Authors

  1. Cagle, Crystal AAS, RN
  2. Florence, Jessica BSN, RN
  3. Hemphill, Jennifer AAS, RN
  4. Hicks, Ramona AAS, RN, ACLS, BLS, NIHSS
  5. Sewell, Jason AAS, RN
  6. Jordan, Rita MSN, RN
  7. Brennan, Jean M. MS, MSN, RN, ACLS

Article Content

Simply defined, dysphagia is difficulty swallowing solid foods, liquids, or a combination of both, depending on the etiology. Although dysphagia is classified as a symptom in the International Statistical Classification of Diseases and Related Health Problems, or ICD-10, it's also been referred to as a condition. Dysphagia affects more than 9 million adults nationwide, often having a significant impact on patients' physical and mental well-being.

  
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Swallowing 101

Swallowing involves three phases: oral, pharyngeal, and esophageal. These three phases must work in sequential order, with the proper function of necessary anatomy, to successfully and safely complete the swallowing process.

 

Oral phase

The oral phase is voluntary and includes utilizing the lips, tongue, surrounding muscles, and nerves to form a bolus in the mouth. The tongue then pushes the bolus to the pharynx. Saliva also plays an important role by lubricating the mouth and helping soften food.

 

Pharyngeal phase

Once in the pharyngeal phase, the bolus activates receptors and the process becomes involuntary. In this phase, the pharynx, epiglottis, and vocal cords must function properly to protect the airway. If the airway isn't sufficiently protected, the bolus may enter the lungs and cause aspiration. As swallowing ability worsens in affected patients, aspiration may go unnoticed because there are no obvious signs, such as coughing. This is referred to as silent aspiration and can cause serious infection.

 

Esophageal phase

In the esophageal phase, the bolus travels down the esophagus using peristalsis and enters the stomach through the lower esophageal sphincter.

 

When dysphagia occurs, one or all of these phases may be involved. With neurologic dysfunction, there's a loss of nerve supply. In muscular dysfunction, the muscles used in the swallowing process may be damaged or weakened. With mechanic dysfunction, an obstruction, such as a tumor, is present.

 

Common causes

Dysphagia is defined as being either esophageal or oropharyngeal. Several disorders can cause dysphagia, as well as certain congenital abnormalities.

 

Esophageal dysphagia

Esophageal dysphagia occurs when the esophagus has a problem processing food or liquids from the mouth to the stomach. This can lead to acid reflux, coughing, choking when swallowing liquids or solids, or food stuck in the throat or chest. Causes of esophageal dysphagia include:

 

* achalasia

 

* diffuse spasm

 

* esophageal stricture

 

* foreign bodies

 

* eosinophilic esophagitis

 

* scleroderma

 

* radiation therapy.

 

 

Congenital anomalies include:

 

* esophageal atresia

 

* tracheoesophageal fistula

 

* cleft lip

 

* cleft palate.

 

 

Oropharyngeal dysphagia

Oropharyngeal dysphagia occurs in the first process of propelling liquids or food from the oral cavity to the throat. Causes of oropharyngeal dysphagia include:

 

* multiple sclerosis

 

* muscular dystrophy

 

* Parkinson disease

 

* neurologic damage caused by hemorrhagic or ischemic stroke, traumatic brain injury, or other injuries associated with the spinal cord

 

* dementia

 

* pharyngeal diverticulitis

 

* cerebral palsy, meningitis, or encephalopathy in children.

 

 

Signs and symptoms alert

Although dysphagia isn't a normal part of aging, its incidence does increase with age as a symptom of several disease processes. Because these disease processes may make it more difficult for patients to verbalize symptoms, it's imperative to be able to identify signs and symptoms of dysphagia. These include:

 

* coughing or choking while eating or drinking

 

* weight loss

 

* a changed or wet sounding voice

 

* recurrent chest infection related to silent aspiration

 

* hypoxia

 

* regurgitation

 

* food refusal

 

* spitting

 

* complaints of the sensation of a lump in the throat

 

* complaints of feeling the food or drink "went down the wrong way."

 

 

Next steps

The initial diagnosis for an outpatient experiencing swallowing difficulties usually begins with the primary care provider. This visit should include a thorough review of past medical history, predisposing conditions, and current medications. The primary care provider should inquire about how long the swallowing difficulty has persisted and if it's intermittent or continuous. If the patient has experienced weight loss, discussion about whether the dysphagia occurs with liquids, solids, or both is important.

