Dysphagia

Abnormal swallowing, or inability to swallow. Dysphagia can result from such diverse causes as surgery on the larynx or neck, stroke, the aging process, tumor, injury to the neck, or radiation, among other things.

Treatment for Dysphagia (Swallowing therapy)

This therapy is typically provided by a speech-language pathologist (and, more informally and adjunctively, by other healthcare professionals). General areas of teaching might include: choosing wisely which food types and consistencies to eat; swallowing maneuvers such as tucking the chin, double swallow, effortful swallow, head turning, and supraglottic swallow; and direct exercises for the tongue, pharynx, palate, and larynx.

Diet Modification

These are suggested dietary changes, particularly regarding food consistencies, directed at improving a patient’s ability to swallow and at avoiding aspiration. For example, an individual who is struggling with aspiration might be advised to avoid thin liquids and use thicker or carbonated liquids instead. Or this individual might be advised to avoid composite foods, since his or her swallowing deficiency could make it harder to “stay organized” with several consistencies in the mouth at once.

Dysphagia / Delayed Swallow Reflex

Laryngopharynx (1 of 3)

Panoramic view of laryngopharynx before administering blue-stained applesauce.

Dysphagia / Delayed swallow reflex (2 of 3)

Same view after first bolus of blue-stained applesauce. The vallecula fills with material before the swallow “happens”—signifying a delayed swallow reflex.

Hypopharyngeal pooling (3 of 3)

After several rapidly-administered boluses (to assess patient’s “limits”), note hypopharyngeal pooling, but none within the laryngeal vestibule.

Hypopharynx Pooling After Swallow

Hypopharynx pooling after swallow (1 of 1)

Shows trace of blue-stained applesauce remaining behind after the patient has swallowed.

Cricopharyngeal dysfunction, before and after myotomy

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (seen as a dark column). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.

Cricopharyngeal dysfunction: after myotomy, resolved (2 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction, before and after myotomy

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (the dark material seen here in the throat). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.

Cricopharyngeal dysfunction: after myotomy, resolved (1 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Dysphagia, Due to Tongue Weakness

Dysphagia, due to tongue weakness (1 of 4)

Left tongue paralysis and atrophy (the left side is right of image), due to injury of the left hypoglossal nerve during neck surgery elsewhere. The tongue and its midline raphe (arrows) deviate to the atrophied side. This atrophied side of the tongue cannot “do its part” in the propulsive stage of swallowing.

Dysphagia, due to tongue weakness (2 of 4)

Hypopharyngeal pooling of saliva in the “swallowing crescent.” This pooling can suggest non-relaxation of the cricopharyngeus muscle as an additional swallowing impediment, though in this case a videofluoroscopic swallowing study does not confirm this hypothesis.

Dysphagia, due to tongue weakness (3 of 4)

After administration of blue-stained applesauce, the same hypopharyngeal pooling is seen, now of now-blue-stained saliva.

Dysphagia, due to tongue weakness (4 of 4)

This closer view within the larynx shows not only soiling of the laryngeal vestibule with saliva bubbles, but also a left contact granuloma (right of image). This injury could be the result of intubation four months earlier, or else of the continual coughing and throat clearing that occurs with this patient’s swallowing disorder.

Scarring diverts swallowed materials directly into the larynx

Post tonsillectomy (1 of 4)

A young woman struggles to swallow after extensive cauterization of severe bleeding after tonsillectomy elsewhere. The arrows here show the path food and liquid should follow to get into the esophagus (opening indicated by flat oval).

Closer view (2 of 4)

Closer view shows that the epiglottis is tethered to base of tongue at the dotted line. Furthermore, the “ski jump” scar appears to be ready to divert swallowed material directly into the larynx ( arrow) rather than into the pyriform sinus at *.

The “chute” (3 of 4)

A closer view shows even better the “chute” into the larynx.

Abnormal diversion (4 of 4)

While swallowing blue-colored water, arrows indicate the normal path on the left (right of photo) and the abnormal diversion into the larynx on the right (left of photo). The patient manages, but must swallow carefully, especially since the epiglottis cannot invert since it is scarred to the base of tongue as shown in photo 2.

Solid Food Dysphagia Due to An Unexplained Benign Mass

Benign mass (1 of 4)

This elderly man is having a hard time swallowing solids. There is a mucosa-covered mass (marked with lines) between the posterior pharyngeal wall (longer dashed line) and the arytenoid towers ( marked with A). “V” denotes the right vocal cord.

Closer view (2 of 4)

At much closer range while having the patient perform a trumpet maneuver.

One week post-op (3 of 4)

This is a week after laser excision of this mass. The dashed line again shows the posterior pharyngeal wall and A and V again denote arytenoid apices and V, the right vocal cord. The pathology examination shows only fibrosis and other nonspecific benign findings.

Trumpet maneuver post-op (4 of 4)

Now performing trumpet maneuver (as in photo 2), the upper edge of the excision is shown (dashed line, left of photo). In spite of a very sore throat, this man can already sense improvement in his swallowing.