TREATMENTInitialThe treatment of dysphagia depends on its causes and mechanism. Common treatments are listed in Table 121-3. Whenever possible, initial treatment should be directed at the underlying disease process; for example, levodopa for Parkinson disease, or steroids for polymyositis. Esophageal dysphagia necessitates evaluation and treatment by a gastroenterologist. When no therapy exist for the underlying disease or the therapy is ineffective or contraindicated, rehabilitative strategies are appropriate. Patients and their family members are encouraged to learn the Heimlich manuever; this is important because airway obstruction is potentially fatal.

Differential Diagnosis

Myocardial ischemia

Globus sensation

Heartburn due to gastroesophageal reflux disease

Indirect aspiration (aspiration of refluxed gastric content)

RehabilitationMany patients benefit from a structured swallowing therapy provided by a speech-language pathologist, including instruction and supervision about diet, compensatory manuevers, and exercise.17 The goals of therapy are to reduce aspiration, to improve the ability to eat and drink, and to optimize nutritional status. Therapy is individualized according to the patients specific anatomic and structural abnormalities and the initial responses to treatment trials observed at the bedside or during the VFSS.18

Table 121-3 Principal Treatments of Selected Disorders Affecting SwallowingProblemsPrincipal Treatments

Amvotrophic lateral sclerosisDietary modificationCompensatory manueversCounceling and advance directives

Carcinoma of esophagusEsophagectomy

Gastroesophageal reflux diseaseDietary modificationNo eating at bedtimePharmacologic therapySmoking cessation

Parkinson disease, polimyositis, myasternia gravisPharmacologic treatment of underlying disease (dietary modification, compensatory manuevers, and dysphagia therapy only if neccesary).

Esophageal stricture or webDilatation

Stroke multiple sclerosisDietary modificationCompensatory manueversDysphagia therapy

A fundamental principle of rehabilitation is that the best therapy for any activity is the activity itself; swallowing is generally the best therapy for swallowing disorders, so the rehabilitation evaluation is directed at identification of circumstances for safe and effective swallowing for each individual patient.Diet modification is a common treatment of dysphagia.19,20 patients vary in ability to swallow thin and thick liquids, and that determination is usually best made by VFSS. A patient can usually receive adequate oral hydration with either thin (e.g., water or apple juice) or thick liquids (e.g., apricot nectar, tomato juice). Rarely, a patient may be limited to pudding consistency if thin and thick liquids are freely aspirated. Most patients with significant dysphagia are unable to safely eat meats or similarly though foods and require a mechanical soft diet. A pureed diet is recommended for patients who exhibit oral preparatory phase difficulties, pocket food in the buccal recesses (between the teeth and the cheek), or have significant pharyngeal retention with chewed solid foods. Maintenance of oral feeding often requires compensatory techniques to reduce aspiration or to improve pharyngeal clearance. A variety of behavioral techniques are used , including modifications of posture, head position (Fig. 121-1),21-22 and respiration, 23 as well as specific swallow manuevers.24-26 Execise therapy for dysphagia is indicated when the problem is related to weakness of the muscles of swalowing.27 The choice of exercises must be individualized according to the physiologic assessment. The full range of exercises is beyond the scope of this chapter, but several example illustrate the principles. Tongue weakness can be treated with lingual resistance exercise.28 Strengthening of the anterior suprahyoid muscles is useful when the upper esophageal sphincter opens poorly. Flexing the neck against gravity while lying supine can strengthen these muscles (Fig. 121-2).29,30 Vocal fold adduction exercises may be useful in cases of aspiration due to weakness of these muscles. These exercises are done on a daily basis whenever possible.

ProceduresVFSS functions as both a diagnostic and a therapeutic procedures for dysphagia, especially otopharyngeal dysphagia, because it can be used to test the effectiveness of modifying food consistency and other compensatory techniques.31 Endoscopy with dilatation of the esophagus is often indicated in cases of partial esophageal obstruction due to stricture or web. Dilatation is also appropriate in stenosis of the upper esophageal sphincter. Endoscopy can also be used for biofeedback, especially to demonstrate movements of the larynx during swallowing manuevers. Electromyography is also used for biofeedback. Activities of the infrahyoid and suprahyoid muscles are recorded with surface electrodes during swallowing therapy. Biofeedback itself is not a dysphagia therapy but can be a useful adjunct to therapy. Surface electrical stimulation on the submental or anterior cervical muscles is a controversial new treatment of dysphagia. There is little evidence for its safety and efficacy.32-34

