Makindo Medical Notes

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

Dysphagia Assessment and Management

Aspiration pneumonia can occur after inhaling substances like food, drinks, or feeds. Absolute dysphagia is when a patient cannot manage to swallow even their own saliva.

About Dysphagia

• Dysphagia is the medical term for difficulty swallowing.

Swallowing Mechanism

• Swallowing involves over 30 muscles, requiring precise timing and coordination. It consists of three phases:
• Oral Phase: Chewing food into a suitable size and consistency. The tongue moves food to the back of the mouth for swallowing.
• Pharyngeal Phase: Food moves through the pharynx into the esophagus. Muscles elevate the larynx to protect the airway and prevent aspiration.
• Esophageal Phase: Peristalsis (coordinated muscle contractions) and lower oesophageal sphincter relaxation move food into the stomach.

Mechanical Causes

• Dry mouth or sore mouth
• Benign oesophageal strictures
• Achalasia
• Esophageal cancer
• Esophageal webs
• Benign oesophageal tumors or extrinsic compressions

Neurological Causes (Often Bilateral)

• Stroke: large or bilateral strokes, lateral medullary syndrome
• Multiple Sclerosis (MS) with pseudobulbar palsy
• Parkinson's disease
• Bulbar palsy (e.g., MND, polio)
• Myasthenia gravis
• Functional dysphagia
• Muscular dystrophy

Painful Causes

• Infectious mononucleosis
• Acute epiglottitis (requires urgent anaesthetic help before examination)
• Quinsy (peritonsillar abscess)
• Lemierre's syndrome: a rare, severe infection involving Fusobacterium necrophorum

Clinical Signs

• Coughing or choking during eating or drinking
• Regurgitation of food, sometimes through the nose
• Sensation of food being stuck in the throat or chest
• Persistent drooling of saliva
• Difficulty chewing food properly
• A wet, gurgling voice when eating or drinking

Investigations

• Blood Tests: FBC, U&E, CRP, TFTs
• Chest X-ray (CXR): May reveal a fluid level or mass.
• Flexible Endoscopic Evaluation of Swallowing (FEESST): Uses a lighted endoscope to evaluate swallowing mechanics and airway protection.
• Video Fluoroscopic Swallow Study (VFSS): Videotaped X-ray of the swallowing process using barium to visualize the digestive tract.
• Upper GI Endoscopy: To assess oesophageal pathology.
• CT Chest: Useful for detecting structural causes or masses.

Management

• Management depends on whether the issue is neurological or a physical obstruction.
• Speech and Language Therapy: To teach new swallowing techniques and manage food consistency.
• Dietary Modifications: Adjust food texture and consistency to reduce aspiration risk (e.g., thickened liquids, pureed foods).
• Feeding Alternatives: Consider nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding if prognosis is poor or swallowing is unsafe.
• Endoscopic Intervention: For oesophageal strictures that may need dilation or stenting.

Dietary and Swallowing Advice

• Sit upright at a 90-degree angle while eating or drinking.
• Stay upright for 15-20 minutes post-meal.
• Avoid distractions during meals.
• Refrain from talking while swallowing.
• Eat slowly and chew food thoroughly.

Thickened Fluids

• The thinnest liquid that a patient can safely swallow should be used, as thicker liquids can cause dehydration and poor flavor.
• International Dysphagia Diet Standardization Initiative (IDDSI): Grades of liquid consistency:
• Grade 0: Thin (e.g., water)
• Grade 1: Slightly thick (e.g., Ensure, V8 juice)
• Grade 2: Mildly thick (similar to nectar juice)
• Grade 3: Moderately thick (similar to honey)
• Grade 4: Extremely thick (pudding consistency)

References

• Dysphagia Management Guide