SLP 410

Dysphagia

A swallowing disorder

Groher & Crary

A delay or misdirection of a bolus as it moves from the mouth to the stomach

Comprehensive definition of dysphagia

Impairment of emotional, cognitive, sensory, and or motor acts involved with transferring a substance from the mouth to the stomach, resulting in failure to maintain hydration/nutrition and posing a risk of choking or aspiration

Bolus

The food, liquid, or other material placed in the mouth for ingestion

Misdirection of a bolus

Bolus material entering the upper airway/lungs or failing to reach the stomach

Penetration

Passage of material into the larynx but not through the vocal folds

Aspiration

Swallowed materials has entered the trachea below the level of the true vocal folds

Feeding disorder

Impaired oral intake that is not age appropriate, associated with medical, nutritional, feeding skill, and or psychosocial dysfunction

Eating disorder examples

Anorexia or bulimia

Difference between ED and PFD

Patients rarely have demonstrable changes in swallowing difficulty through appetite and oral prep may be affected

Who is affected

Across the lifespan: premature infants to geriatric adults (stroke, H&N cancer, dementia, prematurity). Prevalence of PFD up to 25% in general population, up to 80% in children with developmental delays

Evaluation (non instrumental and instrumental)

Identifying strengths/deficits, assessing anatomy/physiology, verifying aspiration

Treatment

Capitalizing on strengths, facilitating activities/participation, modifying contexts, improving safety/efficiency, maximizing quality of life

Nervous system control

Involves connections at multiple levels (cortex and brainstem)

Cranial nerves

Essential for swallowing

Phrases of the swallow

Oral phase → pharyngeal phase → esophageal phase

Components of oral phase

Oral preparation and oral transit

Oral prep

Food/liquid in mouth stimulates receptors. Tongue manipulates, shapes, holds bolus

Transit

Tongue tip elevates to seal off oral cavity. Tongue retracts to propel bolus posteriorly. Respiration ceases, vocal folds close

Pharyngeal phase

Begins as bolus arrives at valleculae and ends when PES closes

Key events of pharyngeal phase

Constrictor muscles narrow pharynx, hyoid bone moves up/forward, epiglottis inverts to cover airway, PES relaxes and is pulled open. This is a rapid, reflexive phase

Esophageal phase

Bolus moves through esophagus via peristalsis. Lower Esophageal Sphincter (LES) relaxes, and bolus enters the stomach

CN V

Trigeminal

CN V Function

Muscles of mastication, some suprahyoids

Sensory Function of CN V

Face, mouth, anterior tongue, hard/soft palate

CN VII

Facial

Motor function CN VII

Muscles of face, some suprahyoids

Sensory function of CN VII

Taste to anterior ⅔ of tongue

CN IX

Glossopharyngeal

Motor function CN IX

Stylopharyngeus

Sensory function CN IX

Posterior tongue, soft palate, pharynx, taste to post ⅓ tongue

CN X

Vagus

Motor Function CN X

Soft palate, pharynx, larynx, cricopharyngeus

Sensory function CN X

Soft palate, pharynx, larynx, esophagus, taste to epiglottis

CN XII

Hypoglossal

Motor function CN XII

Intrinsic and extrinsic tongue muscles

Sensory function CN XII

Motor only

Nutritive sucking (NS)

For nourishment, 1:1 suck: swallow ratio to 2-3:1 for older (average rate is ~1 suck/sec)

Non-nutritive Sucking (NNS)

For state regulation/exploration. 6-8:1 suck to swallow ratio, ratio = ~2 sucks/sec

Suck to swallow to breath coordination

Essential for safe feeding. Breathing stops during the swallow to protect the airway

Developmental milestones 0-4 months

Full support, fluid only, relies on reflexes (rooting and suckly)

Developmental milestones 4-6 months

Supported sitting, brings hands to mouth, may start runny purees

Developmental milestones 7-8 months

Early chewing, tongue lateralization begins, thicker purees/mashed solids

Developmental milestones 9-12 months

Sits with minimal assistance, chewing improves, soft/meltable solids

Developmental milestones 12-18 months

Sits upright, largely self feeding, advanced chewing (bite/tear)

Pediatric Assessment

Interview/case history: medical history, growth, diet, behavior, cultural competence (understanding diverse feeding practices)

Oral mechanism exam (oral mech)

Assess structure (lips, palate, tongue, jaw), oral reflexes (rooting, suckle, gag, cough) and oral sensory processing (hyper/hypo sensitive)

Observation of feeding

Observe a typical meal to assess feeding competence (intake, growth)

Trial and interaction

Trial modified fluids/ foods/ equipment/strategies. Observe child behavior and parent child interaction

Common Pediatric Disorder and Conditions

Oral tethers (tongue, lip, cheek ties): inhibit movement, cause latching difficulty, poor SSB coordination, high arched palate

Key issues of prematurity

Apnea, respiratory distress, poor stamina, immature SSB coordination

Gastrointestinal (GI)

GER/GERD, necrotizing enterocolitis (NEC), tracheoesophageal fistula (TEF) major etiologies of PFD

Cardiac disorder

Can cause increased energy expenditure, reduced stamina, possible recurrent laryngeal nerve damage during surgery

Neurological disorders (Cerebral Palsy, ABI)

Damage → dysphagia. Altered consciousness, tone abnormalities (high/low)

Autism spectrum disorder (ASD - neurodiversity lens)

High prevalence of feeding difficulties. Neurodiversity affirming approach reframes "sensory sensitivity" and "desire for sameness" as valid differences

Acceptance

Focus on accommodating access to preferred foods.

