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Dysphagia

What is dysphagia?

Dysphagia is the medical term used to refer to difficulty of swallowing. This may also be defined as the feeling of “food sticking” at the chest or throat [1]. It is also described as taking more effort and time to move the liquid or food ingested from mouth to the stomach [2]. This term is derived from Greek words, dys (disordered or bad), and phago (eat) [3].

dysphagia

Picture 1: A person with dysphagia

Source: justrec.com

 

Pathophysiology of Dysphagia

Deglutition refers to the process of swallowing. This process enables the liquid or food bolus to be moved from the moment it enters the mouth, to the pharynx and espohagus, until it arrives the stomach. Normally, deglutition happens in a manner which is smooth and coordinated. It involves series of neuromuscular contractions which may be classified as voluntary and involuntary.

Deglutition occurs in three stages. These are:

 1. Oral phase

  • It involves the movement of food from the oral cavity going to the oropharynx.
  • This phase begins when there are contractions of the striated muscles of mastication and tongue. These muscles are responsible for mixing of the saliva with the food bolus. Then, these muscles push the food coming from the oral cavity towards the oropharynx.
  • Afterwards, the triggering of the involuntary swallowing occurs.
  • The whole process is controlled by cerebellum and involves cranial nerves V, VII, and XII.
  • When liquid is swallowed, it lasts for about 1 second. Meanwhile, swallowing of solid foods takes about 5-10 seconds.

2. Pharyngeal phase

  • It is important that this phase happens correctly. Without intact laryngeal mechanisms, aspiration may occur.
  • In this phase, it begins with the rising of the soft palate. The larynx and hyoid bone move forward and upward. This is followed by movement of the vocal chords to the midline. This results to the folding back of the epiglottis for airway protection.
  • As for the tongue, it is pushed downward and backward to the location of the pharynx. This allows propelling of bolus downward. In this phase, the pharyngeal walls help the tongue, for progressive contraction.
  • This phase is reflexive and involuntary.
  • Swallowing reflex takes approximately 1 second. It is governed by cranial nerves IX and X.

3. Esophageal Phase

  • During this phase, the bolus is moved downward with the aid of peristaltic movements.
  • Relaxation of the lower esophageal sphincter happens next to swallowing reflex. Then, it remains this way until the bolus arrives at the stomach.
  • Upon the arrival of bolus at the stomach, the lower esophageal sphincter closes to prevent gastroesophageal reflux.
  • This phase is controlled by the medulla (swallowing reflex) and cerebral cortex (voluntary swallowing).
  • There is an interval of 8-20 seconds to allow contractions to move the food bolus towards the stomach. [4]

dysphagia-deglutition

Picture 2: Phases of deglutition

Source: medical-dictionary.thefreedictionary.com

dysphagea-pathophy 1

Picture 3: An illustration of the comparison between normal swallowing and dysphagia

Source: hormelhealthlabsblog.com

 

Causes of Dysphagia

Esophageal or Pharyngeal Obstruction

1. Tumors/Cancers

  • Malignant and benign tumors located at the esophagus and pharynx.
  • Other tumors which presses the esophagus
  • Thyroid cancer [5]

2. Strictures or narrowing of the esophagus

  • Gastroesophageal Reflux Disease (GERD): Dysphagia results from the healing of esophageal ulcerations which leads to scarring.
  • Suicide: Stricture caused by ingestion of acids or pills
  • Infections: Infections of lower esophagus and AIDS
  • Radiation therapy
  • Osteoporosis treatment: biphosphates, quinidine
  • Diffuse spasm: This creates poorly coordinated esophageal contractions that cause spasm.
  • Esophageal ring: Causes narrowing in the area of lower esophagus [2, 5, 6]

3. Diverticula

  • This condition involves formation of small sacs located at the esophageal walls or throat.

4. Cricopharyngeal bars

  • Hypertrophy or enlargement of the upper part of the esophageal sphincter.
  • In this condition, the bars are unable to stretch properly to allow passage of bolus.

5. Cervical osteophytes

  • Also known as arthritis of the neck
  • This leads to bone overgrowth that may extend anteriorly from the vertebra. [5]

6. Foreign bodies

  • Ingestion of foreign objects can cause blocking of esophagus or throat.
  • Common in children and older adults.
  • For children, they can swallow small objects like toy parts or coins
  • In older adults, dentures are a common cause. [2]

7. Congenital anomalies

  • Present at birth
  • Causes difficulty in oral feeding for infants
  • Also occurs in children if not managed promptly at birth
  • Examples are: cerebral palsy, cleft palate or lip [2, 4]

Diseases of the brain

1. Stroke

  • It is a common disease which can lead to difficulties to swallowing because it can affect the swallowing center.

