What is Dysphagia? The term dysphagia refers to a swallowing disorder or difficulty passing food or liquid from the mouth to the stomach. It is described as difficulty or pain experienced while swallowing. Dysphagia is common among all age groups, especially the elderly. This may be caused by many factors, some of which are non-threatening and temporary. Dysphagia may occur in the elderly, people who are diagnosed with a stroke, accident/trauma victims, patients with Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Gastro Esophageal Reflux Disease (GERD), respiratory problems (including ventilator patients), Head and Neck Cancer, Brain tumor or traumatic brain injury (TBI), Cleft Palate, or patients suffering from chronic neurological diseases such as Parkinson’s, ALS (Amyotrophic Lateral Sclerosis or Lou Gehrig’s Disease), Cerebral Palsy, Multiple Sclerosis. Swallowing problems may also develop following illness, surgery, or changes in medication. What is the Swallowing process? Fundamental issues in diagnosing and treating the dysphagia include the oral, pharyngeal, and esophageal phases of swallowing. The oral stage begins as food or liquid is manipulated in the mouth and prepared in order to move it to the back of the mouth, starting the swallow trigger. The pharyngeal stage begins as food or liquid is quickly passed through the canal which connects the mouth with the esophagus. The esophageal stage is when the food or liquid passes through the esophagus and into the stomach. If these functions are compromised, the risk is aspiration (food or liquid entering the lungs); this can cause aspiration pneumonia, weight loss, dehydration, or possible death. What are the symptoms of Dysphagia?

• Drooling
• A feeling of pain or food/liquid sticking in the throat
• Discomfort in the throat or chest
• A sensation of a “lump” in the throat
• Weight loss or dehydration
• Coughing OR choking on food, liquid, or saliva
• Wet or “gurgly” vocal quality when speaking or breathing
• Food sitting on the tongue or in the “pockets” of the mouth either without swallowing at all or after the swallow has occurred.

Who Evaluates and Treats Swallowing Disorders? In some cases, a general practitioner physician will diagnose and effectively treat the condition, as with a cold or temporary gastroesophageal reflux. When there is a more significant swallowing problem, a medical specialist may become involved. These specialists include speech-language pathology, otolaryngology-head and neck surgery, gastroenterologist, thoracic surgery, nutrition, neurology, and dentistry. A team approach is ideal to provide complete diagnosis and treatment. It is the ethical responsibility of the primary care physician (PCP) and each specialist to refer to the appropriate professional when further investigation and/or treatment are needed. When is a swallowing evaluation needed? The number one and most prevalent reason to do an instrumental exam is when the person is identified as having dysphagia based on symptoms and specific information is needed to guide the management and treatment. What are the types of swallowing assessments?

1. Bedside Swallowing Evaluation: a non-instrumental, noninvasive means to evaluate the swallow.
2. Fiberoptic Endoscopic Evaluation of Swallowing (FEES): an instrumental examination of the pharyngeal and laryngeal mechanism using a Fiberoptic endoscope. This tool is inserted into the nose and passes beyond the velum (soft palate), providing the examiner with an excellent bird’s eye view of the structures responsible for an effective swallow. It can be performed by a trained speech-language pathologist. The equipment is portable and can be performed in an office, SNF, home, or rehab hospital. The endoscope is inserted in the nose and sits in the pharynx right above the valleculae. The oropharynx, pharynx, and larynx are viewed on a monitor. The exam takes between 3 to 10 minutes in length. This procedure can also be used as a tool for biofeedback for the patient, as well as to teach staff and families. The FEES exam allows the clinician to identify aspiration accurately; view the function of the true and false vocal fold adduction to close the airway; and residue in the pharynx. This test can also be videotaped. The effectiveness of all behavior therapies can be viewed endoscopically (see Behavioral Therapy below).

   The Benefits of FEES are:

• Assess various postures and positions
• Need to determine presence of silent aspiration
• Reveals reflux after the swallow and aspiration of refluxed material
• Reveals medical pathologies
• Assess vocal fold closure
• Assess right and left sided weakness
• Assess laryngeal elevation
• Assess strength of tongue base
• Assess amount and place of residue
• Provides biofeedback to the patient
• Uses actual food/liquid without altering the consistency with barium
• No radiation
• Can be utilized over time without concern for radiation

 

3. Video Fluoroscopic Swallow Study (VFSS): an instrumental examination of the oral, pharyngeal, and esophageal phase of the swallow using barium liquid and barium-coated food of various consistencies. This examination is most often done at a hospital and requires transportation. Some elements to consider with this assessment is the radiation exposure, risk of aspirating barium, transportation required, and altering the consistency of solid food with barium.