What to Know About Swallowing Disorders

Podcast Transcript

Intro: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele:Hi everyone and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Today, we're going to talk a little bit about what to know about swallowing disorders, and I'm very pleased to have Dr. Alison Schneider, who's the Director of GI Motility Lab, and a gastroenterologist at Cleveland Clinic Florida's Weston Hospital. Dr. Schneider, thanks so much for joining us on Butts & Guts.

Dr. Alison Schneider: Thank you very much for having me today.

Dr. Scott Steele: So, we always like to start out with our guests with a little bit about yourself. Tell us where you're from, where'd you train, and how'd it come to the point that you're at Cleveland Clinic Florida?

Dr. Alison Schneider: I am a native of Florida. I grew up in Miami, Florida. After high school, I went to Duke University for my undergraduate, and then I came back to Miami. I went to University of Miami for my medical school training. From there, I went to Philadelphia, where I did training in internal medicine for three years, and then went on to do my GI fellowship there at Drexel University. At my fellowship program, there were many esophagologists, and people that really had an interest in motility disorders. And that's what I got drawn to during my three years of training.

I then came back to Florida, wanted to come back to my home state. And I interviewed here at Cleveland Clinic in Weston, Florida. And I've been here now almost 14 years. And when I started here, the motility lab was sort of in its infancy, and I took on the project of developing the lab, increasing the studies that we did at our motility center. And it's grown, and it's very busy today, and we do many different studies to help our patients out. And help them come to a diagnosis, or help them with treatment with swallowing disorders, which is what we're going to be talking about today. And so, here I am in 2021.

Dr. Scott Steele: Well, that's fantastic. And so when we say swallowing disorders, what type of issues are we talking about?

Dr. Alison Schneider: I guess, when we think about swallowing disorders, the other thing most patients will say that there's some difficulty with them to swallow food or water. The medical term we often will use is the term dysphagia, which comes from the Greek word, meaning disordered eating. I think when we approach a patient who says I'm having difficulty swallowing, or getting food down, as medical providers, we start to think about, "Well, is this really happening in their mouth? Or at the oral phase of when they take a food bolus? Is it more a little bit back further, pharyngeal phase, or is it actually the esophagus?" Which is that tube that connects our mouth to our stomachs, and really acts as a conduit to propulse the food bolus down into our stomach where digestion will begin to occur.

It's a condition. I think we're starting to see... We also tend to break it down to motility or anatopic disorders, as providers. And I think we start to see the symptom of difficulty swallowing increases with age. And I think we do have an older population, so I think we're starting to have this complaint more in our clinics. And I think we're starting to see an increase of some of the motility disorders that we diagnose in our clinics.

Dr. Scott Steele: So how common is this dysphagia?

Dr. Alison Schneider: Depending on the etiology that you're talking about, it's still not the most common condition that we see in gastroenterology, but it is a condition that is starting to gain more prevalent just because of our aging population. One condition that we are starting to see an increase in is a condition known as achalasia. Maybe we'll talk about that a little, but a motility disorder where it tends to have more spastic sphincters in the esophagus that prevents the ability of food to pass into the esophagus. We're starting to see that. I guess, with some neurological conditions, we're starting to see that, but I would say that dysphagia overall is still not a very, very common condition.

Dr. Scott Steele: So a full disclaimer, very, very rarely I will have something. I feel like I get a spasm or something when I swallow, and I feel like my entire chest is going to explode it hurts so bad. Is that dysphagia? Or what are some of the common symptoms associated with dysphagia?

Dr. Alison Schneider: So yes, that would be, I guess, termed a dysphagia. As far as the symptoms, I mean, we can start from the top. We, can start talking about the mouth area. Related to that area, we often say there could be choking, there could be coughing, maybe increased secretions. Moving down a little bit further, the sensation of food sticking in the chest or the throat would be a symptom. So, I guess what you're describing, that one line of it, almost think of like a spasm in the esophagus, and then the food getting stuck within the tube, the esophageal tube.

Sometimes patients can actually have recurrent... They can aspirate, they can have pneumonias, like infections of the lungs related to this. Another symptom that we would think about would be heartburn, belching, a sour taste in the mouth, water brash would be another symptom, and actually making dietary changes on a daily basis because maybe certain types of foods are more difficult than others. And then, a patient might slowly start to make these changes to accommodate for what's easier for them to swallow.

Dr. Scott Steele: So I am a patient that experiences some of these symptoms, I get referred to you, or one of your similar physicians, what can that patient experience, or what can they expect to go through during that visit? And what tests do you have out there that they may have to go through in order to diagnose what's causing that dysphagia?

Dr. Alison Schneider: Well, I think at any time, you would come to the office, I would ask you a number of questions, and that's really what really what we do... Is in our history taking. And I think the history taking is very important with the evaluating difficulty swallowing. Key questions we often ask are, is this happening only to solid foods? Is it happening to solids and liquids? Because usually, when we think about solid foods, we start to think maybe this is more of a mechanical issue, something more obstructive, such as strictures or rings, webs of extra tissue that can be in the esophagus, or a tumor. And then, when we think about solids and liquids, we tend to go down in our minds, well, maybe this is more of a motility disorder related to the muscles and nerves that work with the esophagus to make it have its peristaltic contractions.

