Dysphagia medical therapy: Difference between revisions

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==Overview==
==Overview==
The main objective of treating dysphagia is to avoid [[Aspiration (medicine)|aspiration]] of the food and [[Bolus (digestion)|bolus]] impaction, reduce the morbidity associated with ongoing symptoms. Effective medical management begins with early identification of the underlying cause with a detailed history, [[Physical examination|physical]] examination and, judicious use of investigations.
The main objective of treating dysphagia is to avoid [[Aspiration (medicine)|aspiration]] of the food and [[Bolus (digestion)|bolus]] impaction, reduce the morbidity associated with ongoing symptoms. Effective medical management begins with early identification of the underlying cause with a detailed history, [[Physical examination|physical]] examination and, judicious use of investigations. Several postural techniques and swallowing maneuvers are used to help the patient swallow the food bolus. Other management options are dietary modification, environmental modification, feeding tubes and oral prosthetic devices. Medications that can worsen dysphagia should be avoided. Botulinum toxin injection can be used in the treatment of hypercontractile disorders of esophagus.


==Medical Therapy of Dysphagia==
==Medical Therapy of Dysphagia==
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* Medications known to cause or worsen dysphagia (potassium tablets, [[doxycycline]],[[Non-steroidal anti-inflammatory drug|NSAIDs]], [[Bisphosphonate|bisphosphonates]]) should be avoided.
* Medications known to cause or worsen dysphagia (potassium tablets, [[doxycycline]],[[Non-steroidal anti-inflammatory drug|NSAIDs]], [[Bisphosphonate|bisphosphonates]]) should be avoided.
* After assessment, a Speech Language Pathologist will determine the safety of the patient's swallow and recommend treatment accordingly.
* After assessment, a Speech Language Pathologist will determine the safety of the patient's swallow and recommend treatment accordingly.
* Boltulinum toxin injection is employed for the use of hypercontractile disorders of the [[esophagus]].
* Boltulinum toxin injection is employed for the use of hypercontractile disorders of the [[esophagus]] such as [[achalasia]].


===Postural Techniques===
===Postural Techniques===
The following postural techniques and other postural combinations are used to prevent the complications of dysphagia:<ref name="pmid12588471">{{cite journal| author=Hamdy S, Jilani S, Price V, Parker C, Hall N, Power M| title=Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury. | journal=Neurogastroenterol Motil | year= 2003 | volume= 15 | issue= 1 | pages= 69-77 | pmid=12588471 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12588471  }} </ref><ref name="pmid1499358">{{cite journal| author=Kahrilas PJ, Logemann JA, Gibbons P| title=Food intake by maneuver; an extreme compensation for impaired swallowing. | journal=Dysphagia | year= 1992 | volume= 7 | issue= 3 | pages= 155-9 | pmid=1499358 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1499358  }} </ref><ref name="pmid27016216">{{cite journal| author=Newman R, Vilardell N, Clavé P, Speyer R| title=Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD). | journal=Dysphagia | year= 2016 | volume= 31 | issue= 2 | pages= 232-49 | pmid=27016216 | doi=10.1007/s00455-016-9696-8 | pmc=4929168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27016216  }} </ref>
Each specific postural technique has a particular effect on the flow food and coordination of oropharyngeal structures. They provide compensation for the specific defects in oropharyngeal swallow. The following postural techniques and other postural combinations are used to prevent the complications of dysphagia:<ref name="pmid12588471">{{cite journal| author=Hamdy S, Jilani S, Price V, Parker C, Hall N, Power M| title=Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury. | journal=Neurogastroenterol Motil | year= 2003 | volume= 15 | issue= 1 | pages= 69-77 | pmid=12588471 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12588471  }} </ref><ref name="pmid1499358">{{cite journal| author=Kahrilas PJ, Logemann JA, Gibbons P| title=Food intake by maneuver; an extreme compensation for impaired swallowing. | journal=Dysphagia | year= 1992 | volume= 7 | issue= 3 | pages= 155-9 | pmid=1499358 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1499358  }} </ref><ref name="pmid27016216">{{cite journal| author=Newman R, Vilardell N, Clavé P, Speyer R| title=Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD). | journal=Dysphagia | year= 2016 | volume= 31 | issue= 2 | pages= 232-49 | pmid=27016216 | doi=10.1007/s00455-016-9696-8 | pmc=4929168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27016216  }} </ref>
* 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):''' This technique is used in patients who have difficulty initiating the [[Swallowing|swallow]].
* 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.
** It allows the [[Pharynx|oropharyngeal]] passage to become wider and narrows the airway to prevent [[Aspiration pneumonia|aspiration]].
* Head turned (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.
* Head tilted (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 [[Pulmonary aspiration|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 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 turned 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.


