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BackTable / ENT / Article
A Quick Start Guide to Dysphagia: Diagnosis, Treatment & The Role of Stress
Taylor Spurgeon-Hess • Jun 21, 2022 • 297 hits
Swallowing difficulties, or dysphagia, can profoundly impact the quality of life for patients, but with proper diagnosis and treatment the condition can be managed effectively. ENTs and speech language pathologists achieve diagnosis through the utilization of different types of swallow studies. Recent explorations have looked at the role of stress and the psychological factors contributing to dysphagia, as well as the utility of virtual therapy as a possible treatment option.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• The major swallow studies utilized for diagnosis and assessment of dysphagia include the barium swallow, the fiberoptic endoscopic evaluation of swallowing (FEES), and the modified barium swallow, also known as video fluoroscopy.
• FEES testing provides major benefits when obtaining imaging before and after head and neck cancer as well as when looking for vocal fold paresis. When dealing with esophageal issues, video fluoroscopy provides the most comprehensive image.
• New options for virtual swallowing therapy can maximize treatment success as it is both more accessible to rural communities, and patients can practice swallowing in a natural setting that they are already accustomed to.
• While less is known about the psychological sources, in some cases, the underlying cause of dysphagia may be rooted in stress. Stress can cause muscle tension dysphagia, in which the swallow muscles become inflamed and impaired.
Table of Contents
(1) Diagnosis Through Different Types of Swallow Studies
(2) Dysphagia Treatment and the Rise of Teletherapy
(3) The Role of Stress and the Psychological Component of Dysphagia
Diagnosis Through Different Types of Swallow Studies
Speech language pathologists (SLP) utilize a wide variety of swallow studies in order to properly assess patients for dysphagia and each study comes with its own unique benefits and limitations. Examples of commonly used swallow studies include the barium swallow, the modified barium swallow, and the fiberoptic endoscopic evaluation of swallowing (FEES). While commonly confused, the barium swallow differs from the modified barium swallow; to accentuate this difference, the modified barium swallow test is often referred to as a video fluoroscopy test instead.
The golden rule in swallow study testing is that the best test to use is the “one you can get.” Oftentimes location, setting, or patient tolerance can limit the ability to utilize one test over another so it is important to keep in mind that all tests can provide useful information. If all tests are available, FEES may be the provider’s typical first choice. It provides a live picture which can show the larynx, vocal folds, and esophageal inlet. Physicians and SLPs turn to FEES for imaging before and after head and neck cancer surgery and for diagnosis of vocal fold paresis. Video fluoroscopy shines for assessment of esophageal issues and allows for a better view of the oral phase of the swallow.
[Ashley Agan MD]
So let's get into talking about dysphagia, and Gopi and I, when we were talking about it, we were thinking, well, first we probably need to just set the stage with some terminology because even Gopi and I use different terms when talking about barium swallow, modified barium swallow, video fluoroscopy, FEES, there's all these different terms. These are all technically swallow studies, different ways to look at the swallow, but if you can call them different things depending on who you are or where you are, tell us about that.
[Theresa Richard SLP]
Interesting. The modified barium swallow study has been around a while. Gosh, I think maybe in the seventies I believe is when Dr. Jeri Logemann, basically, I don't want to say invented it, but pretty much is the one that came up with that procedure. And that sort of was the gold standard for the longest time. And that is an x-ray, it's done from the side. So you're able to see the swallow on an x-ray. Dr. Susan Langmore in the nineties, basically invented FEES, which is fiberoptic endoscopic evaluation of swallowing. It's a top-down view obviously with the endoscope. So each has their pros and cons. What I like to say is which test is best. And to me, it's the one you can actually get. And I think we all know limitations of working in hospitals, working in doctor's offices. Are you rural? Where are you located? Sometimes the logistics of getting the ideal test just do not happen, especially if you're in the NICU or working in skilled nursing. For me, ideally, I just always say the test you can get is the best. We can obviously get into the pros and cons of some.