2. Brainstem tumors

  • This can affect the neurotransmission which is responsible for sending information from the brain towards the esophagus.

3. Degenerative diseases

  • Parkinson’s Disease
  • Amyotrophic Lateral Sclerosis
  • Multiple Sclerosis
  • Poliomyelitis

Diseases affecting skeletal muscles of the pharynx

1. Myasthenia gravis

  • A disease which interferes normal signal transmission of both skeletal muscles and motor nerves. This condition may also affect the pharyngeal muscles.

2. Muscular Dystrophies

  • Genetic diseases which cause abnormal protein production. This may lead to muscle cell degeneration.
  • Symptoms include spasm and muscle weakness
  • Examples are Becker’s muscular dystrophy and Duchenne’s muscular dystrophy

3. Metabolic myopathies

  • Another group of rare genetic diseases that leads to deficiency of enzyme activities in the skeletal muscle cells.
  • Manifestations of this condition, are easy muscle fatigability and muscle cramps.

4. Polymyositis

  • A condition where there is inflammation and degeneration of skeletal muscle cells.
  • This also affects the skeletal muscles which control movement of the pharynx.

Diseases affecting esophageal smooth muscles

1. Achalasia

  • A condition in which the lower esophageal sphincter cannot relax properly. As a result, this causes difficulty in getting the food towards the stomach.

2. Ineffective peristalsis

  • This involves a condition wherein there are decreased and ineffective peristaltic contractions. This results to interference in the movement of food bolus from esophagus towards stomach.

3. Spastic motility disorders

  • A disorder wherein the contractions occurring in the esophagus do not happen in an orderly manner.
  • Instead of progressive contractions, it presents as simultaneous and spastic. As a result food bolus is not propelled to the stomach properly.

Other causes

1. Reduced saliva

  • Radiation therapy
  • Diseases: Sjoren’s syndrome
  • Some medications that may reduce saliva production  [5]

 

Signs and Symptoms of Dysphagia

Signs

  • Repetitive swallowing
  • Eating slowly is easier
  • Escape of food and saliva from mouth or nose
  • Coughing and spluttering when eating or drinking
  • Husky voice and usual clearing of throat
  • Fatigue [7]

Symptoms

  • Regurgitation (backing up of food)
  • Odynophagia (painful swallowing)
  • Drooling
  • Heartburn
  • Weight loss
  • Feeling of food stuck at the throat or chest
  • Chest discomfort or chest pain [2, 7]

 

Dysphagia Diagnosis

Patient History

The first step to diagnosing and treating Dysphagia is through self-recognition [7]. Information about an individual’s experience of dysphagia can provide clues to its diagnosis. Questions about the following will be most likely asked by the physician:

  • Presence of signs or symptoms
  • Pre-existing or history of diseases affecting swallowing
  • Weight loss [5]

Physical Examination

Assessment of certain areas may be done to give an impression or clue about the cause of the disease. The areas which may be assessed by the physician include:

  • Neurologic assessment
  • Observation of swallowing
  • Assessment of the trachea: If it cannot be moved from side-to-side using the hand, this may indicate tumor located at the trachea or esophagus.
  • Checking for presence of tumors that may compress the pharynx
  • Observation for presence of tongue atrophy (decrease in size) and fasciculation [5]

Diagnostic Examinations

1. Imaging Studies

  • Endoscopy: Insertion of a tube with camera through the mouth. The tube proceeds to areas such as pharynx, esophagus, and stomach. This procedure enables visualization of the pharynx and esophagus. Biopsies (tissue samples) may be obtained through the procedure as well.
  • Barium swallow: This involves ingestion of a chalky liquid, Barium. Then, it coats the esophagus so it will be seen better using an X-ray.
  • Fluoroscopy: It also uses barium swallow but this includes videotaping of the swallowing process.
  • Laryngoscopy: Visualization of the back of the throat with the use of a fiber-optic scope. [5, 6]

2. Other tests

  • Esophageal manometry: It is also referred to as esophageal motility testing. This is a procedure which allows evaluation of the functioning of the muscles at the pharynx and esophagus.

dysphagea-esophageal manometry

Picture 4: Illustration of Esophageal Manometry

Source: umm.edu

dysphagea-esophageal manometry2

Picture 5: How esophageal manometry is performed

Source: hopkinsmedicine.org

  • Esophageal acid testing: This test determines if acid from the stomach frequently escapes into the esophagus.

