Q&A on swallowing and dysphagia

Why does it feel different to swallow?

Many patients have reported it is harder to swallow following their laryngectomy surgery. That may be true. How the swallow works after a laryngectomy is very different from how someone with a larynx will swallow.

With the larynx in place, there are several structures in the throat that assist in the swallow process. Many of these are removed during the laryngectomy surgery which means how you swallow really is different. And in some cases, this can take some time to adjust.

How do I swallow with a larynx?

Swallowing is a complex and coordinated activity that required various muscle groups and other structures, including the larynx, to function in a swift and coordinated manner. When this doesn’t happen, often this can result in choking aspiration.

To briefly describe how people with a larynx swallow, of course it begins in the mouth. This is referred to as the oral phase of swallowing. A standard laryngectomy surgery should not impact this phase of swallowing. During this phase, you chew any solid food and your tongue works in coordination with your lips and cheeks to organize the material in your mouth and move it, all together, to the back of the mouth, or the oropharynx.

Once this happens, the pharyngeal phase of swallowing occurs. During this phase is when much of the work of swallowing is accomplished. (This is usually what most laryngectomee patients notice has changed since their surgery.)

The tongue base pushes backward and downward, making contact with the superior pharyngeal constrictors. This begins the downward movement of the food material toward the esophagus. As this happens, material fills the vallecula. This is a “pocket” in your throat which is created on one side by the tongue base and by the epiglottis on the other side.

As the tongue base pushes downward, the pharyngeal constrictors begin to contract, like a purse string, from the top of your throat downward in a wavelike manner. At the same time, muscles connected to the larynx and hyoid bone, pull the larynx upward and slightly forward. The vocal cords also close during this to protect the windpipe from food going in.

The closing of the vocal cords also plays a very important role in the swallow process. By closing, they prevent any air from leaving the lungs during the swallow. This subglottic pressure is important for driving a strong swallow.

As the larynx moves upward, two other very important things happen. The epiglottis flips backward or retroflexes over the opening to the larynx, like a lid covering the larynx and trachea during the swallow. While this helps to protect the airway from food material entering, it also allows for the tongue base to now clear the food out of the vallecula. As the epiglottis flips backward, the vallecular pocket turns into a smooth slide, deflecting the food material past the protected larynx and downward toward the vallecula.

Another important action happens when the larynx moves upward and forward during the swallow. This action also pulls open the cricopharyngeus, which is also known as the upper esophageal sphincter. This is a small muscle at the top of the esophagus that opens to allow food and liquid to pass, the closes to prevent reflux or regurgitation back into the throat. At rest, the cricopharyngeus is closed.

The pharyngeal constrictors work in conjuction with these other actions, squeezing in a purse string manner from top to bottom. The middle pharyngeal constrictors are active when moving the food past the larynx. The inferior pharyngeal constrictors  help to squeeze the food material past the cricopharyngeus and into the esophagus.

Once into the esophagus, the Esophageal Phase of swallowing begins. It is not uncommon for laryngectomee patients to experience problems in the esophageal phase, especially affecting the portion of the esophagus exposed to radiation.

The esophagus is a tube like muscular structure that squeezes from the top downward in a wavelike manner called peristalsis. This action is what moves the food into your stomach. Although problems may arise in the lower esophagus and duodenum, this is not impacted by the laryngectomy surgery.

How can I swallow after a Laryngectomy?

During the laryngectomy surgery, many of the structures in the throat useful in swallowing before the surgery, are removed. This does not mean a laryngectomee cannot swallow but the process of swallowing is certainly different.

During the laryngectomy surgery, in addition to the vocal cords and “voice box” being removed, the epiglottis and hyoid bone are also removed. The muscles are also reconstructed in a way that changes what happens when they contract.

After learning how the movement of the larynx and hyoid assist in the pharyngeal phase of swallowing, it becomes easier to understand why swallowing feels so different after the laryngectomy surgery. Also keep in mind that the movement of these structures also help to open the cricopharyngeus to allow food into the esophagus.

This is part of why the trachea or “windpipe” is diverted, sewn to the neck, creating the stoma a laryngectomee breathes through. Without all the structures to drive the swallow and protect the trachea from food entering, it would become impossible to swallow anything, including saliva, without it entering your lungs, creating a very dangerous situation.

This is also, however, why a laryngectomee can no longer choke during meals. 

This is very important to remember. A laryngectomee will not choke or strangle, even if it feels as if the food is “stuck” in the throat. Anxiety over this may create more tension in the throat and make it even more difficult for the food material to pass.

Many patients and family members are often questioning how a laryngectomee can swallow once all the “parts” have been removed. Its important to understand that swallowing is very different following a laryngectomy, but it can also be very effective.

Practice and proper instruction can often speed the process of returning to a more normal diet and way of eating. Essentially, the oral phase will be unchanged in a standard laryngectomee patient. It is the pharyngeal phase of swallowing that is most disrupted, as well as the cricopharyngeal opening.

In the beginning of the pharyngeal phase in a laryngectomee, the tongue base serves to push the food downward toward the esophagus. Many reconstruction techniques may limit the tongue base movement to some degree. If the tongue base is not able to contact the posterior pharyngeal wall,  the downward movement of the food material becomes less effective. In these cases, gravity will help quite a bit in getting the food to the base of the throat. For this reason, it is important that a laryngectomee eat and drink in an upright posture.

During the pharyngeal phasethe pharyngeal constrictors, squeeze from the top down in a purse string, wavelike manner. This serves as the driving force for how a laryngectomee moves food from the throat into the esophagus.

