Excerpts from "Dysphagia" by Nam-Jong Paik, MD, PhD update for E-medicine.com August 19, 2004

Dysphagia is a Greek word that means disordered eating. Typically, dysphagia refers to difficulty in eating as a result of disruption in the swallowing process. Dysphagia can be a serious threat to one's health because of the risk of aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. A number of etiologies has been attributed to dysphagia in populations with neurologic and nonneurologic conditions.

Disorders leading to dysphagia may affect the oral, pharyngeal, or esophageal phases of swallowing. A thorough history and careful physical examination are important in the diagnosis and treatment of dysphagia. The bedside physical should include examination of the neck, mouth, oropharynx, and larynx. A neurologic examination also should be performed. Several clinical bedside swallowing assessments have been suggested, but videofluoroscopic swallowing studies have been accepted as the standard for detecting and evaluating swallowing abnormalities. This method not only estimates risks of aspiration and respiratory complications, but it also helps determine diet and compensatory strategies.

History:

General Signs and symptoms of dysphagia

Phase-specific signs and symptoms

Logemann's Manual for the Videofluorographic Study of Swallowing cites the following oral-phase swallowing symptoms and disorders:

Pharyngeal phase - if clearance is impaired severely, a patient may be unable to ingest sufficient amounts of food and drink to sustain life. In persons without dysphagia, small amounts of food commonly are retained in the valleculae or pyriform sinus after swallowing. In case of weakness or lack of coordination of the pharyngeal muscles, or poor opening of the upper esophageal sphincter, patients may retain excessive amounts of food in the pharynx and experience overflow aspiration after swallowing. Logemann's Manual for the Videofluorographic Study of Swallowing cites the following pharyngeal-phase swallowing symptoms and disorders:

Severity of aspiration can be described in the following 2 ways: (1) estimate the percentage of the total bolus aspirated and (2) estimate the depth of bolus invasion into the airway. The Eight-Point Penetration-Aspiration Scale is an example of an estimation tool.

Esophageal phase - problems may result from mechanical obstruction, motility disorder, or impaired opening of the lower esophageal sphincter. Logemann's Manual for the Videofluorographic Study of Swallowing cites the following swallowing symptoms and disorders of the esophageal phase:

History also should be directed at eliciting information about symptoms related to gastroesophageal reflux disease including heartburn, belching, sour regurgitation, and water brash.


During the physical examination, look for oral-motor and laryngeal mechanisms. Cranial nerve testing of V, VII, through XII is essential for determining physical evidence of oropharyngeal dysphagia. Direct observation of lip closure, jaw closure, chewing and mastication, tongue mobility and strength, palatal and laryngeal elevation, salivation, and oral sensitivity is necessary.

Check the patient's level of alertness and cognitive status because they can impact the safety of swallowing and ability to learn compensatory measures.

Dysphonia and dysarthria are signs of motor dysfunction of the structures involved in oral and pharyngeal swallowing.

Inspect the oral cavity and pharynx for mucosal integrity and dentition.

Examine the soft palate for position and symmetry during phonation and at rest.

Evaluate pharyngeal elevation by placing 2 fingers on the larynx and assessing movement during a volitional swallow. This technique helps to identify the presence or absence of key laryngeal protective mechanisms.

The gag reflex is elicited by stroking the pharyngeal mucosa with a tongue depressor. Testing for the gag reflex is helpful, but absence of a gag reflex does not necessarily indicate that a patient is unable to swallow safely. Indeed, many persons with no gag reflex have normal swallowing, and some patients with dysphagia have a normal gag reflex. Pulling of the palate to one side during gag reflex testing indicates weakness of the muscles of the contralateral palate and suggests the presence of unilateral bulbar pathology.

Cervical auscultation becomes part of the clinical evaluation of dysphagic patients. Assess sound strength and clarity, timing of apneic episode, and speed of swallowing.

Assessing respiratory function also is essential. If there is inadequate respiratory force of a cough or clearing the throat, risk of aspiration is increased.

