Medical Conditions Associated with Concurrent Dysphagia and Dysphonia

Abstract

Swallowing and voice production are important processes enabling a comfortable life. For appropriate alimentation, effective passage of food and fluids through a digestive system is necessary. Interpersonal communication depends on good voice and speech. Conditions associated with swallowing and speech problems leads dysfunctions and seriously affect the patient’s comfort of living. This chapter is a review of medical conditions associated with concurrence of dysphonia and dysphagia. There are a large number of medical conditions leading to the simultaneous occurrence of swallowing problems and hoarseness. The diversity of disorders is a serious interdisciplinary issue. Diagnostics of concurrent dysphagia and dysphonia is complicated and requires a holistic interdisciplinary approach. The reasons include functional and organic dysfunctions, neurological conditions, tumors, vascular disorders, autoimmune inflammations, post-operative complications, post-COVID complications, and others. Our research was conducted by reviewing PubMed and Scopus network using key words “dysphagia”, “dysphonia”, “hoarseness.” We found 966 publications, then narrowed the search to 99 articles describing medical conditions and case reports, which present with dysphagia and dysphonia occurring together. Detailed analysis enabled us to categorize the disorders into groups, depending on characteristics and body region involved in the pathological process. Finally, the description of the medical conditions was done systematically according to those groups.

1. Introduction

Swallowing and voice production are both coordinated by a nervous system. From anatomical and physiological standpoint, these two acts have a lot in common. Appropriate swallowing takes place with the larynx closed by the epiglottis, which is a protective mechanism for the lower part of the respiratory system against aspiration of food and fluids.

Swallowing is a highly complex neuromuscular process modulated by the central nervous system. It requires a timely coordination of laryngeal and pharyngeal muscles. When swallowing begins, food and fluids are pushed from mouth to pharynx and then down to esophagus. To protect the food from accessing the airway, this needs vocal cords to close timely and the epiglottis to cover the glottis. A short apnea appears. Muscles involved in the process are innervated by superior and recurrent laryngeal nerves (RLN) (Figure 1), which on both sides are the branches of the vagus nerve. Left RLN leaves the vagus right after it enters the chest. It bends around the aortic arch and then around the subclavian artery. Further, the RLN of both sides go together upward along the trachea, in the tracheoesophageal sulcus and reach the posterior wall of the thyroid gland. Any condition that leads to discoordination of the above process causes the risk of aspiration. When it happens, the cough reflex is activated by the initiation of intercostal, abdominal and diaphragm muscles.

Figure 1.

Recurrent laryngeal nerve path (description in the text) (source: [1]).

Voice production is also a complex process involving several physiological mechanisms. Laryngeal muscles are responsible for tensioning and closing the vocal cords as well as for relaxing the cords and opening the glottis. They are innervated respectively, by the superior laryngeal nerve (cricothyroid muscle) and by the recurrent laryngeal nerve (all remaining muscles). Specific vibrant movements of vocal folds also need a subglottic air pressure to begin and thus to initiate phonation [2]. The frontal section of the larynx structure is presented below (Figure 2).

Figure 2.

The structure of larynx (source: University College of London Hospitals, NHS Foundation Trust).

Different pathologies may lead to discoordination of swallowing and voicing physiology and be causative factors for dysphonia and dysphagia. A whole group of medical conditions may be reasons for both of them to occur at the same time. Depending on the type and location, pathologies causing coexistence of swallowing and voice production can be differentiated according to the location of the basic disorder. They include disorders in the central nervous system, peripheral nerves, cervical spine, larynx, neck, mediastinum, muscles, connective tissue, and COVID infection complications.

2. Central nervous system

Central nervous system control over swallowing and phonation is a superior mechanism ensuring appropriate function of those two acts. Centers in the brain responsible for efferent signal transmission to peripheral parts of IX, X, XI, and XII cranial nerves need to be supplied with blood and oxygenated in an appropriate way to keep their function. It is assumed that the brain uses approximately 20% of all blood. Therefore, every condition leading to ischemia, hypoxia, or mechanical damage disrupts the function, which may seriously affect both the brain itself and the effector organs.

Lesions that cause dysphagia and hoarseness may localize in different areas in the central nervous system. Cerebral cortex sends signals to nuclei of IX and X cranial nerves (CN). The signals are also sent to them through corticobulbar tracts located in the medulla. Therefore, both lesions localized in cerebral hemispheres and those in the brainstem, may lead to dysarthria by disrupting the nerve conduction. On the other hand, damages to the peripheral nervous system may lead to dysarthria and dysphagia, as they affect the function of motor neurons and cause neuropathies, dysfunctions of the neuromuscular junction or pharyngeal, and laryngeal myopathies. Finally, they also lie behind disturbances in motility of the esophagus.

Dysphagia and dysphonia together often occur in patients after stroke. Both ischemic and hemorrhagic mechanisms cause brain tissue dysfunction. Brain stroke is number one cause of death in developed countries [3]. Vascular mechanisms of the stroke include thrombosis, embolism, and artery rupture. Thrombosis and clots lead to transient or permanent hypoxia, which may lead to brain infarct. Serious hypoxia of the whole brain may also occur in hypovolemic shock. Hemorrhagic stroke causes cell dysfunction as a result of damage and secondary ischemia. All the conditions above lead to the development of neurological symptoms, such as headache, face numbness, hemiplegia, dysarthria, difficulty swallowing, and dysphonia [4, 5, 6].

