Dysphagia / Swallowing Problems ✅
⚠️ Aspiration pneumonia can occur after inhaling food, drinks, or saliva into the lungs. 🤐 Absolute dysphagia is when a patient cannot even swallow their own saliva – a red-flag finding requiring urgent assessment and hospital admission.
🚨 Acute Dysphagia Management 🛠️
- Determine cause: mechanical obstruction (tumour, stricture) vs neurological/motility (stroke, MND, Parkinson’s, myasthenia gravis).
- Assess and secure airway 🫁. Call senior/anaesthetics if compromised or signs of aspiration present.
- Keep patient Nil by Mouth (NPO) 🚫🍽️ until swallow safety is assessed.
- Provide IV fluids to maintain hydration and electrolytes.
- Essential medications should be administered via safe alternative routes (NG tube, PEG, subcutaneous, or transdermal).
- Urgent referral to Speech and Language Therapy (SALT) 🗣️ for formal swallow assessment.
- Consider ENT, gastroenterology, or surgical input if mechanical obstruction suspected.
- Investigations: barium swallow, OGD, CT/MRI depending on suspected pathology.
Swallowing Mechanism 🤯
- Complex process involving >30 muscles; three phases:
- Oral Phase 🦷: Chewing, bolus formation, tongue propulsion.
- Pharyngeal Phase 🫁: Reflex airway closure, laryngeal elevation, bolus directed to oesophagus.
- Oesophageal Phase 🧵: Peristalsis + lower oesophageal sphincter relaxation moves bolus to stomach.
Mechanical Causes ⚙️
- Oesophageal strictures (benign/malignant)
- Oesophageal cancer 🎗️
- Achalasia / motility disorders
- Webs or rings (Plummer-Vinson)
- Extrinsic compression (mediastinal mass, lymphadenopathy)
Neurological Causes 🧠
- Stroke (brainstem or bilateral hemispheric)
- Parkinson’s disease
- Motor neuron disease / bulbar palsy
- Multiple sclerosis
- Myasthenia gravis
- Muscular dystrophies
- Functional dysphagia (psychogenic)
Painful Causes 🔥
- Infectious mononucleosis
- Acute epiglottitis (emergency)
- Quinsy (peritonsillar abscess)
- Lemierre’s syndrome (rare septic thrombophlebitis)
Clinical Signs 👀
- Coughing/choking with liquids or solids
- Regurgitation (including nasal reflux 🤧)
- Persistent drooling 💧
- Difficulty chewing or forming bolus
- “Wet” or gurgling voice after swallowing
- Weight loss, dehydration, recurrent chest infections
Investigations 🔬
- Bloods: FBC, U&E, CRP, TFTs, nutritional markers (albumin, vitamin B12, folate)
- CXR: Look for aspiration pneumonia, mediastinal mass
- FEESST: Endoscopic assessment of pharyngeal swallowing, airway protection
- VFSS (Barium swallow): Visualise bolus transit, aspiration, and motility
- OGD: Evaluate oesophageal mucosa, strictures, cancer
- CT chest/neck: Detect extrinsic compression or mass lesions
Management 🛠️
- Depends on underlying cause: neurological vs mechanical.
- Airway and aspiration prevention 🫁: Positioning, suction, thickened fluids.
- SALT-led interventions 🗣️: Safe swallow techniques, compensatory strategies, oral exercises.
- Dietary modifications 🍲: Texture-modified diet, thickened fluids (IDDSI framework 0–4).
- Feeding support 🧪: NG tube or PEG for persistent unsafe swallow; maintain hydration and medication delivery.
- Medical therapy 💊: Treat underlying cause (e.g., PPIs for reflux, antibiotics for infection, steroids for inflammatory causes).
- Endoscopic/surgical therapy 🪡: Dilatation, stenting for strictures; tumour resection for malignancy where appropriate.
- Monitor for complications: aspiration pneumonia, malnutrition, weight loss.
- Multidisciplinary approach: ENT, gastroenterology, dietitian, SALT, nursing support.
- Ongoing review and reassessment – swallow function may improve or deteriorate depending on disease trajectory.
Dietary & Swallowing Advice 🍽️
- Sit upright (90°) while eating
- Remain upright 15–20 min post-meal
- Avoid talking while swallowing 🛑🗣️
- Eat slowly, chew thoroughly
- Small, frequent meals for safer swallowing and nutrition
- Monitor fluid intake and hydration carefully
Thickened Fluids 💧➡️🥄
- Start with thinnest consistency patient can safely swallow
- IDDSI levels:
- 0️⃣ Thin (water)
- 1️⃣ Slightly thick
- 2️⃣ Mildly thick (nectar)
- 3️⃣ Moderately thick (honey)
- 4️⃣ Extremely thick (pudding)
References 📚
