What is dysphagia?

What is dysphagia?

Dysphagia is a disorder that affects the ability to swallow and/or chew.
The passage of food from the mouth to the stomach is then disrupted because part or all of the mechanisms that allow food to travel are defective. Dysphagia is not a disease in itself, but rather is a symptom resulting from another health problem or side effect of medical treatment.

What are the main causes of dysphagia?

Many health problems can lead to dysphagia. Here are some examples:

  • Cerebral vascular accident
  • Human immunodeficiency virus (HIV)
  • Ataxia
  • Spinal cord injury
  • Cancer
  • Pharyngeal or esophageal diverticulae
  • Hiatal hernia
  • Immaturity of the neuromuscular system
  • Alzheimer’s disease
  • Respiratory diseases
  • Genetic diseases
  • Muscular dystrophy
  • Myasthenia
  • Myopathy
  • Multiple sclerosis
  • Amyotrophic lateral sclerosis
  • Parkinson disease
  • Huntington’s disease, etc.
  • Malformation: mouth, throat, etc.
  • Malnutrition
  • Oesophagitis
  • Cervical osteophytes
  • Cerebral paralysis
  • Mental health problem
  • Gastro-esophageal reflux
  • Wallenberg syndrome
  • Cranial trauma

As well, dysphagia can be an undesirable side effect of certain medications. Some medical treatments may also unintentionally cause dysphagia:

  • Surgery of the mouth and/or larynx
  • Intubation
  • Radiotherapy
  • Tracheostomy

How to detect dysphagia?

In order to detect dysphagia, one needs to be attentive to the following symptoms which can be good indicators of an underlying problem:

  • Spontaneous phlegmy cough while eating or drinking
  • Choking (suffocation after consuming solid foods)
  • Difficulty keeping foods and liquids in the mouth
  • Difficulty to initiate swallowing
  • Presence of food in the mouth after a meal
  • Saliva spilling involuntarily from the mouth or “drooling”
  • Presence of large amounts of secretions in the mouth or throat
  • Sensitivity or pain in the mouth or while swallowing
  • Sensation of foods getting stuck in the throat
  • Frequent need to clear the throat
  • Hoarse or changed voice following a meal or beverage
  • Regurgitation of foods or liquids through the mouth and/or nose
  • Decrease in appetite or tendency to avoid certain foods
  • Fear of eating or refusal of foods
  • Frequent pneumonia
  • Changes in the speed of eating, or length of mealtime
  • Loss of weight or decrease in growth curve of a growing individual (can also be due to other factors)

What to do in case of dysphagia?

Since dysphagia involves health risks, if you have experienced one or more of the symptoms mentioned above, it would be important to consult with a health professional for a thorough evaluation.

Generally a thorough dysphagia evaluation requires a multidisciplinary team comprised of several types of professionals as appropriate

  • physician
  • nutritionist
  • respiratory therapist
  • speech therapist
  • occupational therapist
  • physiotherapist
  • nurse, etc.

The roles of each are different; however a complete evaluation should be comprised minimally of:

  • a medical examination to identify the health condition, medication or treatment responsible for dysphagia and attempt to eliminate these if possible (physician);
  • an assessment of nutritional and hydration status to verify if the consumption of foods and fluids meets the requirements for maintaining adequate physical and immune function (nutritionist);
  • a respiratory function test (respiratory therapist, physiotherapist specializing in respiratory therapy or physician);
  • an examination of the muscles and mechanisms of the mouth and various structures of the throat through a physical examination (all health professionals who are trained in this type of evaluation: occupational therapy, speech therapist, nutritionist, physician, etc.).

Following this, if necessary, meal time observation can be done to allow involved health professionals to better understand, identify and possibly correct the issues causing daily challenges to the individual. As needed, the team may also suggest a radiology test which allows visualization of the inside of the mouth and throat while the individual eats foods containing barium. This technique is called video fluoroscopy or modified barium swallow.

The team’s assessment allows them to pinpoint which stage of swallowing is defective and the associated health risks. Once done, the team can propose temporary or permanent methods to improve quality of life and decrease risk.

What is dysphagia?

If not taken seriously, dysphagia can lead to aspiration pneumonia. Aspiration is the result of an abnormal passage of food (solid or liquid) to the respiratory rather than the stomach. Normally, if a food passes into the respiratory tract our cough reflex clears the food from the airway. For individuals with dysphagia, the cough reflex is sometimes weak or absent, which may increase the incidence and severity of aspiration. If the overall state of health of the individual is insufficient, aspirations can lead to pneumonia which is called aspiration pneumonia.

Several situations can increase the risks of aspiration, including:

  • Poor nutritional status/ decreased muscular strength at the level of the throat
  • Fatigue or decreased alertness during mealtime
  • Inadequate posture during mealtime (i.e.: person not seated properly or semi-reclined)
  • Eating very quickly
  • Inappropriate consistency of liquids or inappropriate food textures

Deterioration of nutritional status

Aside from aspiration pneumonia, there is a major risk of deterioration in nutritional status. In order for the body and immune system to function properly it is important to be well nourished. Unfortunately, people affected by dysphagia often tend to eat less and/or have inadequate hydration: they may leave several food items untouched on their plate (even their favorite foods) and reduce the quality of their food intake because of physical discomfort, frequent coughing, or even ashamed of their difficulty. Health consequences can be serious in both the short and long term.

