Chapter 10:

DysphagiaJusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Focus QuestionsWhat is dysphagia?How is dysphagia classified?What are the defining characteristics of dysphagia?How is dysphagia identified?How is dysphagia treated?10.1JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

IntroductionDysphagia: impairment in the ability to swallow because of neurological or structural problems that alter the normal swallowing processASHA expanded the Scope of Practice for speech-language pathologists to include swallowing disorders in late 1980sDysphagia intervention now makes up about 50% of a SLPs caseload in medical settings (e.g., hospital, nursing homes)10.2JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Case Study #1: Sylvia Anderson78-year old with Alzheimers dementia living in a nursing home needs minimal to moderate assistance while eatingLately, hasnt been finishing meals, has gurgly voice quality during mealtime, and has recently had severe coughing episodes while eating SLP suspects a pharyngeal stage swallowing problem and wants a further instrumental assessment at local hospital10.3JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Case Study #1 QuestionsTransporting Sylvia to the local hospital for an instrumental examination is costly. How can the costs be justified?How might reliance on others for assistance with feeding influence nutritional status and hydration?10.4JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Case Study #2: Lee Chin43-year old bilingual man who has persistent dysphagia following cancer of the right buccal spaceTo treat the cancer, Lee had radiation therapy and neck dissectionCurrently exhibits pharyngeal dysphagia, aspiration, hoarse vocal quality, and right lower facial weaknessCurrently receives nutrition through a g-tube10.5JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Case Study #2 QuestionsIs Lee a candidate for dysphagia therapy at this time? Why or why not?What education should be provided to Lee regarding his situation?10.6JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Case Study #3: Martin Coleman45-year old man diagnosed with ALS 18 months agoUnable to work, on a puree diet with thin liquids, has lost 15 pounds in past two months, just recovered from severe aspiration pneumoniaMBS shows severe oral and pharyngeal dysphagia with aspirationMartin and his family now need to decide whether or not to resort to feeding tube, and want to consult their priest to make sure decision is in keeping with their religious beliefs10.7JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Case Study #3 QuestionsAs the speech-language pathologist, what are your responsibilities to this client and his family in making their decision?What support systems should be provided to this family during their decision-making process?10.8JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

I. What is Dysphagia?Disorder of swallowing rendering person unable to safely and/or efficiently eat or drinkTo understand disorder swallowing, must first understand the normal swallowing process10.9JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

The Normal SwallowInnate ability which is present in the developing fetusNecessary to maintain nutrition and hydrationAdults swallow approximately 580 times daily unconsciously Swallowing is a four-phase process:Oral preparatory phaseOral phasePharyngeal phaseEsophageal phase10.10JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Oral Preparatory PhaseBegins as food or liquid enters the mouthContaining, manipulating, and preparing the food or liquid into a bolusChewing (mastication) occurs to grind solid bolus into manageable textureRequires coordination of lips, tongue, teeth, mandible, and cheeksDuration: variable depending on substanceRespiration: normal through the nose (mouth closed)10.11JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Oral PhaseBolus is propelled to the back of the mouthstripping action by the tongueTension in the cheeks (buccal muscles)Duration: 1-1.5 secondsRespiration: normal through the nose

10.12JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Pharyngeal PhaseBegins as the bolus reaches the tonsils (faucial pillars)Pharygeal swallow reflex is triggered:Pharyngeal wall and back of tongue move together and pharyngeal muscles squeeze to move bolus down through the pharynxUpper esophageal sphincter opens to allow passage of bolus into esophagusTime: 1 secondRespiration: briefly halted (apneic moment)During bolus transit, risk of food or liquid entering the airway10.13JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Pharyngeal Phase Protective MechanismsSoft palate elevates to stop bolus from flowing upward into nasal areaLarynx moves forward and higher in the neck to reduce risk of entrance into airwayEpiglottis forms a cover over the larynxVocal folds come together to close the entrance into the larynxIf material does enter the larynx, reflexive cough to expel it will occur10.14JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Esophageal PhaseBolus is propelled through the esophagus by an involuntary wave or contractionMoves from the upper esophageal sphincter through the lower esophageal sphincter and into the stomachTime: 8-20 seconds, can be influenced by age (often increase in duration in elderly population)Respiration: normal through nose and mouth10.15JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Disordered Swallow: DysphagiaImpairment can occur in one, some, or all of the four phases of swallowingSome persons have impairments that result in aspiration (food or liquid moves below the level of vocal folds into the airway)Some persons have to alter their diet to control the consistencies, but this can cause difficulty maintaining hydration and nutritionSome persons require an enteral feeding tube for nutritional maintenance10.16JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Additional ConsiderationsDysphagia should not be confused with a disruption in feeding, but it is one subgroup of feeding disorders Dysphagia is not a disease but a symptom of several etiologies (e.g., neurological injuries, progressive brain diseases)Social and psychological impacts of dysphagia: changes in eating routines and food choices, decreased personal independence, and challenge to participating in community activities10.17JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Prevalence and IncidenceStatistics on who experiences dysphagia:14% of acutely hospitalized patients30-35% of patients in rehabilitation facilities50% of residents in nursing home environments

