| Swallowing Disorders | | Counselor, Swallowing disorders, or dysphagia, is a general term used to describe the inability to move food from the mouth to the stomach. Feeding disorder, which is the inability to get food to the mouth, and gastric outlet obstruction, the inability of food to pass from the stomach into the small intestine, should be differentiated from swallowing disorders. An average of 10 million Americans are evaluated for swallowing disorders annually. Many causes have been identified for dysphagia, and they are discussed later in this article. We value all your comments, so, if you have a suggestion for a newsletter subject but haven't submitted it yet, or if you have already submitted one but think of another, please take a minute to let us know by clicking on your "Reply" button and dropping us a note. To learn more about AMFS, Inc., the organization run by Physicians and Attorneys that provides medical experts and case review services nationwide, and has produced the following informational newsletter to aid you in understanding complex medical issues, please click here - www.medicalexperts.com. |
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|  Pathophysiology: Normal swallowing involves an oral phase, pharyngeal phase and esophageal phase. The oral phase involves mastication and movement of food into the pharynx. The process of food bolus formation requires taste, temperature, touch, and proprioception senses. Movement of food requires buccal musculature tension and a labial (lip) seal to prevent food from leaking out of the mouth. The pharyngeal phase involves a reflex action which propels food through the pharynx. The reflex involves instantaneous retraction and elevation of the tongue, and occlusion of the velopharyngeal flap which prevents food from moving up into the nasal cavity. The larynx prevents material from entering the airway by closing at the level of the true and false vocal cords and epiglottis. The esophageal phase is the final phase of swallowing and is under control of the brain stem and myenteric plexus. A peristaltic wave beginning in the pharynx pushes the bolus sequentially from the cervical esophagus down through the esophageal-gastric sphincter into the stomach. The act of swallowing usually interrupts the expiratory phase of ventilation, while the completion of expiration occurs when swallowing ends. Abnormalities of swallowing could be secondary to defects in any of the stages of swallowing. Abnormalities lead either to aspiration (passive entry of any food item into the trachea) or penetration (active entry of any food item into the trachea, for example, during swallowing). At the oral stage, weakness of the tongue or cheek musculature will result in "pocketing" of food in the oral cavity. At the pharyngeal stage, dysfunction of the soft and hard palates leads to improper coordination of swallowing. At the esophageal phase, achalasia leads to dysfunction of the gastroesophageal junction and absent esophageal peristalsis. Also, Zenker's diverticulum can lead to swallowing difficulty with possible nocturnal aspiration of residue in the diverticulum. Also, it is important to know that a mass in the cerebral cortex or the brain stem can cause swallowing disorders in the following ways: decrease in range of motion (ROM) of muscles of mastication and bolus propulsion, decreased sensation, delayed or absent pharyngeal swallowing and reductions in pharyngeal peristalsis, and delayed or absent laryngeal adduction and elevation. |
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| History and Physical: When obtaining the patient's history and performing the physical examination, the physician should inquire about onset, duration, timing, associated factors, and progress of the symptoms. The following are symptoms and signs that suggest some degree of dysphagia: difficulty in initiating swallowing, a feeling of obstruction as if food has become stuck in the throat, voice change, difficulty with chewing or weakness of muscles of mastication, pocketing of food in the mouth, globus sensation or pain in the hypopharynx, coughing after eating, drooling, impairment of the gag reflex and ability to clear bolus, nasal regurgitation, inappropriate breathing or speaking while swallowing, weight loss, recurrent pneumonia, weight loss and malnutrition, and a relevant past medical history, including the following: recent stroke, neuromuscular disease, hypertension, diabetes mellitus (DM), thyroid disease, cancer, dementia, and traumatic brain injury (TBI). Medications that may be associated with swallowing disorders include the following: Nitrates, Anticholinergic agents, Calcium tablets, Calcium channel blockers, Aspirin, Iron tablets, Vitamin C, Antipsychotics (eg, olanzapine [Zyprexa]), and Tetracycline. A thorough physical examination should include the following: General examination, including weight and vital signs, full head and neck examination, focusing on cranial nerve functions, dentition, palate, tongue, and pharynx, laryngoscopy to evaluate the supraglottis as well as the vallecular area. Neck masses, thyroid, and bruits should be checked. Structural integrity of the hyoid and larynx also should be checked. Lungs should be checked for rales/ crepitations, wheezes, rhonchi, air entry, and other abnormalities. A thorough neurologic examination, looking at mental status and cranial nerves (especially V, VII, IX, X, and XII) should be done as well as testing of muscle strength, reflexes, coordination, gait, and functional status. |