What I do want to talk about also is the difference between the modified barium swallow study and a barium swallow that GI does, because so many times this is something that I just want to educate every intake coordinator and her schedule or at a hospital. I even went through it with my own son. We were trying to get one scheduled. And she's like, are you sure you don't want the barium swallow? And I was like, no, I know what test I need. And so that's just so frustrating and I hate that they're coined so similarly, but video fluoroscopy is sort of the new name now or a video swallow basically because it's done with fluoro. So, a lot of people still do call it the modified barium swallow study, but video fluoroscopy is now sort of the new term to use.
[Ashley Agan MD]
Okay. And, that's probably better because then it takes the barium name out of it. So you're less likely to confuse barium swallow and modified barium swallow. Okay. Good to know.
[Gopi Shah MD]
And when you're thinking, let's say you, I think you make a great point. It's which one can you get? But let's say you have a patient that will tolerate both. Which one do you like for what problems or which one tells you what?
[Theresa Richard SLP]
So in my perfect world, I would always do a FEES first. And I say that because I think there's so much information that it can give us right off the bat. It's a real live picture. So you're viewing the larynx, you're viewing the vocal folds, you can see the esophageal inlet. So there's things that you can see right off the bat that we might be able to say, “Ooh, this is something that just needs to go right to ENT, or this just needs to go right to GI.” I think sometimes we get ahead of ourselves and try to intervene and try to fix things therapeutically that might need surgical or medical intervention. With the FEES specifically, a lot of times, I mean, we just see so much, effects of reflux or even allergies, things like that. So that's when we got to send them off to you guys to just get them medically or surgically stable first.
So that's why I'm such a big believer in FEES as sort of the primary tool, especially because it is so easy for us to use all the time and doesn't involve all the logistics of radiology, but things that you see on FEES, we assess, especially a lot of secretions, a lot of these patients that are trachs and vents, secretions are a huge thing. So we can sort of tell if they have secretion management or not. We are able to view different foods and liquids and textures that we can actually see them on the FEES. We assess for different laryngeal, pharyngeal anatomy, and sensory deficits. You can view if there's vocal fold paralysis or paresis, you can check out why there might be different voice changes. And especially, it can be really beneficial for things like pre or post head and neck cancer surgery as well. So those are sort of the top things that you would really want to go to FEES first. But like I said, I'm really biased. And I admit that, and I always say that FEES is the best tool to use first, but a lot of people that don't have experience with FEES and still believe that video fluoroscopy is the gold standard, I'll absolutely take the information we can get from that any day, but video fluoroscopy is superior when looking at esophageal issues, because we're able to see basically from the nose down to the stomach, if the radiologist allows us to scan down that far and get a view of the lower esophagus as well, you do get a much better image of the oral phase of the swallow on video fluoroscopy, because it's on the side. So you can tell if there's chewing, rotary chew, if they're able to, basically bolus transit. You're able to tell if the tongue is moving in the right direction, all that stuff. So, Yeah. Those are pretty much the biggest differences about when you would use one or the other, but a lot of it comes down to logistics if I'm being honest.
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Dysphagia Treatment and the Rise of Teletherapy
A crucial aspect needed to build a foundation for successful treatment requires communicating about expectations with the patient and outlining the goals of treatment. While some patients seek rapid improvement and hope to resume eating a variety of chewy foods, others are satisfied with eating softer, easier-to-swallow foods. These patient desires play a large role in both the length and intensity of treatment. For those with larger goals, the mainstay of care is intense rehabilitation with swallowing therapy. In the wake of COVID, teletherapy for dysphagia has become an accessible option for many people, including those in rural communities who would otherwise drive hours for treatment. Patients are able to practice swallowing in a familiar environment where they are already accustomed to eating which can help to maximize success.
[Ashley Agan MD]
When we're sending patients to you, what can we do as far as setting expectations? Because sometimes I'll talk to patients, and say, maybe you may only have to see them one time and maybe they'll give you some exercises you can do on your own. They may want you to come back and see them a few times. It depends on the evaluation. That's kind of generally what I tend to tell patients, but, what other things should we say?