10.18JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

II. How is Dysphagia Classified?No universally accepted system, but usually based on etiology, manifestation, and severitySome available instruments:Penetration-Aspiration Scale: 8-point scale to describe degree of airway protection during the swallow (1 = no material enters airway, 8 = aspiration)New Zealand Index for Multidisciplinary Evaluation of Swallowing: rates swallowing performance on a scale from 0 to 4 (0 = no significant impairment, 4 = profound impairment)10.19JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

III. Defining Characteristics of DysphagiaStructural abnormalities or physiological deficits for each of the phases of swallowing:Oral preparatoryOralPharyngealEsophagealSLP manages oral preparatory, oral, and pharyngeal dysphagias (i.e., oropharyngeal dysphagia); gastroenterologist manages esophageal dysphagia10.20JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Oral Preparatory Phase DysphagiaLikely causes: head and neck cancers, stroke, Parkinsons diseaseCharacteristics:Decreased lip closureProblems controlling ingested materialsProblems biting or chewingInefficient oral preparation (long duration)10.21JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Oral Phase DysphagiaLikely causes: stroke, progressive neurological diseasesCharacteristics:Difficulty moving bolus to the back of mouthInability to control bolus flowDelayed initiation of bolus movement

10.22JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Pharyngeal Phase DysphagiaLikely causes: head and neck cancers, neurological disordersCharacteristics:Incomplete palatal elevation (nasal reflux)Delayed initiation of pharyngeal swallow reflexWeak tongue and pharyngeal muscle forcesReduced laryngeal elevation (more prone to aspiration)Inadequate opening of the upper esophageal sphincter (bolus cannot move into the esophagus)10.23JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Esophageal Phase DysphagiaLikely causes: reflux, certain cancersCharacteristics:Structural abnormalities in esophagusDecreased esophageal motility or contractionInadequate opening of lower esophageal sphincter (bolus cannot move into stomach)Excessive opening of the lower esophageal sphincter, allowing backward flow of contents from stomach to esophagus (reflux)10.24JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Dysphagia Causes: Neurological DiseaseStrokeInterruption in blood supply to brain, resulting in brain damageFrequency of dysphagia is about 50%Increases risk for malnutrition, aspiration, and pneumoniaTraumatic brain injuryDysphagia is common complication of neurological damage (from 26 71%)Delay in pharyngeal swallow reflex, decreased pharyngeal constriction, and oral motor problems10.25JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Dysphagia Causes:Progressive Neurological DiseaseParkinsons disease:Incidence of dysphagia from 50% to 92%Drooling, problems in bolus preparation and transport, delayed swallowing reflex, aspiration, residual materials in pharynxAmyotrophic lateral sclerosis:Also known as Lou Gehrigs disease, patients will experience oropharyngeal dysphagia at some point in their disease processDementia: Dysphagia is common feature in moderate and severe impairment levels10.26JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Dysphagia Causes:Head and Neck CancersMany patients with cancers of the mouth, pharynx, and larynx experience dysphagia prior to medical management of the cancer, but treatments can cause dysphagia or make the already existing case more severeThe extent of the medical intervention to combat the cancer influences the swallowing profile

10.27JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Dysphagia Causes:Medical InterventionsSurgical management: full or partial removal of components of swallowingRadiation therapy: reduced saliva production, edema, tooth decay, and painChemotherapy treatment: nausea, vomiting, and fatigueTracheotomy: tube alters normal air exchange, interfering with swallowing performance10.28JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

IV. How is Dysphagia Identified?SLP is responsible for these tasks:Determine presence or absence of dysphagiaDetermine underlying causesAssess severityMake recommendationsDesign and implement rehabilitation planShare information with other professionalsNeed to achieve a balance between concern for safety issues and quality of life10.29JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Consultation with the SLPReferral from physician or nurse who suspects swallowing impairmentInterdisciplinary approach to screening at hospitals, rehabilitation centers, and clinics:Health care staff members should be trained to recognize possible signs of dysphagia, and then make referral to SLP for further evaluation10.30JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Clinical Swallowing ExaminationAlso called Bedside Swallow Examination:Review of medical recordsComprehensive interview with clientOral mechanism examinationTrial feedings observationFeeding recommendationsReferrals for either:Further instrumental assessment (need physicians prescription to be covered by insurance)Specialized testing by other professionals

10.31JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Instrumental Dysphagia ExamMore objective, quantifiable measure of swallowing functionCommonly used approaches:Fiberoptic Endoscopic Examination of Swallowing: visualization of swallowing through flexible tube with recordable cameraUltrasonography: uses sound waves to recreate a picture of structures (most beneficial in oral phase evaluationVideofluorscopy: same as a modified barium swallow (most commonly used; gold standard)10.32JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

V. How is Dysphagia Treated?SLP works to remediate oropharyngeal dysphagiaCompensatory approachesRestorative approachesTo maintain nutrition, dietary modifications and/or alternative nutrition via a feeding tubeNasogastric, gastrostomy, jejunostomyInclude ongoing assessment of clients response to intervention, and adjust goals and approaches to fit evolving needs10.33JusticeCommunication Sciences and Disorders: An IntroductionCopyright 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.