Part I

Foundations

CHAPTER 1
Dysphagia Unplugged
Michael E. Groher

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CHAPTER OUTLINE
What Is Dysphagia? 1 Gastroenterologist 12
Incidence and Prevalence 3 Radiologist 12
Prevalence by setting 4 Neurologist 12
Community 4 Dentist 13
Acute and chronic geriatric care 4 Nurse 13
Acute general hospitals 4 Dietitian 13
Acute rehabilitation unit 4 Occupational therapist 13
Special populations 4 Neurodevelopmental specialist 13
Consequences of Dysphagia 8 Pulmonologist and respiratory therapist 13
Medical consequences 8 Levels of Care 14
Psychosocial consequences 9 Acute care setting 14
Clinical management 9 Neonatal intensive care unit 14
Clinical examination 10 Subacute care setting 15
Imaging examination 10 Rehabilitation setting 15
Treatment options 10 Skilled nursing facility 15
Who Manages Dysphagia? 10 Home health 16
Speech-language pathologist 11 Take Home Notes 16
Otolaryngologist 12

OBJECTIVES it connotes a disorder of or difficulty with swallowing. It is

1. Define dysphagia and its ramifications. correctly pronounced with a long or short a. The final syl-
2. Discuss the epidemiology of dysphagia. lable, “ja,” requires a hard pronunciation rather than the soft
3. Discuss the medical and social consequences of dysphagia. “dja” to avoid confusion with the communicative language
4. Provide an overview of the clinical management of disorder, dysphasia (see Practice Note 1-1).
dysphagia. Taber’s Cyclopedic Medical Dictionary1 defines five
5. Discuss the role of persons who manage dysphagia. subcategories of dysphagia:
6. Discuss the types of settings in which dysphagic
1. Constricta: narrowing of the pharynx or esophagus
patients might be seen and how this might affect their
2. Lusoria: esophageal compression by the right subcla-
management.
vian artery
3. Oropharyngeal: difficulty with propulsion from the
WHAT IS DYSPHAGIA? mouth to the esophagus
Dysphagia takes its name from the Greek root phagein, 4. Paralytica: paralysis of muscles of mouth, pharynx, or
meaning to ingest or engulf. Combined with the prefix dys-, esophagus
1
2 PART | I Foundations

PRACTICE NOTE 1-1 BOX 1-1 SUMMARY OF CONDITIONS THAT MAY

CONTRIBUTE TO DYSPHAGIA
While acting as a consultant to a food production com-
pany, I asked them what they thought the extent of their
Neurologic Diagnoses
market would be, indicating that to my knowledge we
Stroke
only had gross estimates of how many persons with dys-
Traumatic brain injury
phagia would benefit from specialized foods. They told
Dementia
me that they had been working with a firm that did an ex-
Motor neuron disease
tensive analysis on this topic and had prepared a detailed
Myasthenia gravis
report on the potential market. I asked them to send me
Cerebral palsy
a copy because I was interested in data that document-
Guillain-Barré syndrome
ed the incidence of dysphagia in the United States. Two
Poliomyelitis
weeks later, I received a package with a copy of the data.
Infectious disorders
To my surprise, there were at least 15 pages of referenc-
Myopathy
es. On closer inspection of the first page, I noticed that
the firm they had hired had used the key word dysphasia, Progressive Disease
not dysphagia. I broke the news to them that what they Parkinsonism
had paid for was an extensive review of the literature on Huntington’s disease
language disorders after neurologic injury, not swallow- Progressive supranuclear palsy
ing disorders. What a difference a single letter can make! Wilson’s disease
Age-related changes

Connective Tissue/Rheumatoid Disorders

5. Spastica: dysphagia from spasm of the pharynx or Poly- and dermatomyositis
esophagus Progressive systemic sclerosis
In clinical practice, only oropharyngeal dysphagia from Sjögren’s disease
Scleroderma
this list is used with any frequency. Interestingly, medical
Overlap syndromes
students learn that dysphagia is a swallowing problem pri-
marily associated with disease of the esophagus. However, Structural Diagnoses
when used properly the term should refer to a swallowing Any tumor involving the alimentary tract
disorder that involves any one of the three stages of swal- Iatrogenic Diagnoses
lowing: oral, pharyngeal, or esophageal. Some might extend Radiation therapy
the term to the stomach or lower gastrointestinal tract as pri- Chemotherapy
mary disorders in these structures such as the stomach may Intubation or tracheostomy
secondarily affect other parts of the gastrointestinal tract Postsurgical cervical spine fusion
such as the esophagus. It is not a primary medical diagnosis Postsurgical coronary artery bypass grafting
but rather a symptom of underlying disease and therefore is Medication-related
described most often by its clinical characteristics (signs). Other or Related Diagnoses
Complaints such as coughing and choking during or after Severe respiratory compromise
a meal, food sticking, regurgitation, odynophagia, drool- Psychogenic condition(s)
ing, unexplained weight loss, and nutritional deficiencies all
may be associated with dysphagia. Because dysphagia is a
symptom of underlying disease that is not necessarily spe- attempts but fails to reach the stomach. In these circum-
cific to the swallowing tract, it can be associated with var- stances, classification of dysphagia by either clinical or
ied diagnoses. These diagnoses are summarized in Box 1-1. imaging examination seems warranted and straightforward.
Throughout this text, most of these diagnoses will receive However, not all patients with physiologic abnormalities
individualized attention. See Chapter 9 for a full discussion of the swallowing mechanism show obvious delay in bolus
of symptoms and signs associated with dysphagia. flow or misdirection of bolus flow. The question that may
Dictionary-based definitions of dysphagia imply that it arise for the clinician (and often for the researcher who has
is the result of a physiologic change in the muscles needed selected a cohort of patients with dysphagia) is the degree
for swallowing. Physiologic change often leads to the two of severity of physiologic changes in the swallowing mus-
hallmarks of dysphagia: delay in the propulsion of a bolus culature needed before a patient is classified as having dys-
as it transits from the mouth to the stomach or misdirec- phagia. For instance, physiologic changes in the swallowing
tion of a bolus. Misdirection can be defined as bolus ma- musculature have been described in older persons2—such
terial entering the upper airway or lungs, or material that as reduction in tongue strength or esophageal motility—
enters the mouth, pharynx, or esophagus during swallowing both of which may delay the delivery of food or liquid to
 Dysphagia Unplugged CHAPTER | 1 3

the stomach. However, only when such changes result in bolus, patients with bulimia and anorexia rarely have de-
perceptible changes in eating habits or associated medical monstrable changes in or complaints of swallowing diffi-
complications such as undernutrition or aspiration pneu- culty.4
monia is a person classified as truly having dysphagia.
Clinical Pearl: When researchers describe a group of
patients who are dysphagic, it may not be clear how they INCIDENCE AND PREVALENCE
defined dysphagia or how they classified the severity of The incidence of a disorder is the reported frequency of
their subjects. Readers should be aware of this issue when new occurrences of that disorder over a long time (usually
interpreting the results of their study. at least 1 year) in relation to the population in which it oc-
Because swallowing is a dynamic process, persons may curs. The prevalence of a disorder is the number of cases in
not exhibit signs and symptoms of dysphagia with every a population during a shorter, prescribed period, usually in
swallow and every bolus type. In these cases, they may a specific setting.
be considered to be at risk for dysphagia or, alternatively, Clinical Pearl: Exact measures of the incidence and
operationally defined as dysphagic. It is also possible that prevalence of swallowing disorders in large and various
the swallowing musculature is normal but the patient is not populations are impossible because of differences in ac-
alert enough to use that musculature because of his or her cepted definitions of dysphagia, the setting in which it is
decompensated medical condition. In such cases, it is as- measured (acute, rehabilitation, chronic), and differences
sumed that attempts to swallow would result in dysphagic in the measurement tools across studies to detect it.5
complications. In these cases, the patient may be classi- For instance, asking a patient if she or he has a swallow-
fied as at risk for dysphagia. Patients may demonstrate ing disorder to determine the prevalence is a very different
abnormalities of behavior that interfere with the normal method of detection compared with the use of an imaging
swallowing process; these may cause dysphagic signs and examination such as videofluoroscopy. Most demographic
symptoms or put the patient at risk for dysphagia. There- data that are reported relating to swallowing disorders are
fore, dysphagia is defined not only by abnormalities of the prevalence data. The importance of knowing the prevalence
mechanics of the swallowing musculature, but also by the of a disorder can help guide clinicians in the detection of
consequences of failure, or potential failure, of that mus- that disorder and therefore helps plan how resources might
culature owing to factors not always specifically related be devoted to that disorder. For instance, if an examiner
to swallow mechanics. For this reason, the authors prefer knew that a certain abnormality was found in less than 1%
the definition of dysphagia offered by Tanner3: “Dyspha- of that population, the examiner may not spend time look-
gia: [an] impairment of emotional, cognitive, sensory, ing for that abnormality because its expected frequency of
and/or motor acts involved with transferring a substance occurrence would be low. If, however, a particular abnor-
from the mouth to stomach, resulting in failure to main- mality was found in more than 50% of the persons with
tain hydration and nutrition, and posing a risk of choking a particular disorder, the examiner would be alerted to ex-
and aspiration” (p.16). A swallowing disorder should be pect the occurrence of deficits associated with that disorder.
distinguished from a feeding disorder. A feeding disorder Therefore, if the data suggested that 50% of patients who
is impairment in the process of food transport outside the have had an acute stroke could have dysphagia, and that
alimentary system. A feeding disorder usually is the result 20% of that group might have silent aspiration, an exam-
of weakness or incoordination in the hand or arm used to iner would expect that half of the patients with acute stroke
move the food from the plate to the mouth. In the United would have swallowing impairment and about half of those
Kingdom and the United States, a feeding disorder, particu- are at high risk for silent aspiration. Furthermore, pneumo-
larly in the context of infants and children, may be the same nia develops in 37% of acute stroke patients with aspira-
as a swallowing disorder. Persons with feeding disorders tion.6 Knowledge of these prevalence data provides valu-
(motor transfer problems) may also be dysphagic, such as able assistance to medical personnel who initially screen for
those with cerebral palsy whose neurologic disability af- and manage the medical complications after acute stroke
fects both feeding (motoric transfer) and swallowing. It is (see Chapter 4 and 9).
not known whether a feeding disorder that might require The American Speech-Language-Hearing Association
assistance with food transport also affects the subsequent (ASHA) estimates that 6 to 10 million Americans show
act of swallowing, perhaps by interfering with timing of some degree of dysphagia, although it is not known how
swallowing events. these estimates were made.7 Kuhlemeier8 reported that the
A swallowing disorder is also to be distinguished from incidence of reported dysphagia in the state of Maryland
an eating disorder such as anorexia or bulimia nervosa. rose from 3 in 1000 in 1979 to 10 in 1000, probably as a
Whereas patients with dysphagia, bulimia, and anorexia result of better reporting methods. Using these estimates,
may have difficulty with poor appetite, changes in dietary approximately 25,000 persons in Maryland in 1989 had
selections, and problems with the oral preparation of the dysphagia as either a primary or secondary diagnosis.
4 PART | I Foundations