A specific posture has a separate effect in terms of flow of food and relationship of oropharyngeal structures and can provide optimal compensation in patients with specific defects in oropharyngeal swallow. For example, the chin-down posture is well suited in patients with a tongue base disorder, and a reclining posture is useful in patients with bilateral pharyngeal damage or reduced laryngeal elevation.
* '''Head turned (extension):'''
** This posture employs the use of gravity to help move the food from the front of the mouth to the back.
* '''Head tilted (turning head to look over shoulder):'''
** In this technique the head is turned to the damaged or weaker side with chin down.
* '''Lying down on one side:'''
** This technique is used when there is [[Muscle weakness|weakness]] of the [[Pharynx|pharyngeal]] [[Muscle|muscles]] and causes the residue to be aspirated.
The following video demonstrate the postural techniques:{{#ev:youtube|H4S1Afq4fps}}
 
==Swallowing Maneuvers==
 
The following maneuvers are used to manage dysphagia:
*'''Supraglottic swallow:'''
**This maneuver is used when there is late [[Vocal folds|vocal]] fold closure.
**The patient is asked to take a deep breath and then hold their breath.
**They [[Swallowing|swallow]] while holding their breath and [[cough]] after swallowing.
*'''Super-supraglottic swallow:'''
**This maneuver is used when there is reduction in closure of the airway.
**The patient is asked to take a breath, hold their breath tightly while bearing down, [[Swallowing|swallow]] while still holding the breath hold, and then [[Cough|coughing]] immediately after the swallow.
*'''Mendelsohn maneuver:'''
**The maneuver is used when there is discoordination in [[swallowing]].
** The patient is taught to hold their [[Laryngeal prominence|adam's]] apple up during the swallow.


===Swallowing Maneuvers===
* 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.<ref name="pmid1499358">{{cite journal| author=Kahrilas PJ, Logemann JA, Gibbons P| title=Food intake by maneuver; an extreme compensation for impaired swallowing. | journal=Dysphagia | year= 1992 | volume= 7 | issue= 3 | pages= 155-9 | pmid=1499358 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1499358  }} </ref>
* 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.
===Video===
===Video===
The following videos help demonstrate the mendelsohn maneuver and other swallowing exercises used in the management of dysphagia.
The following video helps demonstrate the mendelsohn maneuver used in the management of dysphagia.
{{#ev:youtube|XbKVZN7yJSI}}
{{#ev:youtube|XbKVZN7yJSI}}
{{#ev:youtube|H4S1Afq4fps}}


===Dietary Modification:===
===Dietary Modification:===
Line 49: Line 58:
* Using a straw while drinking liquids.
* Using a straw while drinking liquids.
* Putting a pillow behind the patient's head during feeding.
* Putting a pillow behind the patient's head during feeding.
===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.
* 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)


===Feeding tubes===
===Feeding tubes===
Feeding tubes can be used to provide nutrition to the patient while they are recovering their ability to swallow. Following feeding tube can be used:
Feeding tubes can be used to provide [[nutrition]] to the patient while they are recovering their ability to [[Swallowing|swallow]]. Following feeding tube can be used:
*Nasogastric tube
*[[Nasogastric intubation|Nasogastric]] tube
*Percutaneous endoscopic gastrostomy tube
*Percutaneous endoscopic gastrostomy tube
Complications:
Complications:
*Infection
*Infection
*Internal bleeding
*Internal bleeding