And so, as we start to think about that, and we're looking at the key features, difficulty swallowing, we consider that, at times, an… We often do want to look. We do what's called endoscopies. We have these specialized cameras, they're long, flexible tubes, almost like little hoses that have lights on the end, and we'll have patients come for what's called an upper endoscopy where there are little bite blocks in the mouth, and we pass these cameras down past the oral pharynx, and we'll go down into the esophagus, and we'll look at the lining on the esophagus, see if there's inflammation, see if there's like a stricture or a narrowing, which can occur as a result of chronic acid reflux changes.

Acid on the esophageal lumen is not wanted by the esophagus. That tissue does not like to get chronically inflamed, but sometimes as a product of inflammation, it can scar down a bit, and that could be a stricture. Of course, we also want to make sure there's not a mass there, esophageal cancer.

So, we will often do an endoscopy to look for those anatomic changes. Another condition we look for in a lot of young patients, that this is a condition that we've learned a lot about over the last few decades called eosinophilic esophagitis, it's this allergic condition of the esophagus. And sort of, the esophagus gets sticky, like the back of the stamp, and food can stick, and difficulty swallowing is one of those symptoms. So, we'll often look at the lining of the esophagus for changes related to that. And when we see a mass or if we see inflammation, or if we see changes of a condition like eosinophilic esophagitis, we have the abilities to biopsy, to get a diagnosis for patients.

So, that's one test we'll do. Sometimes, we'll just do esophagrams, or video swallow studies. And these are done in our radiology departments, or sometimes with our speech pathologist that we will work with. And certain types of contrast material will be swallowed by a patient. Sometimes we do contrast pills that will show up on x-rays, and we'll take pictures of the esophagus as the contrast is going down, to see if we can see any narrowings, see if there's a blockage, and/or a stricture. We can do those studies.

And then something like I work at the motility lab here. And so, when we're thinking about motility disorders, if I do an upper endoscopy, I don't necessarily... I mean, sometimes I may have a sense, like if somebody has spasm of the esophagus, I might see a lot of contractions at the time, or if somebody has this condition achalasia, I mentioned earlier, or maybe their esophagus dilated because of how the muscle change movements are occurring, or I may see spasm of the sphincters. The tests that we often will do would be esophageal motility study is what we do in our motility lab. Now, with that test, we put like a sensor catheter down the esophagus, and it goes past the upper sphincter and lower sphincter. So, there are two sphincters to the esophagus, and then the middle is the body, so it's just like a long tube. And we will ask patients to swallow water, sometimes applesauce, and other consistencies. And we basically get pressure reads of the esophagus, and to see... What we call this is a high resolution manometry.

There are 32 sensor transducers on this catheter. And it gives us a far clear idea of motility patterns of the esophagus to let us know if patients have a major disorder of peristalsis, like achalasia or maybe spasm, versus having no peristalsis at all, sort of like a muscle tube that doesn't move. And let us look for, maybe, some specific changes related to other neuromuscular diseases that patients may have that are associated with difficulty swallowing.

Dr. Scott Steele: So, this is a section that we'd like to call Truth or Myth. So, am I telling the truth, or is this false? Truth or Myth: dysphagia typically only occurs to people who have had a stroke.

Dr. Alison Schneider: That's a myth. Now, stroke is probably one of the most common reasons, especially when we're talking about neurological reasons that patients will have difficulty swallowing. But as we've been talking about, there are other causes, and especially when we're thinking about in the world of, let's say, neuromuscular, there are other conditions we can talk about, let's say, Parkinson's disease, ALS, many other neurological conditions that may be associated with difficulty swallowing. And then, there are the conditions that are more, again, structural. Esophageal strictures, esophageal cancers and tumors, that can also be associated with difficulty swallowing.

Dr. Scott Steele: Truth or Myth: changing a patient's diet can treat a swallowing disorder.

Dr. Alison Schneider: I would say that's a myth again. Now, there are dietary changes that help a patient to manage their symptoms, but making the dietary change will not treat the underlying condition.

Dr. Scott Steele: So kind of on this topic, is acid reflux considered a type of swallowing disorder?

Dr. Alison Schneider: Well, what acid reflux does... So, you have to understand the stomach has a very low pH, and it has this low pH to help us begin to break down food. It is not really supposed to enter and touch the esophageal lining much. Now, when it does, and we talk about acid reflux, a lot of it has to do with that lower sphincter at the bottom opening and closing maybe more than it should.

When acid does reach the esophagus, it will make the contractions for some patients less vigorous, and weaker. So yes, symptom of a complaint might be difficulty swallowing, but as far as causing a major disorder, a muscle change, I would say no, but it definitely can affect... Make a patient feel like they're having difficulty swallowing, and it can cause weaker contractions of the muscle.

