What is a Swallowing Disorder?
Before explaining the disorder of swallowing, it is important to understand the basic anatomy and the process of a normal swallow. Usually the lips and tongue hold food and aid in pushing it to the back of the mouth. The soft palate pushes down on the back of the tongue to help form the food into a bolus while the hyoid bone elevates and moves forward. This movement, along with the contraction of several muscles, allows the food to pass over the epiglottis which covers the airway. The bolus and food then move past the covered larynx (voice box) and into the pharynx (back throat). Dysphagia is any abnormality occurring during this process. It can occur due to a stroke, Parkinson’s disease, Lou Gehrig’s disease, or any other condition affecting the neuromuscular structures in the head and neck. Because the structures involved in breathing and swallowing are in such close proximity, ingestion of food particles into the airway is a major concern. The most severe cases of dysphagia can lead to aspiration pneumonia due to bacteria in the lungs from an abnormal swallow. It is not uncommon for aspiration pneumonia to lead to death.
How Will I Know There’s a Problem?
Symptoms include inability to hold food in the mouth, difficulty moving food from the front to the back of the mouth, or “pocketing” of food particles in the mouth after the swallow. Some patients may feel like food is “stuck” in the throat, have pain during swallowing, cough before, after, or during the swallow, or demonstrate esophageal reflux. If any of these signs occur, a dysphagia evaluation is recommended to ensure safe nutritional intake. In the event that a person is hospitalized after a stroke, the physician may request a speech therapist from the Center for Speech, Language and Occupational Therapy, Inc. to evaluate swallow safety before discharge. Not all symptoms present themselves immediately after an accident. However, if they arise as the patient’s condition changes, an outpatient evaluation can easily be performed.
What Happens Next?
A complete diagnostic evaluation is the first step in developing a safe and effective therapy plan. Initially an extensive bedside exam is performed to assess the musculature of the lips, cheeks, and tongue. The coordination and range of motion in these structures dictates the safest diet to ingest. If problems are suspected after the food has left the oral cavity, a Modified Barium Swallow (MBS) test is commonly recommended. This X-Ray exam involves eating food or liquid that contains barium, which “highlights” the food and allows it to be seen on the X-Ray as it travels from the mouth to the stomach. This test is essential for determining whether or not an individual is aspirating or passing food particles into the airway. It also allows speech therapists to pinpoint the location of breakdown and identify the affected muscles and nerves, as well as clearly define the type of therapy most beneficial to the patient. Therapy can be a combination of strengthening muscle range and coordination, increasing sensitivity to the presence of food, diet manipulation, and patient education and training. Each speech therapist has a unique approach to addressing these issues, but diet manipulation uses standard categories to establish appropriate food consistency. Broken into three basic levels, food diets are referred to as puree, mechanical soft, or regular. Puree diets may include applesauce, pudding, or anything that can be blended into that consistency. This diet is considered the easiest to ingest because it requires minimal chewing or bolus formation. Mechanical soft diets contain items of a “mashed potato” consistency which are often put in gravy to lubricate the swallow. These diets are recommended for patients with more muscle coordination and control than those on a puree diet. A regular diet indicates that a patient can safely manipulate any solid consistency, but does not mean that dysphagia is not present. Swallowing difficulties may occur with liquids alone, or in combination with solids. Liquid consistencies are divided based on thickness, and are categorized as thin, nectar thick, or honey thick. Water is the guide used for “thin”, and moves quickly through the mouth to the stomach. A patient who is slow in covering the airway during the swallow may be restricted from thin liquids in order to reduce the risk of aspiration. Nectar thick consistency is that of apricot nectar. Honey thick liquids resemble honey, and move slowest through the oral cavity. The slower a liquid moves, the more time a patient has to prepare for each stage of the swallow and reduce risk of aspiration. By adding a powdered substance known as “Thick It” to liquid, any consistency can be established. For patients requiring diet modification after a hospital stay, “Thick It” can be purchased over the counter and added to foods as needed.
For individuals who aspirate on the Modified Barium Swallow (MBS) exam, eating is not safe. These patients are given nothing by mouth. Medical professionals on the patient’s rehabilitation team discuss alternative methods of feeding and choose one of two nutrition options. Nutrition can be passed through a nasogastric tube or a PEG tube. A nasogastric tube is placed in the nostril, through the nasal cavity and along the back of the throat until it enters the pharynx, bypassing the swallowing mechanism. It is a temporary solution that provides nutrition until the patient’s status has improved to an independent swallow. A PEG tube is surgically placed in the small intestine and food is passed through it directly into the stomach. It is considered a less temporary method of feeding.
What Can I Do to Help?
The most important thing friends and family can do to help individuals with dysphagia is support them. Go to therapy sessions and learn how to prepare safe foods for your loved ones. Encourage them to stay educated and respect the risks involved when eating is unsafe.