Hello! We're in the process of working together to try to figure out your swallowing problem, and
I'd like to begin with a little short course on swallowing to help orient you and move the
process along. What I want to do first is to point out on this model that there is a common area for
both breathing and swallowing here. This area can be used, you can take air in and then breathe it
down into the voice box vocal folds here and the trachea. Or you can also use the same area but
swallow food or liquid down into the esophagus which is right here, behind the airway. Well, it's
very important that from here down—from this level down—that the two functions, swallowing
and breathing, be kept separate. Otherwise you get liquids or food in here, it will make you cough. And
if you do that a lot, then it's even possible to get pneumonia. Well how do we look at swallowing?
There are a lot of ways, but two common ways (actually I'll show you right here). One way that
we use is a fiber scope or, or a video endoscope. It has a light on the end, and it has a little
lens there that lets us get these remarkable photos. And so what we do is we look downwards
at swallowing, happening from above. And if we are using that methodology called the video endoscopic
method, then the pictures that you would see on a screen would be in this orientation. You'd be
looking online, swallowing would be occurring down into the, into the TV screen as you look. The other
method is an x-ray method, and basically, the idea there is that x-ray light—I'm representing that
with this light—x-ray light is shone through. And so what happens there is that we watch a
bolus of barium as makes its path down from the mouth down into the throat and beyond. So those
are the two primary ways. Now swallowing is very complex, so we could spend a lot of time making
it really complicated. But what we like to do is to simplify it into two main parts. We think of
a propulsive part, so we talked about propelling the food, pushing the food down, sending it down
into the throat. And we think about the receiving part which is basically right here in the upper
part of the esophagus. We use an analogy for the pitching. We think of a baseball pitcher, and the
catching, we think here of a little catcher mitt opening up and allowing the food in. Well, what if
the problem is mainly with that pitch, with the push of the food/ What happens then? Well, foods
tend to hang up in the mouth and in the upper throat. People will sometimes cough a little bit,
especially with liquids, and they'll have a little gargle-ly sounding voice. Sometimes they'll hear
that sort of stuff that didn't quite make its way through the throat. A lot of people will describe
slime. They'll say, "Oh there's so much saliva in my mouth. There's a lot of slime in there." And of
course there isn't anymore than there is in a normal person, but it's just that it's hanging
up here and it sort of seems like there's more of it around then there should be. They'll say, "There's
too much saliva. I'm making too much saliva." And again, it's because they're just not pushing it
down into the esophagus. And if you ask people who have primarily the pitcher problem, the propulsion
problem. they'll say that liquids are especially problematic. That's what doesn't seem to want to
work and make some cough. Liquids tend to be worse than soft things like puddings and purees and
applesauce and so forth. Well what if the problem is primarily the catcher, the little sphincter,
the little gate that has to open, down lower in the throat. It won't open up and let the food or
liquid in. Then the person will say, "Well, liquids and soft foods work pretty well, but solid foods
and pills want to catch and lodge right there." And they usually can identify that it's lower in the
throat. Pills and meat and maybe gummy bread, those kinds of things want to lodge much more than apple
sauce or yogurt or softer things. The person with the catcher problem, when the sphincter won't open
and let the food in, will say they have gone over a period of months or years to a progressively
softer and more liquid diet. Now you could have both. You could have the propulsion problem—the
pitcher problem—but also the catcher problem. But to review, if the propulsive—if the—if the push
of the swallow is the more affected, then liquids tend to be harder. If the reception, or the
catcher of the swallow, is harder, than solids tend to be more of the issue. Well what do we do if we
have a pitcher or a catcher problem? If it's a pitcher problem, then we typically get a speech
pathologist a swallowing therapist involved, and he or she may give you exercises, may talk to you
about different food choices, softer things, crackers. May talk about alternating between
them, may suggest use of a drinking straw (sometimes that's helpful) and then they also have strategies;
head positions, a chin tuck, or turning the head to one side or depending on the circumstance. What
if it's the catcher problem that the, the food seems to get lodged low in the throat because
the, the sphincter won't open? Well in that case, we think in terms of a cricopharyngeal myotomy.
And that is a surgical procedure that basically makes sure that the catcher's mitt is always in
the open position. It's, in normal, we'd like it to be closed most of the time, except when the
food goes through and then it opens and lets the food through and then it clamps shut again. But
it seems not to be a problem just to fix it so that it's always open. And then that solves the
person symptoms. Now there are two ways of doing the cricopharyngeus myotomy. One is endoscopically,
that's where we go through the mouth when you're asleep and open the, the muscle from the inside.
There's no incision on the outside. And the other method is trans-cervical, where we make a very
small incision on the low part of the left side of the neck, down about right here, is where that
incision is made. In either case, it's typically one night in hospital could be longer but it's
usually just one overnight in the hospital. Well, this has been a lot of information, but in summary,
if I could just say we swallow normally without even thinking, it doesn't cross our minds, but if
it starts to not work right, then we contend to cough or choke or have a sense that food is
lodging, a sense of increased saliva and so forth. When that starts to happen, we want to figure out
if the main issue is the "pitcher," the pushing of food, thus the initial part of the swallow,
or whether it's the "catcher" receiving the food, or whether it's both. If it's the propulsive side
of swallowing, the push of swallowing, then it's a speech pathologist typically to do exercises,
food choices, head positions and so forth. If it's the catcher, then we usually do the, think about
the cricopharyngeus, the little gate, the sphincter muscle, to make—to prop that
catcher's mitt open all of the time. Well thank you for listening to this little summary and
I hope it takes us one step further along in understanding together the nature of your problem!