Acute and Chronic Geriatric Care

CLINICAL CASE EXAMPLE 1-1
The hospital’s chief of staff was reviewing a request Of the 211 patients admitted to an acute geriatric unit in Singa-
from the dysphagia team to hire an additional speech pore, the prevalence of dysphagia was 29% on admission and
pathologist and dietitian to screen and treat patients on 28% at discharge.13 In a nursing home in Maryland (chronic
the hospital’s new stroke and acute geriatric units. Part care), as many as 60% of residents had a combination of swal-
of the rationale for the request was based on recent lowing and feeding difficulty.14 A similar number (53%) was
published guidelines from the Centers for Medicare found in a chronic care facility in Spain, two urban nursing
& Medicaid Services that screening for dysphagia on a homes in South Korea, and in eight nursing homes in Portu-
stroke unit was prudent because of evidence that early gal.15-17 One study found that when feeding and swallowing
detection may prevent associated morbidity and mortal- difficulty were combined, as many as 87% of the residents in
ity, both of which would increase costs for the health-
a home for the aged were at risk for inadequate oral intake.18
care system and, by implication, the hospital. Further-
more, prevalence data from five studies were submitted
Follow-up data of nursing home residents with oropharyngeal
indicating that at least half of the patients on the stroke dysphagia indicate a mortality rate of 45% at 1 year.19
unit and a similar number on the acute geriatric unit
may have dysphagia. The financial officer estimated that Acute General Hospitals
early detection and treatment of dysphagia would result
in a cost savings that far exceeded the cost of the two Using the Fleming Index of Dysphagia, a tool to identify
new employees who would be assigned to those units. dysphagia, Layne et al.20 found that nearly one third of
After integrating the request from the dysphagia team, their patients had a diagnosis consistent with dysphagia.
the evidence from the literature on prevalence, and the These findings were nearly 18% higher than those provid-
potential cost savings to the medical center, the chief of ed by Groher and Bukatman,21 who reported a 13% preva-
staff approved the request. lence rate in similar settings. The discrepancy in preva-
lence was explained by the fact that patients who were
dehydrated in the study by Layne et al. were classified as
dysphagic, whereas this was not a marker for dysphagia
used in the collection of the Groher and Bukatman data.
Prevalence by Setting
Estimates of prevalence of dysphagia vary by setting be- Acute Rehabilitation Unit
cause certain age groups (older adults and premature
newborns) and diagnoses (neurogenic) are more likely to Of 307 consecutive admissions to an acute rehabilitation fa-
demonstrate dysphagia. For instance, patients entering a re- cility, one third of patients were dysphagic.22 Of this group,
habilitation setting may not have as many accompanying half had dysphagia as a result of a stroke, followed by trau-
medical problems and dysphagia as those entering a nurs- matic brain injury (20%), spinal cord injury and brain tumor
ing home. Conversely, infants born prematurely may have (7%), and progressive neurologic disease (5%). On admis-
many medical problems that may secondarily result in dys- sion, the patients with the most severe dysphagia were those
phagia (see Chapter 14). In a survey of the entire population with traumatic brain injury, followed by stroke. The least
of an acute general hospital, fewer patients with dysphagia severe dysphagia occurred in those with brain tumors.
would be found in the general population compared with
a survey of a special section of that hospital, such as the Special Populations
stroke unit.
Some primary medical diagnoses are more likely to precipi-
tate dysphagic symptomatology, such as diseases that affect
Community the central and peripheral nervous systems and disorders af-
Estimates of the prevalence of dysphagia among older per- fecting the structures of the alimentary tract, such as can-
sons living in the community range from 16% to 22%.9,10 cer. An estimated 300,000 to 600,000 persons in the United
One study reported on the prevalence of dysphagia in a States each year are affected by dysphagia from neurologic
younger cohort (14- to 30-year-olds) living in the commu- disorders alone; most cases occur after a stroke.5 If these data
nity who had been referred for complaints of dysphagia.11 are reliable, dysphagia is a common symptom after a stroke.
In this selected group, 70% had demonstrable pathologic
conditions that accompanied their symptoms. A systematic Stroke
review of 15 studies that met criterion for review estimated Prevalence reports of dysphagia after stroke depend on
that when combined, the prevalence of dysphagia in com- when in the course of recovery the detection of a swallow-
munity-dwelling elderly was 15%.12 ing impairment was made. For instance, in acute stroke
 Dysphagia Unplugged CHAPTER | 1 5

(less than 5 days after onset) the prevalence of dysphagia Head and Neck Cancer
may be as high as 50%, whereas 2 weeks after stroke only Surprisingly, there have been no large studies of the preva-
10% to 28% of patients may be dysphagic. Recognizing lence or incidence of swallowing disorders in unselected
these discrepancies, Smithard et al.23 provided follow-up patients after treatment for head and neck cancer, although
of 121 (untreated) acute stroke patients for 6 months using it is well known that dysphagia is a frequent complica-
a clinical dysphagia examination and videofluoroscopy to tion. Dysphagia can result from the removal of tissue, with
detect swallowing deficits. Immediately after stroke, 51% subsequent sensory and motor loss, and the effects of ra-
were believed to be at risk for aspiration. After 7 days, only diation therapy and chemotherapy. Before patients in their
27% were still considered to be at risk. At 6 months, 3% study received treatment, Pauloski et al.28 found that 59%
of the survivors had persistent difficulty, whereas 3% who had symptoms consistent with dysphagia. In a large multi-
previously were not dysphagic were now considered at risk. center treatment trial of patients with laryngectomies who
These results suggest that early detection is important in were treated with either surgery and radiation or radiation
preventing dysphagic complications and that a significant and chemotherapy, approximately 33% had some type of
number of patients will improve without intervention spe- swallowing-related difficulty at 2-year follow-up.29 Using
cific to their dysphagia. Similarly, comparable prevalence a questionnaire, Maclean et al.30 noted that 71% of their
figures for dysphagia on admission (43% to 51%) were 197-person sample reported some difficulty with their swal-
found by Gordon et al.24 and Mann et al.,25 although the lowing. In a series of 46 patients treated by supraglottic lar-
latter group noted a higher prevalence of dysphagic symp- yngectomy, 60% had dysphagia after their hospital stay.31
toms at 6 months (50%) than other studies with prevalence In 21 patients following supraglottic laryngectomy using a
rates that ranged from 3% to 9%.23,25 Daniels et al.26 found transoral carbon dioxide laser approach, most experienced
that 36 (65%) of 55 patients with acute stroke had dyspha- dysphagia with aspiration after 2 weeks, but it significantly
gia. Of these 36, more than half aspirated. Of these, two decreased at 12-month follow-up.32 In a mixed group of
thirds did so silently, suggesting that events of aspiration 87 patients with head and neck cancer who were at least
could be detected only by videofluoroscopy, not the bed- 1 year posttreatment, oropharyngeal dysphagia was present
side examination. In a long-term follow-up, 94% of these in 50.6%, mostly to solids.33 Fifty-one percent of patients
patients returned to oral intake. Interestingly, the presence reported a decrease in their quality of life because of their
or absence of silent aspiration did not discriminate between swallowing disability. Evidence suggests that patients with
patients who returned to successful oral feeding. After ana- pharyngeal tumor resections and those with tumors involv-
lyzing prevalence reports from two large stroke databases, ing the tongue base are more likely to have dysphagia.34
Gonzalez-Fernandez et al.27 found a significantly higher
prevalence of dysphagia in Asians when compared with
Head Injury
whites and blacks (see Clinical Corner 1-1).
Dysphagia is common after severe head injury. Data report
that the incidence of dysphagia ranges from 4.5% (9 of
199) of consecutive admissions in an acute care setting35
CLINICAL CORNER 1-1 SEVERE DYSPHAGIA to an incidence of 78% (31 of 40) in a similar setting.36
L. G. was admitted to the hospital with a left brain stroke. Discrepancies in reporting may be attributable to the ini-
On admission, he was nonresponsive and a nasogastric tial severity of the injury and the method used to detect and
feeding tube was placed to provide nutrition and hydra- define dysphagia. In 11 patients with severe brain injury
tion. As his responsiveness improved, the nasogastric and coma, Bremare and colleagues documented the preva-
feeding tube was removed and he began oral feeding. lence of dysphagia after arousal using physical and endo-
As he fed himself, it was noted that he choked on most scopic examinations. Seventy-seven percent had oral stage
attempts and dysphagia was suspected. The clinical dysfunction, 66% with pharyngeal stage impairment, and
evaluation noted a weak tongue and poor laryngeal el-
80% with airway protection abnormality.37 Incidence data
evation. The imaging examination showed signs of tra-
cheal aspiration. The diagnosis of dysphagia secondary
are available for patients who survive head injury and en-
to stroke was confirmed. ter a rehabilitation setting; the incidence ranges from 27%
to 30%35,38 to 42% (218 of 524).39 In a mixed group (type
CRITICAL THINKING of injury and time after onset), Lazarus and Logemann40
1. Why might a nasogastric tube be placed on admis- found that approximately half of the patients they exam-
sion?
ined with videofluoroscopy showed evidence of dysphagia.
2. Should the nasogastric tube have been removed?
Why do you think it was removed?
Among patients with head injuries entering a rehabilitation
3. Should it be replaced, or what might the next step in setting, Winstein38 found that 27% were dysphagic on ad-
care be? mission to rehabilitation and that only 6% were dysphagic
after 5 months of rehabilitation. Of 62 consecutive patients
6 PART | I Foundations

