Dysphagia And Other Hard To Swallow Truths

Written by: Kendra Wormald / Medical Rehabilitation / November 08, 2023 / 10 minutes read

Table of contents

1. Swallow Phases

2. Prevalence And Incidence

3. Causes And Risk Factors

4. Signs And Symptoms

5. Role Of SLP In Swallowing Assessment And Management

6. Comprehensive Assessment

7. Intervention/ Management

Dysphagia is the medical term for swallowing difficulties. Dysphagia severity can range greatly between people, some have difficulty swallowing certain foods/liquids while others can’t swallow at all (NHS, 2024). People with dysphagia may also experience pain while swallowing, referred to as odynophagia.

Swallow Phases

(Panara et al., 2023; NIH, 2023)

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Swallowing is a complex process with about 50 pairs of muscles and nerves working together to move food into the mouth, down the throat and to the stomach. 

1. Oral Preparatory Phase: Food manipulation and mastication (chewing), bringing food together to form a ‘bolus’.

2. Oral Phase: The voluntary phase of the swallow when the tongue propels food posteriorly, the swallow reflex is triggered.

3. Pharyngeal Phase: The soft palate rises to close off the nasal passageway. This keeps food/liquid going through your nose. A reflexive swallow occurs as it carries the bolus through the pharynx. The epiglottis deflects and the larynx (voice box) closes tightly as breathing stops to prevent food or liquid from entering the airway and lungs.

4. Esophageal Phase: Esophageal peristalsis (involuntary movements of the longitudinal and circular muscles) carries the bolus through the esophagus into the stomach as it passes the lower esophageal sphincter 

Prevalence and Incidence

(Azer, Kanugula, Kshirsagar, 2023; Adkins,Takakura, Spiegel, Lu, Vera-Llonch, Williams and Almario, 2019; Christmas & Rogus-Pulia, 2019)

Dysphagia can be acute or chronic. 

• Roughly 20% of the overall population experiences dysphagia. 

• Dysphagia can occur at any age, but it's more common in older adults. Of those over 60, the prevalence increases to 40%.

• Reportedly, 63% of elderly patients who denied any history of swallowing problems showed abnormal swallowing evidence upon assessment 

• Dysphagia occurs equally across sexes 

• Between 50-60 percent of head and neck cancer survivors

• Post-extubation dysphagia occurs in 60-80% of the population 

• Following a stroke, occurrences of dysphagia vary between 20-80%. 76% will remain with a moderate to severe dysphagia and 15 percent with profound dysphagia

• “Dysphagia cuts across so many diseases and age groups that its true prevalence in adult populations is not fully known and is often underestimated” (ASHA, 2023).

Causes and Risk Factors

(Adkins,Takakura, Spiegel, Lu, Vera-Llonch, Williams and Almario, 2019; Christmas & Rogus-Pulia, 2019; ASHA 2023)

Neurogenic: Caused or controlled by, or arising in the nervous system.
Examples: Stroke, traumatic brain injury, dementia, Huntington’s Disease, Parkinson’s Disease, ALS, Multiple Sclerosis, Myasthenia Gravis

Mechanical: Caused by a problem in the movement of the swallowing muscles and nerves
Examples: Cervical Spine Disease, tracheostomy tubes, acute Inflammations, trauma carcinoma in the oro-pharyngo-esophageal center)

Iatrogenic: Caused by medical examination or treatment
Examples: Medication induced, post-surgical complications (endotracheal intubation), radiation therapy, infection, hematoma, edema

Medication: Caused by medications
Examples: Xerostomia dry mouth (e.g. antidepressants), dystonia/ dyskinesia (e.g. neuroleptics), increased salivation (e.g. clonazepam)

Normal Aging: Sarcopenia (decreased muscle mass and quality with advancing age) has been shown to affect the muscles used for swallowing

Narrowing, blockages and structural issues: cleft lip/palate, esophageal webs, esophagitis, cancer, GERD, glossectomy, enlarged thyroid, enlarged heart and  problems with your breathing caused by conditions like chronic obstructive pulmonary disease (COPD)

Consider our Masterclass to support Breathing for Communication

Swallowing is a complex process with about 50 pairs of muscles and nerves working together to move food into the mouth, down the throat and to the stomach.

Signs and Symptoms

• Cough or wheezing during or post meals

• Coughing-up undigested food 

• Delayed swallowing

• Need for repetitive swallows

• Throat clearing

• Wet/gurgly voice

• Hoarse voice 

• Choking

• Changes in cognition 

• Sensation of food sticking in the throat

• Changes in respiratory status during or post meals

• Pain while swallowing 

• History of aspiration pneumonia or recurrent lower respiratory infections

• Mouth odor

• Weight loss

• Facial drooping or drooling

• Food/fluid falling from the mouth 

• Difficulty moving food in mouth 

• Inadequately chewed food 

• Difficulty swallowing certain food/liquids

• Acute or recurring aspiration pneumonia/respiratory infection and/or fever 

• Pocketing of food in oral cavity/oral residue post-swallow

Role of SLP in Swallowing Assessment and Management

Screening: A pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services.

Comprehensive Assessment

• Collect health-related history (e.g radiation treatment, metabolic disturbances;

• Medical status, nutritional status and psychosocial, environmental, and behavioral factors.

• Evaluation of cognitive ability - will deficits impact safety/functionality of swallow

• Evaluation of oral-mechanism examination, cranial nerve assessment

• Functional assessment of swallowing muscles/structures, including symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement;

• Analysis of head–neck control and posture, status of oral care 

• Assessment of respiratory status, cough, and throat clearing abilities.

Non-Instrumental: 

• Bedside Swallow Assessment: Following the above assessment components, the SLP will systematically present you with liquids and solids of varying textures. During this time they will be looking for any signs or symptoms of dysphagia in all swallow phases

Instrumental:

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES): Involves passing a flexible endoscope through the nose to obtain a superior view of the pharynx and larynx i.e. a bird’s-eye-view

• Videofluoroscopic Swallow Study (VFSS): Conducted in an x-ray suite, the SLP provides various textures of food and liquid while an x-ray takes a ‘real-time’ snapshot of the swallow process. Here you could see if/where food gets ‘stuck’, the structures, timeliness and whether intake is going into the lungs (aspiration)

Intervention/ Management

Treatment depends on the cause and takes into consideration the person’s culture/beliefs, dietary preferences, safety, efficacy, and client/family goals.

• Rehabilitative Strategies: Work to fix the swallowing concern and change swallowing physiology through repeated practice and exercises. Focus is on strength and skill training 

• Compensatory Strategies: Compensate for the swallowing problem; they do not change swallowing physiology, but rather the external factors to improve swallowing function. 

• SLP will provide counseling and education to individuals and caregivers/families

• Dietary recommendations are also used to support a safe and efficient swallow. The IDDSI framework outlines common terminology used to define food textures and liquid thicknesses.

Any severity of dysphagia can impact your participation, enjoyment around meals and overall quality of life. Early detection and intervention are key in ensuring safety and efficacy of the swallow and your overall health. Your Speech-Language Pathologist will work with you to find strategies that support your lifestyle, optimal nutrition, hydration and your goals.

To speak with a psychotherapist or one of the speech-language pathologists at Well Said: Toronto Speech Therapy, schedule an initial consultation by clicking the link below or calling (647) 795-5277.