Vagus Nerve related Cervical Dysphagia and Laryngeal – Laryngotracheal stenosis

Ross Hauser, MD.

Difficulty swallowing and the inability to breathe properly are two of the most distressing symptoms a person can have. If normal imaging scans and videoscopes do not find any structural lesion, then vagus nerve injury must be suspected and cervical spine instability should be considered when the causes of dysphagia and intermittent laryngeal stenosis are unknown.

This article is a companion work to these articles on our website:

What do doctors know about Laryngotracheal and Laryngeal stenosis?

In the US National Library of Medicine’s STATPEARLS (1) Updated January 2022 doctors write:

“Laryngotracheal stenosis is a narrowing of the upper airway between the larynx and the trachea with potentially devastating consequences, including respiratory failure, cardiopulmonary arrest, and death. The upper airway is comprised of the larynx, glottis (the area of the larynx where the vocal cords are), subglottic region (the area below the vocal cords to the top of the trachea), and trachea. . .

Laryngeal (more focused with blockage at the larynx) stenosis may occur as a result of trauma, related to endotracheal intubation, or due to a neoplasm (cancer or tumor growth), autoimmune (Sjogren’s syndrome, Lupus, etc), or infectious process. It can be asymptomatic or can lead to symptoms of upper airway obstruction.

Laryngeal narrowing from any cause calls for a multidisciplinary approach to management, including, but not limited to, pulmonologists, intensivists, otolaryngologists, gastroenterologists as well as speech and language pathologists, and cardiothoracic surgeons. The determination of the etiology of the laryngotracheal stenosis is critical as it can drive the management and provide prognostic information to the patient.”

You have Laryngotracheal and Laryngeal stenosis and yet, you do not fall within these categories. Where are your answers?

The problems of Laryngotracheal and Laryngeal stenosis are limited in the medical research to those medical conditions described above and congenital abnormality such as (congenital subglottic stenosis), injury impact to the throat, strangulation, neck injuries, burns from inhaling flames, or the digestion of caustic products. Yet, we hear different stories and different suspected causes.

Chiari malformation

People will often contact us with their medical history surrounding a Chiari malformation. They will tell us a story of Chiari malformation diagnosis, their neurologists taking a wait-and-see approach to try to avoid surgical management, and the person’s worsening of symptoms. Among these symptoms were neck pain, headaches, and breathing problems. As symptoms continued or worsened, shortness of breath and difficulty talking became more apparent. People will also note a barrage of tests that revealed nothing and their doctors starting to believe that their neurologic-like problems were entering into psychiatric-like problems. Especially when the person reported problems with throat closure, especially at sleeping, difficulty breathing, and the development of terrible and loud snoring. Occasionally someone will report to us that their larynx feels like it has become detached or loose. When they try to sleep on their back, their larynx is blocking their airways.

The problem of talking

Many people who contact us are seeing speech pathologists for what some describe as a weak tongue. Some have an elevated hyoid bone that their doctors believe to be the cause of the “stuck in the throat sensation,” or the “someone is choking me” sensation. They would also tell of times their throat closed completely for a few terrifying seconds.

The problem of singing

We do hear from people who were vocalists. They, like other professionals including athletes, exercised to develop their vocal range. We will occasionally hear a story of someone who damaged their vocal cords in their pursuit of a singing career and this caused severe and significant problems beyond the inability to sing, which for these people would have been devastating enough.

The larynx, or voice box, is involved in breathing, producing sound, and protecting the trachea against food aspiration. The larynx houses the vocal folds and manipulates pitch and volume, which are essential for phonation. The larynx is located in the anterior neck at the level of C3-C6. The muscles of the larynx are innervated by the vagus nerve. (See Figure 43, #7150) When the vocal cords are abducted, air can enter the lungs, and we can breathe. When the vocal cords are adducted, sounds are produced, and we can speak. The vocal folds (cords) must also be closed when swallowing so food does not “go down the wrong pipe.”

The problems of cervical fusion surgery

Many people have voice issues after Anterior Cervical Discectomy and Fusion. For some the post-surgical problems resolve after a few months, for others, the return of their “natural” voice is more changing. A December 2021 study in the journal Cureus (3) demonstrated: “voice parameters in patients who underwent Anterior Cervical Discectomy and Fusion worsened significantly after the surgery compared with patients who underwent Posterior Cervical Decompression and Fusion; however, these changes recovered within three months postoperatively. The possible causes for these findings include the retraction of the vagus and the recurrent laryngeal nerve, postoperative edema of strap muscles, intubation trauma to the vocal folds, and other laryngeal structures.”

I want to draw attention to a cause of these problems as retraction of the vagus and the recurrent laryngeal nerve and that when the injury to these nerves healed, the voice in many patients returned. This concept is being cervical spine stability treatments. If the vertebrae of the cervical spine can be held in proper alignment by strengthened cervical ligaments, the natural voice can return.