Similar effects of swallowing and voice production problems originated centrally may occur when the brain is mechanically pressed by the mass of edema, intracranial hematoma, or tumors. Swallowing and phonation dysfunctions occurring together are seen in post-traumatic patients when edema develops and leads to gomphosis. The same effect of mechanical pressure appears in those with brain neoplasms, including gliomas (astrocytoma, oligodendroglioma, and ependymoma). Prevailingly, gliomas spread as diffuse and infiltrating tumors (astrocytoma, oligodendroglioma), less as solid masses (ependymoma). Other primary tumors of the central nervous system causing mass effect are medulloblastomas, lymphomas or germ cell tumors. Secondary brain tumors, occurring as 25–50% of all intracranial tumors, include metastases from the lungs, skin (melanoma), kidney, or digestive system. Usually, they are formed as solid masses in between white and gray substances, well separated from the healthy tissues. Dysphagia and dysphonia, accompanied by headaches, were also described in patients with multiform glioblastoma in the cerebellopontine angle with trans-tentorial spread [7]. Similarly, vestibular schwannomas were described to cause swallowing and voice problems. The bigger the tumor size, the more intensity of symptoms were found. Vagal schwannoma occupying the left cerebellar-medullary cistern and extending from the pontomedullary junction to the jugular foramen was also reported to cause similar clinical effects [8].

Literature analysis shows that a whole variety of other conditions in the central nervous system may also affect swallowing and voice simultaneously. Meningitis cases were described in the course of a varicella zoster infection to cause dysphagia, dysarthria, and hoarseness. Sudden vomiting, dysphagia, dysphonia, and food regurgitation were found in the condition named neuromyelitis optica (NMO). This inflammatory disorder affects the spinal cord centers and optic nerves. The pathology has an autoimmune background and causes nerve demyelination. The set of above symptoms is referred to as acute brainstem syndrome [9].

Bulbar symptomatology (progressive dysphagia, dysphonia, and dysarthria) may also appear as a result of vascular brainstem compression in the course of intracranial arterial dolichoectasia (IADE). The condition is often a result of atherosclerosis that leads to local enlargement of the artery, which gets wider, longer, and more tortuous [10]. Dysphonia, dysphagia, and nasality were also reported in patients with isolated bulbar palsy as a result of neurosarcoidosis, a non-caseating granulomatous chronic inflammatory disease that can affect any organ, including the central nervous system [11].

Voice and swallowing impairments are common in movement disorders. The group of diseases is mainly represented by Parkinson’s disease (PD), but also includes essential tremor (ET), dystonia, and other related syndromes named atypical Parkinsonian syndromes (APS). They may lead to disturbed voice production and speech, but often affect swallowing acts as well. Imbalance between breathing, vocal folds’ biomechanics, and vocal tract function used in voicing may negatively affect the quality of voice. Discoordination of muscles activated during swallowing can result in dysphagia, or difficulty moving food or liquid from the mouth to the stomach [12, 13, 14]. In its two variants of spinal and bulbar onset, amyotrophic lateral sclerosis (ALS) affects muscle function and may lead to swallowing and voice problems and dysarthria. The pathology is caused by neurogenerative mechanism involving upper and lower motor neurons [15].

Other conditions in central nervous system were also reported to cause dysphagia and dysphonia together. Alexander’s disease (AD), a progressive disorder of cerebral white matter caused by a heterozygous GFAP pathogenic variant, comprises nonspecific neurologic manifestations in adults. An additional symptom of muscle dysfunction in the disease is nasal speech [16]. Dysphagia, followed by dysphonia, diplopia, and ataxia were described in individuals suffering from Wernicke encephalopathy (WE) that develops as result of thiamine (vitamin B1) deficiency. The condition is seen mainly, but not only, in individuals prone to alcohol abuse [17].

3. Peripheral nervous system

Pathologies involving peripheral nerves include a whole variety of symptoms. They are caused by major mechanisms, including mechanical, inflammatory, degenerative, or neoplasmatic. Pathology disturbs nerve conduction, which results in improper function of effector organs. Therefore, muscles responsible for swallowing and voice may be seriously affected.

Guillain-Barré syndrome (GBS) is a neurological disease of inflammatory origin leading to demyelination and degeneration of nerve fibers. Usually preceded by infection, GBS develops in an autoimmune mechanism. The condition is sometimes seen as a vaccination side effect. Progressive fatigue, muscle weakness, dysphonia, dysphagia, and dysarthria were described in patients diagnosed for GBS weeks after covid infection [18]. Similarly, GBS was described as the cause of polyradiculoneuropathy leading to dysphagia, dysphonia, bilateral facial palsy, areflexia, and ataxia, which are characteristic of a bulbar palsy [19]. The same symptoms may be present in cases of wound botulism seen in heroin users. The symptoms result from a wound contamination with Clostridium botulinum, which produces neurotoxin that inhibits acetylcholine release by binding irreversibly to the presynaptic terminal. Usually, symmetrical cranial nerve palsies occur that lead to mouth dryness, blurry vision, dysphagia, dysarthria, dysphonia, and peripheral muscle weakness. In most serious cases, respiratory muscles are involved, which causes neuromuscular respiratory failure. Appropriate diagnosis and early treatment are crucial [20].

Dysphonia, dysphagia, muscle weakness, and fatigue may also occur in post-polio syndrome (PS), which is defined as a set of various symptoms in subjects who survived acute paralytic poliomyelitis. PS may develop a long time after recovery. The virus, transmitted with contaminated food and water or through the fecal-oral route, causes death of the lower motor neuron by damaging the cells of the anterior horn of the spinal cord [21].