Dr. Scott Steele: So what are some exercise therapies that can be done to help patients?

Dr. Alison Schneider: Well, the exercise therapies really, probably, apply more to those patients that have had more of the oral pharyngeal problems that have occurred related to, let's say, stroke, or other neuromuscular conditions. There are things sometimes, what patients can do, they can work with speech pathologists. They may give them exercises such as like tilting the head to a strong side. Sometimes, they'll work on supraglottic swallow exercises, which really evolves these exercises between focusing on swallowing and breath holding. Sometimes, they'll change body positions, exercises to work on the pharyngeal clearance can be done. But a lot of that is really with speech and swallow therapists, and I'm just mentioning a few of them. There's also some electrical stimulation that can be used to help patients, to help them learn ways to improve neuromuscular stimulation. This is, again, something really done more with our speech pathologists who are experts in this area, as far as giving patients exercises to help them improve their oral pharyngeal swallowing capabilities.

Dr. Scott Steele: And I know that there is a lot of different underlying disorders and, as such, the surgical or endoscopic treatment may vary based on this disorder, but are there some general groups that things fall into that you could say that are helpful to treat dysphagia?

Dr. Alison Schneider: So, if we're going to talk about endoscopic treatments, okay, and that was related to the camera that we do, what we do in our gastroenterologists, this is what we can do. When we're talking about, let's say, a stricture, we have special balloons that can dilate strictures, and widen the lumen of the tube, so that food can flow through more easily. We also, sometimes, if there is a tumor in the esophagus, we have specialized stents, I guess you could think, maybe people know that we put stents sometimes in the heart when there's a blockage. So for this blockage in the esophagus, we can sometimes do that.

For some of the disorders where the muscles are too tight, and for some certain types of outpouchings, we have ways, actually, where we can almost do surgery within the esophagus where we can cut the sphincter muscles, what we call these are per-oral endo-myotomys, these are newer procedures we're doing for achalasia. And so, yes, we have a lot of endoscopic techniques to help people with swallowing disorders.

Now, from the surgical side, obviously, if a patient has esophageal cancer, they might be a surgical candidate to have surgical resection. And with the condition achalasia, the motility disorder, there are well-known surgical techniques, the heller myotomy that's been around for some time now to help cut that spastic muscle at the bottom of the esophagus. So, those are just some examples of endoscopic and surgical treatment approaches.

Dr. Scott Steele: Exciting stuff. And so, we always like to get to know our guests a little bit better, so we're going to wind up with some quick hitters. So for you, what's your favorite food?

Dr. Alison Schneider: I'm going to go with sushi.

Dr. Scott Steele: I like it, I like it, I like it. What is your favorite sport? Whether it is to watch, or to play.

Dr. Alison Schneider: Favorite sports to watch would probably be college football.

Dr. Scott Steele: What is the last non-medical book that you've read?

Dr. Alison Schneider: The last non-medical book was All the Light We Cannot See. And you're going to ask me the author, you're putting me on the spot.

Dr. Scott Steele: I'll have our audience go ahead and Google that. And so tell us, what is one thing you enjoy about living in Florida?

Dr. Alison Schneider: I love the sunsets. I love having the ocean nearby, and smelling the salty water. I love fishing, actually is a big hobby of mine and my family's. So, I love doing that. And I like just having the outdoors 12 months out of the year with activities to do all the time.

Dr. Scott Steele: And the hurricanes.

Dr. Alison Schneider: Oh, yes.

Dr. Scott Steele: So give us a final tip for our listeners regarding this whole idea of these motility disorder, swallowing disorders. What's the final take-home message that we can have for our listeners?

Dr. Alison Schneider: I mean, one thing I would say about motility disorders, if you're having any difficulty with swallowing, from choking, to coughing, to you feel like food is sticking from time to time, do not ignore that symptom. I think you need to see a healthcare provider, see a gastroenterologist to describe it to them in more detail. There probably will be some evaluation. If an upper endoscopy is not conclusive, it might be a motility disorder. You might need to come to a place like Cleveland Clinic here, where we have a motility center, where we can help further the diagnosis. But difficulty swallowing should not be ignored because we really want to make sure we're not missing anything very important. And we don't want any undiagnosed disease to progress further where we may have difficulty with management in the future.

Dr. Scott Steele: Fantastic words of wisdom. So, for more information, or to make an appointment in the Florida region, please visit clevelandclinicflorida.org/digestive. That's clevelandclinicflorida.org/D-I-G-E-S-T-I-V-E. And if you're closer to Ohio, please visit clevelandclinic.org/digestive. That's clevelandclinic.org/digestive.

Finally, remember, in times like these, it's important for you and your family to continue to receive medical care. And be rest assured, here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities, and protect our patients and caregivers. Dr. Schneider, thanks so much for joining us on Butts & Guts.

Dr. Alison Schneider: All right, thank you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.