Vagus nerve innervation of the larynx

The caption of this illustration reads Vagus nerve innervation of the larynx. The superior laryngeal nerve divides into two branches, the internal laryngeal branch that enters the larynx in the thyrohyoid membrane. The second branch, the external laryngeal, supplies the cricothyroid muscles. The recurrent laryngeal nerve innervates all the intrinsic muscles of the larynx except the cricothyroid muscle which is innervated by the superior laryngeal nerve. Vagus nerve input to the laryngeal muscle is necessary for proper swallowing and speech. Vagal nerve injuries can limit vocal nerve function, affecting the voice including pitch quality and power. Symptoms of vagopathy (vagus nerve dysfunction) affecting the larynx can be chronic coughing, difficulty swallowing, hoarseness, loss of singing voice power.

The larynx, or voice box, is involved in breathing, producing sound, and protecting the trachea against food aspiration. The larynx houses the vocal folds and manipulates pitch and volume, which are essential for phonation. The larynx is located in the anterior neck at the level of C3-C6. The muscles of the larynx are innervated by the vagus nerve. When the vocal cords are abducted, air can enter the lungs, and we can breathe. When the vocal cords are adducted, sounds are produced, and we can speak. The vocal folds (cords) must also be closed when swallowing so food does not “go down the wrong pipe.”

The intrinsic laryngeal muscles

The intrinsic laryngeal muscles are responsible for controlling sound production. Cricothyroid muscles lengthen and tense the vocal folds, as occurs with talking. Posterior cricoarytenoid muscles abduct and externally rotate the arytenoid cartilages, resulting in abducted vocal folds—this is the position of breathing. The only muscle that opens the vocal folds so air can enter from the larynx to the lungs is the posterior cricoarytenoid muscle, and it is innervated by the vagus nerve. If both posterior cricoarytenoid muscles are not working from a bilateral recurrent laryngeal nerve injury, the person can have a very difficult time breathing. The illustration below may better graphically explain this:

The caption reads Vocal cord paralysis. Recurrent laryngeal paralysis leaves the vocal cords abducted. The recurrent laryngeal nerve is a branch of the vagus nerve from the nodose ganglion which sits right in front of the atlas (C1).

Vocal cord paralysis. Recurrent laryngeal paralysis leaves the vocal cords abducted. The recurrent laryngeal nerve is a branch of the vagus nerve from teh nodose ganglion which sits right in front of the atlas

All muscles of the vocal cords are innervated by the recurrent branch of the vagus nerve except the cricothyroid muscles, which are innervated by the external laryngeal branch of the superior laryngeal nerve, another branch of the vagus nerve. A patient with a lesion in the laryngeal portion of the vagus nerve will most likely complain of a hoarse voice, difficulty swallowing (dysphagia), and choking when drinking fluids. There can be a loss of the gag reflex or the uvula deviating away from the side of the lesion because there is a failure of the palate to elevate on that side due to a loss of strength of the levator palatini muscle.

The proper functioning of the larynx is critical for life itself. It is involved in swallowing, breathing, eating, coughing, vomiting, and other vital functions. The sensory receptors in the larynx are innervated by the internal branch of the superior laryngeal nerve with cell bodies in the nodose ganglion. There are many laryngeal neurologic reflexes that function during crises to keep the larynx open or closed. All these reflexes are primarily dependent on the vagus nerve.

When the larynx does not open normally, air cannot get into the lungs. This life-threatening situation is called fixed laryngotracheal stenosis, an umbrella term for luminal compromise at the level of the larynx, subglottis, or trachea. What we see with cervical spine instability and upper cervical spine instability caused by cervical ligament weakness is intermittent laryngeal stenosis, which can be missed on laryngoscopic examinations. The word “instability” denotes changeability by definition. Even an intermittent inability to control the opening of airways can permanently change a person’s singing or talking voice and be very anxiety-provoking when breathing. Patients can have trouble breathing or feel like they must “think” to breathe. When the history or examinations prove normal, the neurology of the vocal cords must be considered, which would lead to the vagus nerve.

Swallowing difficulties, called dysphagia, can also be related to the vagus nerve. Swallowing is a complex process involving 3 phases and the coordinated interactions of a network of nerves and muscles. For proper swallowing to occur, the palate and larynx must be elevated, so food does not aspirate into the nose and lungs, respectively. Both processes require the vagus nerve.

In the US National Library of Medicine’s STATPEARLS (2) Updated January 2022 doctors write:

“It is imperative to understand the neuroanatomy of the true vocal folds to understand vocal fold paralysis. The vagus nerve innervates the larynx and its associated muscles. The vagus nerve is comprised of nerve fibers that arise from the nucleus ambiguus (a group of large motor neurons) in the medulla portion of the brainstem. Upper-motor cortico-bulbar neurons (simply among the nerve network that supplies the trigeminal, facial, and hypoglossal nerve nuclei) originate from the cerebral cortex and descend to synapse onto these lower-motor vagal nerve fibers, which originate from the nucleus ambiguus. (Simply again, tracing the network).