The Varicella zoster (VZ) virus has been associated with a wide range of neurological complications. It usually affects upper cranial nerves (trigeminal and facial), but also lower cranial polyneuropathies resulting from Varicella zoster virus reactivation were seen [22]. Herpes zoster (HZ) infection involving cervical, vagus, and accessory nerves causing severe vocal paralysis, asymmetric palate, trapezius atrophy, and scalene muscle atrophy was described as another condition causing simultaneous dysphonia and dysphagia [23]. Varicella zoster is also recognized as the etiology for jugular foramen syndrome (JFS), alternatively named Vernet’s syndrome (VS). Jugular foramen conducts glossopharyngeal and vagus nerves, as well as jugular vein. JFS may be caused by trauma, tumor, or vascular and infectious factors. The syndrome is characterized by paresis of the IX, X, and XI cranial nerves, which causes loss of taste at the posterior 1/3 of the tongue, vocal fold paresis, and weakened function of trapezius and sternocleidomastoid muscles. This ultimately leads to dysphonia and dysphagia.

Cases of Collet-Sicard syndrome (CSS), a rare disorder caused by cranial nerve compression at the skull base, were also identified to cause dysphagia, dysphonia, and a deviated tongue following an upper respiratory tract infection. The syndrome is associated with spontaneous carotid artery dissection leading to the formation of pseudoaneurysm as a result of persistent coughing. Delays in diagnosis could result in subsequent stroke or other morbidity associated with prolonged cranial nerve compression [24].

Transient cranial nerve palsies causing swallowing and voice disorders were observed as a complication of spinal anesthesia with a bupivacaine-fentanyl combination [25]. Dysphagia with dysphonia was also described in epileptic patients developing pharyngolaryngeal spasm as a side effect of vagus nerve stimulation therapy [26]. Progressive dyspnea, dysphonia, dysphagia for solids, and globus pharyngeus were reported in individuals with laryngeal schwannoma [27].

4. Cervical spine

Pathologies located within the cervical spine as well as surgical interventions in this region may lead to various multisymptomatic conditions. Diffuse idiopathic skeletal hyperostosis (DISH) known as Forestier’s disease, is a common elderly disease of unknown etiology that leads to hardening of ligaments and entheses of the skeleton. Cases of DISH were reported to cause dysphonia, stridor, dysphagia, globus, and dyspnea as a result of mechanical compression of ossified tissues and DISH-related cervical osteophytes on the posterior wall of the respiratory and digestive tract [28, 29].

Patients diagnosed with cervical stenosis (spondylosis) are often treated surgically. Cervical spondylosis (CS) is a progressive disease of the cervical spine. It disturbs the cervical spine function as a result of pathological changes leading to stenosis. It is often associated with degeneration or herniation of the disc, the formation of osteophytes, and ligament hypertrophy (Figure 3). Patients may present with any combination of neck pain, radiculopathy, or myelopathy. Unsatisfactory preservative treatment may lead to the need for cervical disc replacement (CDR). This type of surgical procedure includes discectomy and, as a result, enables a disc space to be restored and the stenosis to be decompressed. As a complication of the treatment, dysphagia and dysphonia were also reported in many cases [31].

Figure 3.

Anterior cervical osteophyte in CT scan (sagittal and axial view) (source: [30]).

Dysphagia, dysphonia, and odynophagia were often reported to occur after surgical treatment of degenerative cervical myelopathy (DCM). Degenerative cervical myelopathy causes cord compression and is often treated surgically (ACDF, anterior cervical discectomy) to remove the compressive pathology, increase the space available for the spinal cord, and stabilize the spinal column. Dysphagia can occur during all three phases of swallowing. Dysphonia is most commonly caused by damage to the recurrent laryngeal nerve, which can appear during any of the operations involving the upper cervical region near C3-C4 [32, 33].

5. Muscular/connective tissue disorders

The literature review shows that pathologies of muscles leading to muscle weakness may be associated with swallowing and voice production problems.

Dermatomyositis (DM) is one of a few types of autoimmune inflammatory myopathy together with polymyositis, myositis overlap syndrome (including anti-synthetase syndrome), inclusion body myositis (IBM), and immune-mediated necrotizing myopathy (IMNM). It is a rare autoimmune condition that affects children and adults and is one of the many idiopathic inflammatory myopathies that predominantly affect the skin and muscles. DM is characterized by inflammation-related muscle weakness. Skin rash is often seen. As a result, pathological mechanisms of DM may finally lead to muscle dystrophic calcinosis. Muscle stiffness involves different groups of muscles, including those taking part in the swallowing process as well as voice emission. Therefore, dysphagia and dysphonia are often present in patients with advanced cases of DM [34, 35].

Mitochondrial myopathy (MM), a genetic condition related to nuclear gene TK2, which encodes the mitochondrial thymidine kinase, an enzyme involved in the phosphorylation of deoxycytidine and deoxythymidine nucleosides, leads to serious muscle dysfunction. Pathology mainly involves skeletal muscles. Childhood-onset TK2 deficiency typically causes a rapidly progressive proximal myopathy, which leads to mobility dysfunction and severe respiratory impairment. In some cases of slowly progressive mitochondrial myopathy, ptosis, hypoacusis, dysphonia, and dysphagia were described in the literature [36].

