Treating Swallowing Problems in People with Myositis

Adapted from a presentation to the Myositis Support at Hospital for Special Surgery

Jonathan Aviv, M.D.
Clinical Director Voice and Swallowing Center, ENT and Allergy Associates
Attending Physician and Clinical Professor, Department of Otolaryngology, Mount Sinai Medical Center


This is a presentation titled “Treating Swallowing Problems in People with Myositis.” Discussed are:

  • a definition of swallowing problems, or dysphagia;
  • airway protection; food transport;
  • signs and symptoms of swallowing issues;
  •  factors that can contribute to swallowing difficulties, including acid reflux disease;
  • indications for office-based swallowing evaluations;
  • diagnosis;
  • and treatment.

The definition of swallowing problems (dysphagia) is any complaint or difficulty swallowing, such as coughing, choking or difficulty in handling food or secretions.

In his talk, Jonathan Aviv, MD, discussed the phases of swallowing:

  • Oral (mouth), where food is taken in and transported
  • Pharyngeal (involving the throat)
  • Esophageal (the tube that transports food from the mouth, extending down behind the collarbone to the stomach)

During normal swallowing, which takes one second, the tongue pushes food bolus (the shape of chewed food), toward the rear of the mouth. In the pharyngeal phase, the tongue, larynx and pharyngeal walls create forces that drive the food bolus into the esophagus. These activities require good muscle function, which is often lacking in myositis.

The pharyngeal squeeze is a way to assess the throat muscles or pharyngeal muscles by either coughing or making a prolonged “EEEE” sound. (1)

Owing to muscle weakness in people with myositis, swallowing can take five seconds or longer, and tongue propulsion in the oral phase and pharyngeal peristalsis (movement that pushes food through the digestive tract) can be impaired. This is the result of inflammation of the muscles, the defining characteristic of myositis. These problems can be compounded by the presence of reflux disease—a chronic condition in which the acidic contents of the stomach move back up the esophagus causing a range of symptoms, including inflammation.

Evaluating Swallowing Difficulties

Dr. Aviv stated that one of the areas commonly overlooked is that of airway protection. This may be due to the fact that it is difficult to test for how something feels as it moves through the airway (the path that air follows to move in and out of the lungs).

This is important, however, because without sufficient sensation, food can be aspirated (inhaled and lodged in the lungs), which can lead to inflammation of the lungs.

Dr. Aviv underscored that the traditional X-ray-based test of swallowing, called the modified barium swallow, is not used to assess airway protection because a potential foreign body, that is barium, could possibly enter the lungs.

Doctors therefore use laryngeal sensory testing to assess a patient’s swallowing sensation. Indications for laryngeal sensory testing are:

  • As part of a comprehensive neurolaryngeal examination to rule out superior laryngeal nerve disease, neuralgia (pain and/or burning in the throat), or tumor
  • Laryngopharyngeal reflux and gastroesophageal reflux (Acid Reflux Disease)
  • Dysphagia (difficulty swallowing)

A commonly-used sensory test is called the FEESST Method (Flexible Endoscopic Evaluation of Swallowing with Sensory Testing). This office-based method tests a patient’s swallowing sensation and is a non-radioactive alternative to modified barium swallow studies. Motor and sensory aspects of swallowing are assessed in order to offer a precise guide to the dietary and behavioral management of people with swallowing problems.

Acid Reflux Disease: A Contributing Factor

As noted, swallowing difficulties in patients with myositis may be worsened by the presence of acid reflux disease, which may be diagnosed as either laryngopharyngeal reflux (LPR) or gastroesophageal reflux disease (GERD). The primary difference between the conditions is that in GERD the stomach contents usually do not enter the throat or mouth, but instead “back up” into the chest only.

Two of the key elements in diagnosing LPR are swelling (edema) of the throat tissues and a burning sensation in the throat, or acid reflux.

Acid reflux is often present silently and patients with myositis usually don’t complain of heartburn. It may, however, contribute to swallowing difficulties.

Common symptoms of LPR include:

  • hoarseness
  • chronic cough
  • dysphagia
  • lump like sensation in throat (also known as globus, which is Latin for ball)
  • throat clearing
  • heartburn and/or vomiting

To determine whether acid reflux disease is affecting the throat, a Reflux Symptom Index (RSI) is used. If an abnormal amount of reflux is found in a patient, he or she may be diagnosed with GERD.

Some of the common symptoms of GERD resemble those found with LPR, including: heartburn, vomiting, coughing, and dysphagia.

To minimize the occurrence of these symptoms, Dr. Aviv recommended avoiding the following foods:

  • caffeine
  • chocolate
  • alcohol
  • mint
  • tomato
  • onion
  • garlic

Addressing the Causes: Muscle Damage and Reflux Disease

As noted, dysphagia is assessed based on the results of the FEESST procedure. In people with myositis, there may be muscle damage. Therefore, muscles may not contract normally and food may sit in the mouth or in the throat. While muscle movement cannot be restored in patients with myositis, anything that can reduce overall tissue swelling can reduce the muscle load required to initiate and carry out a safe swallow. If reflux disease is present, antacids and other medications can control symptoms and reduce throat tissue swelling, thereby assisting patients with myositis. Often, reducing throat tissue swelling can also restore some sensation to the throat tissues.

Creating more space for food to travel also facilitates swallowing. Dr. Aviv recommended, and demonstrated, the use of two simple exercises that help in the process. All treatments should first be discussed with your primary medical physician.

The Chin Tuck method is a technique of swallowing that involves protecting the airway. During this method, the chin is tucked forward allowing for the space between the base of the tongue and the vocal folds (also called the vocal cords) to widen, preventing food material from entering the airway. This method also stretches open the top portion of the esophagus, thereby effectively opening the upper esophageal sphincter, and allowing a safe swallow.

A more long-term process and exercise is called the Shaker Exercise, named after Reza Shaker, M.D. This isometric (muscle-strengthening) physical therapy exercise involves lifting and lowering the head at regular intervals while lying flat on a bed or the floor. It loosens a tight upper esophageal sphincter and helps in the process of swallowing.

Summary

Dr. Aviv concluded his presentation with three primary “take home messages” for people with myositis who have swallowing problems:

  • Once lost, muscle movement and function cannot be restored.
  • Airway swelling can be reduced by treating underlying acid reflux disease.
  • Exercises can be done to help make the most of the throat muscles that are working.

Learn more about the HSS Myositis Support Group, a free support and education group, held monthly for people with myositis and their families and friends.


Summary prepared by Suzan Fischbein, LMSW, Myositis Support Group Coordinator

Footer:
1) Bastian Dysphagia 1993; 8:359-367

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