The final step in physical examination is direct observation of the act of swallowing. At a minimum, watch the patient while he or she drinks a few ounces of tap water. If possible, assess the patient's eating of various food textures. Sialorrhea, delayed swallow initiation, coughing, a wet or hoarse voice quality may indicate a problem. After the swallow, observe the patient for 1 minute or more to see if delayed cough response is present. DePippo et al suggested a 3-oz water swallow test, which identified 80% of stroke patients subsequently found to be aspirating based on videofluoroscopic studies.


Initial laboratory evaluations should be limited to specific studies based on the differential diagnosis.


Special studies

Videofluorographic swallowing study

The terms videofluorographic swallowing study (VFSS) and modified barium swallow (MBS) often are used interchangeably.

Some clinical researchers think they can identify patients with potential to develop pneumonia by interpreting findings of the bedside test. Most clinical researchers, however, agree that videofluoroscopy is the standard for detecting patients who have potential to develop pneumonia and for diagnosing aspiration and swallowing problems from potential discrepancies between findings of bedside tests and videofluoroscopy.

Splaingard et al reported that only 42% of patients who manifest aspiration by videofluoroscopy were diagnosed with some abnormalities in the bedside test. This indicates that bedside test results are not enough in evaluation of frequency of aspiration. Generally, 40-70% of patients suffer silent aspiration, which does not manifest specific symptoms.

Fiberoptic endoscopic examination of swallowing: A transnasal laryngoscope is used to assess pharyngeal swallowing. The procedure is a sensitive technique for detecting premature bolus loss, laryngeal penetration, tracheal aspiration, and pharyngeal residue. Because pharyngeal contraction obstructs the lumen, the fiberoptic endoscopic examination of swallowing (FEES) does not show motion of essential food pathway structures or the food bolus during the swallow. Swallowing is evaluated directly, using measured quantities of food colored with blue liquid dye. An FEES may be helpful when a VFSS is not feasible (eg, in critically ill patients unable to tolerate any risk of aspiration, patients in intensive care units who cannot be transferred to the fluoroscopy room, patients who require prompt evaluation).

Scintigraphy: limited value in evaluation of pharyngeal swallowing disorders. This test is useful in quantitative and qualitative evaluation of subglottic aspiration, esophageal motility disorders, and gastroesophageal reflux. Oropharyngeal transit time can be measured through time-activity curves constructed from a specific region of interest (ROI) of the mouth, pharynx, and esophagus. Peaks and nadirs of the first derivative curve correspond to peak emptying or filling rates of the respective regions.

Reflex cough test: The test uses a 20% solution of L-tartaric acid dissolved in 2 mL of sterile normal saline. The solution is inhaled by the patient through a nasal nebulizer, which stimulates cough receptors in the vestibule of the larynx and initiates the laryngeal cough reflex. The laryngeal cough reflex protects the laryngeal aditus from significant aspiration and reduces risk of respiratory complications (eg, pneumonia). Impaired laryngeal cough reflex may permit laryngeal penetration and increase risk of aspiration pneumonia.

Addington WR, Stephens RE, Gilliland K, Rodriguez M: Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke.

An acute cerebrovascular accident often appears to affect the protective cough reflex. Addington et al used the reflex cough test to identify 100% of stroke patients subsequently found to be free of pneumonia (specificity of 100%).

Swallowing electromyography: Mechanical upward-downward movement of the larynx is detected using a piezoelectric sensor while submental integrated electromyography (EMG) activity is recorded during dry and wet swallowing. EMG activity of the cricopharyngeal muscle of the upper esophageal sphincter also can be recorded. In the group of patients with muscular disorders, laryngeal elevators are involved while the cricopharyngeal sphincter is intact. In the group of patients with clinical signs of corticobulbar fiber involvement (eg, patients with ALS and pseudobulbar palsy), dyscoordination between paretic laryngeal elevators and the hyperreflexic cricopharyngeal sphincter is present. Laryngeal EMG can help the clinician diagnose oropharyngeal dysphagia of peripheral nerve origin (ie, recurrent laryngeal or superior laryngeal nerve injury).

