Oropharyngeal dysphagia

Some signs and symptoms of swallowing difficulties include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and dysphagia (patient complaint of swallowing difficulty).[1] When asked where the food is getting stuck patients will often point to the cervical (neck) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived.

• A stroke can cause pharyngeal dysfunction with a high occurrence of aspiration. The function of normal swallowing may or may not return completely following an acute phase lasting approximately 6 weeks.[5]
• Parkinson's disease can cause "multiple prepharyngeal, pharyngeal, and esophageal abnormalities". The severity of the disease most often correlates with the severity of the swallowing disorder.[5]
• Neurologic disorders such as stroke, Parkinson's disease, amyotrophic lateral sclerosis, Bell's palsy, or myasthenia gravis can cause weakness of facial and lip muscles that are involved in coordinated mastication as well as weakness of other important muscles of mastication and swallowing.
• Oculopharyngeal muscular dystrophy is a genetic disease with palpebral ptosis, oropharyngeal dysphagia, and proximal limb weakness.
• Decrease in salivary flow, which can lead to dry mouth or xerostomia, can be due to Sjogren's syndrome, anticholinergics, antihistamines, or certain antihypertensives and can lead to incomplete processing of food bolus.
• Xerostomia can reduce the volume and increase the viscosity of oral secretions making bolus formation difficult as well as reducing the ability to initiate and swallow the bolus[5]
• Dental problems can lead to inadequate chewing.
• Abnormality in oral mucosa such as from mucositis, aphthous ulcers, or herpetic lesions can interfere with bolus processing.
• Mechanical obstruction in the oropharynx may be due to malignancies, cervical rings or webs, crico-phyringeus muscle dysfunction, or cervical osteophytes.
• Increased upper esophageal sphincter tone can be due to Parkinson's disease which leads to incomplete opening of the UES. This may lead to formation of a Zenker's diverticulum.
• Pharyngeal pouches typically cause difficulty in swallowing after the first mouthful of food, with regurgitation of the pouch contents. These pouches may be accompanied by malodorous breath due to decomposing foods residing in the pouches. (See Zenker's diverticulum)
• Dysphagia is often a side effect of surgical procedures like anterior cervical spine surgery, carotid endarterectomy, head and neck resection, oral surgeries like removal of the tongue, and partial laryngectomies[5]
• Radiotherapy, used to treat head and neck cancer, can cause tissue fibrosis in the irradiated areas. Fibrosis of tongue and larynx lead to reduced tongue base retraction and laryngeal elevation during swallowing[5]
• Infection may cause pharyngitis which can prevent swallowing due to pain.
• Medications can cause central nervous system effects that can result in swallowing disorders and oropharyngeal dysphagia. Examples: sedatives, hypnotic agents, anticonvulsants, antihistamines, neuroleptics, barbiturates, and antiseizure medication. Medications can also cause peripheral nervous system effects resulting in an oropharyngeal dysphagia. Examples: corticosteroids, L-tryptophan, and anticholinergics[5]

After assessment, to determine the safety of the person's swallow and recommend treatment accordingly.

Postural techniques.[1]

• Head back (extension) – used when movement of the bolus from the front of the mouth to the back is inefficient; this allows gravity to help move the food.
• Chin down (flexion) – used when there is a delay in initiating the swallow; this allows the valleculae to widen, the airway to narrow, and the epiglottis to be pushed towards the back of the throat to better protect the airway from food.
• Chin down (flexion) – used when the back of the tongue is too weak to push the food towards the pharynx; this causes the back of the tongue to be closer to the pharyngeal wall.
• Head rotation (turning head to look over shoulder) to damaged or weaker side with chin down – used when the airway is not protected adequately causing food to be aspirated; this causes the epiglottis to be put in a more protective position, it narrows the entrance of the airway, and it increases vocal fold closure.
• Lying down on one side – used when there is reduced contraction of the pharynx causing excess residue in the pharynx; this eliminates the pull of gravity that may cause the residue to be aspirated when the patient resumes breathing.
• Head rotation to damaged or weaker side – used when there is paralysis or paresis on one side of the pharyngeal wall; this causes the bolus to go down the stronger side.
• Head tilt (ear to shoulder) to stronger side – used when there is weakness on one side of the oral cavity and pharyngeal wall; this causes the bolus to go down the stronger side.

Swallowing Maneuvers.[1]

• Supraglottic swallow - The patient is asked to take a deep breath and hold their breath. While still holding their breath they are to swallow and then immediately cough after swallowing. This technique can be used when there is reduced or late vocal fold closure or there is a delayed pharyngeal swallow.
• Super-supraglottic swallow - The patient is asked to take a breath, hold their breath tightly while bearing down, swallow while still holding the breath hold, and then coughing immediately after the swallow. This technique can be used when there is reduced closure of the airway.
• Effortful swallow - The patient is instructed to squeeze their muscles tightly while swallowing. This may be used when there is reduced posterior movement of the tongue base.
• Mendelsohn maneuver - The patient is taught how to hold their adam's apple up during a swallow. This technique may be used when there is reduced laryngeal movement or a discoordinated swallow.[7]

Medical device

In order to strengthen muscles in the mouth and throat areas, researchers at the University of Wisconsin-Madison, led by Dr. JoAnne Robbins, developed a device in which patients perform isometric exercises with the tongue.[8]

Diet modifications

Diet modification may be warranted. Some patients require a soft diet that is easily chewed, and some require liquids of a thinned or thickened consistency. The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life.[9] There has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures.  However, the International Dysphagia Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a continuum of 8 levels (0-7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7.[10]

Environmental modifications

Environmental modification can be suggested to assist and reduce risk factors for aspiration. For example, removing distractions like too many people in the room or turning off the TV during feeding, etc.

Oral sensory awareness techniques

Oral sensory awareness techniques can be used with patients who have a swallow apraxia, tactile agnosia for food, delayed onset of the oral swallow, reduced oral sensation, or delayed onset of the pharyngeal swallow.[1]

• pressure of a spoon against tongue
• using a sour bolus
• using a cold bolus
• using a bolus that requires chewing
• using a bolus larger than 3mL
• thermal-tactile stimulation (controversial)

Electrical stimulation

Electrical stimulation (E-stim) is targeted for oropharyngeal dysphagia and uses electrical stimulation to retrain the muscles used in swallowing and facilitate voluntary swallowing activity. This type of therapy has been used in a clinical setting for many years in Physical Therapy. Its use for oropharyngeal dysphagia has received much attention in recent years and is now the most researched treatment intervention in dysphagia therapy.

Prosthetics

• Palatal lift or Palatal obturator
• Maxillary denture

• Swallowing and Feeding