Esophageal Dysphagia: A Guide for the SLP
Robert came to me for a modified barium swallow study as an outpatient. He complained of food sticking in his throat. It's been going on so long that he even knew the medical term for the condition: Globus sensation.
"I don't know what to do about this globus. It's been driving me absolutely crazy and seems to be getting worse. I'm praying that you'll be able to help me."
"How long has this been going on for, Robert?" I asked.
"It seems like for as long as I can remember, but maybe in reality, like two years. It dealt with it for a while. I just took smaller bites of food and smaller sips of liquid, and then after a while I started giving up certain things, like bread and steak. But over the past few months, I've been basically just taking liquids and small amounts of soft food. I've already been to the ENT twice, but she had no answers for me. She told me to come to see you. I've lost 25 pounds. I need to get a whole new wardrobe because of this damn globus. You gotta help me figure this thing out."
Anatomy and Physiology
Esophageal dysphagia can manifest in various ways, impacting individuals differently. Recognizing the nuances of this condition is crucial for effective management and care.
But let's first get a basic understanding of the esophagus. It's a tubular structure that connects the pharynx to the stomach and is composed of striated muscle in the upper third (voluntary and involuntary control) and smooth muscle in the lower two-thirds (involuntary control). You can think of the pharynx and the very top of the esophagus like a worker loading packages onto an automatic conveyor belt (the lower two-thirds of the esophagus). Two sphincters, the upper esophageal sphincter (UES) and the lower esophageal sphincter (LES), act as the entry and exit doors of that conveyor belt. If you want to get fancy, you can call the UES the cricopharyngeal segment opening because it's not a ring of muscle like a true sphincter would be. But let’s be honest: if you call it the LES, everyone will know what you’re talking about.
The esophagus propels the bolus down from the pharynx to the stomach via a coordinated action of peristaltic waves (Like your stomach is doing The Worm). This process typically lasts six to eight seconds and has a velocity of three to four centimeters per second—less than .1 MPH. It's so slow that you can often feel the food or liquid go down, say, if you've swallowed something super hot, cold, big, or scratchy (Yes, chicharrones, I'm talking about you, you day ruiner).
Differential Diagnosis
Clinical complaints alone may be unreliable in pinpointing the exact site of dysphagia, as we'll learn was the case with Robert, but I don't want to give too much away, so I'll hush for now. Symptoms of esophageal issues, such as a stricture, esophageal spasm, or gastroesophageal reflux disease (GERD), might manifest in the pharyngeal or oropharyngeal regions. The SLP (yup, you!) is often the trusted provider for differentiating esophageal dysphagia from oropharyngeal dysphagia. How do we do it? The modified barium swallow study with both lateral and anterior views is the best way to get a comprehensive picture of the oral, pharyngeal, and esophageal phases.
Key questions to consider in diagnosing dysphagia:
Below are some questions we should ask Robert to get to the bottom of what's going on.
Does the patient experience heartburn or reflux?
Does it feel like food or liquid is getting stuck, and where?
Is the problem acute or chronic?
What types of food or liquid trigger symptoms?
Is the dysphagia intermittent or progressive?
Symptoms and Indicators
There are several signs of esophageal dysphagia that we should be aware of.
Fullness or tightening in the throat or chest.
Localized or radiating neck, jaw, or chest pain
Chronic cough or coughing after swallowing
Globus sensation (feeling a lump in the throat)
Regurgitation or acidic taste
Halitosis (bad breath)
Weight loss or diet changes
Odynophagia (painful swallowing)
If we see any of these signs, that might be a time to put up the radiology bat signal and get to work in the suite. We can't treat what we can't see. Let's get to the bottom of the issue to stay on top of what's below the UES (Sorry, I couldn’t help myself with that one).
Types and Causes
Esophageal disorders can be classified into several categories. Let's explore a few of these so you can use them as a reference during your clinical practice. What can you rule out, and what might require further investigation?
Motility disorders: These include achalasia, scleroderma, diffuse esophageal spasm, and nonspecific esophageal dysmotility (NEMD).
Structural disorders involve diverticula, webs, Schatzki's ring, strictures, tumors, hiatal hernias, and neoplasms.
Inflammatory disorders include esophagitis caused by infections, GERD, or pill-induced irritation.
And the following include specific conditions to keep in mind:
Achalasia: This condition involves the failure of the LES to relax, causing food to become trapped in the esophagus. Radiographically, the esophagus may resemble a "bird's beak.”