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| | Other Diagnostic Studies: Videofluoroscopic swallowing study (VFSS) is the gold standard. This test is performed with the modified barium swallow. The VFSS evaluates the pharyngeal phase of the swallowing process, using different consistency of the barium and allowing for evaluation of the effect of different maneuvers in preventing aspiration. Fiberoptic endoscopic evaluation of swallowing (FEES) is used to evaluate any structural abnormalities in the nasopharynx, laryngopharynx, and hypopharynx, especially in patients who cannot be transported to the radiology suite for the VFSS. Ultrasonography evaluates soft tissue dynamics during the oral and pharyngeal phases, looking at tongue function and laryngeal/hyoid elevation. Manometric fluoroscopy is manometry combined with VFSS to check the pressure gradient of the pharynx and the pharyngoesophageal junction. Other tests including CT scan, MRI of the head and neck, chest x-ray, and pulmonary function tests evaluate other possible causal factors. |
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| | Causes of Swallowing Disorders: The list of possible causes is enormous comprising at least 100 separate possible etiologies. These etiologies include structural disorders such as zenker diverticula or strictures, esophagitis due to gastroesophageal reflux disease or medications, esophageal disorders such as motility disorders or achalasia, psychogenic dysphagia from somatoform disorders, medication-induced dysphagia, neuropathic and endocrine disorders, neuromuscular junction disorders such as muscular dystrophies, and central nervous system disorders such as stroke, multiple sclerosis, brain tumors, parkinsons and alzheimers. |
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| | Treatment: The goals of treatment are to maintain adequate nutritional intake and to maximize airway protection. Rehabilitation therapy is the mainstay of dysphagia management and allows for safe swallowing. Rehabilitation requires the cooperation of the patient and the ability of the patient to understand and follow commands. Typical therapy programs involve advancing dysphagia diets with gradually increased consistency of food. Compensatory strategies to reduce the risk of aspiration include such techniques as the chin tuck, head rotation, head tilt, supraglottic swallow, and the mendelsohn maneuver. Description of these techniques is beyond the scope of this basic review. Exercise techniques are geared especially toward range of motion, coordination and strengthening of muscles of the jaw, lips, cheek, tongue, soft palate, and vocal cords. Biofeedback techniques are used to re-educate muscles affected in facial palsy and disorders of articulation. This includes electromyography (EMG) feedback in which surface electrodes are placed over the anterior neck, for example. Visual feedback is obtained in VFSS while experimenting with head positions and swallowing maneuvers. Medical interventions include injection of Botulinum toxin type A endoscopically into the gastroesophageal sphincter and upper esophagus to decrease tone. This could be very useful in cricopharyngeal spasms causing dysphagia. Diltiazem can aid in esophageal contractions and motility, especially in the disorder known as the nutcracker esophagus. Glucagon is used in disimpacting esophageal bodies; diazepam also is used sometimes. Nitrates can be prescribed, especially Isosorbide dinitrate in achalasia. Endoscopic and surgical interventions include esophageal dilatation in achalasia, strictures, and webs, cervical osteophyte resection, cricopharyngeal myotomy for upper esophageal spasm, zenker diverticula resection on suspension, esophageal resection and reanastomosis, and for paralyzed vocal cords, teflon injection or reversible vocal cord medialization can be performed. Nonoral feedings such as parenteral alimentation and IV fluid replacement should be prescribed to meet caloric and fluid requirements. The necessary caloric/fluid needs must be calculated to meet the patient's daily needs. Gastrostomy can be placed by percutaneous endoscopic means (PEG), allowing for continuous or bolus feedings. Reflux prevention is performed by feeding the patient in a vertical position, using H2-blockers to decrease gastric pH, Chlorpromazine or Maxolon to facilitate gastric emptying, and proton-pump inhibitor to decrease gastroesophageal reflux. Jejunostomy may be indicated in patients with known reflux and aspiration. This procedure is performed under general anesthesia and could involve continuous or bolus feeds. |
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| | Summary and Medical/Legal Concerns: Swallowing disorders have become a major source of disability. In the last decade, improvements have been made in the ways these disorders can be treated, especially the consequent malnutrition. With the available tests and management options, the prognosis for patients with swallowing disorders has improved. The need for an understanding of the anatomy and physiology of the areas of the body affected is paramount in the diagnosis and management of swallowing disorders. Early involvement of other specialists, including ENT surgeons, nutritionists, gastroenterologists, general surgeons, and speech and language therapists, offers a good prognosis for the management of swallowing disorders. Medical-legal pitfalls involve delayed diagnosis and treatment and the attendant risks of aspiration and penetration which can lead to serious injury, disability, or even death. |
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