Swallowing Disorders (Dysphagia)

The Voice and Swallowing Institute
New York Eye and Ear Infirmary of Mount Sinai
310 E. 14th Street
New York, NY  10003
TEL: (212) 979-4119

Swallowing problems (dysphagia) have been found to occur in approximately 13 to 14 percent of all hospitalized patients, 40 to 50 percent of patients in nursing homes and approximately 33 percent of the patients in rehabilitation centers. Among the more common reasons for swallowing problems are sudden onset neurologic damage (e.g. stroke, head injury or spinal cord injury), progressive neurologic disease (e.g. Parkinson's disease, motor neuron disease, multiple sclerosis, myasthenia gravis), head and neck tumors and their treatment and medical problems such as rheumatoid arthritis, scleroderma and diabetes. 

Patients with suspected swallowing problems should be carefully evaluated and appropriate treatment initiated in order to prevent complications from their swallowing disorders, such as dehydration, malnutrition, choking and pneumonia. New York Eye and Ear Infirmary's Communicative Sciences Center has been evaluating and treating patients with swallowing disorders since 1992. We provide complete diagnostic and therapeutic intervention in our technologically advanced Swallowing Laboratory. New instrumentation and training have spurred improved videoflouroscopic imaging, timing, and reading of the disordered swallow (procedures include fiberoptic endoscopic examination of the swallow (FEES), flexible endoscopic evaluation of swallowing with sensory testing (FEESST), electromyography, and the modified barium swallow).

Both pediatric and adult clinical assessments are conducted routinely both for the Head and Neck population and for patients with disorders related to GERD, trauma, neurogenic etiologies, and laryngeal incompetence. Treatments include:

Swallowing: An Introduction

Swallowing is a complex process that people who swallow without difficulty often take for granted. We have all experienced the pleasure of eating. From the aromas of our favorite foods as they are being cooked to their flavor once they are ready to eat, the act of eating may be for some among the true pleasures in life. Imagine not being able to taste or smell your food (which may have happened to you if you have had a cold). Often our appetite shrinks when we cannot taste or smell our food. Some people with swallowing problems experience difficulty with tasting/smelling their food. Because of this, they may even lose the motivation to eat as it is no longer enjoyable. 

Apart from the pleasure of eating, eating also serves a very important purpose. As the body expends energy, we replenish our bodies by nourishing it. That is, food allows us to nourish (or feed) the body. Anyone who has ever become weak, dizzy, or light-headed because they delayed eating understands this quite well. You were however probably lucky enough to regain your energy when you were able to eat enough. Some people with swallowing problems already have less energy because they are sick (for other reasons); because they are sick they need to eat in order to build up energy to help them fight the sickness. If they do not have enough energy to chew or swallow a whole meal this would then affect their ability to nourish the body enough to start on the road to getting better. Consider how much energy (and extra time) it may have taken you to chew one small piece of over-cooked meat or a hard piece of bread/roll. Individuals who are sick and have swallowing problems may not have enough energy to completely chew just one mouthful of meat or bread; that would mean they are unable to nourish themselves enough to begin getting better. This situation therefore becomes a vicious circle. 

The basis for eating and nourishing the body is the act of swallowing.

These web pages have been constructed to provide individuals and their family members with some basic information regarding swallowing problems (often called dysphagia) and their treatment. Use the links to the left to navigate the Swallowing (dysphagia) section.

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Swallowing: A Complex Series of Acts

What happens when we swallow? Well, for each mouthful of food or liquid, a variety of things must happen so that we can swallow it safely, in good time, and without wasting or losing any of it. 

Swallowing here refers to the combined acts of:

  1. chewing and preparing food (including getting liquid ready to swallow); this results in a collected mass of food or liquid
  2. transferring the mass back through the mouth to the throat
  3. moving the mass downwards through the throat
  4. passing the mass through the feeding tube (esophagus) to the stomach for digestion 

Below you will find a description of each step:

1. Chewing and preparing (The Oral Preparatory Stage)

When we swallow a mouthful of food or liquid, we start by successfully getting the right amount of food or liquid into our mouths. Obviously, we don’t want to take too much (because it may fall out onto our clothes, plate, or the table or fall into our throats before we are ready to swallow). Also, many individuals have learned to chew with their mouths closed; this is helpful for different reasons with the most obvious being so that food or liquid doesn’t fall or spill out of our mouths as we chew.

