Swallowing Problems (Dysphagia)

Swallowing problems are most often simple and can be easily diagnosed and resolved. To understand swallowing issues, it is best to know the basic anatomy and physiology of swallowing (Figure 2). The mouth essentially lubricates the food and prepares it for passage, and the tongue pushes the food backwards and down into the throat. At this point the most complex process starts: the food sits above the level of the trachea (breathing tube) and esophagus (swallowing tube), and the food has to be maneuvered into the esophagus without any of it accidentally spilling into the breathing tube and causing blockage or pneumonia.

This task is accomplished by the voice box; the voice box serves as a valve that closes the breathing tube and prevents spillage of food and liquids into the lung. The next step is the opening of the valve above the esophagus to accept the food into the esophagus and direct it down to the stomach; this valve is called the upper esophageal sphincter (UES) and the muscle that wraps around the top of the esophagus to create this valve is called the cricopharyngeus muscle. Once the food has passed the UES and is in the esophagus, rhythmic movement of the muscles pushes the food down to the stomach.

Analysis of swallowing problems requires getting a detailed history of the problem, how it started and how it has changed over time. Some problems only affect solid foods (most cases), and others only liquids (usually neurologic causes of dysphagia), and often both. This is followed by a thorough exam that includes a laryngoscopy or an exam of the lower throat. Based on the findings, a variety of tests may then be ordered:

  • Video Swallow Study – Under an x-ray, the patient is given different food materials to eat and drink to visualize how the swallow mechanism is working.
  • Barium Esophogram – Under an x-ray, the esophagus is visualized from the UES down to the stomach.
  • pH Probe Monitoring – A sensor is placed in the esophagus to measure the amount of acidity.
  • Esophageal Manometry – A probe is placed in the esophagus that measures the pressure and sequence of muscle contractions.
  • FEESST – Flexible endoscopic evaluation of swallowing with sensory testing to check the swallowing and movement of the vocal cords and throat muscles under direct visualization with a camera. At the same time, the throat’s ability to sense is checked as well.

Causes of Swallowing Problems

  • Acid Reflux
  • Foreign Material – for example fish or chicken bones.
  • Neurologic disorders – causing weakness of the swallowing muscles or lack of coordination.
  • Cricopharyngeus Dysfunction – sphincter malfunction that leads to food not passing easily from the throat into the esophagus.
  • Zenker’s Diverticulum – Pouch-like sac in the lower throat that collects food and interferes with swallowing.
  • Tumors – Benign and malignant tumors of the throat, back of the tongue, voice box and the esophagus can interfere with swallowing.

Innovative Treatments

Treatment of dysphagia is dependent on the cause; some are treated with medications alone, while others will need swallow therapy, and, at times, surgery. A thorough investigation into the cause of the problem is necessary to start appropriate treatment.

Esophagoscopy

Dr. Larian may perform an esophagoscopy to investigate swallowing disorders in patients of our Southern California practice. During an esophagoscopy, the doctor passes a long, lighted device called an esophagoscope down the throat and into the esophagus. In addition to allowing the doctor to see inside the esophagus, the esophagoscope may be used to obtain tissue samples or to remove an embedded foreign body.

Trans-oral Endoscopic Excision of Zenker’s Diverticulum

Most often found in individuals over the age of 50 (but possible at even younger ages), Zenker’s diverticulum is a disorder of the throat in which a diverticulum, a pouch, develops in the throat wall. Food may accumulate in the pouch, causing it to fill and at times regurgitate up. Most patients feel food gets stuck in their throat. Pills may also end up inside the diverticulum, making their absorption impossible. The pouch forms because of poorly functioning throat muscles that are not coordinated. As such the Cricopharyngeus muscle which is a valve at the bottom of the throat does not open when food is trying to go down towards the stomach, but the throat muscle still continue to squeeze and push. After this continues for a period of time a pouch (sac) forms on the side of the throat in an area of weakness in the wall of the throat called the Zenker’s Diverticulum.

To treat swallowing disorders caused by Zenker’s diverticulum, our Los Angeles-area surgeon performs excision surgery. The objective of an excision of Zenker’s diverticulum is not only to remove the diverticulum, but to release the malfunctioning muscle of the throat – the cricopharyngeus (CP) muscle. There are two methods that may be used:

The Endoscopic Method

A special two-prong scope is inserted through the mouth that allows the head and neck surgeon to view the wall separating the esophagus and the diverticulum. The surgeon then uses either a laser or a stapling device to remove this wall, thus uniting the esophagus and the diverticulum. Recovery after an endoscopic excision of Zenker’s diverticulum is simple. Patients are discharged the same day or the next and must follow a liquid diet for one week, after which they are able to resume a regular diet. Dr. Larian is one of the few surgeons in the country with extensive experience in performing this endoscopic procedure.

The Open Method

The open technique is used only very rarely, in exceptional situations. An incision is made on the side of the neck, allowing the surgeon to access the diverticulum and the CP muscle. After the CP muscle is cut, the diverticulum is removed using a stapling device. The patient may drink liquids three days after surgery and resume a normal diet one week later.

Excision of Zenker’s diverticulum is best performed by a board-certified surgeon who has extensive experience in treating voice and swallowing disorders. Individuals in Beverly Hills, Los Angeles, and other Southern California communities are invited to contact Dr. Babak Larian to learn more about the procedure.

Cricopharyngeus Myotomy

Some complex swallowing disorders may be caused by a malfunctioning cricopharyngeus muscle (or CP). This muscle forms a ring around the upper esophagus. A properly functioning CP relaxes and opens when swallowing so that food may pass through the esophagus and into the stomach. An obstruction may occur if the CP fails to relax. During a cricopharyngeus myotomy, the CP is surgically released in order to facilitate swallowing.

Depending on the needs of the individual patient, an expert in voice and swallowing disorders may recommend one of two surgical methods. During the endoscopic procedure, a long tube attached to a tiny camera is inserted into the mouth. This camera, or scope, allows the head and neck surgeon a clear view of the treatment area. For a patient whose mouth and throat are too narrow to accommodate the endoscope and surgical instruments, open surgery may be necessary. During an open cricopharyngeus myotomy, the surgeon makes an incision in the side of the neck that allows him or her to access and treat the CP muscle.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Patients who have difficulty swallowing may be assessed with a fiberoptic endoscopic evaluation of swallowing (FEES) study. During a FEES study, the voice and swallowing disorders expert (otolaryngologist) carefully passes an endoscope — a long, flexible tube attached to a camera — down the patient’s throat. This piece of equipment allows him or her to view and record images of the throat and larynx (voice box). He or she may ask the patient to swallow foods and liquids in order to form a complete picture of an individual’s swallowing capabilities and diagnose any swallowing disorders. A FEES study can be performed at our Los Angeles office in as little as 10 minutes.

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