Why Can’t I Swallow?

Dysphagia is the medical term used for difficulty swallowing. There are many reasons a swallow can decline or cease to work as it once did. Anyone who has experienced this knows how horribly alarming this can be. It can affect your nutritional intake, hydration and safety with breathing just to name a few. If you have ever choked while eating it’s most likely you remember that experience quite well and how scary it was. Imagine that happening every time you try to eat or drink.

Dysphagia can be the result of a broad variety of factors. It can be extremely difficult to narrow the cause down. Here are some of the more common causes of dysphagia:

1. Structural (strictures, osteophytes, scar tissue, radiated muscle tissue from cancer treatments, surgical complications, herniated disc, aberrant right subclavian artery, etc)
2. Muscle tension (over active muscle contractions can limit movement for efficient swallow)
3. Neurological (stroke, Parkinson’s Disease, brain injury, etc)
4. Cancer (can be due to tumor pressing on nerve or area of swallowing, changes in esophageal tissue or muscles for swallowing, etc)
5. Overactive Upper Esophageal Sphincter (UES) (from chronic reflux)
6. Motility Disorders (difficulty with food moving down the esophagus)
7. Medication Induced (antipsychotic/neuroleptic, meds that depress the CNS, meds that cause esophageal injury, meds that dry the mouth, meds with anticholinergic or antimuscarinic effects, etc)
8. Infections (candidiasis, herpesvirus, HIV, CMV, etc)
9. Age related (loss of muscle mass, calcifications)
10. Psychological (fear of swallowing/choking)

Below is a comprehensive list of tests you can have done to find out the source of your swallowing problems. You will see just from the variety of tests how many different specialists play a role in determining what is going on. As with any invasive procedures, check with your doctor first to determine if you have any contradictions for any of these tests you wish to consider. It is ultimately your job to understand in collaboration with your doctor any potential risk factors due to your own personal medical history.

Beneath some of the descriptions I offer some Personal Experience as a Speech-Language Pathologist (SLP) who has worked in a variety of respiratory hospitals as well as Level II Trauma and VA for over 10 years. This is my attempt to further explain why a test may be good or how things can not go as well as expected. My personal recommendations for anyone having swallowing difficulties is to find specialists that are specially skilled and trained with swallowing difficulties. Find a voice and swallowing clinic, which is usually run by an ENT/Otolaryngologist. An SLP can also be a great place to get started and should be an invaluable resource in helping you to get to the root cause. If not, you may being seeing an SLP with not enough training and/or experience.

Whatever your case, do not settle for doctors that are unable to find the root cause of your swallowing problems. Some patients have to drive to another state, or worse – another country, to finally get real answers to their problems. Do not settle on a place just because it’s convenient. You may even have to go out of your insurance network to do this. If the problem is significant enough, it is absolutely worth it! You can always change insurance plans to a better one that suits your needs once you find a good team of specialists that can actually help you get better.

VIDEO X-RAY

These tests all use a fluoroscopy camera that converts X-rays into video images. These images are recorded on a DVD for reviewing after the test is over.

• Modified Barium Swallow Study (MBSS): This involves an SLP (Speech-Language Pathologist – aka Speech Therapist) and Radiologist. A video X-ray is taken of the patient while they sit upright in a chair and swallow various viscosities of liquids and textures with barium in it. The radiologist typically is the one looking for structural abnormalities and aspiration events (when the barium goes down the airway instead of the food pipe). The SLP typically guides the study and will make decisions that can make for a comprehensive assessment such as utilizing compensatory strategies to see if your swallow ability improves. Both the SLP and the radiologist will write up their own interpretations. The SLP focuses on the function of the swallow while the radiologist will focus on the physical structure of the swallow and aspiration events. The video X-ray typically will only give an inside look at the side view of your mouth and throat area unless the SLP or radiologist has more extensive training with the swallow and knows when to get more imaging.

