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Swallowing problems

People who receive treatment for cancers of the head and neck may need speech therapy to cope with swallowing problems. Speech therapists (speech-language pathologists) work closely with surgeons and oncologists to assess and treat swallowing problems.

Types of swallowing problems

Swallowing problems can occur if any part of the swallowing process is changed or interrupted.

Problems may include:

  • difficulty chewing or controlling food or liquid in the mouth
  • coughing or choking when food or liquid enters the airway (aspiration)
  • food getting stuck in the throat
  • painful swallowing

Swallowing problems can affect your ability to eat and enjoy eating. This may lead to poor nutrition, dehydration, weight loss and poor health. It is important to report any concerns about swallowing or eating to the healthcare team.

Who is at risk

Cancer of the voice box (larynx), throat (pharynx), mouth, tongue or brain can affect the ability to swallow. Surgery and radiation therapy for head and neck cancers may change the anatomy or function of the larynx, vocal cords or epiglottis and reduce their ability to prevent aspiration.

Aspiration occurs more frequently in people who have a partial laryngectomy, especially surgeries that remove the epiglottis. Someone who has had a total laryngectomy (a laryngectomee) does not have a risk of aspiration because during surgery the trachea is physically separated from the esophagus. However, laryngectomees may still have other problems swallowing. For example, food may get stuck in the throat because of damage to tissue, nerves or muscles during surgery.

Radiation therapy and chemotherapy for cancer may also affect the ability to swallow. The most common side effects are dry mouth (xerostomia) or sore mouth and throat.

Diagnosis

If you have difficulty swallowing after cancer treatment, a speech therapist may do a swallowing assessment. A speech therapist is a healthcare professional trained in diagnosing and treating swallowing, language and speech problems.

Physical examination

During an assessment, the speech therapist may ask questions about swallowing problems and may watch you swallow different types of food.

Imaging tests

The speech therapist may order a videofluorographic swallowing study (VFSS). VFSS is an imaging test that uses a contrast substance (barium sulphate) and x-rays to produce pictures of the mouth, throat and esophagus. Barium is a chalky, white liquid that shows up clearly on an x-ray. This test is also called a modified barium swallow (MBS).

During a VFSS, a person is given foods and liquids of various consistencies to which barium has been added. A special x-ray (fluoroscopy imaging) captures moving images of the food and liquid as they pass through the mouth. This allows the speech therapist to identify the type, severity and cause of any swallowing problems in the mouth and throat.

Swallowing rehabilitation

Some people may need to learn to swallow in a new way after cancer treatment. The speech therapist will consider different swallowing rehabilitation techniques and suggest the one that is most helpful for the person’s particular swallowing problems. The following are examples of techniques that the speech therapist may recommend.

Chin tuck

Tuck your chin down toward your chest when swallowing. This helps prevent food and liquid from going in the airway.

Chin up

When swallowing, lift your chin. This helps widen the oropharynx and force the food to the back of the mouth.

Head turn

Depending on which side of the throat is stronger or has more control, turn your head to the left or right when swallowing. This will help move the food into the esophagus so that less food remains in the throat and there is less risk of it entering the airway.

Effortful swallow

Swallow harder, making a strong effort to move the food down your throat. This helps the tongue put more pressure on the palate and improves the movement of the base of the tongue. The swallow takes longer than normal, but it helps clear food that may remain in throat.

Supraglottic swallow

Breathe in and then hold your breath while swallowing. This will close the vocal cords (glottis) and reduce the risk of food or liquid entering the trachea and lungs. After swallowing, cough gently while exhaling. The cough removes any food or liquid that may have entered the larynx. This technique should only be tried with a doctor’s approval because research suggests that it may be not be appropriate for people with a history of stroke or coronary artery disease.

Super supraglottic swallow

This swallowing technique is similar to the supraglottic swallow, except that after holding your breath, you tighten your stomach muscles (“bear down”) as if having a bowel movement. After swallowing, the person coughs while exhaling to remove any food or liquid from the larynx. This technique should only be tried with a doctor’s approval because research suggests that it may not be appropriate for people with a history of stroke or coronary artery disease.

Side lying

Lie down with the stronger side of the throat on the bottom. Gravity causes the food or liquid to fall down to the stronger side, and this reduces the chance of food or liquids entering the airway.

Mendelsohn manoeuvre

Hold the larynx up (using either the muscles of the neck or a hand) for a few seconds during the swallow. This lifts the larynx forward and reduces the risk of food or liquid entering the airway. It also helps widen the opening from the throat into the esophagus, making it easier for food to pass into the esophagus.

Changes to diet or the way you eat

Changes to the diet may help make swallowing foods and liquids easier.

  • Thicken liquids if you have problems swallowing thinner liquids. Add gelatin, puréed vegetables or fruit, instant potatoes, cornstarch, infant rice cereal or commercial thickeners to liquids to make them easier to swallow.
  • Add gravy or sauces to foods to make them easier to swallow.
  • Dip dry, crisp foods, such as biscuits, into milk, coffee or tea to make them softer.
  • Avoid hard and dry foods, such as potato chips or pretzels.
  • Try different food textures to find ones that are easier to swallow. Foods that are soft or have a smooth texture, like mashed potatoes, are often easier to swallow.
  • If medicines are difficult to take with water, they may be taken with thick liquids or soft food, such as applesauce or ice cream. Some medicines may be crushed and mixed with food or liquid. It is important to check with a pharmacist first because some medicines should never be crushed or cut in half.
  • Take small bites of food. Completely swallow each bite before taking another.
  • Make sure to take in plenty of fluid, especially water, every day to help prevent dehydration. Other sources of fluids include juices, soups, milk, popsicles, pudding, yogurt and ice cream.

Tube or intravenous feedings

If swallowing problems become severe, the healthcare team may suggest using a feeding tube. A feeding tube is a thin, flexible tube that is placed into the stomach or intestines. Once the tube is in place, liquid nutritional supplements and medications can be given through it (enteral feeding). If you find it too difficult to eat or drink, feeding tubes can help you meet your nutritional needs. This is especially important if you’ve lost a lot of weight.

Botox injections

A relatively new technique involves injecting Botox (botulinum toxin) into the upper esophageal sphincter. This approach is helpful in cases where the esophageal sphincter doesn’t relax. This treatment is not appropriate for people with other types of swallowing problems and can actually make swallowing worse. Great care must be taken in identifying those who will benefit from this technique.

Finding support

Learning to swallow again can be very difficult. Some people find it helpful to have emotional and practical support from other cancer survivors. The International Association of Laryngectomees has a number of support groups in Canada.

x-ray

A type of high-energy radiation.

The image produced by x-ray.

X-rays are used in low doses to produce images of the inside of the body on film. They are also used in high doses to treat some types of cancer.

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