receiving outpatient rehabilitation, Yorkston et al.36 report- found that 32% of their patient sample complained of dys-
ed that 13% remained dysphagic. In general, the more se- phagia. In patients with early-stage disease, Sung et al.48
vere the initial injury, the higher the incidence of dysphagia. found manometric abnormalities on both liquid and more
In a retrospective review of 219 patients admitted for head viscous bolus types with disruptions of esophageal motil-
injury who were suspected of dysphagia, logistic regres- ity during repetitive swallowing tasks. Interestingly, the
sion revealed that those who were older, tracheotomized, esophageal abnormalities were present even before overt
and aphonic were more likely to enter the next level of care manifestations of dysphagia were present. That patients
with a feeding tube than those who did not evidence these with Parkinson’s disease may not be accurate reporters
findings.41 Some patients remain comatose and are unable of dysphagic symptoms is well known. Kalf et al.49 per-
to eat, whereas others require extensive neurosurgical pro- formed a meta-analysis using 12 studies to establish the
cedures with prolonged intubation and mental status chang- prevalence of dysphagia associated with parkinsonism.
es, all of which may preclude attempts at oral ingestion. One third of the patients sampled complained of dyspha-
However, once patients enter the rehabilitation setting, their gia, whereas more than 80% had objective demonstra-
chances of returning to oral feeding are good. tions of its presence. The prevalence of dysphagia may be
higher in patients with Parkinson’s disease who also have
Progressive Neurologic Disease significant dementia.50
Progressive neurologic diseases that frequently result in
dysphagia include Parkinson’s disease and its variants, Amyotrophic Lateral Sclerosis
amyotrophic lateral sclerosis (ALS), multiple sclero- When ALS affects the bulbar musculature, dysphagia
sis (MS), and myasthenia gravis; diseases of systemic may be one of the first symptoms of the disease. In studies
rheumatic origin such as dermatomyositis, polymyositis, of patients with ALS at first diagnosis, 25% to 30% have
rheumatoid arthritis (RA), scleroderma, and Sjögren’s evidence of bulbar symptomatology.51,52 It can be assumed
syndrome; and variants of dementing syndromes such as that at least one third of patients with a diagnosis of ALS
Alzheimer’s disease and frontotemporal disease. Systemic will have some difficulty swallowing, particularly as the
rheumatic disorders are far rarer than Parkinson’s disease disease progresses.53 Known characteristics of disease pro-
or MS but merit consideration in a discussion of dysphagia gression that affect the bulbar musculature result in progres-
and neurologic disease. Because of the progressive nature sively severe dysphagia symptomatology.54
of these disease processes, the point in disease progression
at which dysphagic symptoms occur is never certain. For
Multiple Sclerosis
instance, some patients report dysphagia as the initial symp-
tom of the disease, whereas others may never mention dys- Hartelius and Svensson55 found that more than 33% of
phagia. In general, however, as disease severity increases, a large series of patients with MS had either chewing or
so does dysphagia. Complications from dysphagia, particu- swallowing problems. Dysphagic complaints in patients
larly those that threaten pulmonary function, may lead to receiving follow-up care in an outpatient clinic ranged
aspiration pneumonia and death (see Chapters 7 and 12 for between 30% and 40%.56 Similar to those with ALS, not
a discussion of aspiration pneumonia). all patients with MS will have dysphagia unless the bulbar
musculature is involved, and symptoms are more likely to
Parkinson’s Disease appear as the disease progresses. After evaluating 143 con-
Although dysphagia secondary to Parkinson’s disease ap- secutive patients with primary and secondary progressive
pears to be common, accurate measurements are restricted MS, Calcagno et al.57 confirmed dysphagic symptoms in
by subject selection bias and dysphagia detection meth- 34%. Their study showed a positive relation between dys-
ods. However, most authors agree that dysphagia occurs phagia and disease severity and between dysphagia and
in at least 50% of patients with Parkinson’s disease.42-44 brainstem involvement. After surveying 309 patients with
Pflug and colleagues studied 119 consecutive patients MS, DePauw et al.58 found that 24% had chronic swallow-
with early-stage Parkinson’s disease using fiberoptic en- ing difficulty and another 5% admitted to transitory dif-
doscopy. Only 5% were without some change in swallow ficulty. As patients became more disabled according to a
performance that included abnormal airway protective scale of disability measurement, the prevalence of dyspha-
mechanisms, increased residue, or leakage of contents into gia increased to 65%
the pharynx. Most all in this group were unaware that they
had any swallowing abnormality.45 In 72 patients with Par- Myasthenia Gravis
kinson’s disease of varying severity, Leopold and Kagel46 In selected populations of patients with myasthenia gravis,
found that as many as 82% reported swallowing difficul- approximately one third will be dysphagic.59 The preva-
ty. Using the Unified Parkinson’s Disease Rating Scale, lence of dysphagia depends largely on the extent of muscle
a scale that acquires data by self-report, Walker et al.47 fatigue and other medical complications such as respiratory
 Dysphagia Unplugged CHAPTER | 1 7

impairment secondary to an acute exacerbation of muscle

weakness. CLINICAL CORNER 1-2 MEDICATION RISK
Clinical Pearl: Prescribed medications often can com- M. M. was admitted to the burn unit with severe burns to
pensate for extreme muscle fatigue in patients with this the head, neck, and upper torso. Because of associated
diagnosis. pain he was heavily sedated. As his condition improved
and before he was allowed to eat orally, a request for a
swallowing evaluation was made because it was noticed
Muscular Dystrophy he was not swallowing his secretions well. The evalu-
There are no published reports of the prevalence of dyspha- ation of swallowing revealed normal strength of the
gia in muscular dystrophy, although there are reports of swal- swallowing musculature; however, he was disoriented
lowing dysfunction secondary to peripheral oropharyngeal and could not maintain his alertness level for more than
and esophageal muscle weakness in those with oculopharyn- 30 seconds. Because of his poor mental status and alert-
geal, Duchenne, and myotonic muscular dystrophies.60-62 ness level, he was not allowed to eat and was considered
to be at risk for dysphagia.

