Swallowing is automatic - until it isn't

Speech therapists can provide testing and tips to help you cope

Swallowing involves several muscles that can grow weaker as we age, leading to coughing or choking. Different strategies
Swallowing involves several muscles that can grow weaker as we age, leading to coughing or choking. Different strategies and exercises can help avoid these difficulties. (Adobe Stock photo)

Swallowing food and drink is kind of like breathing — something most people don’t even think about throughout the day.

However, swallowing is a process that requires several muscles that can grow weaker as we age, making that simple act more difficult and even dangerous.

“A lot of people don’t think about it, they think it’s more a reflex like blinking their eyes, but it’s muscle-based,” said Lindsey Brandhorst, owner of Brandhorst Speech Therapy in Cedar Rapids. “As we age, just like our muscles in our legs and arms get weak or atrophied, our swallow is made up of muscles as

well, and so those muscles, over time, can actually atrophy as well.”

There are many reasons why people’s swallowing can change.

It can be a symptom of medical situations, such as stroke, a neurologic disorder, head and neck cancer, any surgery or trauma to the neck or head, and even constipation. Or it can be a part of the natural slowdown of muscles as we age, making it more difficult to control food or liquid in the mouth.

No matter the cause, the term “dysphagia” is used as a catch-all for difficulty eating and swallowing.

The epiglottis, the flap that covers your airway, or trachea, plays a crucial role in keeping food or liquid from aspirating into your lungs.

“If, for some reason, the muscles aren’t working to move that epiglottis to cover your airway, you might have things go down the wrong way,” said Brandhorst, who specializes in feeding disorders.


“Your body is always going to choose breathing over swallowing, so if you have to take a breath, you’re going to suck something down the wrong way.”

Speech therapists have three tests to help determine the cause of a person’s dysphagia and how to treat it.

First, a clinical bedside evaluation is performed, where a therapist watches a person eat or drink and assesses their rate of swallowing, their posture, even how their dentures fit. Suggestions sometimes can be made at this point that are useful.

Next comes one of two instrumental evaluations. The first is commonly referred to as a “cookie swallow” — a videofluoroscopic swallow study done in radiology that takes 30 pictures a second as the patient swallows water, thicker liquids, pudding, crackers and finally a 13 mm tablet.

“That lets us see if food is trying to go down the wrong way or if it tends to stick around in the throat after they swallow,” said Mandy Morano-Villhauer, a speech therapist at Mercy Iowa City.

“And that lets us determine if there’s any muscle changes that we can maybe work on long-term.”

The second instrumental evaluation is a fiberoptic endoscopic evaluation of swallowing, or FEES. A speech therapist inserts a thin, flexible cope with a camera at the tip through the nasal passage to get a top-down view of a person’s swallow.

“During either the X-Ray or during the FEES, if we see problems, we’ll try a number of things to see if we can make it go better,” Morano-Villhauer said.


This could include having the patient turn their head to a certain position when they swallow, using a straw or avoiding a straw, or swallowing hard.

“If there’s any strategy they can do right now, during eating, that makes them safer, we’ll educate them about that before they leave,” she said.

Morano-Villhauer will use FEES if she suspects acid reflux to see the tissues of the throat, or the cookie swallow if she suspects there’s a problem in the esophagus.

“But for most people, one could do as well as the other, and a lot of times I give the patient the choice of which ne they’d prefer to do,” she said.

Brandhorst said if a person is still feeling a sticking sensation in their throat, a gastrointestinal doctor might order an esophagram, which looks at motility from the neck down to the stomach.

After the evaluation, a speech therapist will make a plan for management of the dysphasia, tailored to an individual’s needs. This could include avoiding certain foods or drinks, using the swallowing strategies identified during the tests, and learning exercises in outpatient therapy. Depending on the person and their need, exercises could focus on mouth or tongue movement or the muscles in the throat.

“Generally, I would say (the exercises) are kind of weird but easy, so most people can learn them and do them at home on their own after a few sessions of therapy,” Morano-Villhauer said.

So when should you seek help? If you find yourself coughing a lot while eating or drinking – or you notice someone in your family does — if it feels like food is getting stuck in your throat, or if you have recurrent pneumonia that is otherwise unexplained.


“Forty percent of people who aspirate don’t do that out-of-control cough or choke that we should do,” Morano-Villhauer said. “I see sometimes folks that under X-Ray, we’ll see a pretty large volume of something go down into the lungs, and they’ll just be sitting there looking at me, and I’ll have to tell them to cough.”

In these people, Morano-Villhauer said, the vocal cords that should sense the food or drink and trigger the body’s cough response are not sensing the food or drink. That could result from becoming desensitized over time or acid reflux damage.

Overall, if difficulty swallowing is affecting your quality of life — if you’re worried about going out to eat because of your coughing and choking, if it’s happening with every meal — you should ask your primary care physician about being tested.

“The challenge of having trouble eating and drinking is that eating and drinking is a part of every important social event in our day and in our lives,” Morano-Villhauer said. “And when we can’t participate in that in the same way, it’s really hard from an emotional standpoint.”


• Eat smaller meals throughout the day instead of three large ones.

• Reduce distractions while eating and drinking.

• Eat smaller bites and drink smaller amounts so your tongue doesn’t have to control too much at one time.

• Alternate solids and liquids.

• Eat meals more slowly — we’re conditioned to eat quickly during our working years, but putting down your fork after every couple of bites helps reprogram your mind to slow down.

• Don’t talk with food in your mouth.

• Add moisture to dry or tough foods, meats and breads, in particular — sauces, gravies and condiments, anything that matches the situation, like adding ice cream to cake or gravy to meat.


• Sit upright for 15 minutes to half an hour after a meal to make sure food gets down into the stomach and digestive area.

• If it feels like pills are getting stuck, take liquid beforehand to lubricate the throat. If you’re having control issues, try taking pills in applesauce or pudding.

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