numbed really well with spray, and then a flexible scope goes 5-6 cm through the nose. Physicians can see the structural integrity of the voice box, along with gross mobility and vibratory patterns.
Dysphagia
Dysphagia is a word for disorders of swallowing that render a person unable to safely/efficiently eat or drink. There are several potential causes:
- Structural: Webs, diverticulum, rings
- Neurological: Parkinsons, dystonia, CVA
- Functional: Tension, stress
- Aging: Dementia
- Surgical
Dysphonia is used as a tool for detecting dysphagia. The following symptoms may be seen:
- Hoarseness
- Breathiness
- Vocal fatigue
- Hypernasality
- Velopharyngeal insufficiency
- Tension
- Wet speech
- Weak cough
- Annunciation
Voice and Swallow
Dysfunction in one area can lead to issues in another area. Some examples include:
- Vocal cord paralysis – breathy voice, shortness of breath, difficulty with liquids
- Hypernasal – food regurgitating through nose
- Dysarthria – difficulty chewing/swallowing
- Tension – difficulty with getting food down
There are multiple ways to test swallowing function. One of them is called Fiberoptic Endoscopic Evaluation of Swallow (FEES). Similar to the voice box camera, this involves a camera through the nose. The patient then swallows various consistencies – natural food dyed blue. Several iterations of water are given, with different quantities, and then applesauce and a graham cracker are consumed to see solids and a puree kind of diet.
Another way to assess is an x-ray in a technique called the Modified Barium Swallow Study (MBSS). A speech-language pathologist (SLP) is there. After the swallow is assessed, if it is non-surgical, the SLP will give the patient strategies that can then be tested while doing the swallow assessment. It bypasses the oral cavity, so they cannot get a good assessment of that.
Management and Treatment
Treatment is multidisciplinary, with an ENT, SLP, etc. For dysphonia, voice therapy, surgery, and medications are options. Dysphagia means swallow therapy, diet modification, and/or surgery. If there is a deficit, there are some therapeutic interventions, but they are not a one-and-done kind of thing. The same goes for voice therapy. Patients have to continue implementing the strategies.
There are also some tricks for treatment, like the EMST, or Expiratory Muscle Strength Training Mechanism. It helps patients strengthen muscles involved with breathing, and helps protect the airway and things from going down the wrong pipe.
A fairly new device is the Tongueometer or a similar one called the IOPI, which help with tongue strengthening mechanisms. The Tongueometer has an app that provides feedback and allows patients to see their progression.
On the surgical side, balloon dilation is done regularly in the clinic. Often, these patients need repeat procedures, so offering them the ability to avoid general anesthesia is nice. Patients with vocal fold paralysis can receive injections while awake.