The Ehlers-Danlos syndrome (EDS) is a heritable disorder of connective tissue (HDCT), characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. Hypermobile EDS (hEDS) is the most common subtype, representing more than 90% of cases. EDS presents with pain, fatigue, anxiety, gastrointestinal issues, autonomic dysfunction, temporomandibular joint disorder (TMJD), dysphagia, dysphonia, and LPR symptoms [37].

Inflammatory diseases of the muscles may also be caused by parasite infections. A rare case of myositis caused by Haycocknema perplexum characterized by progressive facial and limb weakness, dysphagia, and dysphonia was described by the researchers of Mayo Clinic [38].

Another group of muscular diseases are those related to dysfunction of the neuromuscular junction. Myasthenia gravis (MG) is an autoimmune disease affecting the function of the neuromuscular junction. Dysfunction of the junction disturbs nerve-muscle conduction, leading to muscle weakness. The pathology relates to various groups of muscles and may present as dysphonia, dysphagia, dysarthria, and weakness of skeletal muscles. Affecting muscles of the eyes and face, this may also lead to ptosis, diplopia, and difficulty in closing the eyelid. The body of an MG patient produces autoantibodies that bind to acetylcholine receptors on skeletal muscle, thus causing muscle weakness and fatigability. Bulbar symptoms, including dysarthria, dysphagia, and dysphonia due to IX and X cranial nerve dysfunction, occur in approximately 15% of patients [39, 40].

6. Mediastinum

Mediastinum is a large space located in the chest containing various anatomical structures and organs. Superiorly, it is connected with the neck through a superior thoracic aperture, also named a thoracic inlet. It is a space limited by the first thoracic vertebra, ribs, and the sternal manubrium. The space includes various anatomical structures, including the trachea and esophagus, as well as nerves, arteries, and veins. Due to the connection, some pathologies (i.e., inflammation) may include neck and mediastinum at the same time.

Variability and proximity of the structures makes the mediastinum vulnerable to diseases involving different organs and functions. Large mediastinal tumors may lead to dysphagia, dysphonia, coughing, chest pain, and dyspnea. An example of such a tumor is a posterior mediastinal liposarcoma causing compression on the esophagus, trachea, and carotid arteries [41]. Other tumors in the chest may cause similar symptoms.

Various cardiac conditions may influence the swallowing and voice. Ortner’s syndrome (OS), also named cardiovocal syndrome, is a cardiac disease related condition presented with hoarseness as well as dysphagia, cough, and dyspnea. Pathophysiology underlying the syndrome is a dysfunction (or palsy) of the left laryngeal nerve, which results from its friction, stretching, pulling, or compression. The many reasons leading to OS include aortic aneurysm, pulmonary hypertension, arterial hypertension, or mitral stenosis [42, 43].

Dysphonia and dysphagia may also occur as complications after cardiac surgery. Tapia’s syndrome (TS), a palsy of recurrent laryngeal nerve and hypoglossal nerve, is one of such conditions. The most probable background is considered a compression on X and XII cranial nerves a result of orotracheal intubation. This may occur after a variety of cardiac surgeries, such as aortal valve replacement (AVR), coronary artery bypass grafting (CABG), atrial septal defect closure (ASDC), or mitral valve repair (MVR) [44, 45].

Diverse symptoms that include a palpable neck mass, dyspnea to asphyxia, dysphagia, dysphonia, and superior vena cava syndrome may also be seen in large thyroid tumors. One of them is substernal goiter, a thyroid tumor trespassing the line of the thoracic inlet and entering the mediastinum. This can cause various symptoms due to the compression of adjacent anatomical structures [46]. The same symptoms can be observed in the presence of other types of masses in the chest, that is, enlarged lymph nodes, sarcoidosis, cancer, thymoma, or mid-esophageal diverticula. The superior vena cava syndrome occurs when masses compress the superior vena cava and occlude its lumen. The occlusion blocks the flow down of the blood from the veins of the head and neck, leading to an increase in pressure in the vessels. This increases the compression on the anatomical structures and on the recurrent laryngeal nerve. The symptoms, apart from dysphagia and hoarseness, include edema, head, neck, chest, and arms veins enlargement and face cyanosis (Figures 4 and 5) [48, 49].

Figure 4.

Images presenting the symptoms of superior vena cava syndrome, frontal view (source: [47]).

Figure 5.

Images presenting the symptoms of superior vena cava syndrome, lateral view (source: [47]).

The diverticula are often formed as result of mediastinal lymph nodes inflammation. They adhere tightly to the esophagus wall and pull it to form various sizes diverticula. Another diverticula type, named pulsion mid-esophageal diverticula, tend to be associated with esophageal motor disorders (Figure 6) [50].

Figure 6.

A barium swallow test showing esophagus dilatations (diverticula) (source: [50]).

Esophageal perforation (EP) is a critical clinical status. EP may occur in the cervical thoracic, or abdominal part of the esophagus. Depending on the perforation location, symptoms may present various characters and intensities. Cervical perforation is mainly associated with dysphagia and neck pain (Figure 7), while this in the thoracic part is characterized by dyspnea, epigastric, back, or chest pain, suggestive of mediastinitis. Abdominal pain as a result of developing peritonitis is present in perforation of abdominal esophagus. Dysphagia in such cases is usually caused by dysfunction of inflamed tissues and muscles and thus disturbed esophagus motility. In cases of anterior perforation leading to tracheoesophageal fistula, mediastinitis or aspiration pneumonia may develop. Dysphonia is then often caused by the palsy of the recurrent laryngeal nerve that runs in the tracheoesophageal groove, the sulcus formed by the trachea anteriorly and esophagus posteriorly. The mortality rate associated with esophageal perforation is high, as it may lead to the development of systemic inflammatory response syndrome (SIRS), accompanied by fever, hypotension, and tachycardia. Reasons for EP may differ, including surgical procedures, endoscopy, external trauma, scleroderma, neoplasms, inflammation, achalasia, esophageal stricture, or hiatal hernia. EP can also be a complication of bariatric procedures, mostly related to the intraoperative use of bougie. Laparoscopic sleeve gastrectomy (LSG) may be associated with emphysema, cervical pain, dysphagia, dysphonia, and fever [51, 52].

