Swallowing Disorders Prospective
What is the Swallowing Disorder
- Swallowing disorders – defined as difficulty in passing food or liquid from the mouth to the stomach – occur in all age groups, especially in the elderly. The disorders can occur at any stage of the normal swallowing process, in which food and liquid move from the mouth, through the pharynx, into the esophagus, and finally, into the stomach.
- The Oro-Pharyngeal swallowing disorders are common in individuals with sudden neurological damage as in stroke, or head or spinal cord injury. They may also occur after degenerative neurological disorders such as amyotrophic lateral sclerosis (ALS), post polio syndrome, myasthenia gravis, multiple sclerosis, and Parkinson’s disease. In addition, patients with head and neck malignancy have difficulty with swallowing who should be seen by Swallowologist pre and post-operative.
- Recently, Oro-Pharyngeal dysphagia is considered as one of Speech-language pathology specialties and Swallowologist can assist in the evaluation and management of patients with oro-pharyngeal dysphagia. This unique specialty will provide clinical services such as evaluation, counseling, treatment, and management of oropharyngeal dysphagia, and minimizing compromises in respiratory or nutritional status associated with impairments in swallowing and feeding.
The Roles of The Physician
Swallowologist is one of Speech-language pathology specialties who can evaluate and manage patients with oro-pharyngeal dysphagia. Patients complaining of swallowing difficulties such as drooling, coughing and/or choking on liquids or foods during or right after eating or drinking, wet or gurgle sounding voice during or after eating or drinking, feeling of food sticking in the throat or upper chest, extra time and effort required for eating, recurring pneumonia or chest congestion after eating, and weight loss or dehydration from not being able to eat enough may benefit from the swallowing clinical assessment by a certified speech-language pathologist. A comprehensive dysphagia clinical assessment by a speech-language pathologist (Swallowologist) may help in the differential diagnosis for patients with respiratory disease, failure to thrive, unintended weight loss, and chronic cough.
Other roles for speech and swallowing physician include, but are not limited to:
- Performing clinical feeding and swallowing assessments.
- Performing instrumental assessments that delineate structures and dynamic functions of swallowing. Assessment services are provided as needed, requested, or mandated or to rule in or out a specific disabling condition.
- Defining the abnormal swallowing anatomy and physiology and diagnosing swallowing disorders.
- Identifying additional disorders in the upper aerodigestive tract and making referrals to appropriate medical personnel.
- Making recommendations about management of swallowing and feeding disorders.
- Developing treatment plans for individuals with swallowing and feeding disorders.
- Providing treatment for swallowing and feeding disorders, documenting progress, and determining appropriate dismissal criteria.
- Teaching and counseling individuals and their families about swallowing and feeding disorders.
- Educating other professionals regarding the needs of individuals with dysphagia, and the speech-language pathologists’ role in the evaluation and management of swallowing and feeding disorders.
- Outcomes of services are monitored and measured in order to ensure the quality of services provided and to improve the quality of those services.
- Appropriate follow-up services are provided to determine functional outcomes and the need for further services after discharge.
- Results of assessment and treatment are reported to the patient/client and family/caregivers, as appropriate. Reports are distributed to the referral source and other professionals when appropriate and with written consent.
The Clinical Features of Dysphagia
You need to see your physician for swallowing evaluation, if you have one of the following signs and symptom.
- Extra effort or time needed to chew or swallow.
- Food or liquid leaking from the mouth or getting stuck in the mouth.
- Suspected or observed difficulty swallowing saliva/oral secretions and/or solids food.
- Pocketing of food in the mouth.
- Globus sensation or pain in your throat.
- Drooling.
- Difficulty in initiating swallowing.
- Pain with swallowing.
- A feeling of obstruction as if food has become stuck in the throat.
- Coughing or choking when eating.
- Wet or gurgly sounding voice during or after eating or drinking.
- Recurring pneumonia or chest congestion after eating.
- Frequent episodes of regurgitation, reflux, or spitting up after a meal.
- Weight loss or dehydration from not being able to eat enough.
Who are the target patients?
Any patients who have the following problems or diseases should be referred to the Swallowing disorder physician (Swallowologist):
- Difficulty with eating or drinking.
- Difficulty with chewing food.
- Loss of food or liquids from the mouth.
- Food sitting in the mouth long after a meal.
- Difficulty with swallowing of solids and/or liquids food.
- Coughing or choking when eating.
- Wet or gurgled voice after eating or drinking.
- Food sticking in the throat or chest.
- Oro-facial muscle weaknesses associated with dysphagia.
