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When to Worry About Nasal Regurgitation

Written by Dr. Michael Ruscio, DC on January 28, 2022

Written by Dr. Michael Ruscio, DC on January 28, 2022 — Reviewed by Hilary Watts

• Is Nasal Regurgitation a Swallowing Disorder?|
• Causes of Nasal Regurgitation|
• Diagnosing Nasal Regurgitation|
• Nasal Regurgitation Treatment|
• Bottom Line|

Nasal regurgitation is a swallowing disorder that occurs when food or fluid comes up into the nose while eating or drinking. It’s most common with elderly patients, but it can happen with patients of all ages (including infants). 

This type of swallowing disorder is not only a potentially dangerous health hazard — it can also affect the patient’s speech and ability to keep down food in public. These issues can be embarrassing and may lead to social anxiety, so it’s best to treat them as early as possible.   

Fortunately, there are treatments and therapies that can help address the issue and prevent it from damaging your body. But first, it’s important to understand the symptoms and cause of nasal regurgitation and how it relates to other health issues. Let’s take a look at each of these. 

Is Nasal Regurgitation a Swallowing Disorder?

Nasal regurgitation occurs when food or fluid comes up into the nose due to the nasopharynx not closing properly during swallowing 1. There’s a difference between the type of regurgitation that signals a swallowing disorder and the type that signals acid reflux/heartburn or gastroesophageal reflux disease (GERD). The difference is the taste of the food bolus — the mixture of chewed food and saliva — that comes back up. 

If the bolus tastes like the food you’ve just tried to swallow, chances are your nasal regurgitation is a result of a swallowing disorder. If the substance is bitter or sour, that’s typically stomach acid, which means your food made it all the way down to your stomach and then came back up. In this case, you’re likely dealing with reflux.

Nasal Regurgitation Symptoms

Nasal regurgitation can be a symptom of a swallowing disorder. Other symptoms of a swallowing disorder may include 1 2 3:

• Dysphagia: a sensation of food sticking to the throat and difficulty swallowing food or liquids
• Odynophagia: painful swallowing
• Coughing during or immediately after swallowing
• Choking
• Drooling
• Sore throat
• Hoarseness
• Shortness of breath
• Chest discomfort or pain
• Posture changes
• Weight loss
• Repeated chest infections or pneumonia 
• Bronchitis
• Changes in voice, articulation, speech, and language
• Frequent repetitive swallows
• Frequent throat clearing
• Dehydration
• Aspiration
• Malnutrition

It’s important to be aware that throat dysfunctions and abnormalities are serious problems that require intervention, especially if your airway is restricted or affected. Aspiration pneumonia (swelling or infection in the lungs due to food, saliva, liquids, or vomit being breathed into the lungs or airways), dehydration, and airway obstruction are all serious side effects of a swallowing disorder.

What Causes Nasal Regurgitation?

Nasal regurgitation can be a symptom of dysphagia, namely oropharyngeal dysphagia, which is a swallowing disorder that occurs in the mouth and throat 2.

It may also be a symptom of a dysfunction of the velopharyngeal sphincter, which is the threshold that separates the nasal and oral cavities during speech, swallowing, vomiting, blowing, and sucking 4.

The velopharyngeal sphincter consists of the soft palate (velum) and the back and sides of the pharynx (throat), all of which are critical to proper swallowing. In other words, if this sphincter misfires during dilation or closing, all of these functions can be affected — your speech or voice can change, or you may swallow air or aspirate on your food, for example 5.

There are a number of potential causes of nasal regurgitation, including the two swallowing disorders we’ve already mentioned: oropharyngeal dysphagia and velopharyngeal dysfunction (VPD). 

Since swallowing is a set of coordinated muscle movements that control the mouth, back of the throat (pharynx), and the esophagus, all manner of swallowing disorders could result in nasal regurgitation and aspiration (food entering the airway) 6.

During normal, healthy swallowing, the soft palate goes up and contacts the back and sides of the throat (pharynx), which closes off the nasopharynx and prevents regurgitation of food or liquids into the nasal cavity 6. Any impairment of this coordinated set of muscles can lead to nasal regurgitation.

A combination of oropharyngeal dysphagia and esophageal dysphagia (this often causes GERD and possibly laryngopharyngeal reflux) can also lead to nasal regurgitation. Mixed dysphagia happens mostly in the elderly and can include impaired saliva production, loss of jaw strength and muscle, gum and dental problems, and loss of upper esophageal sphincter elasticity 7.

What Causes Velopharyngeal Dysfunction (VPD)?

