Swallowing problems

Definition

Swallowing problems refers to a group of disorders characterized by difficulty in moving food from the mouth into the throat and esophagus, moving food down the esophagus, or having a sensation of pain during swallowing. Some swallowing problems are caused by abnormalities in the structure of the senior's mouth and throat, while others are caused by neurological disorders, disorders affecting the muscles that control swallowing, or damage to the tissues lining the esophagus caused by prescription drugs. The general term for swallowing problems is dysphagia, which comes from two Greek words meaning “disordered” and “eating.” Painful swallowing is known as odynophagia. Odynophagia can occur with or without dysphagia.

A third sensation related to swallowing is called globus pharyngis, or simply globus. Globus is the persistent feeling of having a lump in one's throat or some other small obstruction when there is nothing present. Globus does not interfere with swallowing, but it can be irritating to the patient, and has to be considered during the diagnosis of a swallowing problem.

Description

It is helpful to review the process of normal human swallowing in order to understand the different types of swallowing problems in seniors. The medical term for swallowing is deglutition. It is a complex process involving the coordination of messages from the brain, skeletal muscles in the mouth and jaw, and smooth muscles in the pharynx (throat) and esophagus.

There are three phases to normal swallowing:

• Oral (sometimes called buccal). In the oral phase of swallowing, the teeth and tongue grind food and mix it with saliva to form a soft mass called a bolus. The muscles in the tongue lift the bolus and push it toward the throat. This phase of swallowing is voluntary. It is controlled by three major cranial nerves: V, VII, and XII.
• Pharyngeal. This phase of swallowing is not voluntary. After the bolus enters the pharynx, it is pushed further downward toward the esophagus by peristalsis, which is the rhythmic contraction of smooth muscles that propels food through the digestive tract. At the same time, another set of muscles temporarily closes the windpipe to prevent the bolus from entering the windpipe and the respiratory system. Skeletal muscles in the throat contract to push the food past the upper esophageal sphincter (a circular muscle) and into the upper portion of the esophagus. This phase of swallowing involves cranial nerves V, X, and XI.
• Esophageal. In the third phase of swallowing, the muscles in the upper esophagus push the food downward toward the stomach. This phase is involuntary; it is controlled by the medulla, a part of the brain stem. Another sphincter at the lower end of the esophagus relaxes and allows the bolus to pass into the stomach. It takes between 8 and 20 seconds for the contractions of the esophagus to push the bolus into the stomach.

From the foregoing description of normal swallowing, the reader can see that any disease or disorder that affects the brain stem and the cranial nerves (such as stroke , Parkinson's disease, or Alzheimer's disease); the skeletal muscles of the body (such as polio or muscular dystrophy); the smooth muscles of the digestive tract; or blocks the throat or esophagus (such as foreign objects, malignant tumors, or a swollen thyroid gland) can cause swallowing problems.

Demographics

Swallowing problems are common in seniors; various estimates range from 10 percent of all adults over 50 to as many as 50 percent of seniors in nursing homes . It is thought that the actual incidence of swallowing problems in seniors in the community may be higher than 10 percent because many do not seek medical advice for them.

Causes and symptoms

The causes and symptoms of swallowing problems depend on the location of the difficulty. They are usually grouped into two categories, oropharyngeal and esophageal.

Oropharyngeal dysphagia

Oropharyngeal dysphagia is caused by diseases or disorders affecting the mouth and throat. These may include:

• Stroke. Stroke may affect the parts of the brain that control the voluntary phase of swallowing in the mouth. Between 51 and 73 percent of stroke patients develop dysphagia.
• Brain tumors, Parkinson's disease, and Alzheimer's disease. These disorders prevent impulses from the brain and cranial nerves reaching the muscles of the mouth and throat.
• Syphilis. Syphilis is a sexually transmitted disease that causes nerve cells in the spinal cord to degenerate during its third or final stage. The loss of these cells can affect swallowing as well as walking, hearing, and sight.
• Abnormalities of the upper esophageal sphincter. Some people have a sphincter that does not relax normally during swallowing. In others, the sphincter closes too quickly. This overly rapid closure eventually results in the formation of a pouch in the upper esophageal wall known as Zenker's diverticulum. Most patients with Zenker's diverticulum are over 50.
• Cancerous tumors of the throat and esophagus. These cause dysphagia by blocking the passage of food.
• Myasthenia gravis, polio, and muscular dystrophy. Diseases affecting skeletal muscles elsewhere in the body also affect swallowing.
• Esophageal rings and webs of tissue. These are noncancerous membranes along the walls of the esophagus that some people are born with. They cause narrowing of the esophagus that is usually not noticeable until the patient is over 40.

