What is dysphagia?
Dysphagia simply means swallowing difficulty and can be used to describe a few different types of swallowing problem. When someone describes dysphagia, they may be referring to:
- True dysphagia – difficulty or inability to swallow.
- Painful swallowing – such as in tonsillitis or after trauma to the throat.
- Gastro-oesophageal reflux – when food or stomach acid are regurgitated into the throat or mouth, often causing pain.
- A feeling of a lump in the throat.
- Feeling that food is stuck in the throat.
Dysphagia can be ‘oro-pharyngeal’, meaning that it arises from problems in the mouth or top of the throat, or it can be ‘oesophageal’, meaning that it arises from a problem in the oesophagus – the ‘gullet’ or food tube.
To understand dysphagia, it can be helpful to understand the normal swallowing function.
How do we swallow?
When we chew, we grind and moisten food in the mouth until it forms a soft ball, called a bolus, that is easy to swallow.
Swallowing this bolus of food is quite a complex process. The back of our mouth leads to both the oesophagus – the tube which passes food and drinks to the stomach – and the passageway to the lungs (also known as the windpipe or trachea). Food and liquids need to go down the right passageway. When we swallow, the movement causes the structures at the back of our mouth and throat to cover the entrance to the windpipe and allow food to only enter the oesophagus.
The swallowing action triggers a natural wave of movement called peristalsis through the oesophagus, which propels the food and fluids down into our stomach. There is a tight band of muscle at the point where the oesophagus meets the stomach – this should open enough to allow food to pass into the stomach, but also be able to close tightly so that stomach acid and contents don’t regurgitate into the oesophagus and cause pain and inflammation.
Sometimes we can get the feeling that our food or drink has gone down the wrong way. For someone who doesn’t normally have swallowing difficulty, this means that a small part of food or fluid is near the windpipe and the natural reflex is to cough until the irritating particles have moved. A compromised swallowing reflex may mean that this coughing does not happen or that a significant amount of food or fluid can enter the windpipe and lungs.
Causes of Dysphagia
There is a wide range of conditions that can cause dysphagia. As dysphagia is generally a symptom of another illness, the risk factors for dysphagia are many and varied.
Some of the most common causes of oropharyngeal dysphagia include:
- Benign (non-cancerous) or malignant (cancerous) tumours or lumps around the throat
- Parkinson’s Disease
- Bell’s Palsy
Oesophageal dysphagia is usually caused by disease in or around the structures of the throat and neck.
As some of the conditions that can cause dysphagia are more common in certain groups of people, some individuals are more at risk of dysphagia than others. For example, dysphagia arising from dementia is more common in older people. Dysphagia relating to cancers of the throat or mouth is more common in heavy smokers and may affect a slightly younger population. People who have dysphagia due to stroke are more likely to have some of the risk factors associated with cardiovascular disease, and so on.
To diagnose dysphagia, a healthcare professional who has had training in swallow assessment will perform an examination. They take a brief history of the problem, consider underlying causes, and assess the patient’s ability to swallow sips of water and food and drinks of different consistencies. They may feel the throat while their patient swallows, and also listen for coughing, gurgling, and changes in the voice and breathing.
If the cause of dysphagia is not clear, the person with swallowing difficulties may need further investigations, such as a ‘gastroscopy’ (an endoscopy where a doctor uses a tube to look down the oesophagus into the stomach), tests which measure the pressure within your throat as you swallow, or medical imaging scans.
Treating the underlying cause of dysphagia will help to eliminate the condition completely. Besides that, there are several treatment options that can help an individual regain their swallowing function.
The type of surgery available depends, again, on the underlying cause. Surgery may be essential to remove tumours or benign lumps that can press on the throat.
If the dysphagia is caused by a narrowing within the oesophagus then a surgical procedure to dilate that narrowing or ‘stent’ the oesophagus – leaving a special tube in place to keep it open.
Another cause for dysphagia that can be treated surgically is having an overly-tight sphincter muscle at the entrance to the stomach which stops food from passing from the oesophagus into the stomach. A surgeon can make a small incision in that muscle to allow food to pass through properly.
Dysphagia that cannot be fully treated needs to be managed to prevent respiratory complications or malnutrition. The main aims of dysphagia management are to prevent complications and to ensure adequate food and fluid intake.
In mild to moderate dysphagia, it may be possible to manage certain forms of food and fluids. A specialist assessment should identify whether it’s possible for the person with dysphagia to swallow certain textures or consistencies better than others, and to adjust a diet plan accordingly. Some people with dysphagia manage thickened fluids better than thin watery fluids, and thickening products are available. Some people manage soft and mashable or smooth pureed food safely and there are now a wide variety of pre-prepared foods available. The internet has also become a valuable resource for recipes and advice on managing dysphagia.