Pediatric Treatment Goal

Improve sensory/motor skills for eating, modify bolus/delivery for pharyngeal phase issues.

Oral Sensory Motor (OSM) Therapy

Targets structures and function to improve sucking, chewing, biting, and sensory integration.

Therapy Strategies

Includes talk tools, sequential oral sensory (SOS) approach, and food chaining.

Behavior in Feeding Therapy

Goals must be achievable; use reinforcement focusing on positive outcomes.

Tube Weaning

Process of transitioning from tube to oral feeds, focusing on appetite, skill, and behavior.

Stroke

Dysphagia occurs in 39 - 81% of patients.

Key Deficits in Stroke

Delayed pharyngeal swallow, reduced pharyngeal constriction, aspiration.

Dementia

High mortality from aspiration pneumonia; feeding tubes do not provide significant benefit.

Parkinson's Disease (PD)

Characterized by resting tremor, bradykinesia, rigidity; swallowing deficits reflect motor slowness.

ALS

Progressive corticobulbar deficits lead to severe, progressive dysphagia.

Head and Neck Cancer Treatments

Includes surgery, radiation therapy, and chemotherapy.

Importance of Dysphagia in Cancer

Loss/reconstruction of structures like tongue, palate, pharynx; RT causes xerostomia and trismus.

Esophageal Disorders

SLP should be aware but do not diagnose/treat.

Achalasia

LES does not relax; causes dysphagia for liquids and solids.

GERD

Chronic reflux causing symptoms; risk factors for COPD and aspiration.

Tracheostomy

Increases aspiration risk due to loss of subglottic pressure and poor laryngeal excursion.

Aspiration Pneumonia

Risk influenced by frequency, type, and amount of aspiration.

Palliative and End of Life (EoL) Care

Focus on symptom management and quality of living, not curing dysphagia.

Adult Treatment Considerations for Dysphagia

Airway protection, nutrition, hydration

Compensation Strategies

Includes postural adjustments like chin tuck and head turn.

Thickening Liquids

Slows bolus transit; be aware of IDDSI framework and patient acceptance.

Oral Motor Exercises (OMEs)

Includes supraglottic swallow, super supraglottic swallow, and effortful swallow.

Clinical Evaluation Components

Includes medical history, physical exam, and inspection for lesions.

Aspiration Detection Methods

Includes 3 oz water swallow test and cervical auscultation.

Modified Barium Swallow Study (MBSS)

X-ray video of a swallow; gold standard for physiology and airway invasion.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Scope passed transnasally to view pharynx/larynx; ideal for assessing anatomy.

Nutritional Risk

Dysphagia puts patients at risk for prolonged illness, infection, and mortality.

Non Oral Feeding Routes

Includes short-term nasogastric (NG) and long-term gastrostomy (g-tube/PEG).

Total Parenteral Nutrition (TPN)

Nutrition delivered directly into the bloodstream.

Ethical Dilemmas in Feeding

Patient refusing a feeding tube despite known aspiration risk.

Enteral Nutrition

Nutrition delivered directly into the gut (stomach or small intestine).

Parenteral Nutrition

Nutrition delivered directly into the bloodstream (bypasses the gut entirely).

Gavage Feeds

Another term for enteral tube feeding.

NPO

*Nil per os* (Latin for 'nothing by mouth'). A patient is NPO when oral feeding is unsafe.

Nasogastric (NG) Tube

Most common for short-term use. Non-invasive placement. Can be used for bolus or continuous feeds.

Nasoduodenal (ND) Tube

Used when there is GER, high aspiration risk, or delayed gastric emptying.

Nasojejunal (NJ) Tube

Further into GI tract; requires radiographic confirmation. Minimizes dislodgment back into stomach.

Gastrostomy (G-tube)

Surgically or endoscopically (PEG) placed directly into stomach. Cosmetic (covered by clothing). For long-term dysfunction.

Percutaneous Endoscopic Gastrostomy (PEG)

A specific type of G-tube placed via endoscopy (key-hole surgery). A 'button' is visible on the surface.

Gastrojejunal (GJ-tube)

Tube goes into stomach, with an extended port into the jejunum. Allows for stomach decompression while feeding into intestine.

Jejunostomy (J-tube)

Directly into the small intestine. Bypasses the stomach entirely.

Total Parenteral Nutrition (TPN)

Full nutrition (protein, lipids, carbs, electrolytes) delivered directly into the bloodstream, usually via a central vein.

Peripheral Parenteral Nutrition (PPN)

Nutrition delivered via a peripheral vein (simple IV). Usually does NOT meet full nutrition needs due to vein constraints.

Tube Weaning

The process of transitioning a patient from tube feeding back to oral feeding.