Swallowing is a very complex pattern of nerve and muscle interactions that we often take for granted. The swallow is typically described in stages; there is an oral stage (in the mouth), an oropharyngeal stage (where food transitions from the mouth to the throat), a pharyngeal stage (where the food travels down the throat), a pharyngoesophageal stage (where the food transitions from the throat to the esophagus) and an esophageal stage (where the food travels down the esophagus). Abnormalities at any stage can cause difficulty with normal eating.
There are many things that can cause a problem with the swallow. Disorders that cause nerve or muscle weakness can disrupt the timing of the stages of the swallow. Throat weakness from strokes can cause inefficient stripping of the food from the throat leading to food build up and choking. Sensation problems from inflammation or from neurologic problems can cause trouble sensing when food is left over in the throat. Tightness of the muscle at the top of the esophagus can cause pills and solids to stick in the throat which can lead to choking or the need to regurgitate the food. Anatomic problems like Zenkers diverticulum (a pouch in the upper esophagus) can cause food and liquid to build up and make the patient choke or cough. Vocal cord weakness can cause choking while drinking liquids, a problem that is often solved when the surgery to move the vocal cord over to the midline is completed. Tumors or growths in the throat or spine may block normal food passage and cause difficulty with swallowing. Reflux disease (GERD or LPRD) can cause swelling where the food goes down. Radiation therapy can cause stiffness or fibrosis of throat muscles which can make swallowing difficult.
Evaluation of the swallow includes a thorough head and neck exam including a neurologic exam as well as a functional exam of the swallow. “Functional” means watching the throat while swallowing is occurring. The functional exam can be done from the side while using x-rays (otherwise known as “radiographs or fluoroscopy), which is also called a barium swallow. Sometimes a speech therapist is present for that exam to evaluate the swallow using different techniques (modified barium swallow).
The other way is called functional endoscopic evaluation of swallowing (FEES) or with sensory testing (FEESST). This is a test where a small camera in a tube (3 mm in diameter) is inserted through the nose to the back of the throat and the examiner, either a speech pathologist or a physician, records the action of the throat while the patient is swallowing food or liquid. The benefit of this testing method is that the inside view is real-time and no radiation is used to obtain the picture. The nose is anesthetized during this procedure so there is no pain and it only takes a few minutes. In addition, the result of compensatory strategies or maneuvers cn be tested during this procedure to optimize the patients swallow.
The most important thing first is to find out what part of the swallow is affected. For throat weakness, certain exercises (swallowing therapy) can strengthen muscles. Strategies can be taught and used during the swallow to help food to go down the right way. For a tight upper esophagus, balloon dilation can stretch fibrotic muscle or scar to allow for a larger passage for food. Botox injection may also be used for this muscle when it is not relaxing/opening properly. Special endoscopic surgery for the throat can be performed to correct diverticulae or to remove obstructing growths. Your doctor will propose a treatment strategy which may incorporate several different types of recommendations to improve your swallowing.
When you are taking enough calories by mouth to maintain a good body weight and keep protein, nutrients, and calories coming to your body, the doctor will give permission for the feeding tube to be removed. Normally feeding tubes are removed by the same doctor that inserted them, as they all are different and have different retaining mechanisms.