Myasthenia Gravis Care Overlooks Speech and Swallowing Dysfunction

Speech and language pathology evaluation are not occurring at sufficient levels among individuals with myasthenia gravis, according to new research published in OTO Open.1 Investigators uncovered that despite higher rates of dysarthria (inability to speak clearly), dysphonia (hoarse voice), dysphagia (difficulty swallowing), and aspiration pneumonia in persons who have the progressive neuromuscular junction disorder, much remains unknown about how to most effectively implement formal speech and swallow evaluation.

They evaluated retrospective, deidentified electronic medical record data from 64 health care organizations—mostly tertiary care centers—from TriNetX, a repository of clinical trial recruitment information and secondary research. There were 2 cohorts with 3724 patients each, all of whom had a documented virtual care visit: individuals with myasthenia gravis and individuals without myasthenia gravis. They had the same mean (SD) age, 65.1 (16.5) years, a majority female patients (56.5% and 55.8%, respectively), and mostly non-Hispanic/Latino ethnicity (88.9% each); the groups with the smallest representation were unknown gender, Native Hawaiian or other Pacific Islander, and American Indian or Alaska Native (0.3% each). Just over a third of each cohort also had diagnosed gastroesophageal reflux disease, per International Classification of Diseases, 10th Revision, Clinical Modification codes.

The 2 sets of primary outcomes of interest were rates of dysarthria, dysphonia, dysphagia, and aspiration pneumonia, and utilization of speech-language pathology services (ie, voice evaluation, swallow evaluation, voice therapy, and swallow therapy).

These data reveal higher odds of speech and swallowing dysfunction diagnoses than anticipated, given prior research indicating isolated cases and low reporting rates despite significant impairment. | Image Credit: © Zerbor-stock.adobe.com

What the Data Demonstrate

The following 4 disorders of interest were diagnosed more frequently in the cohort with myasthenia gravis compared with the cohort without the condition:

• Aspiration pneumonia: 3.7% vs 0.7%
• Dysarthria: 9.2% vs 0.5%
• Dysphonia: 4.4% vs 1.2%
• Dysphagia: 24.9% vs 4.7%

Translated, this means that a diagnosis of myasthenia gravis conveyed higher odds ratios for each speech and swallowing disorder:

• Aspiration pneumonia: 2.69 (95% CI, 1.95‐3.70)
• Dysarthria: 9.28 (95% CI, 6.67‐12.92)
• Dysphonia: 2.63 (95% CI, 1.97‐3.53)
• Dysphagia: 4.18 (95% CI, 3.62‐4.83)

However, despite having any of these diagnoses, there were high rates of not being evaluated for sleep or speech impediment or for treatment. No swallow or voice evaluation or treatment were offered to 83.1% of all individuals with myasthenia gravis, 53% of patients with myasthenia gravis and any speech/swallow dysfunction, 43.8% who had myasthenia gravis and dysarthria and/or dysphonia, and 51% who had myasthenia gravis and dysphagia and/or aspiration pneumonia.

Similarly, there were respective low levels of the following evaluations and therapies:

• Voice evaluation: 3.6%, 8.7%, 15.2%, and 8.4%
• Swallow evaluation: 12.6%, 33.4%, 35.6%, and 35.5%
• Voice therapy: 2.0%, 5.8%, 10.1%, and 5.5%
• Swallow therapy: 5.6%, 16.2%, 19.0%, and 17.4%

“While rare, there are many reports of individuals with myasthenia gravis presenting with exclusively otolaryngologic complaints,” the study authors wrote. “The variable presentation of myasthenia gravis is likely due to its variable immunologic pathenogenic origins, which has caused myasthenia gravis cases to be divided into subgroups based on immunologic and clinical profiles.”2-6

Study’s Significance

The authors noted that their data revealed higher odds of the dysfunction diagnoses than anticipated, given prior research indicating isolated cases and low reporting rates of speech and swallow dysfunction despite significant impairment. To their knowledge, their investigation is novel because it explored rates of formal evaluation and treatment for speech and swallowing dysfunction in patients who have myasthenia gravis.

They noted that due to a lack of evidence supporting physical therapy for myasthenia gravis, there is a noted lack of management recommendation in current treatment guidance,7-8 despite patients having expressed interest in having their speech and swallow problems evaluated even when they were unaware these services were available.

“Early identification can allow for early interventions,” they conclude, “including attempting swallowing rehabilitation, dietary modifications, and medication adjustment as necessary to prevent unnecessary complications.”

References

1. Gallagher TJ, Santa Maria C, Johns MM. Prevalence of speech and swallowing dysfunction and intervention among individuals with myasthenia gravis. OTO Open. 2025;9(1):e70077. doi:10.1002/oto2.70077

2. Yang X, Niu L, Yang C, Wang L, Liu J, He G. Clinical features of laryngeal myasthenia gravis: a case series. Am J Otolaryngol. 2019;40(2):292‐296. doi:10.1016/j.amjoto.2018.11.002

3. Liu W, Xia Q, Men L, Wu Z, Huang R. Dysphonia as a primary manifestation in myasthenia gravis (MG): a retrospective review of 7 cases among 1520 MG patients. J Neurol Sci. 2007;260(1‐2):16‐22. doi:10.1016/j.jns.2007.03.019

4. Wang F, Xiang T, He L, Wang J. Laryngeal myasthenia gravis following influenza vaccination: a case report and literature review. Hum Vaccines Immunother. 2021;17(12):5529‐5531. doi:10.1080/21645515.2021.1977580

5. Mao VH, Abaza M, Spiegel JR, et al. Laryngeal myasthenia gravis: report of 40 cases. J Voice. 2001;15(1):122‐130. doi:10.1016/S0892-1997(01)00012-1

6. Romi F, Hong Y, Gilhus NE. Pathophysiology and immunological profile of myasthenia gravis and its subgroups. Curr Opin Immunol. 2017;49:9‐13. doi:10.1016/j.coi.2017.07.006

7. Sanders DB, Wolfe GI, Benatar M, et al. International consensus guidance for management of myasthenia gravis: executive summary. Neurology. 2016;87(4):419‐425. doi:10.1212/WNL.0000000000002790

8. Narayanaswami P, Sanders DB, Wolfe G, et al. International consensus guidance for management of myasthenia gravis: 2020 update. Neurology. 2021;96(3):114‐122. doi:10.1212/WNL.0000000000011124