As we are chewing and/or preparing the material, we add saliva that helps to make the food easier to chew as well as to keep it all together and create a collected mass called a bolus. We also use our teeth for chewing food. The incisors and cuspids (the front teeth) help to tear and cut the food. The molars (the rear teeth) help to grind food and make a cohesive bolus. When we are chewing something we move the material onto and off of the molars (the grinding surfaces) as we are organizing and unifying one bolus. In addition, our tongue and other parts of the mouth work to help keep the food out of the throat until it is ready to be swallowed. 

2. Transferring the bolus back through the mouth (The Oral Transit Stage)

When we are done adding saliva and preparing the bolus, we use our tongue to move it from the front of the mouth towards the back of the mouth. Our tongue squeezes the bolus backwards by pushing it against the roof of the mouth. Throughout this stage and the previous stage, our buccal (cheek) muscles are at work and help to keep the bolus or any part of it from falling into the lateral sulci (the space between our gums and cheeks). When the mass reaches the back of the mouth, our body sends a message to our brain to begin swallowing and the swallow reflex is triggered. 

3. Moving the bolus downwards (The Pharyngeal Stage)

Before the mass enters the throat (that is, when it is at the rear edge of your tongue and starting to move down), various events happen as part of the swallow reflex. One thing that happens is the velum raises to close off the connection to the nose. Looking into someone’s mouth, you will see the uvula (a "bell" looking structure in the back of your mouth that is part of the velum) hanging down from the velum (the tissue making up the back part of the roof of the mouth). When the velum raises it closes off the passage to the nose. Many people have probably seen at least one occasion when the bell did not raise fast enough and liquid may have come out of a person’s nose. 

Also, your larynx (voice box) closes off and moves up and forward. If you swallow your saliva and pay attention to your throat you will feel something in your throat moving up and forward. That’s your larynx, or the part of your body that contains your voice box. The larynx sits on top of the trachea (the breathing tube), and the trachea leads down to your lungs. It is very important that no food or any other material get into your trachea. It is called aspiration when any material gets past your larynx and into your trachea. You will start coughing (and maybe choking) if material falls into your trachea. If a piece of food or other material is big enough it may even make breathing difficult if it gets stuck. The coughing is one response that the body has to help protect your lungs from dangerous material. Another way is what usually happens to the larynx when we swallow.

As mentioned before, the larynx closes off and moves up and forward out of the way of food to help protect the lungs. Several muscles in our larynx normally close the larynx off at different levels to make sure that nothings falls into the larynx. In addition, a cartilage in the throat called the epiglottis will usually flip over and cover the laryngeal aditus (the entrance to the larynx) to provide another layer of protection for the lungs. 

The pharyngeal (throat) muscles squeeze and push food down along with the help of gravity to move it to the hypopharynx (the bottom of the pharynx). A muscle called the upper esophageal sphincter separates the hypopharynx from the esophagus (the natural feeding tube that leads to the stomach). As part of the swallowing reflex the upper esophageal sphincter opens to let food into the esophagus. It is also stretched open further by the pressure of the food as it moves through it as well as the passive stretching due to the anatomical/physical attachment to the larynx (recall that the larynx moves up and forward; in doing so then it helps to stretch the adjacent upper esophageal sphincter).

As food travels down through the pharynx it passes many nooks and crannies. Some of these nooks and crannies are called sinuses (in particular the vallecular and pyriform sinuses). In normal swallowing, food and liquid pass by these without any noticeable amounts getting stuck. 

4. Passing the bolus through the feeding tube to the stomach (The Esophageal Stage)

As the bolus arrives in the esophagus in the normal swallow, a “wave” of muscle contractions occurs. The muscles contract in a sequential-like fashion (from top to bottom) helping to carry the bolus downward towards the stomach. A muscle called the lower esophageal sphincter separates the esophagus from the stomach. When the bolus reaches the bottom of the esophagus, the lower esophageal sphincter opens and the bolus passes through to the stomach.

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What is Dysphagia?

Dysphagia is the technical term used for swallowing disorders. That is, people with dysphagia have difficulty swallowing. These difficulties may include, but are not limited to:

There are many causes of dysphagia. People with many different kinds of illnesses may develop dysphagia. Illnesses that are often related to dysphagia include strokes, progressive neurological disorders (like Parkinson’s Disease or multiple sclerosis), brain tumors, head and neck cancers, and reflux. Individuals who have had head injuries may have dysphagia. Some elderly people may also develop dysphagia. Some infants may be born with disorders that can be associated with dysphagia, including cleft palate, Down Syndrome and cerebral palsy.