After arising from the brainstem, the vagus nerve then exits the skull base at the jugular foramen and descends into the neck to give off three main branches (the pharyngeal branch, the superior laryngeal nerve, and the recurrent laryngeal nerve. The superior laryngeal nerve supplies sensation to the larynx above the glottis and innervates the cricothyroid muscle. The recurrent laryngeal nerve descends further into the neck, loops around the subclavian artery (on the right) or the aortic arch (on the left), and ascends back up into the neck in the tracheoesophageal groove, where it enters the larynx posteriorly, near the cricothyroid joint. The recurrent laryngeal nerve innervates all remaining intrinsic muscles of the larynx including the posterior cricoarytenoid, inter arytenoid, lateral cricoarytenoid, and thyroarytenoid muscles.”

What are we seeing in this illustration?

The caption reads The three phases of swallowing. The vagus nerve is involved in all three phases of swallowing as it innervates most of the pharynx and larynx mucosal surfaces as well as the muscle that elevates the palate and causes the larynx to contract.

The vagus nerve is involved in all three phases of swallowing

Glossopharyngeal and vagus nerve dysfunction

Glossopharyngeal and vagus nerve dysfunction are typically the cause of chronic dysphagia when no structural lesion is found. The glossopharyngeal nerve innervates the stylopharyngeus muscle, which elevates the larynx and pulls it forward during the pharyngeal stage of swallowing. This action also aids in the relaxation and opening of the cricopharyngeus muscle. Along with the vagus nerve, it provides innervation to the upper pharyngeal constrictor muscles.

The glossopharyngeal nerve also mediates all sensation, including taste, from the posterior one-third of the tongue (the facial nerve is responsible for the anterior two-thirds). It also carries sensation from the velum and the superior portion of the pharynx. A lesion in this nerve can unilaterally impair the gag reflex.

The vagus nerve is responsible for raising the velum, as it (along with the spinal accessory nerve) innervates the glossopalatine and levator veli palatini muscles. The vagus nerve innervates the intrinsic musculature of the larynx. The spinal accessory nerve innervates the palatopharyngeus muscle, which depresses the velum and constricts the pharynx. It is responsible for vocal fold adduction during swallowing. The vagus nerve also innervates the cricopharyngeus muscle and controls the muscles involved in the esophageal stage of swallowing, as well as those that control respiration. It is the only cranial nerve that influences the structures inferior to the neck. The vagus carries sensory information from the velum and posterior and inferior portions of the pharynx. The vagus also mediates sensation in the larynx. Damage to vagal nerve fibers resulting in decreased motor conduction velocity can cause serious contractility problems with the esophagus, including esophageal dysmotility and megaesophagus. As the vagus nerve is sensory to the esophagus and innervates the lower esophageal sphincter, CVG can also be the etiology of gastroesophageal reflux and the chronic cough that often occurs with it.

In this video Ross Hauser, MD explains the functional dynamics and possible solutions to speech and swallowing difficulties.

Video Summary Transcript

Cranial Nerve X or the Vagus Nerve plays a vital role in the pharyngeal phase of swallowing. This is what happens during this phase:

Patients with swallowing difficulties caused by a disruption in the pharyngeal phase may suffer from:

When somebody does have cervical instability it’s normally because of excessive stretching of the ligaments in the back of the neck. When these ligaments are weak, injured, or torn what happens is the cervical vertebrae move forward when they move forward they can impair the nerve’s impulse through these various nerves. More symptoms such as choking on excretions, spit, or mucus can occur. Difficulty in talking may occur as if your muscles are too weak to talk.

In our office, we use injection techniques like Prolotherapy to help stabilize the cervical spine. In many patients, we can reverse these symptoms by stabilizing the cervical spine and restoring the neck’s natural curve.

The importance of the vagus nerve as related to overall health cannot be overstated. In cases of cervical ligamentous instability or CD, the vagus nerves and their proper functioning may become disrupted, leading to cervicovagopathy. In severe cases, sympathetic dominance and dysautonomia, as well as widespread illness, may develop. Structural deficiencies in the neck should be addressed with treatments aimed at restoring the structural alignment and integrity of the cervical spine. It is only with these structural treatments that we may be able to reverse many of the chronic diseases that plague humanity.

What are we seeing in this image?

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient’s neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2.

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient' neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety and other symptoms common in TMJ/TMD patients.

Repairing the ligaments and curve for a long-term fix

The goal of our treatment is to repair and strengthen the cervical ligaments and get your head back in alignment with the shoulders in a normal posture.

What are we seeing in this image?

In this illustration, we see the before and after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights.

In this illustration we see the before an after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights, documented below.

In this video, a demonstration of treatment is given

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Treating cervical ligaments with Prolotherapy  – published research from Caring Medical

Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can stress tendons, atrophy muscles, pinch on nerves, such as the vagus nerve,  and cause other symptoms associated with cervical instability including problems of digestion among others.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding Cervical disc disease and swallowing and speech difficulties. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

1 Almanzar A, Danckers M. Laryngotracheal Stenosis. StatPearls [Internet]. 2020 Nov 24. [Google Scholar]
2 Singh JM, Wang R, Kwartowitz G. Unilateral Vocal Fold Paralysis. 2021 Sep 2. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30085602. [Google Scholar]
3 Cengiz AB, Doruk E. Assessment of Acoustic Voice Parameters After Anterior Cervical Discectomy and Fusion. Cureus. 2021 Dec 22;13(12). [Google Scholar]

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