Figure 7.

Radiograph image of cervical emphysema post-esophageal perforation (source: [51]).

Dysphagia, dysphonia, and subcutaneous emphysema together, with pain in the back or neck were described as symptoms accompanying a condition called pneumomediastinum, also referred to as mediastinal emphysema (ME). Usually caused by trauma, barotrauma (mechanical ventilation), or happening spontaneously, it leads to air accumulation in the mediastinal space. This can also be induced by vigorous coughing or esophagus rupture as a result of intense vomiting. Underlying factors increasing the risk of mediastinal emphysema are respiratory diseases affecting the lungs and smoking (Figure 8) [53, 54].

Figure 8.

PA chest X-ray showing diffuse subcutaneous emphysema in neck and chest with pneumomediastinum (source: [53]).

Postpneumonectomy syndrome (PPS) is a condition occurring in some cases after pneumonectomy. In such condition, mediastinum with its organs gets shifted into the additional space created in result of pneumonectomy. Trachea and bronchus are compressed, which leads to dyspnea, dysphonia, and wheezing. In the long course, recurrent infections are also seen [55].

Mediastinal lipomatosis (ML) is presented with fatty tissue accumulation in mediastinum or pleura. Cases were described with manifestation of dyspnea, thoracic pain, cough, dysphonia, dysphagia, supraventricular tachycardia, and persistent pneumonia. In such cases an association of lipomatosis with myotonic dystrophy type 1 (MD1) was found. MD1 is the most prevalent myopathy in adults. The phenotypic spectrum of MD1 is highly variable and depends on the mutation load (homozygote and heterozygote) [56].

Swallowing problems associated with dysphonia were reported as complications of heart and lung transplantation procedure. The etiology of voice and swallowing complications in these patients can involve compromised respiratory function, prolonged intubation, trauma to the recurrent laryngeal nerve (RLN), intensive care unit acquired weakness, alterations to neurological status, and chronic gastro-esophageal reflux [2].

7. Larynx

Pathologies of the larynx that lead to voice dysfunction may be of functional or organic origin. Dysphonia is a key symptom of the pathologies; however, some of them may also be associated with dysphagia. Literature data shows that dysphagia occurs in about 5–10% of patients with voice disorders [57, 58, 59].

Functional voice disorders include hyperfunctional, hypofunctional, and mixed dysphonia. The background of the disorders is inappropriate voice emission with hypertension or hypotension of internal and external muscles of the larynx. The muscle tension abnormalities in some cases also lead to swallowing problems referred to as muscle tension dysphagia (MTD). Literature data shows that some researchers confirmed tension abnormalities by laryngeal electromyography (LEMG) and superficial electromyography (SEMG) results [60].

Hoarseness and swallowing problems are also seen in functional voice disorders in the elderly. Due to muscle weakness progressing with age, glottal insufficiency appears (presbyphonia). This is linked to reduced ability to produce effective glottal closure and difficulty in expectoration. As glottal closure is needed to increase subglottal pressure, allowing effective coughing, glottal incompetence in the elderly also gives a higher risk of aspiration and pneumonia [61]. Apart from functional insufficiency, incomplete glottic closure can also be a result of vocal fold paresis (VFP) due to neck and chest pathologies, lung cancer, complications of thyroid, and mediastinal operations or idiopathic [62].

Bilateral vocal fold paresis (BVFP), a serious life-threatening condition, apart from breathing difficulties, leads to dysphonia and swallowing problems. BVFP is often seen in the course of various conditions including cancer (of lungs, larynx, and brain), infectious diseases (tuberculosis, Treponema pallidum, poliomyelitis, and Lyme disease), autoimmune conditions, neurological disorders (myasthenia gravis, Parkinsons disease, multisystem atrophy, motor neuron disorders, encephalopathy, and cerebrovascular lesions), intoxications (pesticides), bilateral cricoarytenoid joint fixation or laryngeal amyloidosis, and others [63]. Failure of abduction of bilateral vocal cords may lead to an insufficient airway passage resulting in stridor or decrease in exercise tolerance, often requiring intervention (Figure 9).

Figure 9.

Bilateral vocal fold paralysis in adult (source: [64]).

Chronic cough, throat clearing, pain, dysphagia, and hoarseness were described in patients with laryngopharyngeal reflux (LPR). LPR is a multisymptom syndrome which appears as gastroduodenal contents moves backward from the stomach into the larynx or pharynx. The etiopathology of LPR is still subject to further research; however, usually it is associated with the insufficiency of the lower esophageal sphincter. Acid fluids lead to irritation of the mucosa of the pharynx and larynx, causing globus and throat clearing. Ultimately, this may lead to swallowing problems [65]. LPR may lead to laryngeal edema and voice disorders. Apart from an irritation of the mucosa, the pathophysiology of dysphagia and dysphonia is also related to the stimulation of the vagal nerve by the backflow of gastric fluids, particularly at the lower part of the esophagus [66].