Symptoms associated with oropharyngeal dysphagia include:

• Coughing or choking.
• A nasal quality to the patient's voice.
• Regurgitation. Regurgitation refers to food coming back up through the mouth or nose when swallowing is not proceeding normally.
• Aspiration. Aspiration occurs when the bolus enters the respiratory system (the windpipe and lungs) rather than proceeding down the digestive tract.
• Some seniors experience globus along with the dysphagia.
• Chest pain. This symptom is often found in anxious or depressed patients with dysphagia.
• Bad breath. This is a common symptom of Zenkel's diverticulum.

Esophageal dysphagia

Causes of esophageal dysphagia include:

• Achalasia. Achalasia is a disorder in which the sphincter at the lower end of the esophagus does not relax normally and allow food to enter the stomach.
• Scleroderma. This is a disease characterized by fibrous deposits of collagen in the skin and internal organs. It can cause a narrowing of the esophagus near the point at which it joins the stomach.
• Spontaneous spasms of the muscles of the esophagus.
• Narrowing of the lower portion of the esophagus by tumors.
• Narrowing of the lower end of the esophagus caused by scarring from radiation treatments, certain medications (most commonly antibiotics, NSAIDs, and potassium chloride), or peptic ulcers.

Symptoms of esophageal dysphagia include:

• A sensation of food sticking in the back of the throat or further down the chest. The patient's identification of the trouble spot, however, may not be the actual location of the blockage or narrowing.
• Pain or a feeling of heartburn underneath the breastbone.
• Regurgitation.
• Changing dietary habits, typically eating fewer solid foods and taking in more liquids and soft foods.

Diagnosis

Office examination In many cases the doctor can narrow the diagnostic possibilities by looking at the patient's medical history and by performing a careful physical examination in the office. The doctor can examine the senior's mouth and throat in the office for evidence of anatomical abnormalities and to test the senior's ability to move and control the tongue, chew, and swallow. The doctor will also check the senior's level of mental alertness and cognitive status.

Other tests that can be performed in the office include the use of a tongue depressor to see whether the gag reflex is working normally; placing two fingers over the patient's throat and asking him or her to swallow; feeling the thyroid gland in the neck for signs of enlargement; and asking the patient to cough or clear the throat. If the patient cannot clear the throat adequately, the risk of aspiration is increased. The doctor will also palpate (feel) the patient's abdomen for signs of abnormal masses or enlargement of the internal organs.

The final part of an office examination for dysphagia is to have the patient swallow several different types of solids and liquids while the doctor watches. Delayed swallowing, hoarse voice, coughing, or drooling indicate a problem.

Special tests

Most swallowing problems can be diagnosed on the basis of the patient's history and the office examination. In some cases, however, the doctor may order special tests:

• Laboratory tests. A complete blood count can be used to screen for syphilis or other infectious diseases, and a thyroid function test can be ordered to screen for thyroid disorders.
• Neurological examination. A neurologist may be consulted to check the functioning of the patient's cranial nerves and other parts of the brain that affect swallowing.
• Upper endoscopy. This is a procedure in which the doctor passes a tube called an endoscope through the mouth, over the tongue, and down the throat. The endoscope allows the doctor to see whether there are any tumors or other abnormalities blocking normal swallowing. The doctor can also use the endoscope to remove a piece of tissue for biopsy.
• Barium swallow. This test is used to evaluate the presence of such abnormalities as tumors, webs, or Zenkel's diverticulum. The patient is given a solution of barium sulfate to drink, which coats the inside of the throat and esophagus. While the patient is swallowing, the radiologist takes images with a fluoroscope at the rate of 2 to 3 frames per second. In most cases images will be taken from the side as well as the front and back while the patient drinks the barium.
• Manometry. This test, which takes about 45 minutes, is performed to evaluate the internal pressure at various points along the length of the esophagus. A catheter containing pressure probes is guided through the nose into the patient's stomach and slowly withdrawn. At various points the patient is asked to swallow some water or take a few deep breaths while the catheter records the changes in pressure inside the esophagus during these maneuvers.

QUESTIONS TO ASK YOUR DOCTOR

• What is causing my difficulties in swallowing?
• Where is the problem located?
• Will I need special tests to find the cause?
• Will I need a special diet?
• What other treatments will be needed?

Treatment

Treatment depends on the cause of the dysphagia. It may involve surgery, medications, radiation therapy, physical rehabilitation, or dietary changes.

Nutrition/Dietetic concerns

Nutrition is a major concern with dysphagia because some patients stop eating, or eat only soft foods. Malnutrition, dehydration , and weight loss are common in seniors with swallowing problems. In some cases the patient benefits from a diet of soft or pureed foods. In other cases the patient is taught a variety of techniques to train their mouth and throat muscles to hold food in the mouth and swallow more efficiently, or to hold the head in certain positions to assist in swallowing. Patients who are able to improve their swallowing by retraining the muscles of the mouth and throat can gradually be moved from liquid or soft diets to semi-solid foods or even some solid foods.

