Investigation & management of adult patient with dysphagia

Dysphagia: is a Greek word for disordered swallowing.

Common causes of dysphagia in an adult:

Dysphagia due to conditions affecting the oral phase of swallow:

• Cannot hold food in the mouth anteriorly due to reduced lip closure
• Cannot form a bolus or residue on the floor of the mouth due to reduced range of tongue motion or coordination
• Cannot hold a bolus due to reduced tongue shaping and coordination
• Unable to align teeth due to reduced mandibular movement
• Food material falls into anterior sulcus or residue in the anterior sulcus due to reduced labial tension or tone.
• Food material falls into lateral sulcus or residue in the lateral sulcus due to reduced buccal tension or tone.
• Abnormal hold position or material falls to the floor of the mouth due to tongue thrust or reduced tongue control
• Delayed oral onset of swallow due to apraxia of swallow or reduced oral sensation
• Searching motion or inability to organize tongue movements due to apraxia of swallow
• Tongue moves forward to start the swallow due to tongue thrust.
• Residue of food on the tongue due to reduced tongue range of movement or strength
• Disturbed lingual contraction (peristalsis) due to lingual dyscoordination
• Incomplete tongue-to-palate contact due to reduced tongue elevation
• Unable to mash material due to reduced tongue elevation
• Adherence of food to hard palate due to reduced tongue elevation or reduced lingual strength
• Reduced anterior-posterior lingual action due to reduced lingual coordination
• Repetitive lingual rolling in Parkinson disease
• Uncontrolled bolus or premature loss of liquid or pudding consistency in to the pharynx due to reduced tongue control or linguoaveolar seal
• Piecemeal deglutition
• Delayed oral transit time

Dysphagia caused by disorders affecting Pharyngeal phase of swallow:

• Delayed pharyngeal swallow
• Nasal penetration during swallow due to reduced velopharyngeal closure
• Pseudoepiglottis (after total laryngectomy) - Fold of mucosa at the base of the tongue
• Cervical osteophytes
• Coating of pharyngeal walls after the swallow due to reduced pharyngeal contraction bilaterally
• Vallecular residue due to reduced posterior movement of the tongue base
• Coating in a depression on the pharyngeal wall due to scar tissue or pharyngeal pouch
• Residue at top of airway due to reduced laryngeal elevation
• Laryngeal penetration and aspiration due to reduced closure of the airway entrance (arytenoid to base of epiglottis)
• Aspiration during swallow due to reduced laryngeal closure
• Stasis of residue in pyriform sinuses due to reduced anterior laryngeal pressure
• Delayed pharyngeal transit time

Dysphagia caused by oesophageal disorders:

• Esophageal-to-pharyngeal backflow due to esophageal abnormality
• Tracheoesophageal fistula
• Zenker diverticulum
• Reflux

Investigations:

1. Chest radiograph

2. Ultrasound abdomen

3. Barium swallow

4. CT / MRI scan neck

5. Videofluroscopy study of swallowing

6. Fibreoptic endoscopy

7. Scintigraphy for oesphageal disorders

8. Oesophageal pH monitoring - reflux oesophagitis

Management:

Dietary modification: This plays an important role in oropharyngeal dysphagia. Diet can be mashed and made into a puree to enable easy swallowing. If the patient's swallowing improves the consistency of the food can be improved.

Increased viscosity of liquid: If liquid diet gets aspirated while attempting to swallow then viscosity can be added to the liquid by addition of starch. This increases the consistency of the liquid preventing aspiration.

Ryles tube feeding: If the patient is suffering from dysphagia due to obstructing lesion in the pharynx, laryngopharynx, oesophagus due to tumors then Ryles tube can be inserted and feeding initiated.

Feeding gastrostomy / jejunostomy: Are advised in patients with absolute dysphagia due to tumors involving postcricoid area and oesophagus.

Exercises and facilitation techniques:

Methods belonging to this group are useful in patients with dysphagia due to paralysis of oropharyngeal muscles / lip muscles. Lip, tongue and jaw exercises play a vital role.

Facilitating maneuvers: These are helpful in preventing aspiration during swallow. They also help in swallowing process in a patient who has undergone total laryngectomy. These include:

Supraglottic swallow

Extended supraglottic swallow

Super supraglottic swallow

Mendelson maneuver - helps in cricopharyngeal opening and laryngeal elevation during swallow