Adult Speech Therapy......and SWALLOWING?????

When you look at the name of my business, it would be reasonable to wonder 1) what the heck does a Speech-Language Pathologist have to do with swallowing, and 2) oh wow! I had no idea that someone could have difficulty swallowing! These were thoughts I had myself when I started on my journey to become an SLP.

What is swallowing all about?

Miller, Karen & Plowman, Emily & Tabor Gray, Lauren. (2018). Living with ALS_Adjusting to Swallowing Changes and Nutritional Management. ​

The pictures you see above are to be looked at in sequence as snapshots of time.

Aside: The pictures may remind you of the picture presented in my 1st post on voice---the shared anatomy for voice & swallowing function is the primary reason WHY Speech-Language Pathologists play a role in joining you in facing swallowing problems!!

Imagine this is your face sliced right down the middle and you are looking in at it from the side (I'm not sure how to word that to not make it sound gross!!!). To the far left, you see your nose and lips. Right behind the lips are your teeth and hard palate (in white). Your tongue is the pinkish mass attached to the bottom of your mouth (pictured behind the teeth). This image is a bit misleading, as the tongue attaches at its farthest point down in our throat, a bit farther down than the image suggests. If you move to the back of the mouth you see that there is an opening that goes up into the nose area, and then as you proceed downwards........

HOUSTON...WE HAVE A PROBLEM!

Design flaw!

Our throat divides into 2 tubes: our airway in the front (where that 1st blue arrow is pointing), which leads to the lungs, and the esophagus behind it that goes toward the stomach. We are anatomically set up to have problems with anything we put in our mouths (or anything that lives there...lots of bacteria) ending up in the lungs where it shouldn't be. We all have the occasional feeling that something tries to go down the wrong tube and we cough and cough and cough and that tickle is so annoying....but how is this prevented most of the time?

How swallowing usually works...in a nutshell
​
1) We hold our breath when we swallow, and the breath cycle is paused at some point during our exhalation so that when we have finished swallowing, we finish breathing out. This is helpful so that just in case any of that food or liquid is still near the airway, the airflow is more likely to push it up and out rather than suck it in toward the lungs.

2) Our airway moves up and forward as we swallow. This literally gets it out of the way and opens that soft flexible tube in the back, the esophagus, to let food and liquid in. Do not rely on this picture to show you this, but you can get a sense of this yourself if you swallow your saliva right now. Place your fingers on your Adam's apple, and then swallow. Do you feel your Adam's apple bob up and then back down? That is your airway moving during swallowing!

3) OK, so now picture your saliva as the green blob in the pictures. By virtue of this movement, the handy flap of cartilage between the base of our tongue and the entrance of the airway flops over and covers the entrance to the airway. This cartilage, the epiglottis, is pictured as a rose thorn in the 1st picture, and folded over the airway in the 2nd picture. In this 2nd picture, you see the green blob of saliva or food bypassing the airway and entering the esophagus.

4) Our vocal cords, which are pictured as that lighter band at the top of the airway, close just in case anything should think about trying to enter the airway. Typically when we get that tickle feeling of something going down the wrong tube, it has entered that upper part of the airway, above or at the level of the vocal cords. Your cough response is generated by power from your lungs and your vocal cords opening and closing forcefully to move the material back up out of the area.

 How is the design flaw a recipe for swallowing challenges?

https://www.reddit.com/r/CrappyDesign/comments/3umn8j/they_must_have_been_short_on_wall_parts/

Oh dear! So a privacy wall was built with the intention of having this bathroom be multifunctional, but SIGH...there are problems. Our throats are a bit like this. They were designed to take care of swallowing, breathing, and vocal functions, but alas...things can get a bit dicey. If any one or combination of the 4 components of swallowing goes a bit haywire, trouble can start. There are many ways we can have challenges with swallowing! It is actually more amazing when we DON'T than when we DO! 

Some possibilities:
Please be aware that any listed symptoms may have a variety of specific causes, and need to be thoroughly evaluated by the correct healthcare professional to know how to proceed with managing them for YOU.

• We can have trouble holding our breath, or interrupting the breath cycle at the typical point, when we swallow. Since our bodies will give priority to breathing for survival, any material that is in the mouth or throat can end up in the airway. This can lead to coughing or choking episodes.
• We can have trouble in our mouths related to breaking down food with our teeth & saliva and moving it back into the throat. This can be due to problems with our teeth/dentures, awareness, muscular function, or sensation.
• We can have trouble with the timing of everything, with food/liquid slipping into our throat before we have protected our airway or closed the passageway to our nose.
• We can have trouble with the muscles needed to move the airway out of the way (which makes the epiglottis not protect the airway properly or open the entrance to the esophagus adequately). This can lead to coughing, choking, gurgly/wet voice, and/or a sensation of food/liquid sticking in your throat. This can also make you feel like you need to swallow many times to get food or liquid down.
• We can have trouble with the muscles or with tissue or saliva changes in our mouth or throat which make propelling food/liquid efficiently & completely through our mouth and throat more difficult. Food and liquid may stick around the throat rather than moving on through, and this material can be inhaled or moved back up higher into the throat or back in the mouth after swallowing. This may make you feel like you need to clear you throat, swallow extra times, or constantly need to wash food down.
• We can have nerve issues that make us not sense when there is material that enters our airway, or when there is material leftover in our mouth or throat after we have swallowed. This may cause us to NOT cough when we really NEED to cough. Other signs of trouble MIGHT be present, like a wet/gurgly voice or throat clearing.
• We can have trouble closing our vocal cords properly to protect the airway during the swallow and to produce a strong cough when things go awry. Our cough or voices might be weaker than we are used to.
• We can have a physical obstruction (medical hardware, swelling, masses/tumors, etc.) of some kind preventing the normal clearance of food & liquid from the throat. This can result in any number of symptoms depending on where the obstruction is.

Note: The esophagus also has a role in the swallowing process, but strictly esophageal issues are within the purview of a gastroenterologist, not an SLP. Sometimes the sensation of food sticking in the throat is actually caused by a problem in the esophagus.

So what can be done when there is a problem? 

Unfortunately, we can't be recalled back to the factory to request an anatomical fix for the flaw!! So what are our options? First, let your doctor or healthcare provider know you are having trouble with your swallowing. They will be able to determine if an SLP may be the right professional to join you on your journey to manage the challenge. Other investigations & treatments may be more appropriate, at least as a first step, depending on the specifics of your situation. If a consultation with an SLP is recommended, the following options (in isolation or in combination) might be considered at your evaluation.

1) Posture changes during the swallow or establishing new swallowing habits, including targeted oral care practices (protect teeth/dentures, manage bacteria) and mealtime strategies.

2) Modifications to food & liquid to change how it is managed in the mouth & throat. In some very specific circumstances, this may mean bypassing the mouth & throat altogether.

3) Exercises to strengthen respiratory muscles that play a critical role in airway protection for swallowing.

4) Exercises for mouth & throat muscles involved in swallowing. These are sometimes used to try to prevent expected swallowing issues stemming from upcoming or ongoing medical treatments, improve swallow function after it changed as a result of an injury or illness, or slow down or better manage the progression of swallow challenges that go hand-in-hand with a progressive disease process.

Each of the above has the potential for risks/limitations & benefits, and these should be discussed openly and thoroughly with your SLP as you work together to design a plan to adequately evaluate and treat your swallowing challenges. The plan may evolve over time if needed and should promote your health & well-being while respecting your goals, values & autonomy.