DYSPHAGIA
Lisa Granville, M.D.
Associate Chair & Professor of Medicine
Department of Geriatrics
Florida State University
Copyright 2008, Florida State University College of Medicine. This work was supported by a grant from
the Donald W. Reynolds Foundation. All rights reserved.
Today’s Learning Objectives:
• Develop an understanding of the five
stages of swallowing function
• Relate at least five of the common signs
and symptoms of swallowing
abnormalities to etiologic conditions
• Describe the swallow evaluation process
including use of radiological assessment
• Compare and contrast the benefits and
limitations of artificial feeding for
dysphagic patients
Importance of Eating
• Pleasure
• Socialization
• Maintenance of health
Mr. D, a 72 year old man living in a
nursing home, has had a right sided
stroke. He has impulsive behavior
with poor judgment consistent with
right sided brain damage.
• What feeding and/or swallowing
concerns might exist for this patient?
DYSPHAGIA - from the Greek
dys = difficulty
phagia = swallowing
Five Stages of Eating
•
•
•
•
•
Feeding
Oral Preparatory
Oral Transport
Pharyngeal
Esophageal
Definition:
Feeding
Voluntary movement of food from the
environment into the oral cavity for
the purpose of ingestion
Patient/Caregiver Reported
Symptoms of Eating
Abnormalities
Self-Feeding:
•Easy distractibility, disinterest, drowsiness
•Rearranging, playing with food
•Attempts to ingest nonfood items
•Incorrect utensil selection or use
•Inability to open containers or grasp utensils
•Dropping food enroute to oral cavity
Definition:
Oral Preparatory Stage
Voluntary mastication and
preparation of food into a bolus
Definition:
Oral Transport Stage
Voluntary posterior movement of a
bolus from the tip of the tongue to
the anterior tonsillar pillars
Patient/Caregiver Reported
Symptoms of Eating
Abnormalities
Oral Preparatory and Oral Transport Stages:
•Drooling or oral spillage
•Impaired chewing, munching
•Pocketing, holding of food in oral cavity
•Delayed or difficult initiation of swallow
•Coughing and choking
Definition:
Pharyngeal Stage
Reflexive passage of a bolus from
the oral cavity into the upper
esophagus
Patient/Caregiver Reported
Symptoms of Eating
Abnormalities
Pharyngeal Stage:
•Nasal regurgitation
•Aspiration
•Wet or gurgly voice quality
•Coughing and choking
Definition:
Esophageal Stage
Reflexive passage of a bolus from
the cricopharyngeal sphincter past
the lower esophageal sphincter into
the stomach
Patient/Caregiver Reported
Symptoms of Eating
Abnormalities
Esophageal Stage:
•Neck or chest pain
•Heart burn
•Food sticking
•Difficulty swallowing solids > liquids
•Regurgitation
Etiology of Feeding
& Swallowing Problems
Neurological
Mechanical
Psychological
Combination
Medication Related
Swallowing Impairments
Mechanism
Drug/Class
Xerostomia
Anticholinergics,
antidepressants, antiemetics,
antihistamines, diuretics,
opiates
Antipsychotics,
metoclopromide,
prochlorperazine
Antibiotics, ASA, Iron, KCl,
prednisone, theophylline
Anticholinergics, calcium
channel blockers, diazepam,
morphine, nitrates,
theophylline
Extrapyramidal
Effects
Esophageal Injury
Reduced LES
pressure
Identification/Evaluation of Feeding
& Swallowing Problems
• Patient / caregiver observations
• Clinical examination
• Instrumental evaluation
Clinical Examination of Swallow
• Background information
– Active medical problems, therapies, nutrition/hydration
status, overall health status, life expectancy
• Description of the problem
– Onset, duration, frequency, progression, speech
• Clinical observation/mental status exam
– Speech, language, voice status, cognitive status
• Oral mucosa and dentition
• Sensory motor exam of oro-facial structures
• Test swallow observations
– Duration of oral stages, oral residue, cough, self
feeding ability
Instrumental Examination of
Swallow Function
• Videoflurographic swallowing study (VSS)
– AKA: modified barium swallow, cookie swallow test
– Considered to be the “gold standard”
– Allows observation of outline of structures from oral cavity to
stomach, this is a dynamic assessment
• Fiberoptic endoscopic evaluation of swallow
(FEES)
– Allows direct observation of structures: nasal cavity,
nasopharynx, oropharynx, larynx, hypopharynx
Three Major Goals of
Dysphagia Intervention
• 1. To maintain or improve nutrition
and hydration.
• 2. To prevent or reduce the risk of
aspiration.
• 3. To maintain or restore the highest
level of functional ability and
maximize quality of life.
Nutritional Support
Enteral vs. parenteral routes of administration
Long-term vs. short-term use
Complete nutritional replacement vs. partial
support
Possible Benefits of Artificial
Feeding
Promotion of healing
Improved resistance to infection
Decreased skin breakdown
Decreased aspiration
Prolonged life
Artificial feeding does not reverse or cure
dysphagia
Possible Burdens of Artificial
Feeding
Tube placement
Infection
Need for restraints or immobility
Increased aspiration
Prolonged life
At lunchtime Mr. D is served a hotdog,
bites off too large a piece, begins
choking and subsequently dies of
asphyxiation.
• Could this outcome have been avoided?
• How would you inform the family of his
death?
• What reaction from his family is
anticipated?