So, VPD can cause nasal regurgitation. But what causes VPD? The four potential causes of VPD are 4:

1. Structural abnormalities
2. Neuromuscular or musculoskeletal injuries
3. Developmental challenges
4. Pediatric syndromes

Structural Abnormalities

The most common cause of VPD is a cleft palate (or cleft lip), which is a fetal development problem in which the palate doesn’t properly fuse together.. Infants born with a cleft palate usually undergo surgical repair before the age of two 8.

Other structural abnormalities that could lead to VPD include congenital short soft palate, nasopharyngeal disproportion (poorly functioning soft palate), poor sphincter mobility from enlarged tonsils (when enlarged tonsils block the soft palate from closing off the oral cavity from the nasal cavity), or scarring from prior surgery 4.

Neuromuscular or Musculoskeletal Injuries

This type of challenge, also called neurogenic dysphagia, comes from the trauma of a disease or neurological disorder. A stroke could result in VPD. Nervous system issues could lead to VPD — examples include cerebral palsy, myopathy, muscular dystrophy, neuropathy, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, Moebius syndrome, Trisomy 21 syndrome, or myasthenia gravis 4.

Developmental Disorders

Swallowing disorders and speech problems often correlate, although they are two different diagnoses. A speech-language pathologist with experience in cleft speech abnormalities can help diagnose issues in these areas. Articulation disorders can often mimic VPD, so it’s important to note that speech issues can also be a red flag for VPD 4.

Pediatric Syndromes

After cleft palate, the second-most common cause of VPD is velocardiofacial syndrome (VCFS, also called 22q11 Deletion Syndrome or DiGeorge syndrome). This syndrome often happens alongside a cleft palate and is a genetic disorder characterized by “cleft palate, or an opening in the roof of the mouth, and/or other differences in the palate; heart defects; problems fighting infection; low calcium levels; differences in the way the kidneys are formed or work; a characteristic facial appearance; learning problems; and speech and feeding problems,” ​according to the National Human Genome Research Institute.

Other pediatric syndromes that are associated with VPD are Trisomy 21, Klippel-Feil, epidermal nevus syndrome, Turner syndrome, and VATER syndrome. VATER stands for vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, and radial and renal anomalies) 4.

What Causes Dysphagia?

Dysphagia is one of the two main causes of nasal regurgitation. There are three types of dysphagia: oropharyngeal, esophageal, and a mix of the two. While dysfunction of the esophageal muscles that leads to swallowing issues is more associated with GERD, it’s worth mentioning here, as GERD and other swallowing disorders have overlapping symptoms. These include chest pain, throat clearing, hoarseness, feeling of a lump in the throat, bronchitis, pneumonia, dysphagia, and odynophagia 9 10.

Oropharyngeal Dysphagia

There are overlapping causes of oropharyngeal dysphagia and VPD, including stroke, the neurodegenerative and neuromuscular diseases we’ve already listed (cerebral palsy, myopathy, muscular dystrophy, neuropathy, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, Moebius syndrome, Trisomy 21 syndrome, or myasthenia gravis), in addition to Alzheimer’s, multiple sclerosis, and poliomyelitis and postpolio syndrome.

In addition to these causes, diseases and procedures local to the throat can also lead to oropharyngeal dysphagia. This includes head and neck tumors, surgery, radiation, goiter, zenker diverticulum, or cricopharyngeal achalasia 3.

Certain medications may also cause dysphagia, such as anti-inflammatory drugs, benzodiazepines, psychotropic drugs, vasoactive drugs, and illicit substances 2 11.

Esophageal Dysphagia

Esophageal dysphagia is the result of either a mechanical obstruction or motility (the movement of the food bolus through the digestive tract) disorder (or both). Mechanical obstructions may include 7:

• Schatzki ring: a ring of tissue that forms inside the esophagus close to base of the stomach that makes it hard to swallow
• Esophageal stricture: abnormal narrowing or tightening of the esophageal muscles that makes it hard for food and liquid to pass through
• Cancer
• Eosinophilic esophagitis: a chronic immune disease that causes a build-up of white blood cells in the esophagus and makes it hard to swallow
• Peptic stenosis: esophageal narrowing due to damage or inflammation
• Post-surgical complications

Motility disorders include 7:

• Esophageal spasm: painful contractions of the esophagus that can feel like chest pain or angina
• Achalasia: when the lower part of the esophagus fails to relax and won’t allow food to pass through to the stomach
• Ineffective esophageal motility: when the smooth muscle of the esophagus doesn’t contract properly to move the food through to the stomach
• Scleroderma: an autoimmune disease that results in a chronic hardening or contraction of connective tissue

Since a mixture of the two types of dysphagia is a potential cause of nasal regurgitation in the elderly, it’s important to understand the causes of esophageal dysphagia as well. 