The whole variety of other laryngeal organic disorders and tumors were also described to cause voice problems and swallowing disorders. Lymphomas localized in the region of the head and neck may lead to dysphonia and dysphagia. They usually include lymph nodes, while those with extra nodal location (ENL) occur rarely. Some cases of non-Hodgkin lymphoma (NHL) of the larynx were described, usually occurring in the supraglottic region (Figure 10). They may present with dysphagia, dysphonia, snoring, and progressive respiratory distress [67]. Similarly, laryngeal cancer or neuroendocrine carcinoma (NEC) of the larynx, as well as laryngeal paraganglioma and paraganglioma of the recurrent laryngeal nerve, may lead to dysphonia with coexisting dysphagia. Paragangliomas are tumors of neuroendocrine origin that develop from the paraganglia in the head and neck. They originate from the chromaffin cells from the paraganglionic tissue of the autonomic parasympathetic nervous system. Among all paragangliomas, 65–70% occur within the head and neck, usually involving the carotid, jugular foramen, and vagal nerve. Some cases were described in the nasopharynx, nose and sinuses, larynx, thyroid gland, and orbit [68]. Other, non-neoplastic rare tumors of the larynx were also reported to produce swallowing and voice problems. One of them is adult laryngeal hemangioma (ALH), which usually involves the supraglottic or glottic region. It appears as a result of vocal abuse, cigarette smoking, or laryngeal trauma from intubation [69].

Figure 10.

Video laryngoscopy showing laryngeal lymphoma (source: [67]).

Tuberculosis of the larynx is a rare disease with laryngeal symptoms in the absence of constitutional symptoms. Cases of isolated laryngeal tuberculosis were reported as a reason for dysphonia with coexisting dysphagia [70]. Dysphonia, dysphagia, and respiratory distress occurred in patients with bullous pemphigoid (BP), an autoimmune condition with laryngeal manifestations. BP primarily affects skin, however, it may also be seen in the mucosa of the upper respiratory tract, larynx or esophagus [71].

Other cases described in the literature include multiple dermoid cysts of epiglottis [72], postradiotherapy laryngopharyngeal edema [73], traumatic laryngocele as a result of blunt trauma of the neck [74] or interarytenoid tumor-like lesions and ulcerative inflammatory lesions of the larynx in laryngeal leishmaniasis [75]. Hoarseness, voice fatigue, dysphonia, and dysphagia were also seen as complications of injection laryngoplasty, causing subchordal cysts containing non-degraded hyaluronic acid [76].

Blunt laryngeal trauma (BLT) is a serious, potentially life-threatening condition that leads to damages that may affect voice production, swallowing, and breathing. BLT results may vary, however, symptoms spectrum usually includes laryngeal edema, hoarseness, dysphagia, stridor, subcutaneous crepitus, vocal fold(s) immobility, and anterior neck pain [77].

8. Neck

Deep neck infection (DNI) is a complex infectious condition developing and spreading in the tissue spaces of the neck (intermuscular and fascial). It may ultimately lead to the formation of an abscess. Years ago, most DNIs originated from tonsillar and peritonsillar infections. Currently, most cases are odontogenic (38–49%) [78]. The tissues involved in an inflammatory process get swollen and cause a compression to surrounding organs. Dysphagia and dysphonia are usually present, and the symptoms may be accompanied by trismus, dyspnea, and infection symptoms. Dysphonia and complete dysphagia were also reported in patients with parapharyngeal and retropharyngeal space abscess with or without mediastinal emphysema [79]. High-grade fevers, dysphonia, dysphagia, anterior neck, and facial swelling may be present in Ludwig’s angina. The condition progresses rapidly, causing edema and soft tissues gangrenous infection of the neck and floor of the mouth. A more aggressive course may end up with infection transmission to mediastinum (Figure 11) [81, 82].

Figure 11.

CT scans showing left parapharyngeal abscess with tracking into the prevertebral space and significant progression of air pockets in mediastinal and cervical soft tissue extending to the right axillary region (source: [80]).

Lemierre’s syndrome (LS) is a disease characterized by thrombophlebitis of the internal jugular vein. As a result of bacterial infection, it is often preceded by oropharyngeal infection and often associated with Fusobacterium necrophorum. It was also reported to occur after surgical procedures within the neck (for example, transoral approach in a cervical osteophyte operation). Clinical presentation includes acute pharyngitis, high fever, dysphagia, dysphonia, and neck pain [83].

Hematomas can also be present in the neck tissues, leading to dysphonia and dysphagia occurring together. Reports were published in the literature describing such symptoms in spontaneous cervical hematoma caused by hemorrhage from a parathyroid carcinoma [84] and retropharyngeal hematoma appearing under rivaroxaban therapy for other reasons [85]. Commonly reported sites of spontaneous bleeding in patients treated with warfarin are the sublingual and retropharyngeal spaces. Hematomas occurring in these regions usually lead to sore throat, dysphagia, odynophagia, dysphonia, neck swelling, and dyspnea (Figure 12) [86].

Figure 12.

Contrast CT scan, sagittal plane, showing the thyroid gland (solid arrow) displaced anteriorly by a dense collection (open arrow) in keeping with a hematoma (source: [84]).