SurgerySurgery is rarely indicated in the care of patients with oral pharyngeal dysphagia. The most common procedure for pharyngeal dysphagia is cricopharyngeal myotomy, during which the upper esophageal sphincter is disrupted to reduce the resistance of the pharyngeal outflow tract. However, the effectiveness of myotomy is highly controversial.35 Esophagectomy may be necessary in case of esophageal cancer or obstructive strictures. Feeding gastrotomy (usually percutaneous endoscopic gastrotomy) is indicated when the severity of the dysphagia makes it impossible for adequate alimentation or hydration to be obtained orally, although intravenous hydration or nasogastric tube feeding may be sufficient on a time-limited basis.36 Orogastric tube feedings have been used successfully by patients who have absent gag reflexes and can tolerate intermitten oral catheterization.

POTENTIAL DISEASE COMPLICATIONSevere dysphagia may result in aspiration pneumonia, airway obstruction, bronchiectasis, dehydration, or starvation37 and is potentially fatal. Severe dysphagia often causes social isolation because of the inability to consume a meal in the usual manner. This may lead to depression, sometimes severe. Suicide has been reported.

POTENTIAL TREATMENT COMPLICATIONSThe VFSS is safe and well tolerated. Prescription of a modified diet often means the substition of thick for thin liquids. Some patients find these unpalatable and reduce fluid intake to the point of dehydration and malnutrition. Failure to reevaluate patients in a timely manner may lead to unnecessary prolongation of dietary restrictions, increasing the risk of malnutrition and adverse psychological effects of dysphagia. Dilatation of the esophagus or sphincters may result in perforation, but this complication is uncommon. Percutaneous endoscopic gastrostomy may have direct or indirect sequelae. Direct sequelae, such as pain, infection, and obstruction of the feeding tube, are common. Percutaneous endoscopic gastrotomy tube feeding may promote aspiration pneumonia in individuals with severe gastroesophageal reflux disease.

References1. Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005; 36: 2756-2763.2. Achem SR, Devault KR. Dysphagia in aging. J Clin Gastroenterol 2005; 39: 357-371.3. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swalowing impairments.Am Fam Physician 2000; 61: 2453-2462.4. Buchholz DW. Oropharyngeal dysphagia due to iatrogenic neurological dysfunction. Dysphagia 1995; 10: 248-254.5. Smith Hammond CA, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest 2006; 129: 154S-168S.6. Smith CH, Logemann JA, Colangelo LA, et al. Incidence and patient characteristics associated with silent aspiration in the acute care setting [see comments]. Dysphagia 1999; 14: 1-7.7. Arvedson J, Rogers B, Buck G, et al. Silent aspiration prominent in children with dysphagia. Int J Pediatr Otorhinolaryngol 1994; 28: 173-181.8. Leder SB, Sasaki CT, Burrell MI. Fibreoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia 1998; 13: 19-21.9. dePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke [see comments]. Arch Neurol 1992; 49: 1259-1261.10. Tohara H, Saitoh E, Mays KA, et al. Three tests for predicting aspiration without videofluorography. Dysphagia 2003; 18: 126-134.11. Wu MC, Chang YC, Wang TG, et al. Evaluating swallowing dysfunction using a 100-ml water swallowing test. Dysphagia 2004; 19:43-47.12. Palmer JB. Evaluation of swallowing disorders. In Grabois M, ed. Physical Medicine and Rehabilitation: The Complete Approach. Malden, Mass, Blackwell Science, 1999:277-290.13. Leder SB. Gag reflex and dysphagia. Head Neck 1996; 18: 138-141.14. Kumlien S, Axelsson K. Stroke patients in nursing homes: eating, feeding, nutrition and related care. J Clin Nurs 2002; 11: 498-509.15. Palmer JB, Kuhlemeier KV, Tippett DC, et al. A protocol for the videofluorographic swallowing study. Dysphagia 1993; 8:209-214.16. Langmore SE. Endoscopic Evaluation and Treatment of Swallowing Disorders. New York, Thieme, 2001.17. Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol 2006; 5:31-37.18. Ott DJ, Hodge RG, Pikna LA, et al. Modified barium swallow; clinical and radiographic correlation and relation to feeding recommendations. Dysphagia 1996; 11: 187-190.19. Bisch EM, Logemann JA, Rademaker AW, et al. Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and in normal subjects. J Speech Hear Res 1994; 37: 1041-1059.