Polymyositis and Dermatomyositis CRITICAL THINKING

63 1. How might medications contribute to dysphagia?
Oh et al. documented the prevalence of dysphagia in those
2. Could poor mental status result in choking? Give
inflammatory diseases affecting muscle. Of the 783 patients some examples.
studied, 62 were dysphagic. Oropharyngeal dysphagia was 3. What cognitive functions might contribute to nor-
present in 18 with dermatomyositis, and 9 with polymyo- mal mental status for swallowing safety?
sitis. As with other progressive neurologic conditions, with
these disorders the course and response to medical therapy
may differ; therefore the presence of dysphagia is variable.
Because of their predilection to involve the proximal mus- Dementia
cle, swallowing can be affected in these disorders. Multiple Alagiakrishnan et al.71 did a systematic review of the
disorders of pharyngeal function following videofluoro- prevalence of dysphagia in dementia. Nineteen studies met
scopic swallowing studies were noted in a small group of the review criteria. Prevalence ranged from 13% to 57%,
patients with polymyositis (6), dermatomysitis (4), and in- developing in the later stages of those with frontotemporal
clusion body myositis.64 dementia and in earlier stages in those with Alzheimer’s dis-
ease (see Clinical Corner 1-2).
Rheumatoid Arthritis
Geterude et al.65 found that 8 of 29 patients with RA had Developmental Disability
complaints of dysphagia. In a series of 31 patients with Leslie et al.72 discussed the need to document the true
dysphagia and RA, Ekberg et al.66 documented pharyngeal prevalence of dysphagia in those with developmental dis-
dysfunction in 20. orders to highlight the need for appropriate intervention.
They could find only estimates of prevalence ranging from
Scleroderma 36% in the community to 73% who were inpatients. After
studying those patients referred for dysphagia evaluations,
As many as 90% of patients with scleroderma have swal-
Chadwick and Jolliffe73 concluded that the prevalence of
lowing-related complaints.67 Accompanying erosive
those with dysphagia and concomitant mental or physi-
esophagitis was found in 60% of 53 patients with sclero-
cal disability was 8.1%. Observations of adults with Down
derma.68 In these patients, dysphagia was always an accom-
syndrome living in a residential facility who were eating a
panying complaint. In patients with scleroderma, dysphagic
regular diet revealed that 56.5% were at risk for respiratory
complaints are usually confined to the esophagus, although
infection based on overt signs of cough during the meal.74
secondary effects on the oral and pharyngeal stages result-
Smith et al. found a similar prevalence in a younger group
ing from esophageal dysmotility should be considered.
of hospitalized patients with Down syndrome (mean age
7.45 years). Those with significant neurologic delay or tra-
Sjögren’s Syndrome cheostomy were more likely to be at risk for dysphagia.75
As many as 75% of patients with Sjögren’s syndrome have Using videofluoroscopy as a diagnostic tool, Jackson and
dysphagia.69 As the severity of the disease increased, 64% colleagues studied a cohort of 138 patients admitted to a
in a sample of 101 self-reported swallowing disorders with teaching hospital with Down syndrome between the ages
an accompanying reduction in the quality of their life.70 The of 31 days and 18 years. Their findings showed that 65%
potential of this syndrome to involve all stages of swallow- had oral stage disability, and 56% with pharyngeal abnor-
ing function is well known, especially in overlap syndromes mality including aspiration. Of particular interest was of
such as with scleroderma. the 61% who aspirated, 9 of 10 did so silently.76
8 PART | I Foundations

Mental Illness Premature Infants

Few prevalence data have been recorded on patients with The incidence of infants born prematurely in the United
mental illness who may show signs of dysphagia. Noting States has increased to more than 12% of all live births and
this omission, Aldridge and Taylor77 completed a system- 18% of African-American births.81 A growing concern has
atic review in an attempt to document prevalence and treat- been the incidence of emotional and neurodevelopmental
ment interventions. Ten studies met the inclusion criteria disabilities in the very low birth weight population (less
documenting those with dysphagia or those who expired than 26 weeks’ gestation). Estimates indicate that as many
from choking asphyxiation. Adults with mental illness in as 90% of low-birth-weight infants may be prone to disor-
one study were 43 times more likely to die from organic ders of feeding.82
mental illness compared with the general population. Six
studies revealed a range of prevalence of dysphagia from Spinal Cord Injury
9% to 42%. Kulkarni and colleagues noted that the side- In a study that evaluated the use of clinical versus imag-
effects of psychotropic medications produced Parkinson- ing studies in adults with tetraplegia, Shem et al.83 reported
like symptoms including dystonia and tardive dyskinesia. that 38% of the 39 patients who were enrolled had evidence
These side effects interfere with oral stage preparation of oropharyngeal dysphagia. Four subjects were diagnosed
that secondarily may affect pharyngeal stage function.78 In with aspiration.
acute and community mental health settings, the prevalence Clinical Pearl: Because of positioning they may be li-
of dysphagia was 35% of those admitted, 27% in the day able to esophageal motility disorders as well as mental sta-
hospital, and 31% in long-term care.79 None of the studies tus changes if their injury involved the cortex in addition
provided data on treatment intervention or outcomes (see to the spinal cord.
Clinical Corner 1-3).

Phagophobia CONSEQUENCES OF DYSPHAGIA

Phagophobia, or the fear of swallowing, may be associated
Because dysphagia frequently accompanies many medical
with psychogenic etiologic factors such as panic disorders,
diagnoses, it is important to appreciate its potential effect on
posttraumatic stress disorder, social phobia, or obsessive-
patient care. It is well recognized that dysphagia is a symp-
compulsive disorders. Those with phagophobia usually de-
tom of disease, but it also has the potential to secondarily
scribe their problem as the sensation that they are unable to
precipitate morbidity and mortality. As such, its influence
swallow in the absence of any documented sensory or motor
on health can be substantial. Additionally, it can affect the
abnormality. Baijens et al.80 reviewed 12 published studies
patient’s overall quality of life.
that attempted to establish the prevalence and treatment of
the disorder. Most had serious methodologic flaws with low
levels of evidence that made it too difficult to establish reli- Medical Consequences
able prevalence statistics.
A potential complication of patients with oropharyngeal
dysphagia is aspiration pneumonia. The treatment of as-
piration pneumonia is costly, and it is associated with
CLINICAL CORNER 1-3 PSYCHIATRIC DIAGNOSIS increased length of stay in the hospital,84 greater disabil-
L. T. was admitted to the psychiatry unit with symptoms of ity at 3 and 6 months,84,85 and poorer nutritional status
acute schizophrenia. When eating, it was noted he would during hospitalization.84 One study84 found an increased
take excessive time to finish, with intermittent choking epi- mortality risk in stroke patients for whom swallowing
sodes. The speech pathologist who evaluated him for signs
was considered unsafe at 6 months’ follow-up, whereas
and symptoms of dysphagia found that the oropharyngeal
another study did not find this relation at 3 months.85 De-
swallowing musculature was intact. As she watched the pa-
tient eat, she noted a rapid feeding rate with inappropriate
hydration is a frequent adjunct in those with dysphagia
bite sizes. She also noted excessive talking while eating, after stroke.85,86 Dehydration can lead to increased mental
and the choking episodes occurred during these talking confusion and generalized organ system failure, both of
periods. The patient was classified as dysphagic as a result which lead to greater decompensation of swallowing.87
of emotional and behavioral abnormalities. Dysphagia may lead to undernutrition, which adversely
affects energy levels (ability to sustain a swallow), and
CRITICAL THINKING
1. What other types of behavioral disorders might con-
if severe or chronic, compromises the immune system.
tribute to dysphagia? Compromise to the immune system potentially delays
2. Why did this patient choke while eating and talking? healing and increases susceptibility to infection, sepsis,
and death.87
 Dysphagia Unplugged CHAPTER | 1 9

