Swallowing is a set of coordinated muscle movements that control the mouth, the back of the throat (pharynx) and the food tube (esophagus). Swallowing occurs without us even thinking about it, yet it is a complex and vital function, as it is very important to eating and social interaction.
See illustration: Steps in swallowing.
See animation: Mechanisms of swallowing.
Types of Swallowing Disorders
Trouble with swallowing refers to two problems:
— the sensation of food or fluid being regurgitated or stuck in the chest; also any throat dyscoordination leading to coughing or choking during swallowing
Odynophagia — pain in throat or chest during swallowing
Swallowing disorders may result from a lack of coordination of the nerves or muscles, or sometimes from infections and tumors.
Symptoms of Swallowing Disorders
Swallowing disorders result in a number of troubling symptoms. If you have trouble swallowing, you may have just one problem (like pain with swallowing) or you may experience a few different problems (like difficulty when starting to swallow and then coughing during the swallow). Since some swallowing disorders may be serious, it is important to get a proper diagnosis. Johns Hopkins gastroenterologists can quickly and accurately diagnose any swallowing disorder you may have.
Symptoms of swallowing disorders include:
- Dysphagia — a sense of food "sticking" on the way down and difficulty passing food or liquid from the mouth to the esophagus to the stomach
- Coughing during or immediately after swallowing
- Choking — a feeling of food or liquid sticking in the throat or esophagus followed by coughing
- Regurgitation — the return of food or liquid back to the mouth or pharynx after it successfully passed. This happens effortlessly, unlike vomiting, which involves contraction of abdominal muscles. If the regurgitation tastes like ingested food, it usually indicates a swallowing disorder; if it tastes sour or bitter, that indicates it reached the stomach and it is more likely gastroesophageal reflux disease (GERD).
- Nasal regurgitation — when food or fluid comes up into the nose; this occurs when the nasopharynx does not close properly
Other symptoms may include:
- Sore throat
- Shortness of breath
- Chest discomfort or pain
It can be hard to match up symptoms to a specific disorder on your own. An experienced gastroenterologist is specially trained to help diagnose all types of swallowing disorders. It is important to make an appointment with a gastroenterologist if you are having any of these symptoms.
Diagnosis of Swallowing Disorders at Johns Hopkins
At Johns Hopkins, we combine the latest diagnostic equipment with the expertise of the nation's top gastroenterologists. Our physicians have years of experiencing diagnosing and treating even the most challenging swallowing disorders. Our high volume of cases means we have the necessary experience and capability to diagnose your condition quickly and accurately.
Diagnosing and treating swallowing disorders requires a multidisciplinary team approach. There are many specialties involved in evaluating and managing swallowing disorders. Your gastroenterologist is at the heart of the diagnostic team, directing care and guiding patients through the appropriate procedures. Other members of your team may include:
- Motility specialists
- Ear, nose and throat physicians
- Speech therapists
Diagnostic Procedures for Swallowing Disorders
Your doctor will begin with a thorough physical examination and will ask you about your medical history. It may be helpful to write down when you have your symptoms, whether any foods in particular aggravate your symptoms and when you think the trouble started, and bring this list to your appointment.
Your history of symptoms will help your doctor determine the type of disorder you may have and the tests necessary to determine the cause.
Diagnostic procedures your doctor may order include:
Gastroenterologists at Johns Hopkins routinely perform endoscopies, a frequently used diagnostic procedure for swallowing disorders. Their vast experience with these tools allows for an accurate diagnosis.
Your doctor may perform an endoscopy to examine the esophagus and stomach. An endoscope is a thin, lighted tube with a camera at its tip that allows your doctor a better view of your condition.
During an endoscopy:
- You are sedated.
- Your doctor inserts a flexible endoscope through your mouth and into your esophagus.
- The endoscope allows your doctor to examine your stomach, duodenum (the first part of your small intestine) and esophagus.
- Your doctor looks for tumors, esophageal strictures (narrowing) and abnormalities in the mucous lining.
- If necessary, your doctor can perform a biopsy, removing abnormal tissue for further analysis.
Our doctors have decades of experience performing barium esophagrams, one of the most important diagnostic procedures for swallowing disorders.
Barium X-ray studies are often the first step in diagnosing swallowing disorders. This procedure allows your doctor to evaluate your entire swallowing channel, which includes the mouth, pharynx and esophagus. This provides a better view of both the structure and function of the swallowing channel, and offers a contrast so abnormalities show up on the X-ray.
During barium esophagram:
- You swallow liquid called barium, which shows up on X-rays in bright contrasts to the other structures.
- The barium coats your gastrointestinal tract, making it easier for the doctor to see the structures and detect abnormalities.
- An X-ray is performed — sometimes a single X-ray and other times a sequence of X-rays, which make a kind of movie to better capture how your swallowing channel works.
- The X-ray pictures are stored for your doctor to evaluate.
An esophageal manometry evaluates the changes in pressure that happen when you swallow.
During an esophageal manometry:
- Your nurse will pass a thin, flexible catheter through your nose or mouth, down your throat and into your stomach. While it can be slightly uncomfortable to have a tube in your nose, the test only lasts about 10 minutes.
- Attached to the tube are a number of pressure sensors.
- Using the pressure sensors, your doctor can assess the recording of your swallowing muscles in action.
- You start by swallowing a few sips of water, then applesauce or something similar.
- You may bring foods that trigger your symptoms; this way, your doctor can see what is happening in real time.
Esophageal manometry provides your doctor with real-time information about:
- Strength and coordination of the muscle movements (peristalsis) of the pharynx and esophagus.
- Strength and relaxation function of the upper and lower esophageal sphincters. A sphincter is a muscle that opens and closes; the lower esophageal sphincter is the muscle that controls the emptying of foods from the esophagus to the stomach.
Wireless pH Testing
Wireless pH testing allows your doctor to evaluate your reflux activity over a 48-hour period, while you are continuing your normal activities. To perform wireless pH testing:
- Your doctor performs an endoscopy and places a small chip in the lower esophagus.
- The chip records acid at that site for 48 hours. A newer version allows for 96 hours of recording when recommended by your doctor.
- The chip transmits your acid level to a wireless recording device that you wear on a belt.
- The recording device is sent to your doctor who downloads the data and can gauge your reflux severity.
24-Hour pH Impedance
Your doctor may order this procedure to evaluate your reflux. During pH impedance:
- Your nurse places a thin, flexible catheter with an acid-sensitive tip through your nose into your esophagus. The catheter is placed in separate recording spots to evaluate the flow of liquid from your stomach into your esophagus.
- The catheter stays in your nose for a period of 24 hours.
- Your doctor is able to evaluate the recordings to see whether you have GERD, the severity of your reflux and the correlation between your reflux and symptoms, along with the presence of nonacid reflux.
Most people have some reflux on a daily basis, but your doctor is looking for an excessive amount of reflux.
Treatment of Swallowing Disorders at Johns Hopkins
Swallowing disorders encompass a wide variety of conditions and causes, so treatment for a swallowing disorder needs to be individualized.
Your doctor will create a treatment plan based on the severity of your symptoms and how they affect your quality of life. Learn more about treatment for swallowing disorders at Johns Hopkins.