 

A complete oral-facial exam is used to determine oral health, tongue protrusion, gag reflex, head control, and any sensorimotor impairment. The physical exam provides information on oral structures, pharyngeal and laryngeal functions, and secretion management. The primary care provider will also assess the patient's speech, such as articulation and resonance. Cognition and alertness are assessed to determine whether the patient is able to participate in further tests, which may require him or her to follow commands.

 

If dysphagia has impacted the patient's ability to eat adequately, a nutritional assessment may be performed by weight/height analysis and calculating body mass index. Blood tests may be ordered to determine if malnutrition exists.

 

A referral to an ear, nose, and throat specialist; speech therapist; neurologist; or gastroenterologist may be needed for additional testing.

 

See Testing for dysphagia for common diagnostic tests.

 

Treatment options

There are several treatment options for dysphagia, including medications, surgical and other invasive procedures, referral to a speech-language pathologist for therapy (muscle exercises and swallowing techniques), the use of feeding tubes, and special diets. For more information on special diets, see Diet consistency continuum.

 

Medications

Dysphagia that's associated with gastroesophageal reflux disease is often treated with medications, such as pantoprazole, that reduce stomach acid and prevent it from entering the esophagus. Dysphagia caused by tightening of the esophageal muscle may be treated with medications, such as calcium channel blockers, that relax the esophagus. Medications, such as diltiazem, may be used to treat dysphagia caused by Parkinson disease. An injection of botulinum toxin type A into the lower part of the esophagus can help treat dysphagia caused by achalasia.

 

Invasive procedures

For patients with achalasia dysphagia or esophageal carcinoma, surgical and other invasive procedures may be the best option. Surgical procedures may also be needed if a growth is suspected or a repair of the anatomy is required. Examples of surgical and invasive procedures include:

 

* laparoscopic Nissen fundoplication

 

* myotomy

 

* laryngeal suspension

 

* pneumatic esophageal dilation

 

* esophageal stent placement.

 

 

Speech therapy

A speech-language pathologist referral is most common in oropharyngeal dysphagia. The speech-language pathologist employs several techniques to help treat dysphagia. For example, when dysphagia is caused by problems with muscles or nerves, or the patient is experiencing neurogenic dysphagia, certain muscle exercises can help train or retrain muscles and nerves to work together to improve swallowing and muscle movement. Learning certain ways to position the head and body, such as the chin tuck, can help improve swallowing. Speech-language pathologists can also teach new ways to place food in the mouth to improve swallowing.

 

Feeding tubes

When dysphagia is unsuccessfully managed by other means, enteral feeding tubes can be used to bypass the area of concern to ensure adequate nutrition. In severe cases of dysphagia, malnutrition is a problem. A percutaneous endoscopic gastrostomy tube can be placed to insert nutritional supplements and medications directly into the stomach, bypassing the part of the swallowing mechanism that isn't functioning properly. These feeding tubes provide a more permanent solution for chronic dysphagia, but can be temporary if the cause of dysphagia is effectively treated at a later point in time.

 

For some pediatric cases or temporary, acute causes of dysphagia, a nasogastric (NG) tube may be used to provide nutrition and medication. NG tubes can be placed and left in temporarily or removed after each feeding. NG tubes aren't usually a permanent solution; if dysphagia persists, a more permanent feeding tube should be considered. Although an NG tube provides nutrition for those unable to take in food and liquids by mouth, it doesn't reduce the risk of aspiration. For patients at high risk for aspiration, a gastrojejunal or jejunal feeding tube may be placed. Both of these tubes are commonly placed for permanent use, but can be removed if the cause of dysphagia and aspiration is effectively treated.

 

Patient impact

Physically, dysphagia places a person at risk for multiple life-threatening conditions, such as acute respiratory distress syndrome, dehydration, and aspiration pneumonia. Additionally, comorbidities of dysphagia include, but aren't limited to, malnutrition, impaired skin integrity, gastric reflux, and odynophagia. In most cases, the physical impact of dysphagia becomes the principal obstacle to negotiate. This can lead to the psychosocial impact of dysphagia being undertreated.

 

It's long been understood that the conditions that cause dysphagia often also cause dysarthria, with an acknowledged corresponding psychosocial impact, but large-scale studies on the psychosocial impact of dysphagia itself are few and far between. One such study was performed in 2000, with 360 participants across four nations (France, Germany, Spain, and the United Kingdom). This study found that 85% of patients with dysphagia believed that eating should be an enjoyable experience, but only 45% of the participants felt that eating was actually enjoyable. The same study also determined that 36% of patients with dysphagia experienced moderate-to-severe anxiety during meals, whereas 41% stated that dysphagia was their primary reason for avoiding social interactions with friends and loved ones during meal times.