Psychosocial Consequences PRACTICE NOTE 1-2

Oral ingestion of food and liquid is a pleasurable activity
I first met George at the New York Hospital in the out-
for most people. Social interactions often revolve around patient clinic. He obviously was a man of means, as he
sharing a meal. “Let’s have lunch, are you free for din- told stories of extensive travel. His swallowing evalua-
ner, or can we meet for an early breakfast?” Having a tion that day revealed it was not safe for him to eat orally
piece of wedding cake, being offered an hors d’oeuvre because of a specific muscle weakness, and a gastros-
at a party, enjoying a midnight snack, and going to one’s tomy tube was recommended. He was noticeably upset
favorite restaurant are all examples of common situations by this recommendation. Because he was only 35 years
that require the ability to swallow. Swallowing difficulty old, we suspected that this might put an end to his life
as a world traveler; however, George was not convinced.
After his gastrostomy was placed, to my surprise he told
me he had made arrangements for a 3-week trip to Spain
CLINICAL CASE EXAMPLE 1-2 and Portugal. He had arranged to ship cases of formula
A request for services was sent to the speech pathologist for his tube to each hotel on his travel itinerary before
to evaluate a 70-year-old man for suspected dysphagia. his departure. When he arrived in Spain, his formula
He had lived in the nursing home for 2 years after a left was waiting. Normally he would have dined on bouil-
brain stroke that left him with aphasia and poor mobility. labaisse and fresh fish with a fine Chablis. Instead, he
He spent most of his day sitting in a wheelchair or in bed self-administered six cans of a liquid formula per day
watching TV and was beginning to show evidence of de- into his gastrostomy tube and continued to enjoy the
cubitus ulcers on his coccyx. The nurses reported he was ambience of Europe. He was determined not to let his
showing increased disinterest in his soft mechanical diet severe pharyngeal dysphagia interfere with other as-
and was choking at most meals on his liquids. He rarely pects of his life.
finished a meal. A review of his medical record revealed
a consultation from the dietitian who noted that his al-
bumin was 3.0 g/dL, he had lost 5% of his body weight
therefore may limit the extent to which a person might so-
in the past 2 weeks, and he was hypernatremic. Based
cialize, leading to major changes in a normal lifestyle (see
on these parameters, the dietitian concluded that the
patient was undernourished and dehydrated and won- Practice Note 1-2). Fear of overt choking episodes and the
dered if his previous history of dysphagia was contribu- associated discomfort might contribute to social isolation
tory. The patient was examined in bed. He was able to and accompanying depression. Spouses and family mem-
follow one-step commands and name simple objects but bers are equally affected because of the potential social
was not oriented to time or place. During the examina- limitations dysphagia may precipitate. Even making sub-
tion, the patient fell asleep every minute and the speech tle changes in dietary preferences to compensate for dys-
pathologist had to continually awaken him to maintain phagia may lead to feelings of discontent. Eating may no
his attention and cooperation. An examination of his longer be pleasurable. It becomes an activity performed
oral peripheral speech mechanism revealed a mild right only for nourishment. The need for special preparations at
facial weakness but otherwise was normal. Test swallows
mealtime provides additional stress. Special dietary sup-
with various food items were delayed but without overt
plements may be costly, often posing financial burdens.
coughing. Tests with liquids revealed numerous chok-
ing episodes. Based on his physical examination and the Clinical Pearl: An assessment of family burden should
results of his laboratory tests, it was concluded that his be an important part component of treating dysphagic pa-
swallow may improve if he were properly hydrated and tients living at home.
nourished, and that it was unlikely that hydration and
nourishment could be accomplished by mouth because
Clinical Management
his alertness level was poor. Furthermore, his nutritional
and hydration requirements would have to be elevated The care of patients in whom dysphagia is suspected usu-
because of fluid loss from the decubitus ulcers. It also ally begins with a basic process of identification in an
was likely that his ulcers would not heal unless his pro- attempt to answer the question of whether dysphagia is
tein stores were improved. For this reason, a nasogastric present. This process can be the result of a simple screen-
tube was recommended with regular reevaluation of
ing, such as watching a patient eat or drink small amounts
his laboratory values and mental status to make recom-
of food. Such a screening might be done after a patient
mendations for possible return to oral feeding. It was
hypothesized that because he had been eating normally has had an acute neurologic event such as a stroke. Some
before this acute change, the dysphagia was most con- patients begin to eat without screening because the risk
sistent with a change in metabolic status and not related factors for dysphagia are not present. An example might
to a change in his neurologic presentation. be a patient who has not had any swallowing difficulty in
the past, but required a feeding tube immediately after an
10 PART | I Foundations

operation for medical purposes and who has been cleared Treatment Options
by the physician to return to oral ingestion. As the patient
Ideally, the clinical and imaging evaluations will lead to a
returns to eating, either the medical staff or the patient
treatment plan.
notices swallowing difficulty. Outpatients may report to
Clinical Pearl: There is evidence that even after combin-
their general practitioner that they are having swallowing
ing these two modalities, there may be disagreement among
difficulty. In all these situations, a clinical evaluation of
clinicians about what treatment should be implemented.
swallowing will be initiated.
The goal of most treatment plans is to ensure that the
patient can consume enough food and liquid to remain
Clinical Examination nourished and hydrated and that the consumption of these
materials does not pose a threat to airway safety, result-
The clinical evaluation should include a thorough review of ing in aspiration pneumonia. If treatment is indicated,
the medical and psychosocial history (see Chapter 9). four main areas are considered: behavioral, dietary, medi-
Clinical Pearl: This part of the examination often is cal, and surgical. These options may be applied as com-
too cursory with important information not well integrat- pensatory, rehabilitative, or preventive interventions (see
ed; its importance to diagnosis underestimated. Chapter 11)
This is followed by a physical evaluation that includes Behavioral interventions include engaging the patient
a screening of mental status, an evaluation of the mus- in some change in swallowing behavior. Changes may take
culature of the head and neck, and, if appropriate, trial the form of simple compensations, such as a change in
swallows of liquid, semisolid, and solid materials. If the posture or eating rate; in rehabilitative strategies, such as
clinical examination fails to adequately explain the pa- teaching a patient a new way to swallow; or in strengthen-
tient’s symptoms or requires more in-depth visualization ing muscles. Dietary interventions might include modifi-
of any phase of the swallowing sequence, an imaging cations of texture, taste, or volume. Medical interventions
study may be necessary. The clinical indicators for the use may include a change in medication negatively affecting
of imaging assessment techniques have been published by mental status and swallow or the placement of a nasogas-
ASHA.88 tric feeding tube. Surgical interventions might include
mobilization of a weak vocal fold or the placement of a
gastrostomy tube. Combinations of these options are com-
Imaging Examination mon; however, the timing of each intervention is patient
Imaging the aerodigestive tract most commonly is done dependent. A full discussion of treatment planning, in-
by barium x-ray studies, direct visualization, and mea- cluding options and details of rationale and use, is pre-
surement of pressures within the aerodigestive tract dur- sented in Chapters 11 and 16.
ing swallowing attempts. The most common x-ray tech-
nique that assesses the oral, pharyngeal, and cervical
esophageal phases of swallowing is the modified barium WHO MANAGES DYSPHAGIA?
swallow (videofluoroscopy). ASHA provides a statement
Patients who have disruptions in swallowing potentially
of guidelines for speech-language pathologists (SLPs)
involve many members of the medical community. Those
who perform this procedure.89 A standard barium swal-
whose dysphagia is related to the head and neck may see an
low (esophagram) may be used to evaluate the esopha-
otolaryngologist, dentist, SLP, or neurologist. To further de-
gus. Direct visualization of the pharyngeal, laryngeal,
fine the disorder, these specialists often need the services of
and esophageal compartments is done by endoscopy.
a radiologist. Those whose swallowing disorder may be of
Guidelines for the performance and interpretation of the
esophageal origin may require the services of a gastroenter-
endoscopic evaluation of swallowing by SLPs are pro-
ologist. If the swallowing disorder is related to an acute re-
vided by ASHA.90 Patient preparation and positioning
spiratory condition, a patient may be under the care of a pul-
for each of these studies vary according to focus of the
monologist, pulmonary physical therapist, and respiratory
anatomic region being examined. Pressure measurements
therapist. If the swallowing disorder is related more to the
during swallowing (manometry) are more routinely done
process of feeding, an occupational therapist is frequently
for clinical purposes in the esophagus than in the mouth
involved. If the swallowing disorder results in compromise
or pharynx, although there has been an increased use in
to the nutritional system, a dietitian is consulted. While the
the pharynx and pharygoesophageal segment to better un-
patient is in the hospital, the nurse frequently is involved
derstand their physiology. A full discussion of these and
in the identification and treatment of the patient’s swallow-
other instrumental techniques used in the evaluation of
ing disorder. In short, patients with swallowing disorders
swallowing is provided in Chapter 10.
require the attention of many specialists who must work in
 Dysphagia Unplugged CHAPTER | 1 11