===Prosthetics===
===Prosthetics===
* [[Palatal lift]] or [[obturator]]
* [[Palatal lift]] or [[obturator]]
* Maxillary denture
* [[Maxillary]] denture


===Swallowing Rehabilitation in the elderly===
===Swallowing Rehabilitation in the elderly===
Elderly patients benefit from swallowing rehabilitation programs regardless of the fact that underlying cause is treatable or not.<ref name="MalandrakiRobbins2013">{{cite journal|last1=Malandraki|first1=Georgia|last2=Robbins|first2=Joanne|title=Dysphagia|volume=110|year=2013|pages=255–271|issn=00729752|doi=10.1016/B978-0-444-52901-5.00021-6}}</ref>
Elderly patients benefit from swallowing rehabilitation programs regardless of the fact that underlying cause is treatable or not.<ref name="MalandrakiRobbins2013">{{cite journal|last1=Malandraki|first1=Georgia|last2=Robbins|first2=Joanne|title=Dysphagia|volume=110|year=2013|pages=255–271|issn=00729752|doi=10.1016/B978-0-444-52901-5.00021-6}}</ref><ref name="KhanCarmona2014">{{cite journal|last1=Khan|first1=Abraham|last2=Carmona|first2=Richard|last3=Traube|first3=Morris|title=Dysphagia in the Elderly|journal=Clinics in Geriatric Medicine|volume=30|issue=1|year=2014|pages=43–53|issn=07490690|doi=10.1016/j.cger.2013.10.009}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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[[Category:Needs overview]]
[[Category:Needs overview]]
[[Category:Needs content]]
[[Category:Needs content]]
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[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Otolaryngology]]
[[Category:Otolaryngology]]
[[Category:Primary care]]
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Latest revision as of 21:30, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

The main objective of treating dysphagia is to avoid aspiration of the food and bolus impaction, reduce the morbidity associated with ongoing symptoms. Effective medical management begins with early identification of the underlying cause with a detailed history, physical examination and, judicious use of investigations. Several postural techniques and swallowing maneuvers are used to help the patient swallow the food bolus. Other management options are dietary modification, environmental modification, feeding tubes and oral prosthetic devices. Medications that can worsen dysphagia should be avoided. Botulinum toxin injection can be used in the treatment of hypercontractile disorders of esophagus.

Medical Therapy of Dysphagia

Medical treatment:

The medical treatment of dysphagia is as follows:[1][2][3]

  • Supportive care
  • Treat the underlying disorder.
  • Postural techniques
  • Swallowing maneuvers that facilitate strengthening of the swallowing muscles.
  • Dietary modification
  • Medications known to cause or worsen dysphagia (potassium tablets, doxycycline,NSAIDs, bisphosphonates) should be avoided.
  • After assessment, a Speech Language Pathologist will determine the safety of the patient's swallow and recommend treatment accordingly.
  • Boltulinum toxin injection is employed for the use of hypercontractile disorders of the esophagus such as achalasia.

Postural Techniques

Each specific postural technique has a particular effect on the flow food and coordination of oropharyngeal structures. They provide compensation for the specific defects in oropharyngeal swallow. The following postural techniques and other postural combinations are used to prevent the complications of dysphagia:[4][5][6]

  • Chin down (flexion): This technique is used in patients who have difficulty initiating the swallow.
  • Head turned (extension):
    • This posture employs the use of gravity to help move the food from the front of the mouth to the back.
  • Head tilted (turning head to look over shoulder):
    • In this technique the head is turned to the damaged or weaker side with chin down.
  • Lying down on one side:

The following video demonstrate the postural techniques:{{#ev:youtube|H4S1Afq4fps}}

