What is Dysphagia?

Dysphagia can be diagnosed by a physician or speech-language pathologist.  Often a speech-language pathologist is the first to diagnose dysphagia, particularly when the difficulty is occurring in the mouth or throat.  Although swallowing is very complex, it can be split into three phases for ease of understanding.  The oral stage includes the oral cavity (lips, jaw, tongue, hard/soft palate).  Some issues that may occur include difficulty with masticating, pocketing/holding foods, reduced ability to transport the food anteriorly.  In the pharyngeal phase problems can occur such as delayed swallowing, residual material in the throat.  The more concerning issues include penetration  where material enters the airway above the vocal folds or aspiration where material enters the airway below the level of the vocal folds.  If other factors are at play, aspiration can result in pulmonary compromise such as pneumonia.  These issues in the oral and pharyngeal stage are often diagnosed and treated by a speech-language pathologist.  

Dysphagia can also occur in the esophagus.  Symptoms of esophageal dysphagia include heartburn, reflux or foods feeling stuck lower.  If those symptoms are present, a gastroenterologist is recommended for evaluation.  A GI doctor may suggest an esophagram (barium swallow study) which is an x-ray study (distinct from the modified barium swallow study) and views lower into the esophagus and stomach.  An upper endoscopy may be performed to directly view the esophagus lining.  

A bedside swallowing evaluation is the first step in diagnosing dysphagia.  A cranial nerve exam is performed to assess for any damage to the nerves responsible for swallowing that may increase the risk for dysphagia.  A thorough history is performed for risk factors for dysphagia, aspiration and pulmonary compromise.  The clinician typically provides foods and liquids to assess the patient’s swallowing.  However a bedside swallow cannot determine if there is a delay.  It cannot assess for residue in the throat.  And although there can be signs of aspiration (coughing/throat clearing), a bedside swallow test is unable to determine if penetration or aspiration occurred.  

Instrumental swallowing assessments are often used to further assess the swallowing in patient’s with clinical signs of dysphagia.  Instrumental swallowing assessments include the Flexible Endoscopic Evaluation of Swallowing (FEES) and the Modified Barium Swallow Study.  You can learn more about the differences between those two studies here.  SLPs interpret these tests and then make recommendations based on the results such as food consistencies, postures, positioning, compensatory strategies and treatments to help improve the swallowing.