People with dysphagia may see a range of specialists, including otolaryngologists, neurologists, dentists and speech and language therapists. Specialists can also advise on the best ways to manage dysphagia through positioning, chewing and movement, slowing the rate of feeding, and managing breathing/swallowing patterns.
If the dysphagia is severe enough such that safe swallowing is impossible, then alternatives have to be found to enable the person to stay well-nourished while unable to have food or fluids by mouth. A pharmacist should be able to advise on which medications can be given in liquid or non-oral form. Tablets should not be crushed and capsules should not be opened unless specifically advised by a pharmacist.
Alternatives to Oral Feeding
There are short- and long-term alternatives for people who are unable to eat and drink by mouth.
Nasogastric Tube (NGT)
A fine tube is passed through the nostril into the stomach, through which boluses or continuous infusions of specially prepared liquid food and fluids can be given. NG tubes have the risk of being dislodged so they are not usually considered a long-term solution.
Percutaneous Endoscopic Gastrostomy (PEG)
A PEG tube is a short port which goes through the skin of the abdomen into the stomach. It is a long-term solution to severe dysphagia and can be used to deliver boluses or infusions of food, fluids, and medication in a similar way to an NG tube.
Total Parenteral Nutrition (TPN)
TPN is most often given in a hospital setting when a person is acutely unwell and is used to adequately meet a person’s nutritional needs when they are unable to eat and digest food in the usual way. People with serious gastrointestinal problems or malabsorption conditions may require TPN for life and some people do have TPN as part of a complex care package in a home setting.
There are circumstances where it may be deemed appropriate to let someone have oral food and fluids despite severe dysphagia and high risk of serious and life-threatening complications. Doctors and nurses should always allow someone to make their own decisions about their treatment, and if someone wishes to continue to eat despite having a good understanding of the severity of the risks, that wish should be respected.
In addition, if someone is reaching the end of their natural life and would gain comfort from eating and drinking, it is often agreed among the medical team and family that the risks are unlikely to change their outcome and there are times when giving comfort is the most important treatment.
Complications of Dysphagia
Understanding the risks associated with dysphagia can help identify issues early before they become serious problems. Some of the serious complications that can be caused by dysphagia include
Not getting an adequate intake of all the nutrients that our body needs can be a problem. With even a slightly reduced swallowing ability, it might become difficult, uncomfortable or unpleasant to eat. People with poor appetites due to dysphagia should watch out for weight loss or the general symptoms that come with malnutrition, such as hair loss or feeling cold and tired all the time. If malnutrition is a problem, it’s important to get advice from a healthcare professional who can recommend supplements or management plans.
Being unable to get enough fluids can cause dehydration which in turn lead to kidney and urinary conditions, low blood pressure and other serious medical emergencies.
A frequent and serious complication of dysphagia, aspiration pneumonia occurs when a compromised swallow leads to food and fluids – including saliva, stomach acid, and all kinds of viruses and bacteria – getting into the lungs. These cause severe lung infections which can lead to widespread sepsis. People who develop aspiration pneumonia have a poor prognosis, with overall death rates between 11% and 30%, and as high as 70% in some populations.
The risks associated with dysphagia can be serious and it’s important to understand these risks and discuss them with your doctor to choose the most suitable treatment plan for your loved one.
Living with Dysphagia
It may take additional planning, but with careful management, many people around the world still live full and satisfying lives with dysphagia. Exploring food consistency options or choosing alternatives gives you control over an important aspect of your daily living.
As dysphagia is not always static, it’s important to see a specialist regularly who can continue to assess your risk and management. If you have a feeding tube, a dietician, nurse or another member of the specialist medical nutrition team should follow up on your diet and care. Feeding tube care can also be completed in the comfort of home by a trained nurse.
Dysphagia is often a symptom of other illnesses, and some of these illnesses may mean that the individual has to follow specific dietary requirements. This poses an additional challenge in managing your diet and nutrition. Some people find that having assistance with their dietary needs can be helpful. Caregivers can help with food preparation and feeding.
Being familiar with the condition of the care recipient and knowing the possible complications of dysphagia is important for you and the people around you, whether they are family members, friends, or the team members of a formal care package. This ensures that you know the problems to look out for and can identify potential signs of complications, such as having new breathing difficulties, an altered tone of voice, or suddenly becoming sleepy, should they arise. Identifying these signs early can lead to prompt treatment and better outcomes.
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