Swallowing Maneuvers

The following maneuvers are used to manage dysphagia:

  • Supraglottic swallow:
    • This maneuver is used when there is late vocal fold closure.
    • The patient is asked to take a deep breath and then hold their breath.
    • They swallow while holding their breath and cough after swallowing.
  • Super-supraglottic swallow:
    • This maneuver is used when there is reduction in closure of the airway.
    • 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.
  • Mendelsohn maneuver:
    • The maneuver is used when there is discoordination in swallowing.
    • The patient is taught to hold their adam's apple up during the swallow.

Video

The following video helps demonstrate the mendelsohn maneuver used in the management of dysphagia. {{#ev:youtube|XbKVZN7yJSI}}

Dietary Modification:

Environmental modification:

  • Environmental modification can be suggested to assist and reduce risk factors for aspiration.

For example:

  • Using a straw while drinking liquids.
  • Putting a pillow behind the patient's head during feeding.

Feeding tubes

Feeding tubes can be used to provide nutrition to the patient while they are recovering their ability to swallow. Following feeding tube can be used:

  • Nasogastric tube
  • Percutaneous endoscopic gastrostomy tube

Complications:

  • Infection
  • Internal bleeding

Prosthetics

Swallowing Rehabilitation in the elderly

Elderly patients benefit from swallowing rehabilitation programs regardless of the fact that underlying cause is treatable or not.[10][11]

References

  1. Lind CD (2003). "Dysphagia: evaluation and treatment". Gastroenterol Clin North Am. 32 (2): 553–75. PMID 12858606.
  2. Navaneethan, Udayakumar; Eubanks, Steve (2015). "Approach to Patients with Esophageal Dysphagia". Surgical Clinics of North America. 95 (3): 483–489. doi:10.1016/j.suc.2015.02.004. ISSN 0039-6109.
  3. Saito K (1995). "[Temporal and spatial pattern analysis of pharyngeal swallowing in patients with abnormal sensation in the throat]". Nihon Jibiinkoka Gakkai Kaiho. 98 (7): 1154–63. PMID 7562237.
  4. Hamdy S, Jilani S, Price V, Parker C, Hall N, Power M (2003). "Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury". Neurogastroenterol Motil. 15 (1): 69–77. PMID 12588471.
  5. Kahrilas PJ, Logemann JA, Gibbons P (1992). "Food intake by maneuver; an extreme compensation for impaired swallowing". Dysphagia. 7 (3): 155–9. PMID 1499358.
  6. Newman R, Vilardell N, Clavé P, Speyer R (2016). "Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD)". Dysphagia. 31 (2): 232–49. doi:10.1007/s00455-016-9696-8. PMC 4929168. PMID 27016216.
  7. Groher ME, McKaig TN (1995). "Dysphagia and dietary levels in skilled nursing facilities". J Am Geriatr Soc. 43 (5): 528–32. PMID 7730535.
  8. Castellanos VH, Butler E, Gluch L, Burke B (2004). "Use of thickened liquids in skilled nursing facilities". J Am Diet Assoc. 104 (8): 1222–6. doi:10.1016/j.jada.2004.05.203. PMID 15281038.
  9. Kotecki S, Schmidt R (2010). "Cost and effectiveness analysis using nursing staff-prepared thickened liquids vs. commercially thickened liquids in stroke patients with dysphagia". Nurs Econ. 28 (2): 106–9, 113. PMID 20446381.
  10. Malandraki, Georgia; Robbins, Joanne (2013). "Dysphagia". 110: 255–271. doi:10.1016/B978-0-444-52901-5.00021-6. ISSN 0072-9752.
  11. Khan, Abraham; Carmona, Richard; Traube, Morris (2014). "Dysphagia in the Elderly". Clinics in Geriatric Medicine. 30 (1): 43–53. doi:10.1016/j.cger.2013.10.009. ISSN 0749-0690.

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