Scleroderma: This connective tissue disorder weakens the LES, leading to increased GERD and hypomotility
Diffuse Esophageal Spasm: Neuromuscular abnormalities result in uncoordinated contractions, causing intermittent difficulty swallowing solids and liquids
Zenker's Diverticulum: This UES structural dysfunction can cause symptoms such as cough, bad breath, regurgitation, and pharyngeal gurgling.
Hiatal Hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm, potentially leading to dysphagia.
Strictures are narrowings of the esophagus, often caused by reflux, motility disorders, or caustic substance ingestion, making swallowing solids difficult.
The Role of the Speech Pathologist
What can we do to help? A lot, actually. However, any SLP assessing and treating this area should have a few prerequisite skills. You'd want your surgeon to be adequately educated and trained before they cut into you, right? We're no different. Let's make sure we have the right foundation before we start digging in under the UES. If you're weak on any of the following prerequisites, I'll include a link to a great course at the end of this article.
SLPs treating patients with esophageal dysphagia should:
Possess a strong understanding of esophageal anatomy and physiology.
Be able to identify diseases and disorders associated with esophageal dysfunction.
Correlate subjective complaints, patient history, and radiographic findings.
Make appropriate recommendations based on historical, clinical, and objective findings in consultation with radiologists.
Develop competencies and protocols for monitoring the safety and efficacy of procedures.
Diagnostic Procedures
We identify a suspected esophageal dysfunction in Robert's modified barium swallow study. What follow-up tests and referrals might we need before a conclusive diagnosis is made and an effective plan of care is implemented?
Referral to gastroenterologist: Still widely considered the go-to medical professional for esophageal disorders. Yes, our role is growing, but the gastroenterologist remains the specialist.
Referral to a neurologist: This may be necessary if a neurological disorder is suspected.
Manometry: Measures pressure changes to identify motility disorders.
Upper GI endoscopy ± biopsy: Allows for visual examination and tissue sampling.
Barium swallow (aka Esophagram): This is similar to the modified barium swallow study, but it examines esophageal function more closely and asks the patient to move in several different positions. This allows the radiologist and gastroenterologist to study bolus flow and look for abnormalities in esophageal structure and function.
Management and Treatment
Management strategies, of course, vary depending on the disorder. Like most things in our field, and in general, for that matter, there is no panacea for esophageal dysphagia. But there's still A LOT of research-backed interventions we can use to help. Here are a few…
Lifestyle and Diet Changes: These include smaller, more frequent meals, avoiding certain foods and beverages, eating upright, slow pacing, leaving time to digest, weight loss, and avoiding harmful habits like smoking and excessive alcohol consumption. Lifestyle and diet changes should be our first approach because there are typically no side effects, and they are cheap and available to anyone who wants to get better. Of course, it's not the magic pill everyone's looking for, but it often works just as well, if not better, than many other interventions we use.
Pharmacological Treatment: Medications such as antacids, H2 blockers, and proton pump inhibitors (PPIs) may be prescribed for GERD. Remember that these medications do not treat the source of the reflux, which is a mechanical issue, but instead treat the symptoms (heartburn) by reducing the acidity of the stomach acids. Altering an important bodily function, such as the production of stomach acid, can have serious side effects, especially when used long-term.
Surgical Intervention: Procedures like dilation, myotomy, or fundoplication may be necessary for conditions that cannot or do not resolve with less invasive interventions.
Conclusion
Robert's symptoms and suspected esophageal dysmotility were severe enough that we immediately referred him to the gastroenterologist, who ordered a barium swallow study and identified a large esophageal stricture. This prompted an esophageal dilation to stretch out the esophagus, which had an immediate positive effect on Robert's symptoms. He can eat his favorite foods again and slowly gain weight weekly. The only thing he's frustrated about now is that it took him so long to come to us for help.
Esophageal dysphagia is a complex condition requiring a comprehensive understanding of esophageal anatomy, physiology, and various potential etiologies. A collaborative approach involving SLPs, radiologists, and gastroenterologists is essential for accurate diagnosis and effective management. Our role is growing in this area, and there is even more we can do to help patients with life-altering diseases. You can be the one who helps the patient figure out what's going on for the first time, just like we did for Robert.
Looking for more education? I recommend Barbara Pisano Messing’s, PhD, CCC-SLP, BCS-S, FASHA Esophageal Dysphagia: Role of the Speech Pathologist. You can access the course (any MANY others) with this link, which gives my readers a huge discount.
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