concert to achieve swallowing safety and nutritional stabil- first papers by an SLP on the diagnosis and treatment of
ity. The prominence of individual roles at any given time swallowing disorders after surgical procedures for cancer in
depends on the patient presentation. the head and neck. That the paper was accepted at the con-
Ideally, healthcare professionals who are concerned vention was a monumental achievement because there was
about the patient’s swallowing safety and nutritional ade- no recognized category for a paper on swallowing, and eval-
quacy will work together toward the mutual goal of improv- uating and treating patients with swallowing disorders was
ing the patient’s swallowing performance. Coordination not within the accepted scope of practice for an SLP. This
of effort is important if timely results are to be achieved. radical departure from the traditional role of the SLP raised
Some medical centers have designated swallowing teams more than a few eyebrows (see Practice Note 1-3). As Loge-
and swallowing team leaders. In many hospitals, an SLP mann was beginning her distinguished career in dysphagia
assumes the role of swallowing team leader. The role each management, Dr. George Larsen, also working in a medical
specialist plays on the team varies across settings. For in- setting with adults, began to develop treatments specific to
stance, some gastroenterologists diagnose and treat swal- patients with neurogenic swallowing disorders. Because so
lowing problems that involve the esophagus, but disorders many of his patients with speech and language disorders
of the esophagus are not their special interest. Specific in- had accompanying swallowing dysfunction, he began to
terest in the swallowing-impaired patient also varies. For search the literature for relevant treatment approaches. He
instance, few radiologists have a specific interest in patients discovered a literature full of descriptions of how a person
who report dysphagia. The result of this variance in inter- swallows but no mention of how to treat the impairment.
est and focus is that not all swallowing disorder teams are Using his background in neurology and physiology, he be-
the same, and in some cases not all potential members are gan to develop treatment approaches and reported them in
represented. the literature. He wrote about appropriate postures92 and the
need for some patients to bring the swallowing sequence
under volitional control.93 He was convinced that the most
Speech-Language Pathologist successful approaches would result from a team effort, and
SLPs have taken a leading role in the management of pa- he described the use of trained feeding volunteers as part of
tients with dysphagia related to poor oral and pharyngeal the process.92 The momentum to evaluate and treat swal-
swallowing mechanics. In most centers, they coordinate the lowing disorders in children and adults grew throughout
swallowing team and are frequently the first profession- the 1980s. The momentum was sustained by the publica-
als to perform a history and physical examination that is tion of two texts by SLPs summarizing empirical evidence
specific to oropharyngeal dysphagia. Based on these data, supporting the role of the SLP and emphasizing the need
they consult other members of the dysphagia team, obtain for collaboration among various medical professionals.94,95
approval from the patient’s attending physician for any ad- Both texts have undergone revisions. Today, SLPs have as-
ditional testing or referrals, and integrate the rehabilitative sumed a leadership role in providing care to children and
components of the dysphagia treatment program. Only adults with oropharyngeal dysphagia. SLPs are at the fore-
within the past 20 years have specific practice guidelines front of providing the research and educational components
for managing dysphagia by SLPs been developed. These in- that support their clinical efforts. Miller and Groher96 have
clude an outline of the knowledge and skills needed to treat
oropharyngeal dysphagia and the need to understand the
esophageal components of swallowing to make appropriate PRACTICE NOTE 1-3
medical referrals.91 I well remember the reaction of ASHA in the 1970s and
SLPs were evaluating and treating articulation disor- early 1980s to the acceptance of the role of the SLP in
ders of children with cerebral palsy as early as the 1940s. managing patients with dysphagia. It was the “new
Because of the decompensation of the oromotor system in guard” versus the traditionalists. Letters to the edi-
children with cerebral palsy, both speech and swallowing tor flew back and forth, most arguing that this area of
were affected; however, treatments specific to swallowing practice was potentially life threatening and SLPs did
were not a routine part of care by the SLP. Working in a not have the medical background necessary to be com-
petent. Treating patients with dysphagia labeled one as
medical setting studying patients with Parkinson’s disease
borderline heretic with threats of a breach of ethics.
in the late 1960s, Dr. Jeri Logemann found that videoflu-
Today, patients with dysphagia dominate the caseloads
oroscopy was ideally suited to study patients’ speech and of SLPs working in medical settings, and children with
swallowing skills. Soon this technique was used to study the dysphagia are being managed in the public school set-
effects of cancer in the head and neck on swallowing per- ting. And both ASHA and the medical community have
formance, and in 1976 at the American Speech and Hearing embraced the role of the SLP in these efforts.
Association National Convention, she presented one of the
12 PART | I Foundations

esophagus. Because primary esophageal disorders that pre-

CLINICAL CORNER 1-4 ELECTRICAL cipitate dysphagia can have secondary effects on the pha-
STIMULATION ryngeal and oral stages of swallowing, it is important to in-
Dr. Miller and I followed Dr. Larsen to a patient with clude the gastroenterologist in the evaluation of the patient
occult hydrocephalus who could not initiate a swallow. who may appear to only have symptoms that relate to the
Results of examination of his oral peripheral mecha-
oral or pharyngeal stages of swallowing (see Chapter 6).
nism were normal, and Dr. Larsen suggested that we
The gastroenterologist is familiar with the management of
needed to stimulate laryngeal elevation. The following
day we watched in disbelief as Dr. Larsen approached
gastroesophageal reflux disease (GERD), or heartburn, a
the patient with a probe tip wrapped in gauze, dipped symptom that may be related to dysphagia. The gastroen-
in saline solution, and attached to a primitive facial terologist may use special sensors that measure the amount
nerve stimulator. As he applied the electric current of acid content in the alimentary tract using a test called
to the thyroid notch, a swallow was initiated and the 24-hour pH monitoring. The gastroenterologist may use
patient continued to swallow without the assistance manometry, or combined impedance and manometrics, to
of the stimulation. Our collective elation that “treat- measure esophageal motility and prescribe medications to
ment” could be so easy was quickly dampened when improve esophageal motility or to control GERD. The use
Dr. Larsen warned it could be dangerous to use such a of esophageal endoscopy to make visual observations of
technique with every patient because it could trigger
the esophageal mucosa to rule out a stricture or cancer is
laryngospasm and death. We learned two things that
a role of the gastroenterologist. The gastroenterologist is
day: not all treatments are for every patient and some
treatments carry accompanying risk.
responsible for the nonsurgical placement of a feeding tube
in the stomach called a percutaneous endoscopic gastros-
CRITICAL THINKING tomy tube.
1. Why might an electrical current facilitate swallowing?
2. Name other types of medical treatments that carry risk.
3. Find a paper that summarizes the effects of electrical Radiologist
stimulation on swallowing.
The radiologist who may be a regular member of the swal-
lowing disorders team often has a special interest in the
described a more detailed history of the involvement of the gastrointestinal tract. Radiologists provide both dynamic
SLP in the management of swallowing disorders (see Clini- (videofluorographic) and static (plain films) imaging of
cal Corner 1-4). the aerodigestive tract and lung fields. Often these studies
provide the diagnostic information that guides swallow-
ing treatment. Special tests such as computed tomography
Otolaryngologist performed after static images of the aerodigestive tract are
The otolaryngologist is skilled in the evaluation of the up- done by a radiologist. The SLP frequently works in con-
per digestive tract. In particular, the use of endoscopy by junction with the radiologist in performing the modified
otolaryngologists for direct visualization of the structures barium swallow (see Chapter 10). The interpretation of the
of the nasopharynx, oropharynx, pharynx, and larynx adds modified barium swallow study is often done concurrently
information relative to the structural, sensory, and motor by the SLP and the radiologist.
aspects of the pharyngeal stage of swallowing. In patients Clinical Pearl: Not all radiologists have extensive
with head and neck cancer who require surgery, otolaryn- familiarity with the modified barium swallow study and
gologists provide surgical and postsurgical management. often rely on the SLP for guidance in procedure and in-
In this regard, they must be sensitive not only to issues terpretation.
of cancer control, but also to the preservation of speech
and swallowing functions. The otolaryngologist may be Neurologist
involved with the surgical placement and removal of a
patient’s tracheostomy tube. Because these tubes may Because the majority of patients with oropharyngeal dys-
interfere with normal swallowing, these specialists work phagia have swallowing impairment as a result of neuro-
with the dysphagia team to remove the tubes as soon as logic disease, the neurologist has an important role in the
medically feasible. identification and subsequent management of swallowing
problems. It is critical that patients with symptoms of dys-
phagia without a known cause be considered for evaluation
Gastroenterologist
by the neurologist. Some neurologic diseases that precipi-
The gastroenterologist who participates on the swallow- tate dysphagia can be treated with medication. Finding a
ing disorders team usually has a special interest in the cause is also important in providing the patient with an
 Dysphagia Unplugged CHAPTER | 1 13

explanation for the dysphagia and in providing a prognosis amount and rate of tube feeding frequently are recom-
for future complications. mended by the dietitian. As patients return to oral feed-
ing, the SLP and dietitian closely monitor intake. As oral
feeding improves, the dietitian adjusts the amount of tube
Dentist feeding to appropriate levels.97
Patients with dysphagic symptoms may be identified first
by the dentist during routine dental care. Of particular inter-
Occupational Therapist
est to the dentist are any oral-stage manifestations of swal-
lowing disorders, such as problems with chewing, bolus The occupational therapist is skilled in retraining the pa-
formation, or dental disorders such as osteoradionecrosis tient to self-feed. If the patient is unable to self-feed be-
that would make swallowing painful. The dental prosth- cause of weakness or incoordination, the occupational
odontist is skilled at making appliances for the oral cavity therapist needs to be involved in the patient’s care. Special
that can facilitate swallowing in patients who have had oral adaptive feeding devices, such as a plate guard or built-
structures removed because of cancer. In Japan, the dentist up utensils for easier grasping, are ordered by the occu-
is often the team leader in the care of patients with dys- pational therapist to assist the patient in achieving feeding
phagia. Dental hygienists may play a role by providing oral independence. In some medical centers, the SLP and occu-
care that limits the presence of oral pathogen formation. If pational therapist work closely with infants in the neonatal
colonized, such pathogens when aspirated may precipitate intensive care unit (NICU).
pneumonia and secondary lung infection.
Neurodevelopmental Specialist
Nurse The NICU setting can influence the infant’s brain develop-
The nurse has 24-hour responsibility for monitoring the pa- ment and organization as well as the parent-infant relation-
tient’s swallowing problem. Monitoring the amount of in- ship. The neurodevelopmental specialist (NDS) is keenly
take and recording it in the medical record is an important aware of this relationship and will tailor the infant’s care to
role for the nurse. Not only do nurses often identify prob- individual needs. An NDS may be an SLP or occupational
lems during eating in patients in whom dysphagia is not therapist who has specialized in assisting the premature in-
suspected, but they also provide the guidance necessary to fant in developmental growth by fostering supportive care
help the patient with identified dysphagia use recommended during the infant’s nervous system development. Neuro-
swallowing strategies. Other responsibilities include admin- developmental care includes, but is not limited to, proper
istering tube feedings, maintaining good oral hygiene, and infant positioning to support neurodevelopmental tone and
assigning volunteers to assist selected patients at mealtime. maturation. Often it is important to regulate the tolerance of
Clinical Pearl: Because nurses are responsible for 24 the infant’s visual, tactile, and auditory stimulation. Feeding
hour care, they can provide important feedback about the is one of the most difficult tasks in which a premature in-
patient’s eating progress that may not get documented in fant can succeed. The NDS provides continued assessment
the patient’s medical record. regarding the timing and safety of the infant’s oral feed-
ings by breast or bottle. The NDS also monitors the infant’s
physiologic and behavioral responses to the environment
Dietitian
and fosters a positive outcome.
The dietitian assesses the patient’s nutritional and hydra-
tion needs and monitors the patient’s response to those
needs. Because dysphagia frequently affects a patient’s
Pulmonologist and Respiratory Therapist
nutrition and hydration status, and because the result of Although the pulmonologist may not be a regular mem-
poor nutrition and hydration affects a patient’s overall ber of the dysphagia team, patients of pulmonologists fre-
medical stability, it is important to involve the dietitian quently have swallowing disorders that require manage-
in the care plan for patients with dysphagia. Because di- ment by the swallowing team. Patients with respiratory
etitians frequently monitor mealtime activities, they may disorders that require tracheostomy and ventilatory sup-
be the professionals who initially detect a swallowing dis- port (respirators) often have accompanying swallowing dif-
order. If specialized dysphagic diets are ordered for the ficulty. Working with the respiratory therapist and pulmo-
patient, the dietitian may communicate with the food ser- nologist to improve pulmonary toilet is an important step
vice to ensure that the special diet is prepared properly. toward decannulation. Removing a patient’s respiratory
If a patient is unable to eat orally, the dietitian may make supports often is a prerequisite for improving the swallow-
a recommendation for a tube feeding. Guidelines for the ing response.
14 PART | I Foundations

