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Related Subjects: |Dysphagia |AIDS(HIV) Gastrointestinal Disease |Achalasia |Bulbar vs Pseudobulbar palsy |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus

Aspiration pneumonia can develop after accidentally inhaling something, such as a small piece of food or drinks or feeds. Absolute dysphagia when patient cannot even manage to swallow their own saliva.

About

• Dysphagia is the medical term for swallowing difficulties.

Swallowing

• Swallowing involves more than 30 muscles, so timing and coordination are crucial. It takes your brain, along with several nerves, muscles, two muscular valves, and an open oesophagus to work just right. There are three phases of swallowing
  • 1. First phase - oral preparatory phase where food is chewed into a size, shape and consistency that can be swallowed. The tongue is critical in controlling the food for chewing and for moving the food into the proper position for swallowing which is at the back of the tongue. Health and Safety Guidelines Dysphagia
  • 2. The second phase - pharyngeal phase. Food is advanced through the pharynx (behind the mouth; the throat) and into the oesophagus. During this phase muscles move the larynx (the area below the root of the tongue and above the trachea which contains the vocal cords) upward and forward to close the airway (trachea) and protect from aspiration. Normal muscle and nerve coordination must occur for this to work
  • 3. Third phase - oesophageal phase: Coordinated contractions of muscles (peristalsis) in the oesophagus along with the relaxation of the lower oesophageal sphincter moves food into the stomach

Mechanical causes

• Dry sore mouth - multivitamins
• Benign oesophageal stricture
• Achalasia
• Oesophageal cancer
• Oesophageal web
• Benign oesophageal tumour s, Extrinsic lesions

Neurological causes (usually bilateral lesions)

• Stroke: large or bilateral or Lateral medullary syndrome
• MS with pseudobulbar palsy
• Parkinson's disease
• Bulbar palsy (MND, Polio)
• Myasthenia gravis
• Functional
• Muscular dystrophy

Painful

• Infectious mononucleosis
• Acute Epiglottitis - drooling - get Anaesthetic help before examining
• Quinsy and abscess
• Lemierre's syndrome is a rare and potentially life-threatening condition. Fusobacterium necrophorum

Clinical signs

• Coughing or choking when eating or drinking
• Bringing food back up, sometimes through the nose
• A sensation that food is stuck in your throat or chest
• Persistent drooling of saliva
• Being unable to chew food properly
• A gurgly, wet-sounding voice when eating or drinking

Investigations

• FBC, U&E, CRP, TFT
• CXR may show a fluid level or a mass
• Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), uses a lighted fibreoptic tube, or endoscope, to view the mouth and throat while examining how the swallowing mechanism responds to such stimuli as a puff of air, food, or liquids.
• Video fluoroscopic swallow study (VFSS) is a test in which a clinician takes a videotaped X-ray of the entire swallowing process by having you consume several foods or liquids along with the mineral barium to improve visibility of the digestive tract.
• Upper GI endoscopy
• CT chest

Management

• Depends very much on the cause whether it is a difficulty in the swallowing process neurologically or an actual obstruction
• Speech and language therapy to learn new swallowing techniques changing the consistency of food and liquids to make them safer to swallow
• May need to consider other forms of feeding – such as tube feeding through the nose or stomach or PEG feeding depending on prognosis and cause
• Endoscopy to look for oesophageal stenosis that may require stretching it or inserting a plastic or metal tube (stent)
• Advice
  • Sit upright at a 90-degree angle
  • Remain upright for at least 15 to 20 minutes after eating
  • Minimize distractions while eating
  • Refrain from talking when food is in the mouth
  • Eat slowly and chew thoroughly
• Dietary modifications are often needed to improve swallowing and avoid aspiration. These include
  • Special diets such as pureed foods or thicker liquids.
  • Smaller bites
  • Alternating solids and liquids
  • Using particular implements such as a cup, straw, or spoon

Thickened fluids

• Thicker is not always better or safer. The thinnest liquid that is tolerated should be what is used. It is known that those requiring thickened liquids have significant dehydration issues. Studies have shown that individuals who require thickened liquids consume less liquid than if they were to consume unthickened liquids. The thicker the liquid, the less liquid was consumed. Other factors regarding thickened liquids include
  • Thickened liquids are poor at quenching thirst
  • Thickened liquids have poorer flavour - the thicker the liquid, the worse the flavour
  • The type of thickener and how much is used also affects the absorption of medications.
  • Xanthan gum and guar gum tend to be broken down in the colon thus release of medications are delayed.
  • Thickened liquids also cause individuals to feel full faster thus often not consuming as much other food as they need
• New standardization: Because of the variability in liquid consistencies seen across assorted products that are sold for use, the International Dysphagia Diet Standardization
• The initiative created a new standardization for thickened liquids. There are now five levels orgrades:
  • Grade 0: Thin liquid is level 0.
  • Grade 1: Slightly Thick – thinner than Nectar Thick and similar to V8 juice, Ensure, or breastmilk.
  • Grade 2: Mildly Thick – the same level of thickness as Nectar Thick. Smoothies and Nectar Juice such as Mango Nectar juice can be used.
  • Grade 3: Moderately Thick – the same level as Honey Thick. Using a blender with fruit and yogurt can make a naturally thick smoothie for a mildly to moderately thick liquid. Boost, Carnation Instant Breakfast, protein powders, etc. can improve taste and caloric content.
  • Grade 4: Extremely Thick – the same level as Pudding Thick

References

• Dysphagia management