Aspiration has been associated with the development of some types of pneumonia. If your oral secretions contain too much gram-negative bacteria (GNB), then aspiration of these might result in additional problems including pneumonia. GNB may sometimes develop in the mouth if you use a feeding tube, if you take antibiotics, if you have oral/dental disease, if you have cavities that have not been treated, if you suffer from malnutrition, or if you don’t clear your saliva regularly. 

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Diagnosing Dysphagia

Diagnosis of dysphagia is done by speech-language pathologists, often with the help of medical doctors like oto-laryngologists and radiologists. Diagnosis comes after thorough examination of many factors. This complete examination usually has several parts and may be done on several days. 

A dysphagia examination must include a thorough case history and an assessment of the structures involved in swallowing as well as their function. A case history is the part of the examination where you are asked specific questions about the problem and about many related issues, including past swallowing problems, your current medications, and associated medical conditions. Also, examination of your lips, teeth, jaw, tongue, pharynx and other parts of your body involved in swallowing is done to make sure that none of these parts is broken, is out of place, has been removed (maybe because of a surgery), or is not working correctly. An examination of how your (swallowing) muscles move and work is also done to make sure they are not weak or there is no other problem with them. As part of this examination you may be asked to taste different flavors, drink and eat small amounts of food and liquid, and to learn/practice potential swallowing maneuvers.  

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The Voice and Swallowing Institute has speech language pathologists with up-to-date and specialized training in diagnosing and treating dysphagia in adults and children.

Examination may also include different tests that involves technical machines.  Three common tests like this are:

The Voice and Swallowing Institute offers all 3 of these studies.

You are asked to eat and drink a variety of things during each of the studies. Some of this may be combined with special substances, like green food coloring or barium, to make it easier to watch what is happening as you swallow. At the same time the speech-language pathologist and oto-laryngologist identifies the exact source of the problem, and may also attempt different strategies to help you swallow better and more safely. Strategies include evaluating different food consistencies and liquids of varying thicknesses, as well as maneuvers, that may help improve how well and safely we swallow. The names of some of these maneuvers are the chin tuck and Mendelsohn maneuvers. They will be discussed further in the treatment section.

Video-fluoroscopic swallow studies are done in the X-ray suites of hospitals. These studies are also called modified barium swallow studies. During this examination you are asked to eat and drink a variety of things while being X-rayed. At the same time the speech-language pathologist attempts to identify the exact source of the problem, and may also attempt different strategies to help you swallow better and more safely. The results of the study help identify where food and liquid get stuck (if they get stuck), if there is a problem with muscle or sensory function, and how well and safely all of the swallowing stages are coordinated. The speech-language pathologist and oto-laryngologist will decide if you are a good candidate for this procedure.

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The Voice and Swallowing Institute has specialized equipment for video-fluoroscopic examination of swallowing in children. 

Flexible endoscopic swallow studies can be done in a hospital clinic. A flexible endoscope is a machine that consists of a long tube and a camera. During this examination the device is passed through one of your nasal passages to the back of the throat where passage of food and drink can be observed. These studies tell us about what happens before or after the food is actually swallowed. They can help identify if the bolus enters the pharynx early and where things get stuck when they get stuck. These studies may also be applied to therapy situations and are extremely helpful in determining the best and safest food consistencies and liquid thicknesses for a patient to swallow. The speech-language pathologist and oto-laryngologist will decide if you are a good candidate for a flexible endoscopic swallow study.

Fiber-endoscopic evaluation of swallowing with sensory testing (FEESST) can also be done in a hospital clinic. A specialized flexible endoscope is used during this test. During this examination the device is passed through one of your nasal passages to the back of the throat where passage of food and drink can be observed, just like with a flexible endoscopic swallow study. However, the specialized flexible endoscope also allows us to look at the sensory functioning in your throat by giving small puffs of air. Sensory functioning might be altered (changed) for some individuals diagnosed with acid reflux (also known as laryngo-pharyngeal reflux). Like flexible endoscopic swallow studies, these studies tell us about what happens before or after the food is actually swallowed. They can also help identify if the bolus enters the pharynx early and where things get stuck when they get stuck. The speech-language pathologist and oto-laryngologist will decide if you are a good candidate for FEESST.

