Dysphagia

Dysphagia is a swallowing disorder resulting from diseases, neurological conditions, or surgical intervention. Dysphagia can occur at different phases in the swallowing process.

Four Phases of the Normal Swallow:

  • Oral Prep Phase
    • voluntary phase that involves saliva, chewing and the forming of the bolus
  • Oral Phase:
    • when the bolus is transported the the back of the oral cavity, the tongue nestles the bolus, the tongue elevates and pushes against the hard palate and propels the bolus back
    • when the tongue moves this way & the bolus moves past the faucial pillars, it triggers the swallow response
  • Pharyngeal Phase:
    • a complex series of events that happens simultaneously:
      • velopharyngeal closure- closing of the nasal cavity
      • peristalsis- pharyngeal constrictors contract (to help the food go down)
      • hyoid/larynx elevate- vocal folds close & epiglottic inversion (epiglottis folds over)
      • cricopharyngeus relaxes
  • Esophageal Phase:
    • Involuntary phase
    • the bolus travels (peristalsis movement) in esophagus to stomach

SYMPTOMS:

  • coughing during or right after eating or drinking
  • wet or gurgly sounding voice during or after eating or drinking
  • extra effort or time needed to chew or swallow
  • food or liquid leaking from the mouth or getting stuck in the mouth
  • recurring pneumonia or chest congestion after eating
  • weight loss or dehydration from not being able to eat enough

As a result, adults may have:

  • poor nutrition or dehydration
  • risk of aspiration (food or liquid entering the airway), which can lead to pneumonia and chronic lung disease
  • less enjoyment of eating or drinking
  • embarrassment or isolation in social situations involving eating

ASSESSMENT:

Assessment Areas

  • Oral Prep Phase: anterior spillage (leakage), food that has not been chewed adequately, cohesive bolus, how long does it take, residue and pocketing after swallowing
  • Oral Phase: anterior spillage/leakage, posterior leakage (coughing, gurgaling), residue, excessive tongue pumping, delayed swallow response
  • Pharyngeal Phase: coughing, chocking, wet vocal quality, watery eyes (if they aspirate), sneezing (velopharyngeal issues- pushing food into nasal cavity), feel the outside of the client’s throat
  • Esophageal Phase: the gastrointestinal doctor will evaluate this phase, beyond SLP scope of practice

Interview Questions

  • Does the client have difficulty with chewing or swallowing since his/her stroke?
  • Has the client noticed a change in his/her appetite?
  • Are there foods that the client prefers to eat?
  • Are there foods that are easier for the client to eat?

Informal Assessment Measures

Gather information:

  • thorough chart review
  • interview with the client/caregiver
  • cognitive status
  • neurological/medical status
    • list of medications
    • stroke, Parkinson’s, neurological?

Oral Mech Exam:

  • weakness or un-coordination?
  • sensation?
    • pocketing food
  • laryngeal & pharyngeal strength
    • indirect observations
    • listen to voice
    • can they clear their throat/cough?

Presentation of Foods and Liquids:

  • have them try foods
  • start with small bites of whatever is easiest (puree) and progress to hard (in most situations)
  • liquid levels:
    • thin (regular liquid)
    • nectar (naturally nectar thick- like syrup in a fruit cup)
    • honey (like honey, but not as sticky)
    • pudding
  • diet levels:
    • pureed (foods that are pureed, the easiest to handle in most situations- mashed potatoes, baby food)
    • blendarized (not as smooth as pureed, more chunky- fork mashed pasta)
    • mech soft (things that are easier to chew- well cooked pasta, cooked veggies, cooked fruit)
    • general (normal, no restrictions)

Formal Tests

  • The Swallowing Ability and Function Evaluation (SAFE)
  • The BELZ Dysphagia Scale
  • The Fleming Index of Dysphagia (FID)
  • The Clinical Evaluation of Dysphagia (CED)
  • The Northwestern Dysphagia Patient Check Sheet
  • Ultrasonography: the use of transducers to observe structural movements
  • Traditional barium swallow concurrent with radiography: a videofluoroscope is used; provides a dynamic view of swallowing from the oral cavity through the lower esophageal sphincter
  • Flexible endoscopic evaluation of swallowing (FEES)

Initial Treatment Goals

  • The client will self-recognize pocketing of food and clear residue by the use of their tongue or drinking water with 100% accuracy.
  • The client will masticate food adequately to safely consume least restrictive diet with minimum verbal, visual and tactile cues.

CLIENT & FAMILY EDUCATION:

  • http://www.amyspeechlanguagetherapy.com/dysphagia.html
    • This webpage give a basic foundation for the swallowing disorder, dysphagia. Facts about dysphagia, including prevalence, etiologies, etc. Important for the clients and families, it provides a list of the signs and symptoms associated with Dysphagia.
  • http://dubuqueinternalmed.com/patient-education/hw-view.php?DOCHWID=tp23477spec
    • This webpage simply and clearly states the definition of a swallowing disorder. The page also lists common causes of dysphagia, as well as the symptoms, and how dysphagia is diagnosed.  The page also gives clients and their families an idea of what treatment is like for someone with a swallowing disorder.
  • https://californiaspeechie.wordpress.com/2013/08/21/dysphagia-brochure-for-family/
    • This blog provides family education for people with dysphagia. It includes the different stages of swallowing. It also includes the type of treatment available for clients. The blog also provides information about the differences with dysphagia depending on right hemispheric strokes and left hemispheric strokes.

PROFESSIONAL MATERIALS & RESOURCES:

  • Swigert, N. B. (2007). The source for dysphagia (3rd ed.) Austin,TX: LinguiSystems.
    • This text provides SLPs with information about Dysphagia. It elaborates on the current evaluation and treatment information with particular attention to  updated evidence and information for treatment techniques in dysphagia.
  • http://medicalspeechpathology.wordpress.com/swallowing/dysphagia-exercises/
    • This blog is useful for SLPs by providing information about dysphagia treatment exercises. The different exercises provided are all evidence-based. The exercises mentioned give specific steps for the treatments, and range from head movements to tongue maneuvers.
  • http://www.asha.org/slp/clinical/dysphagia/
    • This webpage, from the American Speech-Language-Hearing Association, provides a variety of links and resources for SLPs. The page includes the roles of the SLP, as well as basic information about swallowing and feeding disorders. The page has information about the assessment and treatment of swallowing disorders. The important aspect of diet and feeding is included on the page as well.

REFERENCES:

Haynes, W. O., & Pindzola, R. H. (2012). Diagnostics and evaluation in speech pathology (8th ed., pp 215-237). Pearson.

(1997–2014) American Speech-Language-Hearing Association (ASHA)

SPAUD 501: Diagnostics notes; Heather Koole (Calvin College)

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