Have you heard of dysphagia? Although it can be quite widespread—every year, about 1 in 25 people experience it, according to a study in the journal Otolaryngology–Head and Neck Surgery—many people don’t know much about it.
To learn more about the condition, we asked Jennie Valles, MD, Attending Neurologist in Burke’s Spinal Cord Injury and Mixed Neurologic Program and Susan Wortman-Jutt, MS, CCC-SLP, Speech-Language Pathologist, Advanced Clinician, Outpatient Speech Department, to answer a few questions on the topic:
How would you describe dysphagia?
Swallowing is a complex and well-coordinated biological function that we as humans often take for granted. Dysphagia can occur due to dysfunction anywhere along the path of the swallow: the mouth, the back of the throat (pharynx), the base of the tongue, the epiglottis or the esophagus; or, it can be caused by an airway that does not close properly when food or liquid move toward the esophagus. Symptoms may include chronic coughing when eating or drinking, but these symptoms can be as mild as occasional throat clearing when eating, or as severe as choking. Other symptoms may include a wet, gurgly voice after eating, which can indicate that food or liquid is trapped near the vocal cords—dangerously close to the airway. In very severe cases however, one might not even feel the food or liquid entering the airway and outward signs of impaired swallowing, like coughing, may not occur.
When health professionals talk about food or liquid during the analysis of swallowing, they refer to it as a "bolus." If a patient has dysphagia, portions of the bolus may enter the airway and cause "aspiration" of bolus particles into the lungs. Most healthy people can tolerate small amounts of aspiration from time to time—as you may have noticed when food "goes down the wrong way." But doctors are especially concerned about people who may be too ill to withstand aspiration, or who may aspirate chronically, which can cause an infection known as "aspiration pneumonia” and can be life-threatening.
Is dysphagia something that a person will have forever or does it go away?
Fortunately, it is rare to have dysphagia forever (although in cases of certain very severe illnesses or injuries, it can happen). The duration of the swallowing disorder may be based upon the severity of damage to nerves or muscles anywhere along the path of the swallow, or in some cases, it may be determined by the degree of injury to the swallowing anatomy. In many instances, dysphagia is the result of damage to brain centers responsible for swallowing. Swallowing is unique in that it requires the healthy function of the brainstem—which controls automatic functions like breathing and digestion— but it also requires proper functioning at higher levels in the brain.
What types of illness or injuries might result in dysphagia?
The fact that a swallow has so many components means that any disease or injury along the path of the swallow can cause dysphagia. Stroke and brain injury are very common causes of dysphagia, but dysphagia may also be caused by cancer, neurological and progressive diseases such as ALS or Parkinson’s Disease, as well as other illnesses. In fact, any disorder that involves the health of the human body can impact swallowing.
What is the first step in diagnosing dysphagia?
In a hospital setting, when a doctor suspects a patient might have difficulty swallowing, he or she asks a speech-language pathologist (SLP) to examine the patient. If the SLP suspects the patient has dysphagia, he or she will ask the doctor to request a "modified barium swallow" (MBS). An MBS is essentially a video X-ray of the swallow. It is conducted by the SLP and doctor. The SLP presents various consistencies of food and liquid mixed with small amounts of barium—a benign white liquid or paste that permits the swallow to be viewed during the X-ray. The SLP may ask the patient to try different strategies or positions.
In some cases, instead of an MBS, the SLP may recommend the use of an endoscope, or thin flexible tube with a camera at the end, to observe the swallow. This is called a "fiberoptic endoscopic evaluation of swallowing" (or FEES). Based upon the outcome of either test, the SLP will design a course of swallowing therapy if necessary, or might recommend different consistencies of food or liquid, or changes in swallowing behaviors during regular meals. If dysphagia is confirmed, the doctor will order a course of swallowing therapy with an SLP.
Along with these tests, what role does a speech therapist play in treatment?
The speech therapist will tailor dysphagia treatment based upon the specific type of swallowing impairment. For example, if a patient has difficulty moving solid food from their mouth to their throat, the SLP might recommend the use of exercises to strengthen the base of the tongue. On the other hand, if the problem is that the vocal cords are not closing properly to protect the swallow, the SLP might recommend exercises such as breath holding, or pressing their hands forcefully against a wall, in order to bring the vocal cords closer together. Many times, the SLP will recommend compensatory strategies, such as a head turn, tucking the chin, or slowing down the patient's rate of eating. There are many ways in which an SLP might customize treatment.
How can a caregiver help their loved one?
Caregivers can play a pivotal role in dysphagia recovery, especially when the patient is discharged from the hospital. The SLP will provide family training in what types of foods and exercises will benefit the patient in their continued recovery. Once at home, it will be the patient and caregiver working together to promote the patient's safe and healthy eating. The patient and caregiver may be asked to follow-up with a repeat MBS or FEES a few weeks after discharge, and may be given new exercises or food consistencies to try.
Are there any cutting-edge treatments or research on the horizon?
There are emerging technologies being developed to assist SLP's in the assessment and treatment of dysphagia. Currently, we are collaborating together as Consulting Physician and SLP/Study Coordinator on a multi-site research study here at Burke to help in the development of one such technology. Other technologies being explored in the research community include non-invasive brain stimulation, pharyngeal electrical stimulation and medications that promote swallowing, though these are still in the experimental stages.