Personal experience: I was completing my clinical fellowship year at a large level II trauma center in California, which is basically a 9-month period where the clinician is heavily supervised until they can be fully licensed (Certificate of Clinical Competence) to perform on their own. Just after completing my fellowship, I then completed 25 successfully supervised MBS studies which was enough to let me run them on my own with just the radiologist. The hospital had a waiting list for people needing this study done. I knew I wanted to keep gaining experience in this area so I didn’t want to decline, but I felt I knew enough to be dangerous. They do not teach you how to run an MBS in college. These skills are learned on the job. I searched and was very fortunate to find a weekend course being held locally for SLPs learning MBS. I also found a course on line that was shockingly comprehensive with a compilation of videos, case studies and quizzes to ensure knowledge.

What I learned confirmed I truly knew enough to be dangerous. I went back and shared with my colleagues some key things I learned that we were not currently doing in our studies, such as allowing for a scan of the esophagus. You would do this if esophageal (the food pipe area) problems are indicated. Or looking at an anterior (front) view vs lateral (side) view to find out if one side has a greater weakness (or paresis) compared to the other. Some appreciated this, while others did not. In fact, I had a case where there was indication of esophageal involvement and I requested a scan of the esophagus during the study. The radiologist working that day refused stating “That’s a different test!”. It isn’t. This is well within the scope of the MBSS. Unfortunately, it is just not understood by most professionals when and why it needs to be done. This story is to stress the importance of the experience and competency of the medical professional. You can have all the right tests done, but they mean nothing without expert administration and interpretation.

• Barium Swallow Study (BSS or Esophagram): This is typically run by a Radiologist who looks for structural abnormalities in the upper GI (gastrointestinal) tract. The upper GI consists of your mouth, throat, esophagus (food pipe), stomach, and first part of your small intestine. The test is then interpreted by the radiologist and sent to the ordering physician. With this test, you will stand up for the first part and drink liquid barium. The second part you will lie down on your stomach and drink liquid barium.

This is NOT a test you want to do if you are having significant swallowing difficulties where you choke drinking liquids. It’s much better to start with an MBSS as this is done sitting upright in a chair and quantities are more controlled. If you aspirate at all on a BSS they will stop the procedure immediately. This study is great for people with suspected reflux, ulcers, hiatal hernia or feeling of things getting stuck in throat when they eat food.

 Personal experience: This test is sometimes accidentally used when ordering an MBSS because most scheduling techs only hear “barium swallow study”. The “modified” is a very important part to make sure they hear. I usually have my patients ask for “a modified barium swallow study with speech therapy present”. That helps to eliminate the confusion. Also, most patients with significant swallowing problems that come to me that have had a BSS have a report that says “inconclusive due to aspiration”. Read on to learn of other ways to assess the esophagus.

ENDOSCOPY

These are all performed with an endoscope, which is basically a long tube that is able to get video recordings of the areas being viewed while also performing surgical interventions.

• Upper GI Endoscopy or EGD (esophagogastroduodenoscopy): This can be performed by either a GI or ENT. You will either be under anesthesia or given a sedative based on your doctor’s recommendation. This test is often accompanied with a colonoscopy (performed by GI) for people having issues with reflux or stomach pain. Tools can be inserted through the endoscope to do things such as open/dilate a restricted area, take a biopsy, or remove obstructions. This tends to be a better test for those complaining of things getting stuck in their throat when they eat food. This may be due to a prominent cricopharyngeal bar, strictures, osteophytes or diverticulum. If you suspect you have reflux (aka GERD) know that it can wreak havoc on the lining of your esophagus if left untreated. This may result in things like inflammation, strictures, Barrett’s esophagus or cancer. Those with reflux and/or complaints of difficulty getting their food to “go down” would certainly benefit from having this test performed.

 

• Direct Laryngoscopy: An ENT will perform this and it involves looking into the back of your throat, beyond the base of your tongue. Because of this sensitive area, it usually requires sedation or anesthesia. This is good for swallowing difficulties that are accompanied with pain in the throat, chronic coughing, hoarse voice, bad breath or difficulty breathing. This can be a great test for discovering things like cancer just below, at, or above the vocal folds. However, it is not a test for understanding the function of the swallow. Often a person will need a variety of tests to rule out and finally pin down the problem.