Following the dysphagia examination, recommendations may be made that could include further consultation with medical specialists, swallowing therapy, changes in or restrictions on what you eat, and other testing that may be useful. 

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Treating Dysphagia

View endoscopic cricopharyngeal myotomy (ECPM) video

Treatment for dysphagia can come in several different forms, and may include surgery, a diet regimen, and dysphagia therapy.

Dysphagia therapy is conducted by certified speech-language pathologists and likely involves learning exercises and/or strategies for improved swallowing, as well as monitoring for improved swallowing as therapy continues, and adjusting therapy as necessary to address any noticeable changes. 

The goal of dysphagia therapy is most often to help the patient learn to swallow more safely and effectively. Some patients in dysphagia therapy may be recommended restricted diets that specify what kinds (thickness/consistency) of foods and liquids they can swallow safely. Some patients may even be recommended that they nourish their bodies by non-oral methods. These non-oral methods frequently include devices called feeding tubes that allow people to feed without putting them in danger of choking or aspirating. Individuals on feeding tubes may benefit from therapy with the goal of increasing the safety of their swallow so that they might eat again by mouth one day. 

Exercises include activities that aim to strengthen muscles, improve movement and improve coordination. Among the possible exercises that may be recommended for dysphagia patients are the Masako maneuver, the Shaker exercise, gargling, and others. 

Strategies include postural changes (for example head turn and chin tuck postures), multiple swallows, and other "maneuvers". Remember that during the examination, the patient might be taught and asked to carry out different maneuvers. These are techniques that help to make the swallow safer or more effective. They include the supraglottic swallow maneuver, the super supraglottic swallow maneuver, the Mendelsohn maneuver, the effortful swallow maneuver, and others. Other strategies may involve the use of special implements, including the use of drinking cups for people with limited head motion and glossectomy spoons.

Diet modifications can include changes in food consistency, bolus size, and food/liquid temperature. Other modifications might include alternating solids and liquids.

An important and often overlooked aspect of dysphagia therapy is oral hygiene. Oral hygiene refers to promoting and preserving good oral (mouth) health. Oral hygiene is especially important for individuals with dysphagia because anything that is aspirated can carry traces of oral secretions (see Dysphagia: A Definition section). You may find oral hygiene tips here.   

The Voice and Swallowing Institute has expert speech language pathologists with specialized training in determining which therapy options are best for you. 

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Glossary of Terms

Glossary

Aspiration

the passage of material below the level of the vocal folds

Barium

a material that can be added to food or liquid to assist in seeing these on X-ray

Bolus

a collected mass of food or liquid

Buccal

of or relating to the cheeks

Cartilage

a dense type of tissue

Cuspids

the teeth that are used to cut food

Deglutition

the act of swallowing

Diagnosis

the identification and/or determination of the nature and cause of a problem

Dysphagia

a swallowing disorder

Epiglottis

a cartilage in your pharynx that is involved in the swallowing process

Esophagus

the natural tube that leads from the pharynx to the stomach

Esophageal

of or relating to the esophagus

Hypopharynx

the inferior, or lower, part of the pharynx

Incisors

the teeth that are used to tear food

Lower esophageal sphincter

the muscle separating the esophagus and stomach

Larynx

the “voice box;” the larynx sits on top of the trachea

Laryngeal

of or relating to the larynx

Laryngeal aditus

the entrance to the larynx

Lateral sulci

the grooves that you find between the gums and the cheeks

Molars

the teeth that are used to grind food

Palate

The roof of the mouth

Pharynx

the throat

Pyriform sinus

a cavity or depression in the pharynx where food or liquid may collect

Reflex

an involuntary or automatic action or response

Trachea

the natural tube that leads from the pharynx to the lungs

Upper esophageal sphincter

the muscle separating the pharynx and esophagus

Uvula

the small mass (or “bell”) that hangs from the rear portion of the roof of the mouth

Vallecular sinus

a cavity or depression in the pharynx where food or liquid may collect

Velum

the soft palate, or the rear portion of the roof of the mouth

Vocal folds

the tissue covered muscles in your larynx whose vibration helps to create your voice

Additional Resources for Information about Swallowing Disorders

American Speech Language Hearing Association
www.asha.org

National Institute on Deafness and Other Communication Disorders
www.nidcd.nih.gov/health/voice/dysph.asp

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