Brace yourselves - This is a long one: reading time 10 minutes (give or take).

As an ENT Speech Therapist I come across medically unexplained conditions on a daily basis. Of course this usually applies to voice or globus, but over the past couple of years I have had more and more referrals for patients who have a 'normal swallow' but report an inability to eat or discomfort when doing so. This growing phenomena left me inquisitive and concerned for my client's wellbeing so I started to scour the internet in search of some answers. 

My acute colleagues are often sceptical about these cases and I have sensed an air of frustration at times. There have been comments of ‘it’s all in their head’ (perhaps a subconscious reference to the fantastic book by Suzanne O’Sullivan?) or references that they are ‘putting it on’. Some clinicians refuse to take on these cases once an instrumental assessment has demonstrated no aspiration. I can’t help but feel that this approach is failing these individuals.

After treating almost 50 patients with medically unexplained dysphagia, it is clear to me that the symptoms are absolutely real and very quickly take start to take over people's lives. More often than not these patients spend the first 30 minutes of their appointment crying. They have usually limited their intake to baby food or mashed up bananas and are fearful of going out to eat. Not to mention the two stone weight loss some experience.

The Evidence base: 

The evidence for this condition is patchy at best, which is disappointing as an estimated 12% of outpatient dysphagia referrals are medically unexplained. Jennifer Short and Sam Harding have recently conducted some research looking into the terminology used for dysphagia with no clear medical cause, which of course showed a lack of consensus. 

David Cottrell looked at medically unexplained conditions in paediatrics and highlighted a high prevalence of a sensation of food sticking. This study showed that a combination of; reassurance, gentle questioning about stressors, a rehab pathway to treat the symptoms and resuming normality was effective. Verdonschot et al looked at the swallow in more detail, finding a regular pattern of piecemeal swallowing and discussed a requirement for psychological therapies. 

In 2019 a chapter in the book ‘The Evaluation and Management of Dysphagia’ covered medically unexplained dysphagia, highlighting the need for further research- surprise surpise! This chapter discusses a treatment plan of; lifestyle modifications, avoidance of triggers, neuromodulators and management of psychological comorbidities. 

And finally there are numerous studies talking about ‘phagophobia’, the fear of swallowing or choking, which has been recognised within the DSM-V. Interestingly, this is often misdiagnosed as Anorexia Nervosa, very worrying! These studies talk about the successful use of psychological therapies including CBT, hypnosis, EMDR and desensitisation.

My Approach (after an organic cause for dysphagia has been ruled out):

1) Listen, listen, listen : Ppen questions are key here.

2) Build rapport: Gradually unpick the story, often stresses are subtle. There may be a previous vomiting or choking experience that the client doesn’t hold in their conscious mind.

3) Demystifying symptoms: There is often a heightened throat sensitivity aspect to this, explain this in detail to the patient.

4) Identify patterns and triggers and educate about throat clearing. There will be a LOT of throat clearing.

5) The most important point: Collaborate, a minimum of three professionals: 1) ENT Consultant, 2) psychologist, 3) SLT. CBT is recognised as a treatment in the literature. Refer and work together!

6) Treat the symptoms: Tightening in the throat? Use head and neck stretches, relaxation or emergency breathing. Floor of mouth tension? Use tongue stretches.. You get the gist.

7) Medical management: There may be cricopharyngeal tightening or reflux. ENT doctors may have answers and treatments for this including; medication, botox or myotomy. 

8) Biofeedback: This must be done with a gentle approach and I have found FEES most successful. Allow the patient to watch as they are eating and record the images for them to watch back regularly. 

Conclusion

SLT has a vital role in educating, listening, sign posting and treating this condition. Of course the help of other professionals is vital. SLTs are the experts in swallowing and as an ENT SLT I think it is important to incorporate this client base in with the voice and upper airway caseload as many of the principles and treatments cross over. As with treating any throat condition, the client may not improve with input if it is not the right time to change. 

References

Cottrell, D (2016), "Fifteen-minute consultation:medically unexplained symptoms", British Medical Journal.

Verdonschot, R. Baijens, L. Vanvelle, S. Florie M. Dijkman, R (2019), "Medically unexplained oro-pharyngeal dysphagia at the University Hospital outpatient clinic for Dysphagia: a cross sectional cohort study.

Short, J. Harding S, (2019), "A systematic exploration of the terminology used in the diagnosis and treatment of oropharyngeal dysphagia in the absence of a clear medical condition".

Fass, O (2019) "Functional dysphagia", From book 'The Evaluation and management of Dysphagia", P201-218.

Reid, D (2016), "A case study for hypnosis for phagophobia: It's no choking matter".

O'Sullivan, S (2016) "Its all in your head".