Among the range of symptoms that may affect patients with rheumatoid arthritis (RA), oral, pharyngeal, and esophageal motility disorders are common. The estimated prevalence of swallowing dysfunction in this patient population is 13.1% to 33.3%.1,2 Oropharyngeal dysphagia caused by xerostomia, masticatory impairment, and cricoarytenoid joint dysfunction has been reported.3 In addition, esophageal dysphagia may arise from esophageal motor dysfunction, complications from antirheumatic therapy, and other causes.
Despite the high rates of dysphagia in RA, data are scarce regarding prevalence, risk factors, symptoms, and effects on quality of life. As recently reported in the Annals of Otology, Rhinology, and Laryngology, researchers at the University of Utah and Brigham Young University sought to address these gaps in a descriptive epidemiology study.3
The sample included 100 adult patients with RA (84 women) with a mean age of 61.1 years and a mean disease duration of 19.6 years. Extensive interviews were conducted, which included various scales to assess general health, swallowing problems, and health-related and dysphagia-specific quality of life.
The following results were observed:
- Swallowing disorders were noted in 41% of participants, with many reporting daily symptoms for at least 4 years.
- Dry mouth was the most frequently reported symptom (52%), and symptoms suggesting solid food dysphagia were especially common.
- Risk factors for swallowing disorders included voice or thyroid dysfunction, esophageal reflux, and physical inactivity.
- Dysphagia was positively associated with self-reported RA disease severity, regardless of length of disease duration or years of medication use. Only 3 patients linked their dysphagia to medication use.
- Significantly reduced quality of life was found in patients with RA with vs without dysphagia. Dysphagia was associated with reduced quality of life as indicated by lower scores on 7 of 8 subscales and the Mental and Physical Health summary component measures of the 36-Item Short Form Health Survey.
- Only 46% of the patients with dysphagia had ever sought professional help, which reportedly improved symptoms in 74% of these individuals.
“While RA adversely affects [quality of life], the addition of a swallowing disorder clearly adds to the mental and physical burden placed on the individual,” the authors concluded. “Thus, swallowing disorders in individuals with RA and their origins need be explored.”
For clinician perspectives on dysphagia in RA, Rheumatology Advisor spoke with study co-author Karla L. Miller, MD, rheumatologist and assistant professor in the Division of Rheumatology at the University of Utah; Edward J. Damrose, MD, FACS, chief of laryngology at Stanford Health Care; and Alba Azola, MD, a resident in the Department of Physical Medicine and Rehabilitation at the Johns Hopkins University School of Medicine, and co-author of a recent study on swallowing disorders.4
Rheumatology Advisor: What do these findings suggest about the prevalence of swallowing disorders in RA? Do they align with what you’ve seen in practice?
Dr Miller: Yes, the findings of this study align with what we have observed in practice, with complaints of swallowing difficulties being common.
Dr Damrose: Yes, I think that’s probably pretty accurate. I was a little bit surprised at the high number, but when you factor in that some of these patients may have secondary Sjogren syndrome, that makes sense, since it has such a negative impact on oral health and swallowing.
Dr Azola: The prevalence of dysphagia found in this study definitely aligns with what we see in practice at our institution and in the dysphagia literature at large. In general, dysphagia is underreported by patients and thus underdiagnosed. When we inquire regarding difficulty swallowing or changes in habits during meals, we find that people are noticing these changes. However, they don’t tend to present to their [physician’s] office for evaluation of this problem. For example, in Roy et al, less than half of patients who admitted to having issues swallowing actually sought help for it.3 It’s unfortunate, as without intervention this can have a significant impact on nutritional status, a negative effect on quality of life, and can increase morbidity and mortality. Eating in general is an important part of our social life and interactions with family, and our general well-being is worsened greatly when dysphagia is present.
An interesting point of Roy et al is that about 80% of the cohort was over the age of 60, and we know that the aging population has a significantly increased prevalence of swallowing disorders. I believe that the high prevalence in the current study is influenced by the large representation of the older age group. In a recent study from our group, 29% of healthy community-dwelling aging adults (age >60) who did not have a diagnosis known to result in dysphagia, admitted having moderate to severe swallowing impairment when completing a swallowing questionnaire.4
Rheumatology Advisor: Which patients appear to be most at risk for swallowing disorders, and how do these disorders influence disease course?
Dr Miller: From a clinical perspective, older patients and those with moderate to severe RA and secondary Sjögren syndrome seem especially affected by swallowing difficulties. The presence of swallowing difficulty can result in anything from challenges in swallowing medications, a sensation of food sticking, and increased risk for aspiration to impaired nutrition and weight loss — all of which are associated with adverse effects on quality of life.
Dr Damrose: Patients with secondary Sjogren syndrome or temporomandibular (TMJ) involvement are the ones who are most at risk of developing swallowing disorders. In severe RA, it is very likely that patients may be taking drugs like prednisone and other medications that may exacerbate gastroesophageal reflux disease.
Many immunosuppressants can increase the risk for secondary fungal infection in the throat (candidiasis), which could exacerbate a preexisting swallowing problem. With secondary Sjogren syndrome, the dryness already increases the risk for fungal infection. So, if patients have some baseline dysphagia and come in with marked, acute deterioration in symptoms, clinicians should keep in mind the possibility that a secondary fungal infection may be at work.
Also, with the increased risk for cachexia in RA, patients can get caught in sort of a downward spiral, in which the swallowing disorder further contributes to cachexia.