dysphagea-esophageal acid testing

Picture 6: A. Shows Proximal and distal pH level monitoring B. Illustrates distal esophageal and gastric pH level monitoring

Source: nature.com

  • Esophageal impedance: It involves catheter insertion which aids in the detecting if the bolus moves in coordination with the recorded esophageal pressures seen through manometry.

dysphagea-esophageal impedence

Picture 7: Illustration of esophageal impedance

Source: medscape.com

  • Electromyography
  • Muscle biopsies
  • Genetic testing [5, 6]

 

Dysphagia Treatment and Therapy

Medical/Surgical Management

1. Medicine

  • If the dysphagia is associated to a certain underlying disease, prescription of medicines targeted to treat the underlying cause, may be done.
  • Commonly, medications given are those which can resolve hyperacidity, prevent stomach acid from going to esophagus, or drugs to treat infections.
  • On the other hand, if dysphagia is caused by a medication, this may be stopped or replaced with another one. Usually, drugs for insomnia and epilepsy can affect swallowing.

2. Surgery

  • This is advised if the cause of dysphagia is obstruction such as diverticula or tumors.
  • It can also be used to treat achalasia.

3. Dilation

  • This is used to expand the narrowed areas of the esophagus. This is done with the use of a special device.

4. Endoscopy

  • Aside from diagnosis, endoscopy can also play a role in the treatment of dysphagia.
  • This is used for the removal of the object that has been stuck at the esophagus. [6, 7]

Physical modification

1. Maintenance of good posture

  • It is advised for people with dysphagia to always sit up straight as much as possible.

2. Exercises

  • Exercises for jaw and tongue may be advised to resolve weakness in these areas. With exercises prescribed, these weakened areas can be strengthened for more effective chewing.

3. Other suggested techniques

  • For an instance that food gets stuck, stand up immediately. Then, try stretching the upper half of the body and walk around. This aids in helping the food to move down the stomach.
  • Do not lie down during and after eating.
  • Avoid eating three hours prior to bedtime.
  • Do long deep breathing exercises.
  • Make sure that dentures fit properly. [7]

Food/Eating Habits Modification

1. Improve eating habits

  • Cut food to smaller pieces.
  • Increase fluid intake.
  • Eat slowly.
  • Eat in a quiet and peaceful place.
  • For people who have problems in their sense of taste and smell, prepare foods in an appetizing way. Use colourful plates and utensils. Also, eat foods with plenty of color.

2. Food modification

  • Pureed or softened foods: This requires less chewing and less force to be cleared from the pharyngeal area.
  • Avoid sour and acidic foods. This may cause automatic swallowing reflex.
  • Prepare foods which can stimulate appetite.
  • Thicken liquids. This helps in controlling the flow of drank liquids to avoid aspiration. This may be obtained by having a prescription from a physician or dietician. [7]

 

Dysphagia Diet Levels

Foods recommended for people with dysphagia are divided into four levels. These levels are:

Level 1: Pureed foods

This includes pureed foods. This is advised for people who have severe dysphagia or chewing problems. To puree foods, a blender or food processor is needed, to make it easier and safer to swallow. Examples are:

  • Soups
  • Mashed potato or bananas
  • Milk shakes
  • Puddings

Level 2: Mechanically Altered Foods

Involved in this diet, are foods which are more solid in consistency. This diet is recommended for those who have moderate dysphagia. Also, the foods included in this diet needs chewing efforts. Examples are:

  • Soft desserts and breads
  • Chopped or ground meats
  • Soft vegetables

Level 3: Advanced Food

This group of foods have an almost regular texture. Though that’s the case, the foods still need to be soft and moist. This diet is advised for patients with mild dysphagia. Foods which are cut into bite-sizes are needed before going back to the regular diet. [8]

Level 4: Regular diet

This is for people who have normal swallowing reflex. In this diet, all types of foods are allowed. [9]

 

References:

1. http://www.umm.edu/altmed/articles/dysphagia-000053.htm

2. http://www.mayoclinic.com/health/difficulty-swallowing/DS00523

3. http://en.wikipedia.org/wiki/Dysphagia

4. http://emedicine.medscape.com/article/324096-overview#aw2aab6b3

5. http://www.medicinenet.com/swallowing/page2.htm

6. http://www.webmd.com/digestive-disorders/tc/difficulty-swallowing-dysphagia-overview

7.http://www.dysphagiaonline.com/en/pages/03_what_are_the_signs_and_symptoms.aspx

8. http://www.livestrong.com/article/417623-recommended-dysphagia-diet-stages/

9. http://everythingspeech.com/articles/dysphagia-diet-levels/



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