 Personal experience: I remember a patient I was working with in the hospital was not able to eat or drink, requiring his food to be fed to him through a tube. He had a history of throat cancer which had been treated through radiation and chemo. When we did the MBSS, we could see that both food and liquids would pool in his vallecula and pyriform sinuses. The vallecula is located between the base of the tongue and the epiglottis. The pyriform sinuses are located closer to the back of the throat, past the base of the tongue. You have one on your right side and one on your left side.

 There are a number of reasons why this could happen, but based on his medical history it was most likely due to a fibrotic UES (this is the upper sphincter of your food pipe). Radiation changes the tissues and can become worse over time, often years after a patient has had it performed. When the UES becomes fibrotic, it loses the ability to relax and open the way it should when we eat or drink. When the ENT did the direct laryngoscopy, he declared the patient’s swallow was fine, even though the MBSS showed a severely problematic swallow. His reasoning? “I was able to pass my hard scope into his esophagus just fine!”. Compare this to the automatic doors at your local grocery store when the electricity is cut off. They won’t open as they should when you approach. This would be like an electrician saying “These doors work fine because I was able to open them with my crow bar!”. Fortunately, we were able to convince the family to get a more appropriate test to confirm our suspicions. Read on to learn about Pharyngeal and UES Manometry.

• Flexible (or Fiber-Optic) Laryngoscopy: An ENT will do this to view into the esophagus, much like a direct laryngoscopy only less invasive and with no surgical interventions.

• Nasolaryngoscopy: ENTs are more commonly using this procedure to assess the structures from the point of the nasal passage down to the larynx (past the vocal folds).

• Nasopharyngoscopy: Same as the nasolaryngoscopy except this does not go past the vocal folds and is overall a more comfortable examination.

• Video Laryngeal Stroboscopy (VLS): This is performed by either the ENT or SLP for better assessing the quality of the vocal folds, which play a role in our ability to swallow as much as they do with speaking. Voice exercises are performed while flashes of light from the stroboscope allow for better visualization of how the vocal folds are vibrating and coming together. If your swallowing problems involve a hoarse voice or pain while speaking, this may be a valuable test for you. If an SLP performs this procedure, they can better tell you what is going on with the function of your vocal folds and voice; however, they can not diagnose a medical problem. If they see a structural abnormality, they will refer you to an ENT. If an ENT does the procedure, they are typically best at identifying structural abnormalities. Ideally, an ENT that understands the function as much as the anatomy is who you would want.

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES): This is basically the same as the nasopharyngoscopy except that instead of an ENT, an SLP performs this. They are specifically looking at the function of the swallow. The SLP will have you drink various viscosities and eat various textures (just like with the MBSS) only instead of barium there is usually green dye in these items to allow for better viewing on the camera. I usually recommend this if a patient has already had an MBSS and we were able to rule out any structural abnormalities or involvement of the esophagus. I’d rather have their follow-ups done without the involvement of radiation (which is used with the MBSS) if at all possible. It also depends if this service is available in their area as it tends to be more difficult to find. You can call your local hospital’s speech therapy department to see if they do this as an outpatient or try this locator: https://theresarichard.com/mobile-swallow-study-service-locator/
• Esophagoscopy: Much like endoscopy, this can be performed in a variety of ways (through the nose or mouth, viewing only or with surgical capabilities). Key difference is that this type of study will observe both the esophagus and upper GI tract.

COMPUTED TOMOGRAPHY (CT) SCAN

CT Scans are good for the following: Imaging bone, soft tissue and blood vessels at the same time; Pinpointing issues with bony structures (injuries); Evaluating lung and chest issues; Detecting cancers; Imaging patients with metal (no magnet). Whether you will need one with or without contrast should be determined by your doctor as the dye is not always well tolerated. If there are no contraindications for the dye, they tend to give the best image for the radiologist to interpret.

