SPA 127 - Ch. 11: Swallowing Disorders (Dysphagia)

What is Dysphagia?

• Difficulty in swallowing

• Includes difficulty with safe ingestion of food and liquid, saliva management, discomfort during/after eating

• Impacts nutrition and hydration

• Impacts respiratory status

Who is impacted?

• Occurs in both children and adults (across the lifespan)

• Can be a symptom of a congenital disorder or acquired injury/disorder

• Example: Incidence rate of 37-78% of all post-stroke patients

• Accounts for about 75% of SLP caseload in acute care

Causes

• Congenital/Developmental

  • Cerebral Palsy

  • Intellectual disability

  • Cleft lip/palate

  • Autism

• Acquired

  • Stroke (CVA)

  • Cancer (throat, larynx, mouth, esophagus)

  • MS

  • ALS

  • Parkinson’s disease

  • TBI

  • Dementia

4 Stages of the Normal Swallow

1. Oral Preparatory

   1. Occurs only in the oral cavity. Food is chewed, tasted, and mixed with saliva

2. Oral Transport

   1. Velum elevates to seal off nasal cavity, food is moved to the back of the oral cavity by the tongue

3. Pharyngeal

   1. Epiglottis inverts to protect the airway as bolus is swallowed/moves down the pharyngeal cavity

4. Esophageal

   1. Muscle at the top of the esophagus (UES) relaxes to allow the bolus to pass into the stomach

Symptoms of Dysphagia

• Choking on food or drink

• Coughing during or after swallowing

• Coughing or vomiting up food

• Having a weak, soft voice

• Aspirating (getting food or liquid into your lungs)

• Excessive saliva or drooling

• Difficulty chewing

• Trouble moving food to the back of your mouth

• Food sticking in your throat

Disordered Swallowing

• Penetration: When food/liquid/saliva reach your vocal folds

  • Frequently called “going down the wrong pipe”

• Aspiration: When food/liquid/saliva/reflux enters the airway

Aspiration

• All evaluations of dysphagia are intended to determine risk of aspiration

• Aspiration - passage of food/liquid past the level of the vocal folds into the trachea. Can sometimes be expelled (cough), often will continue to pass through to the lungs

  • May be overt (resulting in cough/attempt to clear)

  • May be silent (patient is unaware - no attempt to clear)

• Aspiration Pneumonia - bacterial infection caused by foreign material (food/liquid) in the lungs

  • Incidence of aspiration - between 38-70% of acute stroke patients

  • An average of 58,576 people in the US die of aspiration pneumonia every year

Aspiration Pneumonia

• Bacterial infection caused by foreign material (food/liquid) in the lungs

• Between 38-70% of acute stroke patients will experience aspiration PNA

• Mortality: An average of 58,576 people in the US die of aspiration PNA every year

Bedside Swallow Assessment

• Subjective, non-instrumental assessment done by an SLP to assess safety for oral (PO) diet

  • Assesses for difficulty/disorder in various stages of swallowing with different textures

  • Cannot directly visualize pharyngeal or esophageal dysphagia

Modified Barium Swallow Study (MBSS)/Video fluoroscopic Swallowing Study (VFSS)

• Objective, instrumental assessment of oral, pharyngeal, and partial esophageal stages

• Done in a radiology suite (hospital) utilizing barium-coated liquids and foods

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• The other primary objective, instrumental assessment

• Visualizes pharyngeal phase of swallow, can visualize some esophageal stage. Cannot visualize oral stages

• Endoscopic camera is fed through the nasal cavity and the nasopharynx

• Can be done in multiple healthcare settings and Speech/ENT clinics by a trained SLP or physician

Treatment: Diet Modification

• Goal is to maximize safety while maintaining the least restrictive diet

• Different consistencies are recommended based on results of swallow eval

  • Solids: Regular, Chopped, Mechanical Soft, Puree

  • Liquids: Thin, Nectar, Honey, Pudding

• NPO - nil per os (nothing by mouth)

  • Alternative forms of nutrition required - PEG, NG, etc.

Swallow Modification

• Swallow exercises

  • Strengthen muscles, improve clearance (like physical therapy, but for swallowing muscles)

• Swallow strategies and techniques:

  • Environmental modifications, adaptive feeding equipment, specific feeding techniques, and positioning

• Therapeutic modalities (required special training):

  • Neuromuscular Electrical Stimulation (NMES), Deep Pharyngeal Neuromuscular Stimulation (DPNS)