Tumors of the neck region causing voice and swallowing problems together may represent the whole variety of histological and morphological types. Retropharyngeal liposarcoma can lead to neck swelling accompanied with dysphagia, orthopnea, and dysphonia [87]. Head and neck squamous cell carcinoma and head and neck low-grade chondrosarcoma were described in the literature to cause dysphonia and dysphagia as well as pain and neck mass sensation [88, 89]. Other tumors, like rhabdomyomas (RM), are benign and rare mesenchymal tumors made up of striated muscle cells. Extracardiac rhabdomyomas occur mostly in elderly men, prevailingly in the head and neck region like the oral cavity, larynx, pharynx, and soft tissue. Dysphagia, dysphonia, and stertor are common symptoms [90]. A large sublingual dermoid cyst may become a reason for swallowing and voice problems [91] and so can an epidermal cyst of the thyroid gland with swelling in the anterior neck [92]. Similarly, Zenker diverticulum (ZD) or pharyngeal pouch, a structural or functional abnormality of the cricopharyngeal muscle, may cause dysphagia, dysphonia, cough, and regurgitation, while dysphonia is more frequent among patients with rather small pouches [93].

The thyroid gland, apart from its usual location in the anterior part of the neck, can also be seen in any place when remains of the thyroglossal duct (TGD) occur. In embryonic life, TDG comes down from the tongue to the diaphragm. Thyroid ectopia is commonly found at the base of the tongue in 90% of the reported cases. As such, it causes dysphagia and dysphonia at the same time [94].

Post-thyroid surgery hypocalcemia (PTSH) may occur after total thyroidectomy. Low calcium levels lead to neuromuscular instability and muscle numbness. The most severe cases may end up with laryngospasm and bronchospasm leading to breathing difficulties and stridor. Dysphonia and dysphagia are often in such cases [95].

A mass effect in the neck leading to swallowing problems and voice dysfunction with a weight loss was described in necrotizing sialo-metaplasia (NSM). This is a benign tumor of the salivary gland that occurs as a result of injury, chemical or traumatic metaplasia [96].

9. COVID complications

COVID infection was reported to have caused different clinical conditions with a whole variety of clinical manifestations. Many patients treated for COVID in intensive care units often suffered from dysphagia and dysphonia, laryngeal injuries as a result of prolonged intubation and neuropathies [97]. Post-extubating dysphagia and dysphonia were often described in COVID patients [98]. COVID patients often presented with dysphagia, dysphonia, middle airway disorders, such as chronic cough and hyper-sensitive larynx syndromes. The symptoms are multifactorial and wide ranging in pathophysiology, including medical interventions, tissue, and neurological injury [99].

Prolonged endotracheal intubation (also for non-COVID related reasons) may lead to some complications associated with dysphonia and dysphagia. Laryngeal granuloma (LG) is a late complication of intubation and results from a trauma of the mucosa which ends up with granuloma formation (Figure 13). Compression of mucosa by an intubation tube may also lead to edema, ischemia, or damage to laryngeal mucosa and ultimately cause recurrent laryngeal nerve palsy. Dysphonia and dysphagia occur [100, 101, 102].

Figure 13.

Laryngoscopic view of right-sided vocal cord granuloma. The granuloma appears lower than the level of the vocal cords (source: [100]).

The post-COVID condition (PCC) is a disabling syndrome affecting at least 5–10% of subjects who survive COVID infection. As the main pathogenetic background of the condition, a SARS-CoV-2-mediated vagus nerve dysfunction is considered. The vagus nerve innervates the larynx, pharynx, lungs, heart, and gastrointestinal tract. PCC is therefore presented with dysphonia, dysphagia, dyspnea, dizziness, tachycardia, orthostatic hypotension, and gastrointestinal disturbances [103].

10. Treatment

Depending on the reason, dysphagia and dysphonia in cases described above, require multidisciplinary treatment. Due to complex etiology and possible life-threatening character, every medical condition associated with swallowing and voice problems needs a detailed, individual approach. As the causes are complex and vary, some cases may need medication; others are subjects to complicated operations and a systematic follow-up.

11. Conclusions

The above review is a detailed analysis of medical conditions and case reports described in the literature. Different pathologies leading to dysphonia and dysphagia need a complex approach both in diagnostics and treatment. It is a serious clinical problem and relates to various medical specialties. Due to this fact, concurrent dysphagia and dysphonia lie not only within the interest spectrum of otolaryngologists and phoniatricians but also neurologists, spine surgeons, chest surgeons, dental surgeons, oncologists, speech pathologists, rheumatologists, gastrologists, specialists in infectious diseases, and others. Effective diagnosis and treatment need the close cooperation of various specialists. Many cases may present a chronic course in some acute cases, however, the dynamics may lead to serious systemic complications, and ultimately to death.

Below, a list of abbreviations and a summary of the causes of concurrent dysphagia and dysphonia are presented (Table 1).