[Theresa Richard SLP]
It's really patient specific, to be honest, like a lot of patients want to improve rapidly. They want to be able to chew the finest chewiest steak ever, or some really just don't care. So, the prognosis and the length of treatment and the intensity of treatment really depends on their goals of care. And I think that's somewhere that we sort of get ourselves in trouble because we just assume, oh, well, let me just put you on a puree diet, you'll be on your way. And the patient gets home and they're like, what the heck? Like, no, I want a burger. I want a steak. Or on the flip side, you have somebody that maybe doesn't have dentures or just wants to eat ice cream for the rest of their life. They don't care about eating a steak. So it really, truly depends. So I think getting that information out in the case history. And when you're doing the swallow study, we have a lot of wonderful tools available to us. Technology is beautiful in what we're able to do. Now, we have a lot of different biofeedback tools that we can use. We do have some really intense dysphasia exercise programs too. So, there's a few different programs that, I mean, it's hours of swallowing therapy for three to four weeks on end. And we've seen some patients go from NPO back to eating again in a month on these protocols. So it really just depends on how much the patient wants to put into it and really what they want their quality of life to be. And if they want to eat ice cream for the rest of their lives, and they're fine with that, then we'll just do one or two sessions and tell them, do this, don't do this, do this, come back and see me if you change your mind or we will do some really intense rehab.
[Gopi Shah MD]
Can you do some of it virtually? Are y'all able to?
[Theresa Richard SLP]
Yeah, yeah. And the beauty of COVID, if there is such a thing, is that was one thing that right when COVID first hit I believe Medicare allowed us to do teletherapy for dysphasia, which they didn't used to allow. And then I believe they were going to overturn it, but they actually kept it that we still can do it. So I think that's been a game changer, especially for a lot of these rural, if you live three hours away from a major medical center, come in for your swallow study, but then if we can just do treatment, over Zoom or something, it's a huge, huge benefit to the patient. So, short answer, yeah. There's still obviously a lot of nuances with the different insurance companies and what they'll pay for and dealing with technology with patients. But I believe for the most part, it's a huge, huge, huge blessing. I actually have a friend in Texas and she just got some teletherapy regs overturned for working with babies. So she's actually, she's doing a whole seminar called “Fed with Telemed.” Just really helping the parents.
[Gopi Shah MD]
That's awesome.
[Ashley Agan MD]
Yeah. I think for now virtual is here to stay in some form or another.
[Theresa Richard SLP]
Yeah. Yeah. And I think it's beautiful in this aspect, we can just do a lot of consulting and things like that and have them only come in when they really truly need to.
[Gopi Shah MD]
Well, and they're eating at home. So to be able to do therapy at home in their natural setting and where they're going to be, also those adjustments, modifications, questions, hopefully only maximizes [success].
[Theresa Richard SLP]
Yeah. Yeah. And we do have, like I said, the technology is just wild, what we're able to do now. And there's a lot of different biofeedback tools that the patients are able to place on themselves and then we're able to read the muscle activation and things like that on our end. So that's really cool.
The Role of Stress and the Psychological Component of Dysphagia
On occasion, a patient’s chief complaint is dysphagia but their swallow study results and scope exam both return normal results. No other external cause presents itself but they still struggle with swallowing. In these patients, stress or other psychological factors may be playing a large part in their symptoms. Most often, the patient suffers from muscle tension dysphagia; stress and tension have been held in the muscles responsible for swallowing and the inflammation has caused impairment. Vocal relaxation techniques may help to relax the swallow and provide relief. While less studied, there is a proposed connection between psychological components, the patient's subconscious, and their ability to swallow. Often, guided meditation exercises, or other techniques involving the subconscious, work to improve symptoms.