Loss of pleasure in eating

Finally, another serious risk is the loss of pleasure in eating. At first glance, this may seem less serious than pneumonia or health conditions related to nutritional status, however it can be detrimental to the mental health and social life of the person affected by dysphagia. For example

  • If eating becomes unpleasant and meals are usually eaten three times daily, life will seem less enjoyable, affecting your mood.
  • If eating a meal takes longer and is more difficult and you are invited to a party or a restaurant, you may refuse the invitation which can further socially isolate you.
  • If you cough frequently during meals, this may disrupt family mealtime and you may decide or be asked to eat before or after other family members, which will put you one more time away. Dysphagia can drastically diminish quality of life even in cases where there are no obvious physical problems.

Is it possible to treat dysphagia?

Treatment options are varied. As for the evaluation, the determination of a treatment plan is done by a team comprised of various health care professionals. For optimal results, the multidisciplinary team should customize interventions according to the problems identified at the time of evaluation and also on the willingness of the individual affected with dysphagia.

Treating underlying causes of dysphagia

We have seen that dysphagia can have several causes. The first line of treatment is to eliminate or reduce the impact of any causes where possible.

  • Whether the problem is an illness or another treatable health problem (i.e.: pharyngeal diverticulum) that can be controlled by medication (i.e.: Parkinson), the physician will use the appropriate treatment.
  • If the problem is linked to medication (lack of compliance, dryness of the mouth,…..), the physician in collaboration with the pharmacist when required, will attempt to modify the medication to minimize the undesirable side effects.
  • If the nutritional or hydration status is compromised, the nutritionist will attempt to correct and prevent further deterioration of the latter. To do this, the nutritionist will guide the person in their food choices and offer nutritional support as needed.
  • If the problem is due to positioning, an occupational therapist can make the necessary adjustments.

Rehabilitation of the muscles and mechanisms involved in swallowing

  • In many cases, it is possible to rehabilitate by physically training the muscles and associated anatomical structures involved in chewing and swallowing to strengthen them and increase their efficiency.
  • In these cases, rehabilitation therapists (occupational therapists, physiotherapists and speech therapists) will assess the needs and suggest appropriate exercises that can help improve the capacity to swallow and, in some cases, solve the problem of dysphagia completely for a period of time. Breathing exercises (physician, respiratory therapist, physiotherapist specializing in respiratory therapy) to prevent pneumonia may also be recommended as needed.

Reduce the symptoms

  • In some cases, compensatory techniques (changing the position of the head, the manner in which one eats or the way food is swallowed) can be attempted by different health professionals. These techniques when applied can allow the person to swallow more normally, but they do not correct the problem permanently. If the person ceases to apply the learned techniques, the problems will reoccur.
  • Sometimes, the nutritionist will have to adapt textures and consistencies of foods to facilitate swallowing. As with all compensatory techniques, it is a preventive way to avoid the daily inconveniences, reduce health risks and sometimes increase the amount of food that can be consumed, but this will not improve the mechanisms of swallowing in the long term. Thus, if the individual stops eating the modified foods, the original problems will reoccur. Compensatory exercises and modified textures and consistencies used must be periodically reassessed as in many cases, rehabilitation and recovery time (after a CVA, for example) will allow an improvement of the person’s condition.
  • In the case of degenerative diseases, in contrast, observation for deterioration of the person’s overall condition and ability is needed. In both situations, compensatory methods will then be used and modified as required.

Oral hygiene

In all cases, cleaning teeth more often is a recommended practice. This decreases the number of bacteria present in the mouth and reduces the risks of aspiration pneumonia. Indeed, in cases where foods inadvertently go into the airways due to dysphagia, foods (or even saliva!) can play a carrier role of bacteria to the lungs, which is to be avoided as much as possible. If you have not visited your dentist in a long time, an appointment is indicated.

Living with dysphagia

With medical treatment, improved nutritional status or rehabilitation, it is possible to eliminate the problem of dysphagia but, in cases where this does not work, be aware that it is possible to live with this disorder by applying various compensatory techniques recommended by your health care professionals.

  • As previously indicated, if the problem cannot be eliminated, it is possible to use compensatory techniques (position of the head, so to swallow) or to adapt by modifying the texture of food and the consistencies of liquids which helps to maintain a certain pleasure of eating.
  • Vigilance and making an effort to eat meals in a pleasant surrounding will also improve mealtime. We recommend to rest before mealtime and build on the ambiance, which can be done by turning off the television or other distracting elements, playing soft music, to have a nice presentation of the dishes and take time to enjoy the food. Different professionals can give you advice on practical ways to make meal time more enjoyable and thus improve your quality of life without increasing your risk.
  • Finally, it will be possible to be followed periodically by the dysphagia multidisciplinary team. This will allow them to reevaluate, according to the frequency recommended by the physician, your overall health and stage of swallowing in order to assess the evolution of dysphagia (improvement or deterioration). Following a reevaluation, new treatments may be recommended (medical, nutritional or rehabilitation) to render the mealtime experience as enjoyable and normal as possible and to improve quality of life and the pleasure of eating.

What is the role of the nutritionist in dysphagia?

The nutritionist will assess your ability to swallow different types of liquids and solid foods. Then the nutritionist will help you:

  • Adjust textures and consistencies of food/beverages to help you swallow
  • Optimized your diet to maintain good health
  • In improving your immune system which reduces the risk of pneumonia
  • In helping to maintain your muscle mass and,
  • In balancing your food intake in order to have energy for your day’s activities