Patients whose dysphagia is caused by neurological disorders or cancer usually require tube feeding.

Therapy

Some patients whose swallowing problems are caused by muscular disorders can be helped by medications. Stroke patients can often be evaluated and retrained to swallow by a speech therapist. Seniors with cancers of the head and neck usually require a combination of surgery, radiation therapy, and chemotherapy . Surgery is used occasionally to treat anatomical abnormalities of the throat or esophagus, but this approach is effective only in selected patients. In patients with Alzheimer's or Parkinson's disease, changing the diet to soft foods or using tube feeding are usually necessary, as these disorders are incurable.

KEY TERMS

Achalasia —A disorder in which the lower esophageal sphincter fails to relax during swallowing.

Aspiration —The passage of food from the throat into the airway during swallowing rather than further down the esophagus.

Bolus —A soft mass of chewed food formed in the mouth during the first stage of swallowing.

Deglutition —The medical term for the act of swallowing.

Dysphagia —The medical term for difficulty in swallowing.

Globus pharyngis —The persistent sensation of a lump or some other small object in the throat even though no obstruction is present.

Medulla —A structure in the brain stem that controls breathing, swallowing, and other vital functions.

Odynophagia —The medical term for painful swallowing. It may be present with or without dysphagia.

Regurgitation —The casting up of undigested food through the nose or mouth.

Sphincter —A ring-shaped muscle that is able to contract or relax in order to close or open a body passage. The esophagus has two sphincters, one at the upper end in the throat, and the other at the lower end where the esophagus joins the stomach.

Zenker's diverticulum —A disorder in which an overly tense sphincter at the upper end of the esophagus leads to the formation of a pouch in the wall of the esophagus.

Prognosis

The prognosis depends on the cause of the swallowing problem.

Prevention

There is no way as of the early 2000s to prevent all the possible causes of difficult swallowing in seniors.

Caregiver concerns

Caregiver concerns include:

• Obtaining advice about maintaining the senior's nutrition.
• Assisting with feeding (if necessary) or with exercises to improve swallowing.
• Watching for signs of aspiration. The major danger associated with food getting into the windpipe and lungs is a type of pneumonia called aspiration pneumonia.
• Making sure that the senior takes any medications prescribed to treat difficult swallowing.
• Making sure that the senior is getting proper dental care. Swallowing disorders can lead to tooth decay and other dental problems.

Resources

BOOKS

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 105, “Dysphagia.” Whitehouse Station, NJ: Merck, 2005.

Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day: A Family Guide to Caring for People with Alzheimer Disease, Other Dementias, and Memory Loss in Later Life, 4th ed. Baltimore, MD: Johns Hopkins University Press, 2006.

Morris, Virginia. How to Care for Aging Parents, 2nd ed. New York: Workman Publishing Co., 2004.

Sonies, Barbara C. Dysphagia: A Continuum of Care. Austin, TX: Pro-Ed, 2004.

PERIODICALS

Ferreira, L. E., D. T. Simmons, and T. H. Baron. “Zenker's Diverticula: Patho physiology, Clinical Presentation, and Flexible Endoscopic Management.” Diseases of the Esophagus 21 (January 2008): 1–8.

Roy, N., et al. “Dysphagia in the Elderly: Preliminary Evidence of Prevalence, Risk Factors, and Socioemotional Effects.” Annals of Otology, Rhinology, and Laryngology 116 (November 2007): 858–865.

Spieker, Michael R. “Evaluating Dysphagia.” American Family Physician 61 (June 15, 2000): 3639–3648.

OTHER

Fisichella, P. Marco. “Achalasia.” eMedicine, October 10, 2006. http://www.emedicine.com/med/topic16.htm [cited February 27, 2008].

National Institute of Neurological Disorders and Stroke (NINDS). NINDS Swallowing Disorders Information Page. Bethesda, MD: NINDS, 2007. Available online at http://www.ninds.nih.gov/disorders/swallowing_disorders/swallowing_disorders.htm?css=print [cited February 27, 2008].

Paik, Nam-Jong. “Dysphagia.” eMedicine, December 6, 2006. http://www.emedicine.com/pmr/topic194.htm [cited February 27, 2008].

ORGANIZATIONS

Alzheimer's Association, 225 North Michigan Ave., Floor 17, Chicago, IL, 60601, (312) 335-8700, (800) 272-3900, (866) 699-1246, [email protected], http://www.alz.org/index.asp.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Building 31, Room 9A06, 31 Center Drive, MSC 2560, Bethesda, MD, 20892, (301) 496-3583, http://www2.niddk.nih.gov/.

National Institute of Neurological Disorders and Stroke (NINDS) Brain Resources and Information Network (BRAIN), P.O. Box 5801, Bethesda, MD, 20824, (800) 352-9424, http://www.ninds.nih.gov.

Rebecca J. Frey Ph.D.