Furthermore, reflux disorders like GERD and nasal regurgitation may both be associated with other chronic pharyngeal and nasal conditions such as rhinosinusitis (inflammation of the sinuses and nasal cavity) and post-nasal drip, according to two small studies 12 13.

How to Diagnose Nasal Regurgitation

Since we now know that nasal regurgitation is a symptom, rather than a disease itself, you’d want to talk with your GI doctor or functional medicine doctor about diagnosing VPD or dysphasia. In both cases, your doctor would start by taking a careful and thorough patient history. They may also want certain types of imaging, such as endoscopy, to be able to see how things move in your throat as you swallow. 

Diagnosing VPD

After a thorough accounting of a patient’s medical history and physical exam, your doctor will also ask about your sleep history to see if you’ve had sleep apnea, snoring, restlessness, or other problems. They’ll also determine if nasal regurgitation takes place as you eat 5.

A speech language pathologist may also check your speech quality for hoarseness, nasal tones, or other issues. They may also look at your nasometry, which measures the ratio of sound coming from your nose and your mouth 4.

Your doctor may also want to take a video-nasal endoscopy, a multiview videofluoroscopy, cephalometrics, or an MRI to determine if there are any structural abnormalities or evidence of other causes of VPD. 

Diagnosing Dysphagia

Finally, after getting your medical history and conducting a physical examination, your doctor will assess your swallowing through a series of screening tools. This will help them diagnose oropharyngeal dysphagia. They may do a combination of the following tests 2:

• Toronto Bedside Swallowing Screening Test
• Volume-viscosity swallow test
• Standard Swallowing Assessment
• Guggen Swallowing Screen

You might also hear your doctor talk about a few different types of imaging tools they want to use to help them assess swallowing function, including videofluoroscopy (modified barium swallow), fiberoptic endoscopic evaluation, high resolution manometry, functional imaging probe, and/or accelerometry 14. It’s ok if you don’t know these terms. If your doctor wants to use one, they will explain the process to you.

To diagnose esophageal dysphagia, your doctor may use one or more imaging tools, including endoscopy with biopsy, videofluoroscopy (barium swallow), esophageal manometry, intraluminal impedance, and/or impedance planimetry.

How to Treat Nasal Regurgitation

To treat nasal regurgitation, you need to address the root cause, either VPD or dysphagia. For the former, the treatment options are speech therapy, oral prosthetics, and/or a number of different surgical options. 

Most physicians will start with speech therapy in children in order to minimize surgical procedures unless absolutely necessary 4. Surgery can help by creating a functional seal between the nasopharynx and oropharynx during speech 4. There are four main types of surgery to address VPD. We won’t go into detail about these, but you might hear your doctor mention them:

1. Pharyngeal flap
2. Sphincter pharyngoplasty
3. Palatoplasty
4. Posterior pharyngeal wall augmentation

All four seem to be effective at improving nasal resonance, speech intelligibility, swallowing, and obstructive sleep apnea 15. The earlier the intervention, the better. Getting a diagnosis as soon as possible is especially important for children who may still be developing speech habits and patterns. 

To treat oropharyngeal dysphagia, certain head, throat, tongue, and swallowing exercises are prescribed in order to tone and strengthen the areas that are malfunctioning. A systematic review of the research shows these exercises have not only improved swallowing but also reduced the length of hospital stay and incidence of chest infection or pneumonia 16.

Acupuncture and electrical stimulation are also viable treatment options. Specific exercises to address oropharyngeal dysphagia will depend on how the patient presents and should be determined by a qualified speech pathologist 17.

Treatment of esophageal dysphagia depends on the cause. Some treatments for esophageal dysphagia may include surgery, radiation, or chemotherapy for cancer, balloon dilation for mechanical obstructions, and an elemental diet or elimination diet for eosinophilic esophagitis 18.

The Bottom Line

Nasal regurgitation is a sign of a potentially serious swallowing disorder like velopharyngeal dysfunction (VPD), oropharyngeal dysphagia or a mix of oropharyngeal dysphagia and esophageal dysphagia. If these issues are left unaddressed, quality of life can suffer. Whether it’s due to social anxiety due to abnormal speech, reduced enjoyment of food, or something more serious and deadly like chronic chest infections or aspiration pneumonia, the consequences of leaving these health issues unchecked are serious. 

If you’d like to talk to one of our functional medicine doctors to find out if you’re dealing with one of these issues, reach out to schedule an appointment.