Dysphagia medical therapy
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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
The following postural techniques and other postural combinations are used to prevent the complications of dysphagia:[4][5][6]
- 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 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 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. {{#ev:youtube|H4S1Afq4fps}}
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.[5]
- 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
The following video helps demonstrate the mendelsohn maneuver and other swallowing exercises used in the management of dysphagia. {{#ev:youtube|XbKVZN7yJSI}}
Dietary Modification:
- Dietary modification, such as thickened liquid diet are commonly used for the prevention of aspiration in oropharyngeal dysphagia.[7][8][9]
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.
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 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
- Palatal lift or obturator
- Maxillary denture
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
- ↑ Lind CD (2003). "Dysphagia: evaluation and treatment". Gastroenterol Clin North Am. 32 (2): 553–75. PMID 12858606.
- ↑ 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.
- ↑ 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.
- ↑ 5.0 5.1 Kahrilas PJ, Logemann JA, Gibbons P (1992). "Food intake by maneuver; an extreme compensation for impaired swallowing". Dysphagia. 7 (3): 155–9. PMID 1499358.
- ↑ 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.
- ↑ Groher ME, McKaig TN (1995). "Dysphagia and dietary levels in skilled nursing facilities". J Am Geriatr Soc. 43 (5): 528–32. PMID 7730535.
- ↑ 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.
- ↑ 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.
- ↑ Malandraki, Georgia; Robbins, Joanne (2013). "Dysphagia". 110: 255–271. doi:10.1016/B978-0-444-52901-5.00021-6. ISSN 0072-9752.
- ↑ 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.