What is Dysphagia?
Dysphagia means difficulty swallowing. Millions of people are diagnosed with dysphagia each year. One in 25 adults will experience a swallowing problem in the United States (Bhattacharyya, 2014). However, the general public is typically unaware of dysphagia and it’s devastating effects. Many people do not seek treatment for dysphagia, although there are many treatment options!
Symptoms of Dysphagia
Symptoms of dysphagia can vary. Symptoms of dysphagia can include the following;
- Coughing or choking during eating/drinking
- Wet vocal quality
- Foods feeling “stuck”
- Pain during swallowing
- Regurgitation of foods
- Unable to trigger a swallow
- Heartburn, reflux, hoarseness
How is Dysphagia Diagnosed?
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.
When is Instrumental Testing Needed?
The following items are from the American Speech and Hearing Association (ASHA) for indications for instrumental swallowing assessment for oral or pharyngeal dysphagia symptoms:
- concerns regarding the safety and efficiency of swallow function
- contribution of dysphagia to nutritional compromise
- contribution of dysphagia to pulmonary compromise
- contribution of dysphagia to concerns for airway safety (e.g., choking)
- the need to identify disordered swallowing physiology to guide management and treatment
- the need to assist in the determination of a differential medical diagnosis related to the presence of dysphagia
- the presence of a medical condition or diagnosis associated with a high risk of dysphagia
- previously identified dysphagia with a suspected change in swallow function; and
- the presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function