Central nervous system	Hemorrhagic cerebral stroke; Ischemic cerebral stroke; Cerebral oedema; Intracranial hematoma; Primary brain tumors; Glioma; Glioblastoma; Medulloblastoma; Lymphoma; Germ cell tumors; Vestibular schwannoma; Vagal schwannoma; Other; Secondary brain tumors (metastases); Lung cancer; Melanoma; Prostatic cancer; Renal cancer; Gastric cancer; Other; Gomphosis; Meningitis; Neuromyelitis optica; Acute brainstem syndrome; Intracranial arterial dolichoectasia; Parkinson’s disease; Essential tremor; Atypical Parkinsonian syndromes; Amyotrophic lateral sclerosis; Alexander’s disease; Wernicke encephalopathy; Bulbar palsy; Cranial nerves palsy
Peripheral nervous system	Guillain-Barre syndrome; Botulism; Post-polio syndrome; Varicella zoster infection; Herpes zoster infection; Jugular foramen syndrome (Vernet’s syndrome); Collet-Sicard syndrome; Spinal anesthesia complications; Vagus stimulation therapy complications
Cervical spine	Diffuse idiopathic skeletal hyperostosis; Cervical osteophytes; Cervical spondylosis (stenosis); Cervical disc replacement complications; Degenerative cervical myelopathy; Anterior cervical discectomy and fusion complications
Muscles/connective tissue	Dermatomyositis; Mitochondrial myopathy; Ehlers-Danlos syndrome; Haycocknema perplexum induced myositis; Myasthenia gravis
Mediastinum	Liposarcoma; Ortner’s syndrome (cardiovocal syndrome); Tapia’s syndrome; Thymoma; Lymphoma; Substernal goiter; Sarcoidosis; Mid-esophageal diverticula; Esophageal perforation; Mediastinal inflammation; Laparoscopic sleeve gastrectomy Complications; Pneumomediastinum (mediastinal emphysema); Post pneumonectomy syndrome; Mediastinal lipomatosis; Heart and lung transplantation complications; Gastro-esophageal reflux
Larynx	Functional voice disorders; Muscle tension dysphonia; Glottal insufficiency (presbyphonia); Unilateral vocal fold paresis; Bilateral vocal fold paresis; Laryngopharyngeal reflux; Extra nodal lymphoma; Non Hodgkin lymphoma; Laryngeal cancer; Neuroendocrine cancer; Laryngeal paraganglioma; Paraganglioma of the recurrent laryngeal nerve; Adult laryngeal hemangioma; Tuberculosis of the larynx; Laryngeal bullous pemphigoid; Epiglottic cyst; Postradiotherapy laryngopharyngeal edema; Traumatic laryngocele; Laryngeal leishmaniasis; Injection laryngoplasty complications; Blunt laryngeal trauma
Neck	Deep neck infections; Para/retropharyngeal abscess; Ludwig’s angina; Lemierre’s syndrome; Cervical hematomas; Neck tumors; Cancer; Retropharyngeal liposarcoma; Neck squamous carcinoma; Rhabdomyoma; Sublingual dermoid cyst; Epidermic cyst of the thyroid gland; Pharyngeal pouch (Zenker diverticulum); Thyroid ectopia (tongue location); Post thyroid surgery hypocalcemia; Necrotizing sialometaplasia
Covid complications	Prolonged intubation; Covid neuropathies; Post covid condition (vagus nerve dysfunction)

Table 1.

Summary of conditions associated with concomitant dysphagia and dysphonia.

Conflict of interest

The authors declare no conflict of interest.

Abbreviations

RLN	recurrent laryngeal nerve
CN	cranial nerve
NMO	neuromyelitis optica
IADE	intracranial arterial dolichoectasia
PD	Parkinson’s disease
ET	essential tremor
APS	atypical Parkinsonian syndromes
ALS	amyotrophic lateral sclerosis
AD	Alexander’s disease
GFAP	glial fibrillary acid protein
WE	Wernicke encephalopathy
GBS	Guillain-Barre syndrome
PS	post-polio syndrome
VZ	varicella zoster
HZ	herpes zoster
JFS	jugular foramen syndrome
VS	Vernet’s syndrome
CSS	Collet-Sicard syndrome
DISH	diffuse idiopathic skeletal hyperostosis
CS	cervical spondylosis
CDR	cervical disc replacement
DCM	degenerative cervical myelopathy
ACDF	anterior cervical discectomy and fusion
DM	dermatomyosistis
IBM	inclusion body myositis
IMNM	immune mediated necrotizing myopathy
MM	mitochondrial myopathy
EDS	Ehlers-Danlos syndrome
HDCT	heritable disorder of connective tissue
hEDS	hypermobile Ehlers-Danlos syndrome
TMJD	temporomandibular joint disorder
LPR	laryngo-pharyngeal reflux
MG	myasthenia gravis
OS	Ortner’s syndrome
TS	Tapia’s syndrome
AVR	aortal valve replacement
CABG	coronary artery bypass grafting
ASDC	atrial septal defect closure
MVR	mitral valve repair
EP	esophageal perforation
SIRS	systemic inflammatory response syndrome
LSG	laparoscopic sleeve gastrectomy
ME	mediastinal emphysema
PPS	post-pneumonectomy syndrome
ML	mediastinal lipomatosis
MD	myotonic dystrophy
MTD	muscle tension dysphagia
LEMG	laryngeal electromyography
SEMG	superficial electromyography
VFP	vocal fold paresis
BVFP	bilateral vocal fold paresis
LPR	laryngopharyngeal reflux
ENL	extra nodal lymphoma
NHL	non-hodgkin lymphoma
NEC	neuroendocrine carcinoma
ALH	adult laryngeal hemangioma
BP	bullous pemphigoid
BLT	blunt laryngeal trauma
DNI	deep neck infection
LS	Lemierre’s syndrome
RM	rhabdomyoma
ZD	Zenker diverticulum
TGD	thyroglossal duct
PTSH	post-thyroid surgery hypocalcemia
NSM	necrotizing sialo-metaplasia
LG	laryngeal granuloma
PCC	post-COVID condition