June is Dysphagia Awareness Month, a time to spotlight the millions living with swallowing difficulties—and the clinicians working to understand and treat them. George Barnes is a Board-Certified Specialist in Swallowing and Swallowing Disorders (BCS-S) with advanced training in dysphagia and years of experience supporting patients and clinicians through complex reflux and swallowing diagnoses. He’s passionate about helping people get to the root cause of their swallowing problems, especially when it’s not easy to see. Below, he shares a clinical case and a deeper look into what might be going on beneath the surface when it comes to reflux and dysphagia.
Jerry, a middle-aged man, walks into my hospital for a modified barium swallow study (MBSS). He’s outgoing, energetic, and friendly, but his smile quickly fades as he begins to tell me about his dysphagia. For the past 6 months, when he’s trying to eat the food he used to love and enjoy, it now doesn’t feel like food at all. Instead, it feels like a hard stone that sticks in his throat and refuses to go down. Left with nowhere to go, it just sits there aimlessly and hopelessly. And Jerry has grown to feel the same way. It started with hard, dry foods, which were easy to avoid at first, but now it pretty much happens with everything, including even liquids at times.
What can we do for Jerry?
To say this is frustrating for Jerry would be an absolute understatement, but the most frustrating part was yet to come. We did a comprehensive MBSS for Jerry, and we found a whole lot of… nothing. Yup, not even a bit of transient laryngeal penetration. Instead, we found a completely functional oropharyngeal swallow with adequate airway protection and clearance.
Imagine feeling like you broke your leg because you can’t even walk, but having the X-ray come back without even a hairline fracture. “You’re fine. Go ahead and start walking.” And, trust me, I felt tempted to tell Jerry, “You’re fine. Go ahead and start eating.” But that’s the equivalent of telling him, “It’s all in your head.” Was it possible that there was more going on here? Could I have been missing something?
The short answer? Yes, I certainly could be missing something—and I most definitely was.
There’s an interesting and often misunderstood link between dysphagia and its quiet, sneaky neighbors: laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD).
The SLP’s scope is widening. Not only do we now have the ability to assess and manage deficits below the upper esophageal sphincter (UES), but we have an ethical and moral responsibility to do so. Without an understanding of what happens below the UES, we are literally missing the full picture. Because conditions that start out by impacting only one, single part of our bodies are like viruses that start out impacting only one, single country. If untreated, they’re going to spread. And that’s exactly what was happening to Jerry.
“It feels like a lump in my throat.”
“It’s stuck.”
“I still feel it there.”
“It feels like a lump in my throat.”
“I can’t get it down.”
These are all common complaints I receive from patients like Jerry, coming in for an MBSS. Their complaints are real. Their symptoms are real. And they have a real impact on real outcomes.
Bringing food and liquid from the mouth to the stomach is taken for granted by most of us, but dysphagia is a growing condition, especially in our aging population. Approximately 1 in 25 adults in the U.S. are impacted by dysphagia. And many present to SLPs with elusive complaints that often aren’t explained by the perfect function we see on the imaging.
So what do we do? We certainly can’t ignore it. Dysphagia can result in serious complications, impacting quality of life, nutritional status, and overall health.
The Reflux Files: How LPR and GERD Are Secretly Causing a Raucous
While dysphagia can have many origins, reflux is a major, yet frustratingly overlooked, player in this complex clinical picture.
We all recognize GERD for its classic heartburn. But when stomach acid constantly sloshes back into the esophagus, it can start to go further than a bit of chest discomfort. It can begin to cause swallowing problems or exacerbate existing ones.
Think about it: the pH of the acid in your stomach is low enough to strip the paint off of your car. Throw a razor blade in a vat of stomach acid, and it’ll dissolve in a day. Yeah, this stuff is strong. And the stomach is built to contain it safely without burning a hole through it. But those areas north of the stomach? Not so much.
This is why chronic reflux can lead to anatomical changes, such as strictures in the esophagus, which physically impede bolus transit. It can also result in esophageal dysmotility—issues with the coordinated peristaltic contractions that move food distally. And, remember, the pharynx is connected to the esophagus, so any problems that happen south of the UES border will affect function north of it.
LPR and Dysphagia: The “Silent” Attack on the Airway
You thought GERD was bad? LPR, or “silent reflux,” is exactly what it sounds like: it often presents without the tell-tale heartburn that flags GERD. Instead, stomach contents—including acid, pepsin, and bile—back up into the delicate tissues of the larynx and pharynx.
If we thought the esophagus was in trouble, know that the laryngopharyngeal tissues are utterly defenseless. They are far more sensitive to corrosive refluxate than the esophageal lining. Even small amounts of reflux can cause significant inflammation and damage, leading to the symptoms we see all too often:
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Hoarseness
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A chronic cough
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Constant throat clearing
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And that infuriating, persistent lump in the throat (globus sensation)
When that throat mucosa is constantly irritated by reflux, it disrupts the complex neural networks and digestive enzymes crucial for a coordinated swallow. This chronic inflammation can even cause changes in the tissues. Like Michael J. Fox in Teen Wolf, our laryngopharynx starts morphing into something unrecognizable.
What does this look like clinically?
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Erythema and Edema
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Ventricular Obliteration
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Postcricoid Hyperplasia
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Pseudosulcus
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Granulomas and Ulcers
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Fibrosis and Atrophy
Here’s a crucial clinical pearl: LPR symptoms often flare up when patients are upright or during the day. Typical GERD regurgitation, on the other hand, is more commonly reported when lying down at night. This difference in presentation is a big reason why LPR often gets misdiagnosed, and its role in dysphagia is completely overlooked.
The Only Way Out is Through: Comprehensive Evaluation and Targeted Treatment
Given this intricate, often confusing, overlap between dysphagia, LPR, and GERD, relying solely on symptom questionnaires like the GERDQ and RSI is like trying to put together a puzzle with pieces from three different sets. Research confirms that symptoms alone may not correlate well with objective reflux findings, especially in patients with conditions above the UES.
So, what diagnostic tools should we be using?
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FEES, VFSS, and/or Esophagram
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24-hour pH-Impedance Monitoring
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Laryngoscopy
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Esophageal Manometry
Treating reflux-related dysphagia requires a multidisciplinary approach, combining medical management, swallowing therapy, and lifestyle modifications.
While PPIs are commonly prescribed, they aren’t always effective, especially for non-acidic reflux. That’s where alginate therapy becomes a powerful tool.
Derived from seaweed, alginates form a physical "raft" on top of stomach contents. You can read more about it in my article Seaweed for Reflux? Learn the Amazing Science Behind Alginates. Think of it as a cap, sealing off acid and stopping both acidic and non-acidic reflux from irritating those sensitive throat tissues. Products like RefluxRaft create a physical shield that keeps refluxate down where it belongs. They act fast—within minutes—and are safe because they’re not absorbed into the bloodstream like traditional medications.
For mild to moderate symptoms, or as an adjunct to other treatments, this is a valuable addition to a comprehensive reflux management plan.
So, What Happened to Jerry?
Let’s go back to Jerry from the intro. What do you think was going on with him? Yup, you guessed it—he had LPR. We didn’t find out until he was referred to an ENT who discovered some intense inflammation. And now that we have an answer, we have a plan.
More from George Barnes, MS, CCC-SLP, BCS-S
Want more insights from George? Read his previous post here, where he answers top reflux questions, demystifies swallowing studies, and explains how clinicians can better support patients with reflux and dysphagia.
Disclaimer: This blog post is for educational purposes only and is not intended to diagnose or treat any medical condition. Always consult your healthcare provider for personalized guidance.