[Ashley Agan MD]
There's a patient group that I always struggle with. The patient comes in and their chief complaint is dysphasia. They're having some trouble swallowing. They have a normal, flexible scope exam. They are not losing weight, seem perfectly healthy and normal otherwise. Get a modified barium swallow, it's also normal. And they're like, well, doc, why can't I swallow? I really am having trouble swallowing. I'm really not gonna let this go. Because you tell them, okay, the good thing is everything looks normal, normal, normal, but they're like, no, I'm not normal. What's going on? How do you take care of those patients or what do you usually find?
[Theresa Richard SLP]
A majority of the time it's muscle tension dysphasia, I'm not sure if you guys are familiar with that.
[Ashley Agan MD]
Yeah. Yeah. Let's talk about that. As I feel like I learned that term in the last, maybe couple of years from our speech therapists.
[Theresa Richard SLP]
Yup. Yup. And that's really sort of what we're finding. And, I believe there's even more work that came out this year. Even spelling it out even more. And a lot of it is just stress. They're seeing it a lot more now after COVID. It's really interesting because it's a lot of just where people are holding their stress and their tension, but it's so bad that the muscles are so inflamed that it's really impairing the swallow. So a lot of it is these vocal exercises, these vocal relaxation techniques. So, speech pathologists work with swallowing and voice. I only do swallowing, but a lot do both or some just do voice, but that's sort of where I rely on my SLP colleagues that specialize in voice to do these vocal relaxation techniques, which can help to relax the swallow. Something else that I don't know that it's controversial now, but I did write about it in my book because it comes up enough is sort of the psychological component too. And patients going for hypnotherapy or therapy, or they may have been through trauma subconsciously long, long, long ago. And so there actually is research and there are studies that have shown that, sometimes these patients need this subconscious change in order to be able to swallow if there is nothing that we can see on an actual swallow study.
[Gopi Shah MD]
I mean it makes sense when you think about, in our GI clinic, there's a GI psychologist, you know what I mean? So your swallow, it's all together. It's part of that theme. So it makes sense for sure.
[Theresa Richard SLP]
Yeah, I think as a medical professional, you want to just be able to see the problem and diagnose it and fix it. And it's not that easy sometimes. And I know some people think that's woo woo and isn't the truth, but there is some truth to it. And so I do want patients to know that is something. If they're desperate and want to research that a little bit further.
[Gopi Shah MD]
I think in ENT, especially because so much of it is quality of life, right? Some of the problems that we have, or see in our patients, whether it's vertigo, feeling dizzy, the migraine, the sinus headache patient, or, dysphasia. Any little bit that can help the patient move forward, whether you've identified something or not. And many times there's not necessarily a pathologic reason, or a surgery or medicine, but if there's some things, some tool, that's always helpful.
[Ashley Agan MD]
Yeah. And I've had patients who bring up stress to me. So, I may be talking to him and say, well, good thing is everything looks normal. We're not finding anything. And like, sometimes they'll say, do you think it could be stress? You know? And I'll be like, well, yes. Tell them are you stressed? Like, yeah, actually let's talk about that. So I think, patients are, kind of, cluing in, on how that mind-body connection works and how if you are stressed out, sometimes your body doesn't work right.
[Gopi Shah MD]
Sometimes as physicians, especially, I don't think we're always clued into that.
[Ashley Agan MD]
Right. That's not part of our training. Yeah.
[Gopi Shah MD]
We’re supposed to find that pathologic problem.
[Ashley Agan MD]
See the problem. Yeah. And fix the problem.
[Theresa Richard SLP]
I've definitely gotten into some arguments with other professionals just in our field about it, because I'm just like, there's nothing else to explain. Like you said, and then you send a patient off to a psychologist or to further explore it and they come back and they're like, that worked. I had to do these exercises or do these different guided meditation exercises and it helped. So, I think it's one thing I know from being a mother and dealing with my son's issues, you have to listen to the patient, we know what we know, but we only know what we learned.
Podcast Contributors
Theresa Richard, SLP
Theresa Richard is a speech language pathologist and the founder of Mobile Dysphagia Diagnostics in Florida.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, May 10). Ep. 59 – Feeding Difficulties in Adults [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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