• CT Scan of the Chest with Contrast: This test is to rule out dysphagia caused by esophageal compression from a dilated left atrium of the heart. This is known as Dysphagia megalatriensis (also referred to as cardiovascular/cardiac/atrial dysphagia). It can also help find problems such as infection, lung cancer, blocked blood flow in the lung (pulmonary embolism), and other lung problems.
• CT of the head/brain: This is to visualize if there is any swelling or bleeding in the brain, fractures, tumors or any abnormalities. The brain plays a vital role in our breathing and swallowing abilities.
• CT of the neck: This is to visualize any abnormalities that may be impacting your swallow, such as prominent osteophytes, infection (such as an abscess), birth defect, cyst or tumors.
• CT of the abdomen: This is to visualize for abnormalities such as a hernia, tumors, lesions, infections. Hernia’s can contribute to breathing, swallowing and voice difficulties.

MAGNETIC RESONANCE IMAGING (MRI)

MRIs are good for the following: Imaging organs; soft tissue internal structures; showing tissue difference between normal and abnormal; imaging without radiation. If you suffer from claustrophobia, this may not be a test you can do.

• MRI of the chest: This will help your doctor diagnose lung problems such as a tumor or pleural disorder, blood vessel problems, or abnormal lymph nodes. Chest MRI can help explain the results of other imaging tests such as chest x rays and chest CT scans.
• MRI of the head/brain: This better visualizes any soft tissue issues in the brain compared to the CT, such as: cysts, tumors, bleeding, swelling, developmental and structural abnormalities, infections, inflammatory conditions, or problems with the blood vessels. A functional MRI (fMRI) and Diffusion Tensor Imaging (DTI) provide even more details, but are typically only used if surgery is indicated.
• MRI of the neck: This can detect a variety of conditions of the cervical spine as well as problems in the soft tissues within the spinal column, such as the spinal cord, nerves, and disks. This test is used to evaluate injuries of the seven cervical spine bones or spinal cord.
• MRI of the abdomen: This is to better visualize the stomach, intestines (bowels), liver, gallbladder, pancreas, and spleen. These organs help break down the food you eat and get rid of waste through bowel movements.

Personal experience: I was filling in for an SLP for 3 months at a large outpatient center. One of the patients I saw had been seeing this therapist for almost 2 months due to increased difficulties moving his tongue, which was effecting his speech and swallow. I looked at his medical history and there was nothing in it. He was only in his 40s. I asked him if he had any recent head injuries or diagnoses that was not in his chart and he said no. When I asked what his doctor thought was causing this he said he didn’t know. I was trying not to look alarmed. I just couldn’t understand why anyone would take this as normal? I asked him to get a consultation with a neurologist. When I saw him again that week and asked if he had called a neurologist he said he hadn’t. Part of the reason being he is now afraid to talk to people on the phone because of his speech difficulties. So I asked if I could make the call with him in the office and he agreed. After his consultation with the neurologist he was sent for imaging of his brain and it was later confirmed he had Lou Gehrig’s disease (ALS). Without this early detection his medical management of this disease could have led to a steeper decline. It’s ALWAYS important to have a clear understanding of what is causing your problem.   

OTHER TESTS

• Bedside Swallow Evaluation: This is performed by an SLP without any instrumentation. Consider it a medical screening of your swallow. A well trained SLP will be able to make an appropriate referral based on their findings. This is performed just like a FEES, only there is no instrumentation to allow for viewing of where the swallow is taking place, and no green dye. It’s purely subjective. If you have one of these performed and the SLP wants to treat your swallow without referring you for an instrumental, I would consider getting a second opinion. Or even better, an instrumental.

• Esophageal Manometry: This is a great test for determining how things are moving through your esophagus. During esophageal manometry, a thin, flexible tube (catheter) that contains pressure sensors is passed through your nose, down your esophagus and into your stomach. The test measures how well the muscles at the top and bottom of your esophagus (sphincter muscles) open and close, as well as the pressure, speed and pattern of the wave of esophageal muscle contractions that moves food along. Results of the test are interpreted by your GI doctor. If you feel pain when swallowing, a feeling of food getting stuck in your chest/throat, have difficulty getting your swallow to trigger or regurgitation after eating/drinking, then this would most likely be a valuable test for you. If you have Scleroderma or have ever been treated for cancer in or around the throat area, I would highly recommend asking your doctor about this test if you are currently having swallowing problems with any of the previously mentioned symptoms.

