The Medical Consumer's Advocate

Swallowing problems in the elderly

 

Q: I have an elderly gentleman friend who experiences a strange problem--he chokes on food, coughs up phlegm, and then usually vomits. I have encouraged him to take smaller bites, chew them very well and slow down with his eating process. He insists this is an allergy, but one of his granddaughters has a similar problem--she's an adult--and has had her esophagus stretched. Any information you could provide would be helpful.

A: Allergy is one possible explanation, but it would be far down on my list of possible diagnoses. There are many other explanations for his problem, and some of these possibilities are quite dangerous. In other words, the swallowing difficulty you describe may be a sign of a serious medical condition.

The act of swallowing is actually quite complex, and requires much more coordination than many folks realize. First of all, there is the act of "bolus formation." "Bolus" is the medical term for a wad of well-chewed food. Bolus formation requires efficient chewing, coordination of the tongue, lips and cheek (to keep the food in the front part of the oral cavity, and to move it around to the teeth), and adequate saliva production.

Once the bolus is formed, it must be propelled to the back of the oral cavity. Tongue coordination is critical for this phase.

Next is the actual swallow. Nearly simultaneously, several actions occur which are essential for an efficient swallow:

* The soft palate blocks off the nasal cavity by moving posteriorly, to the back of the throat. This action, incidentally, is what prevents food or drink from entering the nasal cavity during a swallow.

* The larynx (voice box) rises in order to move the airway to a safer position. You can feel this by placing your fingers on your thyroid cartilage (Adam’s apple) and swallowing. This movement gets the airway out of harm’s way, and also serves to open upper esophagus.

* Throat muscles, the pharyngeal constrictors, then squeeze down on the bolus, propelling it into the esophagus.

In the final phase, esophageal constrictors move rhythmically to propel the bolus downward, into the stomach.

A well coordinated swallow is critical if one is to avoid aspiration (aspiration: when food, drink or saliva enters the windpipe/trachea, rather than the esophagus.)

From the information you have given me, I can hazard a guess that your friend’s daughter’s problem is an esophageal stricture. A stricture is an abnormal narrowing of a tube– the tube being the esophagus, in this young woman’s case. The safest initial treatment of this problem is to dilate (stretch or widen) the esophagus by very carefully passing lubricated tubes through the stricture. Successively larger tubes are carefully passed, until the strictured area is wide enough to no longer cause problems. This may need to be repeated (typically at intervals of months to a year) if the stricture forms again.

Needless to say, this procedure is usually done under anesthesia by a physician who is well-trained in this method. One of the risks of this procedure is an esophageal tear, which (if not recognized) can lead to a chest infection called mediastinitis, which can be a devastating and lethal infection. A physician’s training is critical for avoidance of an esophageal tear, and recognition of one, should it occur.

Your friend’s problem is more perplexing. From you description, I fear that he is aspirating small amounts of his food and saliva. To find out why, a competent physician would need to take a full history and would need to examine him thoroughly. A good person to start with would be his family practitioner or internist. A gastroenterologist (an internist specializing in the digestive tract) or an otolaryngologist (ear, nose and throat surgeon) may also be consulted. He may also need to see a speech pathologist (therapists who specialize not just in language difficulties, but also in swallowing problems.)

To give you some idea as to the potential seriousness of his problem, I am going to list some of the possible diagnoses which can lead to your friend’s symptoms:

* Neurologic diseases, such as stroke, multiple sclerosis, or amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease.)

* Inflammatory conditions, such as gastroesophageal reflux disease (and, yes, inflammation due to postnasal drainage from chronic sinusitis or nasal allergies... although, as I said previously, this is unlikely.)

* Tumors of the throat, esophagus, or chest cavity.

* Other obstructive problems. For example, older people can develop "osteophytes," bony protuberances from their spinal column. If large enough, an osteophyte can press on the esophagus, causing obstruction.

* Impaired saliva production. In an older person, this is usually due to side effects of medications. Other possible explanations are Sjogren’s disease (a disease of the salivary glands and tear glands, typified by dry mouth and dry, irritated eyes) and previous radiation therapy of the oral cavity.

As you can see, many of these problems are potentially quite serious. Share this information with him, and encourage him to discuss this problem with his doctor.

 

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