Abstract
Dysphagia generally refers to any difficulty with swallowing, including occult or asymptomatic impairments. Dysphagia can result from a wide variety of functional or structural deficits of the oral cavity, pharynx, larynx, or esophagus. Severe dysphagia may result in serious complications such as aspiration pneumonia, airway obstruction, malnutrition, dehydration, and death. The goal of dysphagia rehabilitation is to identify and treat abnormalities of feeding and swallowing while maintaining safe and efficient alimentation and hydration. The bedside swallow evaluation is an important step in the clinical evaluation. Although screening tests can be useful in screening for dysphagia, these examinations are limited in their ability to detect and to characterize dysphagia, so instrumental studies are usually necessary. The videofluorographic swallow study (VFSS) is the gold standard in dysphagia diagnosis and management. During the VFSS, the patient ingests radiopaque foods and liquids and oral, pharyngeal, and esophageal stages of swallowing physiology are evaluated. The results of the study are used to develop a plan for an appropriate diet, therapeutic compensations, and swallowing exercises. Rehabilitation of swallowing can involve structured swallowing therapy, surgical management, and pharmacologic management. An important consideration in dysphagia rehabilitation is maintaining adequate alimentation and hydration.
Definition
Dysphagia refers to any difficulty with swallowing, including occult or asymptomatic impairments. It is a common problem, affecting one third to one half of all stroke patients. and 30% to 40% of independently living elderly individuals. The prevalence of dysphagia increases up to 60% in institutionalized elderly patients. It is frequent in head and neck cancer, traumatic brain injury, degenerative disorders of the nervous system, gastroesophageal reflux disease, and inflammatory muscle disease ( Table 130.1 ). Dysphagia is classified according to the location of the problem as oropharyngeal (localized to the oral cavity or pharynx, not just the oropharynx) or esophageal. It may also be classified as mechanical (due to a structural lesion of the foodway) or functional (caused by a physiologic abnormality of foodway function).
| Neurologic Disorders and Stroke | Structural Lesions | Connective Tissue Diseases |
|---|---|---|
| Cerebral infarction Brainstem infarction Intracranial hemorrhage Parkinson disease Multiple sclerosis Amyotrophic lateral sclerosis Poliomyelitis Myasthenia gravis Dementias | Thyromegaly Cervical hyperostosis Congenital web Zenker diverticulum Caustic ingestion Neoplasm Post-ablative surgery Radiation fibrosis | Polymyositis Muscular dystrophy Psychiatric disorders Psychogenic dysphagia |
Sudden onset is suggestive of stroke. Concomitant limb weakness suggests a neurologic or neuromuscular disorder. Medication-induced dysphagia is commonly overlooked. Medications that impair level of consciousness (such as sedatives and tranquilizers), have anticholinergic effects (tricyclics, propantheline), or can damage mucous membranes (nonsteroidal anti-inflammatory drugs, aspirin, quinidine) may also cause dysphagia.
Symptoms
The most common symptoms of dysphagia are coughing or choking during eating and the sensation of food sticking in the throat or chest. Some of the many symptoms and signs of dysphagia are listed in Table 130.2 . A history of drooling, significant weight loss, or recurrent pneumonia suggests that the dysphagia is severe. The history is most useful for identification of esophageal dysphagia; the complaint of food sticking in the chest is usually associated with an esophageal disorder. In contrast, the complaint of food sticking in the throat has little localizing value and is often caused by an esophageal disorder. Coughing and choking during swallowing suggest an oropharyngeal origin and may be precipitated by aspiration (penetration of material through the vocal folds and into the trachea). However, some patients have impaired cough reflexes, resulting in silent aspiration (without cough). Silent aspiration occurs in 28% to 94% of people with dysphagia, depending on the population of patients. Patients with neurologic disorder have a higher incidence of silent aspiration. Pain on swallowing (odynophagia) may occur transiently in pharyngitis, but persistent pain is unusual and is suggestive of neoplasia. Heartburn is a nonspecific complaint that is usually not associated with swallowing but occurs after meals. Heartburn may occur in gastroesophageal reflux disease, but a more specific symptom of gastroesophageal reflux disease is regurgitation of sour or bitter-tasting material into the throat after eating. To evaluate clinical symptoms of dysphagia, validated questionnaires such as the Eating Assessment Tool 10 (EAT-10) can be used.