• Pharyngeal and Upper Esophageal Sphincter (UES) Manometry: This test is performed in the same manner as the esophageal manometry, however it examines pressures in the areas from the UES and above. The UES can be an important component in the source of dysphagia if it has become overactive. Diseases where this often occurs include Parkinson’s disease, oculopharyngeal muscular dystrophy, achalasia, scleroderma and people with chronic reflux. If the UES becomes overactive, it will not relax and open as easy which typically results in choking on solid foods.

• Endoflip: This is a newer procedure that is gaining popularity as it can be a diagnostic instrument as well as a tool for performing therapeutic dilation within the esophagus without the need for X-rays. This test is performed during upper endoscopy. While you are sedated, your doctor will place a catheter through your mouth into your esophagus. Fluid is passed through the catheter to inflate a cylinder-shaped balloon that contains specialized sensors. From the patient’s perspective, undergoing a diagnostic EndoFLIP is exactly similar to the experience of undergoing upper endoscopy. The procedure can add 10 to 15 minutes to the total duration of the endoscopy. FLIP can assess and guide treatments for esophageal disease states including gastroesophageal reflux disease, achalasia, and eosinophilic esophagitis. This test may eventually become the initial test for patients with undifferentiated dysphagia at their index endoscopy.

• Esophageal 24-hour pH/Impedance Reflux Monitoring: This measures the amount of reflux (both acidic and non-acidic) in your esophagus during a 24-hour period, and assesses whether your symptoms are correlated with the reflux. This test will involve the placement of a catheter (about the size and flexibility of a smartphone power cord) through your nasal passage, and then swallowed into your esophagus with drinks of water. The other end of the catheter will be attached to a small data recorder that you will wear. This test can be done in combination with the esophageal manometry test and is usually ordered by GI.

• Gastric Emptying Study (GET): This is a test to determine the time it takes a meal to move through your stomach. You will be given a meal to eat that is tagged with a radioactive isotope. After you eat this meal, a one-minute image of your stomach will be taken. You will be allowed to leave the department, but you must return in one, two and four hours. A radiologist reviews the information and provides it to your referring doctor. This can be good for swallowing problems due to motility issues.

• Smart Pill: This is a capsule that contains a small electronic device. You swallow the capsule, and as it moves through your digestive tract, it sends information to a receiver you are wearing on how quickly food is traveling through the digestive tract. It monitors PH, temperature and pressure throughout your entire GI tract. The pill is usually passed within a few days, and is a single-use, disposable pill. You will return the data recorder to your GI doctor following the passing of your Smart Pill. This is another good motility test.

• Cranial Nerve Examination: This is performed in the office with the neurologist. It’s a great screener to determine if further testing is needed (such as one of the ones below). Or you can actually go on-line and try one at home yourself: https://geekymedics.com/cranial-nerve-exam/

• Intramuscular Electromyography (EMG): Mechanical upward-downward movement of the larynx is detected by using a piezoelectric sensor while submental integrated EMG activity is recorded during dry and wet swallowing. EMG activity of the cricopharyngeal muscle of the upper esophageal sphincter also can be recorded. EMG can be used for muscle selection and for performing injections of botulinum toxin in patients with dysphagia caused by cricopharyngeal muscle spasm or hypertonicity. This test is usually performed by a neurologist. There is also a surface electromyography (sEMG) that is less accurate, but less invasive and primarily measures the contraction of the muscles in the submental region (below your chin) responsible for lifting up the larynx. It only requires pads to be placed on the surface of the skin vs needle insertion and can be performed by a trained SLP to assess for excess muscle tension or weakening.

• Nerve Conduction Study (NCV): NCV is often used along with an EMG to tell the difference between a nerve disorder and a muscle disorder. NCV detects a problem with the nerve, whereas an EMG detects whether the muscle is working properly in response to the nerve’s stimulus. This is helpful for finding cranial nerve damage and possible developing diseases such as Guillain-Barré syndrome or a herniated disk disease.