home facility or that a radiologist would be on staff in that

CLINICAL CASE EXAMPLE 1-3 facility. Traditionally, levels of care are divided into five
The SLP was called by the thoracic surgeon to the in- categories: acute, subacute, rehabilitation, skilled nursing,
tensive care unit for a consultation. Her patient had just and home health.
undergone cardiac bypass surgery and had respiratory
complications requiring the placement of a tracheos-
tomy tube. The patient was now medically stable and Acute Care Setting
was ready to resume oral feeding. The SLP consulted
with the respiratory therapist, who mentioned that the In a survey of two acute care hospitals, Groher and Bukat-
patient still required some oxygenation by facial mask man21 found the prevalence of swallowing-related disorders
for short periods during the day. After noting those to be 13%. The majority of these patients were found in
times, the SLP returned when the mask was not in use the intensive care units and the neurology and neurosurgery
because it might potentially interfere with the evalua- units. Owing to the acute nature of their illness, patients
tion. On physical evaluation, the patient had reduced in the acute care setting frequently have multiple medical
tongue strength and could make a weak, breathy voice complications, require intubation tubes connected to ven-
only when the tracheotomy tube was occluded. She tilators, have tracheostomy tubes in place, require feeding
had a nasogastric tube in place for nutritional purpos-
tubes for nutrition, and have frequent changes in their physi-
es. During the evaluation, the dietitian came in and told
cal and mental status. Because their stay in the hospital may
the SLP that the patient was not tolerating the feeding
given by nasogastric tube and that it would be benefi-
be short (2 to 5 days), their swallowing needs must be ad-
cial for the patient to begin to eat orally because some dressed rapidly. Frequently there is not sufficient time or pa-
of those complications could be avoided. The SLP gave tient cooperation because of mental status to order sophis-
the patient small amounts of ice chips and water, as ticated laboratory tests. In this circumstance, the clinician
well as gelatin and pudding. The patient showed de- may have to rely on the history and clinical evaluation to
layed swallowing of all materials and a weak cough on make a diagnosis and establish a treatment plan. If an in-
the liquids. The SLP believed that the patient might be strumental evaluation is recommended, care must be given
at risk for aspiration because of pharyngeal weakness to scheduling.
that may have involved the true vocal fold. She believed Clinical Pearl: Developing a strong working relation-
an imaging study that would allow her to observe the
ship with radiology is crucial in order to get timely imag-
pharyngeal stage of swallow would be appropriate and
ing studies when patients are in the acute stage of illness.
that swallowing endoscopy would be the test of choice
because it could be accomplished at the patient’s bed-
If the patient is able to cooperate with laboratory test-
side. She received approval for the study from the ing and is a candidate to proceed for further rehabilita-
consulting physician and the test was performed the tion, his or her future care is facilitated if the acute care
same day. Swallowing endoscopy revealed that during clinician can document the swallowing disorder with an
the coughing episodes, the patient was protecting her imaging technique such as videofluoroscopy or endos-
airway; however, there appeared to be some weakness copy.
in the left true vocal fold. She recommended that the
patient start a special dysphagic diet and communicat-
ed that to the dietitian, who made the arrangements. Neonatal Intensive Care Unit
The otolaryngologist was consulted for his opinion on
Children born prematurely often must stay in the hospital
whether any intervention would be appropriate for the
vocal fold weakness. The SLP designed specific swal-
for extended periods in the NICU. Specialized interven-
lowing instructions and shared them with the patient tions for premature newborns such as improved systems
and nursing staff. This case is a good example of how of delivering respiratory support have resulted in higher
many disciplines can be involved in caring for a patient survival rates of low birth weight infants. In the 1980s,
who has dysphagia. the concept of integrated developmental care was intro-
duced to minimize the potential for emotional and neu-
rodevelopmental disorders after discharge. This type of
care emphasizes the coordinated efforts of nurses, physi-
cians, therapists, and other care providers toward com-
LEVELS OF CARE
mon goals, with each discipline supporting the other. This
The prevalence, cause, and type of swallowing disorder that type of care also recognizes issues of parent–child sepa-
might be encountered depends in part on the setting in which ration and the atypical environment of a hospital on the
the patient is seen. Correspondingly, the role of each profes- child’s development.
sional may be different, or access to some medical special- More recently, infants admitted to the NICU are man-
ties may not be available. For instance, it is rare for a gas- aged by “cluster care.” Before the availability of cluster
troenterologist to have a full-time appointment in a nursing care, infants received medical care at any hour during the
 Dysphagia Unplugged CHAPTER | 1 15

day. However, the cluster care concept allows infants to Clinical Pearl: It is not uncommon that information
sleep for 3 hours, after which time they are awakened for from the acute care setting gets transferred to the reha-
all their care, including feeding, diaper changes, and needed bilitation setting. Therefore establishing good methods of
tests. Cluster care allows the infant to regularize his or her communication can be crucial to the patient’s recovery.
schedule, similar to what would occur outside the hospital On-site visitations to each other’s facilities and grand
environment. round presentations help to solidify these relationships.

Subacute Care Setting Skilled Nursing Facility

Patients admitted to subacute care usually are not ready for Patients who enter skilled nursing facilities usually have
a strenuous rehabilitation program. They may require addi- either not responded to attempts at rehabilitation, are not
tional medical monitoring but not the type of costly care of candidates for rehabilitation after their acute hospitaliza-
an acute admission associated with intensive care. If a swal- tion, are too ill to be at home, or have chronic medical
lowing treatment goal was formulated in the acute setting, conditions that require monitoring in a structured environ-
the action plan to achieve that goal is implemented in the ment. The prevalence of swallowing disorders in this set-
subacute unit. For instance, if the goal was to try to wean ting has been reported to be as high as 60%.14 The high
a patient from the tracheostomy tube as a way to ensure prevalence in this setting is because the patients have mul-
swallowing safety, the swallowing team would work toward tiple medical problems that predispose them to dysphagia.
that goal. If a patient continued to require tube feeding after The majority, for instance, may have a neurologic disease
leaving the acute care unit, a goal of the swallowing team that has compromised the swallowing musculature or has
in the subacute unit might be to begin restoring oral ali- interfered with the cortical controls needed to complete
mentation. Patients may stay in the subacute unit from 5 the swallowing sequence. Their swallowing disorders are
to 28 days. After this admission, they may be discharged chronic. Some patients will have seen some recovery in
home, to a rehabilitation facility, or to a skilled nursing their dysphagia, whereas others will continue to rely on
facility. tube feedings. For those who recover, it is important to
help them maintain their skills. Those who must rely on
tube feedings after their hospital stay will require reevalu-
Rehabilitation Setting ation for the possibility of returning to oral feeding. For
Patients who enter rehabilitation settings usually are judged some, returning to oral alimentation will not be possible.
to have the physical stamina needed to complete a full day Because of the potential for patients in this setting to be
of tasks oriented toward restoring lost function. In most medically fragile, it is easy to decompensate their swal-
cases, the patient will also be able to learn new informa- lowing skills by a slight change in medical status, rather
tion. For those with swallowing impairment, it may mean than a new, major event such as stroke. An example of this
they need to learn or solidify their learning of new swal- phenomenon might be a patient who is not swallowing a
lowing strategies. The role of the SLP is to teach the patient sufficient amount of liquids, who may then develop a uri-
swallowing strategies (see Chapters 11 and 16 ). This may nary tract infection that results in a fever with generalized
include special maneuvers or postures. It also may entail fatigue, anorexia, and a disinterest in eating. In this situ-
specialized diets. Frequently, the goal in the rehabilitation ation, the patient may not be ingesting enough calories to
setting as it pertains to swallowing is to return the patient be able to sustain the strength needed to produce a safe
to a dietary level that is as near to normal as possible while swallow throughout the entire meal. As a consequence of
ensuring swallowing safety. Swallowing safety may be de- fatigue, the patient is more likely to show signs of dyspha-
fined as the maintenance of nutrition and hydration without gia.
medical complications. Not only is it considered medically Another example might be a patient who has been eating
unsafe for a patient to get food or fluid in the lungs, but it well but whose medications were changed. The unwanted
is also unsafe to not get sufficient nutrition and hydration side effect from the medication change could negatively
to maintain normal bodily functions. For instance, lack of affect the nervous system to create a problem with motor
proper nutrition and hydration can lead to excessive fatigue, movement, and swallowing is secondarily affected. For ex-
mental status changes, poor wound healing, anorexia, and ample, medications that create sedative effects are capable
a greater chance of developing infections. After a 1-month of decompensating an already fragile swallow by slowing
period of successful rehabilitation, the patient usually is motor movement and interfering with the cortical controls
discharged home. Those in whom medical complications necessary to complete an entire meal. The potential for
develop during rehabilitation or who do not improve to a fluctuations in metabolism in this patient population often
level of partial independence may be discharged to a skilled makes it difficult to establish a single factor that precipi-
nursing facility. tated the dysphagia.
16 PART | I Foundations