Radiation as well as reconstruction can both negatively impact the strength and effectiveness of the pharyngeal constriction. In many cases, therapy can help improve the overall strength and effectiveness of the swallow, although this will first need to be evaluated by you physician or speech pathologist.

The cricopharyngeus is also impacted as a result of the laryngectomy surgery. The structures used to pull this muscle open, allowing food to pass into the esophagus, have been removed.

What has happened to my sense of taste?

Many laryngectomees feel the sense of taste is lost following surgery. It is important to remember the ability to taste primarily comes from our ability to smell. Tasting with the nose plugged (prior to a laryngectomy), drastically limits how a food tastes. This is because ~70% of the sense of taste comes from our ability to smell.  The tongue has taste buds that are able to detect the taste of sweet, sour, salt, bitter and umami (savory). But it is the sense of smell that tells our brain we are eating a slice of pizza and not a cheeseburger!

Following a laryngectomy, the sense of smell, or olfaction, remains intact. In a standard laryngectomy surgery, there is no impact from the surgery to the nerves of olfaction that allow for smelling scents, aromas and odors. What has changed, however, is the pathway of airflow during respiration. Prior to the laryngectomy, air would flow into the body through the nose and mouth. This movement of air through the nose allowed for scents and aromas to be detected as the smells came in contact with the tiny nerve endings in the nose that are responsible for the sense of smell.

I’m afraid of choking

Many patients experienced difficulty swallowing before their laryngectomy surgery and the fear of choking can remain quite high following the laryngectomy. Although this is very natural, there is no longer any possible way for you to choke while you are eating.

As part of the laryngectomy surgery, a disconnection or separation is made between the mouth/throat and the lungs. Food material you take in through the mouth can now only go through the throat and into the esophagus, ultimately passing into the stomach.

The trachea, which is blocked when a choking event occurs, has been disconnected from the throat and is now diverted out, attaching to the neck. Although you may experience difficulty swallowing and have a natural fear of choking, there is no longer any way for a laryngectomee to choke while eating.

What foods can I swallow best?

A formal evaluation will always be the best way to determine what foods you can swallow best but there are some general guidelines that typically apply to most laryngectomees.

Softer foods will usually be easier to manage that more solid textures. Foods that “crunch” or make a noise when you bit into them would not be a “soft” food. If you are able to mash the food with a fork, this is usually an indication it is a “soft” food.

Because of xerostomia that can occur following radiation, there may not be enough saliva to lubricate the throat as there was prior to your cancer treatment. We are all designed to swallow through a well lubricated throat so it is important to find other means of lubrication when you swallow. Using extra sauces and gravies will always be helpful. Sticking to more moist foods and avoiding very dry one will be important to. Another very helpful technique is to alternate foods with liquids during meals. Essentially, take a sip of a drink with or immediately following each bite of food. This will help to lubricate the throat and “wash” through and food residue that may be left.

Finally, it is very important that food is chewed thoroughly. Before a laryngectomy,  Larger “chunks” of food may have been swallowed safely and effectively. Following surgery, however, the reconstructed pharynx may not be able to pass larger pieces of food. It is very important that food is chewed thoroughly to ensure it passes through the throat and into the esophagus without difficulty. Larger chunks may serve to “clog” the opening to the esophagus, become lodged and not allow any additional food material to pass until it is properly cleared. Be sure to chew your food until no chunks are present.

It is important to note that these are general guidelines and you may be better helped by different food choices and/or eating methods. Is you feel you are having difficulty eating that may not be normal for a laryngectomee, you should bring this to the attention of your doctor or other health care professional. A formal evaluation will better determine how to address your particular concerns.

My doctor says I have a “flap” and I can’t have anything cold to eat or drink. Why?

A “flap” is a term meaning there is a portion of tissue that has been transplanted from a different part of the body. Although there are different types of flaps, the primary concern here is that transplanted tissue be allowed to heal and thrive in its new location on the body. Any time there is tissue attached to other tissues (as with any incision seams in a surgery), healing is always the biggest concern. In order for tissues to heal together though, there needs to be an adequate blood supply to the area. It is the blood supply that delivers the oxygen tissues need to live and survive. Without proper blood supply, the tissues will die.

Cold temperatures have an effect on blood vessels that causes them to constrict. This is one reason we use ice on injuries to prevent swelling. So, when there are newly transplanted tissues in the throat, it is very important the new tissue be allowed to attach well and heal thoroughly. If you eat or drink cold food/drink items, this can serve to limits the blood flow to the area trying to heal. If your doctor limits your cold intake after surgery, it is very important to stick to this guideline to ensure you heal properly following surgery. Not doing so may mean serious complications for you and perhaps even more surgery to repair the throat.

Is there anything I can do to help my swallow?

In many cases, there are interventions that can help optimize your swallowing ability, but a formal evaluation is required to first determine the nature of the difficulty you are experiencing, then identify appropriate methods to help you. These methods can be as simple as altering the foods you eat of how you eat them, to formal therapy or even surgery. (See common treatment methods).

When should I see my doctor about my swallowing difficulty?

If you have any concerns about your ability to swallow, these should always be told to your doctor or speech pathologist. Many times, further evaluation is needed to determine the cause and severity of your swallowing difficulties which will allow them to treat them better and help you to swallow as best as possible.

If you notice increasing difficulty swallowing, painful swallowing, tiresome swallowing, -these should always be addressed immediately with your doctor. If you notice it is becoming more difficult to swallow, that is also something that should be addressed. Finally, if you are struggling to be able to eat enough or are losing weight, these are all issues of concern and should be brought to your doctor’s attention. This doesn’t necessarily mean there is a problem or something worrisome is going on, but it is important you are swallowing as best as possible.

 

by Katrina M. Jensen, Fort Worth, Texas, USA