- History of frequent attack of aspiration pneumonia.
- Frequent episodes of regurgitation, reflux, or spitting up after a meal.
- Losing weight.
- Neurodegenerative disease (e.g., Amyotrophiclateral sclerosis, Parkinson’s disease).
- Spinal cord injury.
- Neurological injury (e.g., cerebrovascular accident or traumatic brain injury).
- Following treatment for head and neck cancer (e.g., surgery and/or radiation therapy and/or chemotherapy).
- Vocal fold mobility disorders (e.g., recurrent laryngeal nerve injury, superior laryngeal nerve injury).
- Tracheostomy.
- Mechanical ventilation or other respiratory issues (e.g., chronic obstructive pulmonary disease (COPD), bronchopulmonary dysplasia.
Complications of Oro-Pharyngeal Dysphagia
Some possible consequences of oro-pharyngeal dysphagia are:
- Aspiration Pneumonia: Aspiration may occur if food or liquid passes into the lungs as a result of entering the airway instead of the esophagus (feeding tube). The person who aspirates may be at risk for pneumonia (inflammation of lungs.)
- Weight Loss and/or Malnutrition: This may occur if the person loses appetite due to fatigue or difficulty with eating.
- Dehydration: Dehydration may occur when the person is unable to swallow enough liquids.
- Airway obstruction.
- Less enjoyment of eating or drinking. Individuals who had dysphagia resulting from stroke often did not find eating to be enjoyable because of their fears, dependency, and appearance.
- Embarrassment or isolation in social situations involving eating.
- Decreased quality of life.
The Clinical Assessment of Dysphagia
- The clinical evaluation of dysphagia typically begins with a non-instrumental clinical examination. This initial evaluation will include a careful review of the patient’s history, evaluation of the strength, range of motion and coordination of the muscles involved in swallowing, and may entail observation of the patient eating and drinking.
- In addition, instrumental assessment of swallowing (Videofluoroscopic Swallow Study and/or Fiberoptic Endoscopic Evaluation of Swallowing) is/are required to completing the oro-pharyngeal swallowing disorders management.
- The Videofluoroscopic Swallowing Study (VFSS) is a dynamic radiographic study. The examination images oral, pharyngeal, and cervical-esophageal bolus flow during swallowing mechanism. Anatomic and/or physiologic abnormalities are identified relative to swallowing. During the study, the effects of modifications in bolus size, bolus texture, patient positioning, compensatory maneuvers, and sensory enhancement techniques on bolus flow are evaluated to determine optimum swallow safety and efficiency.
- In addition, using of Fiberoptic Endoscopic for Evaluation of Swallowing (FEES) instrumentation allows inspection of functions of the swallowing mechanism at the velopharynx, oropharynx, pharynx, and larynx. Endoscopic assessment of swallowing function is not a screening examination but a comprehensive assessment of the upper aerodigestive functions of swallowing. It includes five components:
- Assessment of anatomy involved in the pharyngeal stage of swallowing.
- Assessment of movement and sensation of critical structures within the pharynx.
- Assessment of secretions.
- Direct assessment of swallowing function for food and liquid, and response to therapeutic maneuvers and interventions to improve the swallow.
The purpose of these procedures is the comprehensive evaluation of the swallowing phases to obtain a detailed analysis of the patient’s oropharyngeal swallowing mechanism, correlate these findings with the patient’s dysphagia symptoms. Consequently, the physician will approach care of plan and recommendations regarding the adequacy of the swallow, the advisability of oral feeding, and the use of appropriate interventions to facilitate safe and efficient swallowing.
The available treatment of Dysphagia
Treatment depends on the cause, symptoms, and type of swallowing problem. Therapy may include education in compensatory techniques to make swallowing more efficient and to reduce the risk of aspiration, diet modification, and/or instruction in exercises to strengthen and improve the coordination of the swallowing mechanism. Moreover, using VitalStim therapy (Electrical shock wave that is helpful for some patients to strengthen muscles responsible for swallowing mechanism.) A Swallowing Disorder Physician may recommend:
- Specific swallowing treatment e.g. Rehabilitative exercises to improve muscles movement.
- Positions or strategies to help the individual swallow more effectively.
- Specific food and liquid textures that are easier and safer to swallow.
- After the evaluation, family members or caregivers can be helped by:
- Asking questions to understand the problem and the recommended treatment.
- Assisting in following the treatment plan:
- Help with exercises.
- Prepare the recommended textures of food and liquid, making sure that recommendations for eating safely are followed.
- Keep track of how much food or liquid is consumed.