 

If you suspect that your patient has a swallowing disorder or anomaly, immediately voice your concern to the healthcare team. After diagnosis of dysphagia is confirmed, educate the patient and his or her family about what to expect, including treatment options.

 

With your help

By having a thoughtful awareness of the nuances of dysphagia, we can help our patients alleviate its physical and psychosocial effects.

 

Testing for dysphagia

Water-swallowing test. A speech therapist observes the patient swallowing water, noting the time it takes to swallow the water and how many swallows are needed. The test is used to assess for coughing, choking, or voice changes that occur during and after swallowing. Voice changes, such as a wet or hoarse voice, can be an indication of dysphagia. The speech therapist may include the swallowing of thickened liquids or soft food during this test. Pulse oximetry may be used to determine if there's a problem with oxygenation during swallowing.

 

Video fluoroscopy test. This test, also known as a modified barium swallow test, may be performed to assess swallowing function. An X-ray machine records a live continuous video of the patient swallowing different food and liquid consistencies mixed with barium to determine which, if any, exacerbate swallowing difficulties. Although the barium is nontoxic, it may cause nausea, constipation, and white stools for a few days after being swallowed. Patients should understand that this test involves exposure to radiation.

 

Fiberoptic endoscopic evaluation of swallowing. This test allows the nose and upper airways to be closely examined. An endoscope is inserted into the nares so that the specialist can closely examine images of the throat structures. A colored liquid may be swallowed during the test to assess swallowing function. Although this test is generally painless and can be performed at the bedside if needed, the nares may be sprayed with a local anesthetic before the endoscope is inserted.

 

Imaging scans (computed tomography [CT], ultrasonography, or magnetic resonance imaging). These scans let specialists view bones and soft tissues. Ultrasonography and CT aren't very useful in finding the cause of dysphagia, but can detect masses in the mediastinum and aortic aneurysm (dysphagia aortica).

 

Manometry. This diagnostic procedure is used to assess the esophageal muscles. A small tube is inserted through the nares into the esophagus to the stomach. It's connected to a pressure recorder that measures muscle strength and contraction during swallowing. Usually well tolerated, this procedure determines whether the esophagus is able to move food to the stomach correctly.

 

Diagnostic upper gastrointestinal (UGI) endoscopy. Also called esophagogastroduodenoscopy, this procedure yields a thorough internal assessment. A UGI endoscopy allows visualization of the inside lining of the esophagus, stomach, and first part of the small intestine. The endoscope is inserted down the throat to assess for growths, scar tissue, infections, and erosions in the esophagus that may be contributing to dysphagia. Biopsies can also be performed during this procedure. UGI endoscopy may require I.V. sedation and/or pain medication. After the procedure, some patients experience a sore throat and abdominal bloating; normal activities are usually resumed the next day.

 

Diet consistency continuum

Mechanical soft (National Dysphagia Diet [NDD] Level 3). This type of diet may be ordered for patients without enough teeth or energy to safely swallow. This can also be a temporary diet plan after surgery. Soft breads (thinly sliced), diced (1/4 inch) meats, and rice are all acceptable. Cakes and pies without nuts, seeds, or dried fruit are still on the menu. Hard cheeses and thick cold cuts are forbidden.

 

Minced diet (NDD Level 2). If the patient continues to have difficulty on the mechanical diet, this may be the next step. No French fries, chips, or rice are allowed in this diet. Soups that contain solid elements should be strained and cream soups blenderized. Moist meats and vegetables are acceptable, but have to be cut into pieces no larger than 1/8 inch. (Tip: Use a food processor to make this easier and more uniform.)

 

Ground consistency (NDD Level 2). To be considered ground consistency, food needs to be ground by a machine to the texture of small curd cottage cheese. This consistency is considered Level 2 because it's soft, moist, and requires some chewing. (Tip: Liquids will generally need to be added to obtain the right thickness.)

 

Pureed food (NDD Level 1). To be pureed, food needs to be prepared to the smooth appearance of pudding by first grinding it in a blender and then pureeing. (Tip: There are food molds available to make pureed food more aesthetically appealing.)

 

Liquid diet. There are four types of consistencies: thin, nectar, honey, and pudding. Examples of thin consistency include all liquids, ice cream, and Jell-O. Tomato juice is a good illustration of nectar thickness; most liquids need a thickener to achieve this texture. Liquids that are honey consistency pour very slowly and definitely require a thickening agent. Lastly, pudding consistency indicates liquids that need to be spooned. (Tip: When placing a spoon in the container, the liquid shouldn't be able to hold the spoon straight up.)

 

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