Dr Azola: In patients with RA, there are considerations when it comes to identifying patients at highest risk for swallowing disorders. Some important risk factors include:
- Older age (>60 years)
- Presence of voice changes (breathy or hoarse voice), raising concern of RA involvement of the laryngeal structures
- Decreased pulmonary reserve
- Presence of other autoimmune conditions — myositis, scleroderma, Sjogren syndrome — affecting oropharyngeal muscle strength, compliance of the tissues, and initial phases of bolus processing
Typically, patients do not volunteer that they have concerns about their swallowing or that they have already started modifying their diet. Once patients are questioned in a formal swallowing questionnaire or a few relevant questions during the clinical visit, these issues can become evident and trigger proper workup and treatment.
Rheumatology Advisor: How should clinicians approach assessment and management of swallowing disorders in RA?
Dr Miller: A clinician could start by asking about mouth and throat dryness, hoarseness, and difficulty swallowing. If present, further evaluation with a formal swallow evaluation and referral to a speech-language pathologist could be offered. If concern for laryngeal dysfunction is present, referral to an otolaryngologist for further evaluation of the larynx [may be indicated].
Dr Damrose: One way to begin to understand this is perhaps [in terms of] where the symptoms are localizing. For example, a patient with compromised TMJ function will have difficulty opening their mouth, and those with Sjogren syndrome will very likely complain of dry mouth. If a patient complains about food getting caught in their throat, ask them to [show you] where.
Most swallowing disorders tend to fall under the bailiwick of an otolaryngologist, to whom referral for evaluation is often indicated. This will typically include endoscopy of the throat and esophagus and evaluation of swallowing function using radiologic testing. A speech and language pathologist may also become involved in the evaluation process.
Dr Azola: In the management of swallowing disorders, it’s important to take a systematic approach and make timely and proper referral for instrumental examination to a swallowing specialist. The initial screening during the clinic visit is key in terms of identifying the presence of dysphagia. The gold standard for assessment of swallowing is the modified barium swallow (video fluoroscopic swallowing examination. This examination is best performed by a radiologist in conjunction with a speech language pathologist. Other key instrumental examinations include fiberoptic endoscopic evaluation of swallowing and pharyngeal and/or esophageal high-resolution manometry. These instrumental tests provide insight into the specific pathophysiologic process affecting the swallow, which will guide treatment targeting the etiology of the dysfunctional swallow.
There could be tongue or pharyngeal muscle weakness, limited laryngeal elevation, inability to protect the airway at different levels (closure of laryngeal vestibule or poor vocal fold mobility), or sensory deficits that mute the intrinsic protective mechanism against aspiration. In the case of RA, we know that the disease may affect jaw and cricoarytenoid joints, affecting patients’ ability to process and prepare the bolus and protect the airway, as well as the ability to generate a strong cough that would help clear the airway from food contents that reach the lower airway tract.
Once the specific impairments of the swallow have been identified, the treatment plan can be designed to target the specific problem to maximize and optimize swallow. Keep in mind that modification of diet is not the mainstay of treatment, and this just one of the compensatory strategies. Limiting a patient’s diet can have a significant detrimental effect on the patient’s ability to maintain proper nutritional status, hydration, and quality of life.
Rheumatology Advisor: What should be the focus of future studies on this topic?
Dr Miller: Patients with RA with and without dysphagia should be compared using a comprehensive fiberoptic endoscopic and videofluoroscopic swallowing evaluation of the oropharynx and esophagus to better understand the nature and the risk factors for the development of this important problem.
Dr Damrose: If I had to pick one thing to focus on, it would absolutely be better treatment for Sjogren syndrome — particularly strategies to restore patients’ saliva production. Other priorities would be to understand how these processes begin and how to prevent the autoimmune disease, and better medical therapies to stabilize and reverse active disease.
Dr Azola: As physicians, we should raise awareness of dysphagia and inquire about issues with swallowing and implement the use of a dysphagia screening tool, such as the Eating Assessment Tool, the Dysphagia Handicap Index, or the Swallowing Quality of Life questionnaire, routinely. Studies looking at the impact of implementing these diagnostic tools could provide the evidence needed to promote a paradigm change in the way we treat dysphagia, making earlier interventions and rehabilitation of function possible. A quantitative analysis with instrumental swallowing assessment, such as videofluoroscopy or high-resolution manometry, would aid in the characterization of the pathophysiologic mechanisms of dysphagia in RA and [identify] potential therapeutic targets to maintain a healthy functional swallow in patients with RA.
This interview has been lightly edited for length and clarity.
- Bessa-Nogueira RV, Vasconcelos BC, Duarte AP, Góes PSA, Bezerra TP. Targeted assessment of the temporomandibular joint in patients with rheumatoid arthritis. J Oral Maxillofac Surg. 2008;66(9):1804-1811.
- Kallenburg A, Wenneberg B, Carlsson GE, Ahlmen M. Reported symptoms from the masticatory system and general well-being in rheumatoid arthritis. J Oral Rehabil. 1997;24(5):342-349.
- Roy N, Tanner KM, Merrill RM, Wright C, Pierce JL, Miller KL. Epidemiology of swallowing disorders in rheumatoid arthritis: prevalence, risk factors, and quality of life burden [Published online June 1, 2018]. Ann Otol Rhinol Laryngol. doi:10.1177/0003489418780136
- Mulheren RW, Azola AM, Kwiatkowski S, et al. Swallowing changes in community-dwelling older adults [published online June 8, 2018]. Dysphagia. doi:10.1007/s00455-018-9911-x