Swallowing Disorders

Question: My mother has been having difficulty swallowing. She has a benign thyroid growth that was found, and a doctor in her retirement community (she lives far away from me) wants to do surgery in 2 weeks. We’re feeling uncomfortable…

Answer:

I’m sorry to hear about your mother’s difficulty. While a diagnosis from afar is not possible, here are some thoughts that may help frame the situation more clearly.

It’s important to distinguish between two possibilities:

1. The thyroid growth is causing the swallowing problem;
2. The swallowing problem is unrelated, and the thyroid issue is simply a coincidental finding.

Thyroid Abnormalities and Swallowing

Thyroid enlargement is common, especially in older women, and many nodules or goiters are benign and do not require surgery unless they are:

• Causing clear symptoms (e.g., pressure, breathing difficulty)
• Suspicious for malignancy
• Growing rapidly

When the thyroid does cause swallowing difficulty, it is usually because of:

• Large size, especially if substernal (growing downward into the chest)
• Compression of the cervical esophagus, leading to difficulty swallowing, especially with solids and pills

But Swallowing Trouble Has Many Causes

If her swallowing issue led to imaging that incidentally found a thyroid mass, it’s possible the two problems are unrelated. For example:

• Antegrade Cricopharyngeus dysfunction (A-CPD)
• Presbyphagia (age-related swallow weakening)
• Other neuromuscular or esophageal issues

In such cases, removing the thyroid would not improve swallowing—and could delay correct diagnosis and treatment.

How to Distinguish?

A videoendoscopic swallow study (VESS) will certainly show if the patient has presbyphagia. And if swallowed material is well organized in pyriform sinuses, this would strongly suggest an outlet obstruction. But the most helpful test to clarify the thyroid question is a videofluoroscopic swallow study (VFSS, also known as a modified barium swallow or “cookie swallow”). It shows:

• How material moves through the mouth and throat
• Whether there is obstruction at the level of the cricopharyngeus muscle (upper esophageal sphincter)
• Whether aspiration or pooling is occurring
• If the esophagus is narrowed by external compression (like a thyroid mass)

Based on the findings:

• If it’s A-CPD, thyroidectomy won’t help—but cricopharyngeal myotomy or Botox injection could.
• If it’s presbyphagia, swallowing therapy, varying head position, and careful choice of food consistencies may be best—not surgery.
• If the thyroid is clearly compressing the esophagus, then thyroid surgery might be appropriate.

Bottom Line

Before proceeding with thyroid surgery to “fix” swallowing trouble, it’s essential to confirm causality. Ask the current medical team whether a modified barium swallow (videofluoroscopic swallow study) has been done—or if not, whether they will consider doing one.

A short video called “Swallowing Trouble 101” may also help in understanding the landscape of potential causes.