It is known that patients in skilled nursing facilities

usually are in older age cohorts. Not only do they endure CLINICAL CORNER 1-5 INTERDISCIPLINARY
the effects of diseases that result in dysphagia commonly COOPERATION
found in older persons (e.g., stroke, Parkinson’s disease), An 86-year-old man who had been living in a nursing
but they also have impairments in swallowing as a result home was admitted to the hospital with a suspected
right brain stroke. He was confused on admission, and
of the aging process. Change in taste perception and in the
the attending physician did not think it was safe for him
strength and speed of the swallowing muscles are exam-
to eat orally so a nasogastric tube was placed. At the
ples of these alterations. The SLP working in the skilled nursing home, he was eating a modified soft diet be-
nursing facility is kept busy managing the large number cause his teeth were in poor repair. He had a past history
of patients with swallowing disorders. Many patients of GERD and Barrett’s esophagitis. After 2 days, a swal-
with dysphagia are able to eat safely only if they are at lowing evaluation was ordered before he was allowed to
the proper dietary level and only if they are following the resume oral feeding.
recommended feeding strategies. Any change in baseline
CRITICAL THINKING
metabolism or any new neurologic insult may decompen- 1. How many medical disciplines might become in-
sate their swallowing skills so that they are at risk for de- volved with this patient? Who and why?
veloping medical complications. Many times the focus of 2. What are the chances that he will be dysphagic
therapeutic effort for the SLP working in the skilled nurs- based on his history? Are age and prior living setting
ing facility is one of prevention—attempting to keep pa- considerations in this case? How might these facts
tients as safe as possible while eating, even in the circum- affect the diagnosis and treatment?
stance of suspected dysphagia. Such preventive efforts not 3. Are there any special issues revolving around which
only may require direct intervention with behavioral and side of the brain was injured that might relate to dys-
dietary treatment strategies, but also entail monitoring of phagia?
mealtime activities to ensure that patients who are at risk
of aspiration are following the prescribed dysphagia treat-
ment plan. life-threatening pneumonia. In these cases, the role of the
Often the mental or physical status of patients in the swallowing clinician is to recommend the safest mode of
skilled nursing environment interferes with their ability to ingestion, making sure that the patient and family under-
cooperate with a formal dysphagia evaluation. Clinicians stand the potential risks.
must rely on a combination of the medical history and
detailed observations of each meal to establish the treat-
ment plan. If the patient is not eating orally, the clinician Home Health
often must rely on the physical examination and on his or Patients who have left the hospital or the rehabilitation
her judgment of how well the patient managed attempts setting for home may require additional monitoring or di-
at oral ingestion as part of that examination. The exami- rect treatment from therapists who perform their respon-
nation will be limited further by poor access to modified sibilities in the patient’s home environment. Patients who
barium swallow studies or other laboratory investigations. are unable to swallow should receive regular reevaluations
Transportation of patients to receive these tests presents for attempts at oral feeding unless oral feeding is contrain-
another challenge because chronically ill patients are dif- dicated by the medical care team. Most often, the clinician
ficult to move. responsible for managing the swallowing disorder in the
Clinical Pearl: Some regions of the country have pro- home environment is ensuring that the patient is following
fessionals with mobile units who can provide on-site swal- the swallowing strategies or has improved to a point at
low imaging studies. which consideration should be given to changing the di-
The chronic medical conditions of patients in skilled etary level. These changes often are made in consultation
nursing facilities often are life threatening. For this reason, with the patient and family and are based on the physical
patients and their families may execute an advance direc- examination and observations of eating (review Clinical
tive (see Chapter 12). The advance directive is a statement Corner 1-5).
executed by the patient or family (if they hold medical power
of attorney) of their desires and wishes regarding their
medical care in life-threatening situations, such as wheth- TAKE HOME NOTES
er the patient would want to be resuscitated for cardiac 1. Dysphagia is a symptom of a disease, not a primary
arrest. Part of this directive may pertain to their wishes disease. It is characterized by a delay or misdirection
to sustain nutrition, especially when the support for nutri- of something swallowed as food moves from the mouth
tion may involve feeding tubes. Patients may elect to not to the stomach. It has both medical and psychosocial
be fed by a feeding tube despite the risk of aspiration and consequences on a patient’s quality of life.
 Dysphagia Unplugged CHAPTER | 1 17

2. A feeding disorder usually refers to the process of food 9. Bloem BR, Lagaay AM, van Beek W, et al. Prevalence of subjec-
transport. An eating disorder may not be related to a tive dysphagia in community residents aged over 87. Br Med J.
swallowing disorder. 1990;300:721.
10. Lindgren S, Janzon L. Prevalence of swallowing complaints and clini-
3. The prevalence of dysphagia is highest in patients with
cal findings among 50-70 year old men and women in an urban popu-
neurologic disease.
lation. Dysphagia. 1991;6:187.
4. Patients in acute care intensive care units and those in 11. Lundquist A, Olsson R, Ekberg O. Clinical and radiologic evaluation
skilled nursing facilities tend to be at highest risk for reveals high prevalence of abnormalities in young adults with dyspha-
dysphagia. gia. Dysphagia. 1998;13:202.
5. There may not be a clear link between dysphagic 12. Madhavan A, Lagorio LA, Crary MA, et al. Prevalence of and risk
symptoms and the patient’s primary medical diagnosis factors for dysphagia in the community dwelling elderly: a systematic
in patients who reside in skilled nursing facilities. review. J Nutr Health Aging. 2016;20:806.
6. Patients in skilled nursing facilities are medically frag- 13. Lee A, Sitoh YY, Lien PK, et al. Swallowing impairment and feed-
ile, and their swallowing response can be easily decom- ing dependency in the hospitalized elderly. Ann Acad Med Singapore.
pensated by fatigue or an acute medical condition such 1999;28:371.
14. Siebens H, Trupe E, Siebens A, et al. Correlates and consequences of
as an infection.
eating dependency in the institutionalized elderly. J Am Geriatr Soc.
7. Aspiration of liquid and food is the consequence of
1986;34:192.
those materials entering the airway below the level of 15. Guijarro Silveira LJ, Garcia VD, Fernandez NM, et al. Disfagia oro-
the vocal folds. faringea en ancianos ingresados en una unidad de convalecencia. Nutr
8. Aspiration of liquid or food may or may not produce a Hosp. 2011;26:501.
lung infection known as aspiration pneumonia. 16. Park YH, Hae-Ra H, Faan BMO, et al. Prevalence and associated fac-
9. Respiratory impairments such as those requiring an tors of dysphagia in nursing home residents. Geriatr Nurs (Minneap).
endotracheal tube or tracheostomy tube also interfere 2013;34:212.
with swallowing. 17. Nogueira D, Reis E. Swallowing disorders in nursing home residents:
10. The SLP frequently is the coordinator of the swallow- how can the problem be explained?. Clin Interv Aging. 2013;8:221.
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for the aged: not just dysphagia. Dysphagia. 1997;12:43.
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19. Croghan JE, Burke EM, Caplan S, et al. Pilot study of 12 month out-
patient. Many specialists could become involved in the
comes of nursing home patients with aspiration on videofluoroscopy.
care of a patient with dysphagia. Dysphagia. 1994;9:141.
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