Manometry assesses motor function of the esophagus. A catheter with multiple electronic pressure probes is passed into the stomach, measuring esophageal contractions and defining upper and lower esophageal responses to swallowing. Manometry detects definitive abnormalities in only 25% of patients with nonobstructive lesions, so its clinical use in oropharyngeal dysphagia is very limited.

Esophageal pH meter [or probe] remains the criterion standard for diagnosing patients with suspected reflux disease. A nasogastric probe is inserted into the patient's esophagus and records pH levels. These levels are compared with the patient's record of symptoms over a 24-hour period to determine whether acid reflux contributes to his/her symptoms.

Gastroesophageal endoscopy provides the best assessment of the esophageal mucosa. Endoscopy has the added benefit of detecting infection and erosions and providing biopsy capability.

Ultrasonography only evaluates the region of the tongue posterior to the hyoid level and may aid in evaluation of submucosal and extramural lesions of the esophagus.

Computed tomography and magnetic resonance imaging provide excellent definition of structural abnormalities, particularly when used to evaluate patients with suspected central nervous system (CNS) causes of dysphagia.

The Swallowing Rating Scale was suggested by the American Speech-Language-Hearing Association (ASHA) to describe the functional severity of dysphagia systematically. The categories are as follows:

Han TR, Paik NJ, Park JW: A functional dysphagia scale using videofluoroscopic swallowing study for stroke patients . Arch Phys Med Rehabil 2001; 82(5): 677-82[Medline].

8-Point Penetration-Aspiration Scale

Source: Rosenbek, JC, Robbins, J, Roecker EV, Coyle, JL, & Woods, JL. A Penetration-Aspiration Scale. Dysphagia 11:93-98, 1996.


Date: Fri, 23 May 2003 01:30:24 EDT
To: dysphagia@b9.com
Subject: [Dysphagia] Trach-->PEG

Hi all. I am noticing a very consistent trend in my facility (acute care) and wondering how common this is. I am approximating that about 90% of our pts receiving trachs (vent or weaned to trach collar) are eventually having PEGs placed as well before d/c. This is despite a dysphagia eval that often shows at least a functional swallow for several consistencies PO. I am aware that swallow is frequently affected to some degree, and true, I cannot prove there is 0 aspiration occurring (MBS for all these patients is not a feasible option for many reasons...) but I have to wonder - am I being too idealistic, are MDs (generally pulmonary/GI) simply being practical? What are SLPs in LTC and other settings finding in the long run? Most frustrating is that on subsequent admissions to hospital, many appear malnourished/dehydrated despite the tube feeds (and documented necessity for PEG was to "ensure adequate nutrition, even though tolerating PO")

  1. Is this standard treatment of trach pts?
  2. do you agree/disagree with rationale?
  3. what considerations (relating to respiratory and overall med. status) might help predict which pts are more likely to succeed on full oral diet?
  4. do you think these patients may lose some physiological capacity by actually swallowing less? Or possibly just lose interest?
  5. any research??


Date: Sat, 22 May 2004 10:02:26 -0500
To: dysphagia
Subject: [Dysphagia] dementia and dysphagia

One more thought. Just last week, I evaluated a woman with late stage dementia, new to our SNF / memory care unit because her husband could not get her to eat at home and she was getting weaker. She really showed no signs of chewing or swallowing difficulty, but just was very confused and would not eat much. I counseled him about encouraging fluids, foods that she enjoyed, and good oral hygiene for quality of life.

She ended up in the hosp. 2 days later for critical labs. They found a large cancerous lesion in her lower stomach nearly obstructing her gastric outlet. No wonder she would not eat! Lesson: When the person stops eating, there is usually a reason. In her case, it was nice to know so that we do not get over-zealous about trying to get her to eat (which we do), and can just let her be. Sometimes you don't get to find out, but the point is that you need to listen to the patient, even when they can't talk.