| Oral or Pharyngeal Dysphagia |
| Coughing or choking with swallowing |
| Difficulty with initiation of swallowing |
| Food sticking in the throat |
| Drooling |
| Unexplained weight loss |
| Change in dietary habits |
| Recurrent pneumonia |
| Change in voice or speech |
| Nasal regurgitation |
| Dehydration |
| Esophageal Dysphagia |
| Sensation of food sticking in the chest or throat |
| Oral or pharyngeal regurgitation |
| Drooling |
| Unexplained weight loss |
| Change in dietary habits |
| Recurrent pneumonia |
| Dehydration |
Physical Examination
An examination of the oral cavity and neck may identify structural abnormalities, weakness, or sensory deficits. The finding of dysarthria (abnormal articulation of speech) or dysphonia (abnormal voice quality) is often associated with oropharyngeal dysphagia. However, the examination is primarily useful for finding evidence of underlying neurologic, neuromuscular, or connective tissue disease. The examination should always include trial swallows of water. During the swallow, there should be prompt elevation of the hyoid bone and larynx. Changes in voice quality and spontaneous coughing after swallowing suggest pharyngeal dysfunction. The history and physical examination are limited in their ability to detect and to characterize dysphagia, so instrumental studies are usually necessary.
Neurologic examination is important in the evaluation of dysphagic individuals because neurologic disorders commonly cause dysphagia. Disorders of either upper or lower motor neurons may produce dysphagia. The findings of atrophy or fasciculations of the tongue or palate suggest dysfunction of lower motor neuron or the brainstem motor nuclei. In contrast to the prevailing wisdom, the gag reflex is not strongly predictive of the ability to swallow. It may be absent in normal individuals and normal in individuals with severe dysphagia and aspiration.
Functional Limitations
Functional limitations depend on the nature and severity of the dysphagia. Many individuals modify their diets to eliminate foods that are difficult to swallow; others require special postures or respiratory maneuvers. Some require inordinate amounts of time to consume a meal. In severe cases, tube feeding is necessary. These alterations in the ability to eat a meal can have a profound effect on psychological and social function. Interaction with family and friends often centers on mealtime—family dinners, “going out” for a drink or for dinner, “coming over” for a snack or for dessert. Difficulty in eating a meal may disrupt relationships and result in social isolation. Some patients may require supervision during meals or feel unsafe when they eat alone, causing further disruption of social function.
Diagnostic Testing
Because the mechanics of swallowing are largely invisible to the naked eye, diagnostic studies are commonly needed. The sine qua non for diagnosis of oropharyngeal swallowing disorders is the videofluorographic swallowing study (VFSS). In this test, the patient eats and drinks a variety of solids and liquids combined with barium while images are recorded with videofluorography (x-ray videotaping). The VFSS is usually performed jointly by a speech-language pathologist and a radiologist in the United States. However, in other countries, for example in Japan, many disciplines such as physiatrists, neurologists, ENT doctors, dentists, and the other disciplines join the VFSS and/or the case conference after the VFSS with an interdisciplinary approach. A unique benefit of the VFSS is that therapeutic techniques (such as modification of food consistency, body position, or respiration) can be tested and their effects on swallowing observed during the study. A routine barium swallow study is frequently sufficient if the problem is clearly esophageal.
The fiberoptic endoscopic evaluation of swallowing (FEES) is a useful bedside swallowing examination to visualize the anatomy of the pharynx and larynx and vocal fold function during eating with no x-ray exposure. Although FEES does not visualize the oral and esophageal stages of swallowing, pre-swallow oropharyngeal bolus transport during eating solid food can be evaluated. FEES does not visualize the events of pharyngeal swallowing, including opening of the upper esophageal sphincter, elevation of the larynx, and contraction of the pharynx, but it is highly sensitive for detection of aspiration after swallowing.
In cases of esophageal dysphagia, esophagoscopy is frequently necessary to detect mucosal lesions or masses. Biopsy is indicated when mucosal abnormalities are detected. High-resolution manometry is useful for detection and characterization of motor disorders of the esophagus and is sometimes performed on the pharynx as well. Electromyography is indicated when neuromuscular disease is suspected and is useful for detection of lower motor neuron dysfunction of the larynx and pharynx.
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