Introduction

Dysphagia, not to be confused with dysphasia (difficulty in speaking), is difficulty swallowing. Dysphagia is not a disease but a symptom. Individuals with diseases affecting muscle strength or coordination may have swallowing problems. Eating, swallowing, and nutritional problems have a high prevalence among people with learning disabilities, often leading to poor nutritional status, dehydration, aspiration, and asphyxiation. Adults with cerebral palsy and those with severe intellectual and physical disabilities have a high incidence of dysphagia. Although there is limited research on individuals with IDD who have dysphagia, there is evidence that successful management decreases risk.

A person with dysphagia may have an unsafe swallow that allows food or saliva to enter the airway and/or a slow swallow which makes it difficult to take in adequate nutrients. In addition, many persons feel the need to eat quickly which places them at risk for choking due to not chewing properly or placing too much in the mouth at one time. Behavioral and psychiatric issues, as well as medication side effects, can also impact a person’s ability to safely eat. While some people are aware that they have a swallowing problem and can describe it, others are not. The person who is unaware may compensate by choosing foods that can be eaten more easily, by eating slowly, or by changing the position of the head while swallowing. Many individuals with dysphagia do not spontaneously compensate for their swallowing problems.

Signs of Dysphagia

1. Coughing and choking on food and /or liquids

2. Taking along time to eat a meal

3. Hoarseness or a wet gurgly or bubbly voice

4. Heartburn or indigestion

5. Food/liquid coming out through the nose

6. Excessive drooling, associated with eating

7. Frequent respiratory infection/ history of aspiration pneumonia

8. Weight loss and/or dehydration

9. Current medications changes, may cause difficulty

10. Pain during swallowing

11. Increased mucus/phlegm lump in throat

12. Vomiting during meals

13. Vomiting after meals

14. Food being stuck in “pockets” in the mouth (along tongue or in cheek)

15. Multiple swallows on a single mouthful of food

16. Fatigue or shortness of breath while eating

17. Feeling that something is stuck in the throat or went down the “wrong pipe”

18. Spitting up food

The different stages of swallowing and three types of dysphagia are described on the next two pages.

Stages of Swallowing

First stage- Oral Preparatory Phase

• Voluntary phase
• See and smell food
• Open mouth
• Placement of food on tongue
• Close mouth
• Tongue lateralization(moves food to side)
• Rotary chewing
• Forming food into bolus
• Posterior portion of tongue cups the bolus

Second stage- Oral Phase

• Voluntary phase
• Tongue presses bolus against the hard palate propelling food to back of mouth
• At back of mouth, tongue movement propels the bolus
• Bolus stimulates nerve endings that transmit sensory

information to the cortex and brain stem

Third stage- Pharyngeal Phase

• Involuntary phase
• Food passes anterior faucial arches(receptors)in pharynx triggering the swallow response
• Soft palate and uvula elevate and retract against the back of the throat
• Larynx (voicebox) rises, closing off epiglottis and true vocal cords and stretching the opening of the esophagus
• Esophageal sphincter opens to receive the bolus
• Pressure is applied to food by the tongue base and pharyngeal walls to push it through the pharynx and into the esophagus

Fourth stage- Esophageal Phase

• Involuntary phase
• Bolus entersesophagus
• Primary peristaltic wave occurs first 1/3 of the way through
• Secondary peristaltic wave occurs second 2/3 of the way and into the stomach through the lower esophageal sphincter

Types of Dysphagia

Problems can occur at any point in the swallow, but three general types of dysphagia are described below.

Oral dysphagia

Swallowing difficulties may arise in the mouth. A stroke can weaken the tongue and lip muscles, causing drooling and making it difficult to get food from the mouth into the throat. People with oral dysphagia tend to spill food and liquid from the mouth, take a long time to eat, and sometimes give up before eating and drinking enough.

Indicators of potential problems in the oral preparatory and oral phases:

High or low muscle tone, drooling, inability to form bolus, pocketing food, prolonged chewing, and tongue thrust.

Pharyngeal dysphagia

Difficulties may arise after food or liquid passes through the pharynx if the protective swallowing reflex isn’t working properly, allowing the food or liquid to enter the airway. A sensation of food stuck in the throat or pressure in the throat is common with this type of dysphagia. If food or liquid enters the airway often or in large quantities, aspiration pneumonia may develop.

Indicators of potential problems in pharyngeal phase:

Choking or coughing on solids or liquids, wet or gurgly vocal quality, nasal regurgitation, struggling behaviors, delayed swallow, and rumination.

Esophageal dysphagia

Swallowing problems may occur later in the swallow, after the food or liquid passes into the esophagus. Pressure or discomfort in the chest is common with this condition. This frequently happens due to consistent refluxing of stomach acid into the esophagus which over time can cause inflammation and narrowing of the esophagus.

Indicators of potential problems in esophageal phase:

Indigestion/heartburn, sensation of food being lodged in chest, and rumination.

Role of Dietitian, Referral and Consultation with Clinicians

Historically, the role of the dietitian in dysphagia management has been restricted to diet therapy. Screening, assessment, and treatment are typically within the scope of practice of speech-language pathologists (SLPs). However as dietitians are becoming more comprehensive health care providers, those working with populations at risk for dysphagia should be trained in dysphagia screening, identification of risk, and referral to the SLP. Dietitians can be instrumental in the care of these individuals by identifying and referring people with swallowing problems through early screening and determining appropriate diet orders.

The multidisciplinary approach to evaluation and management is the best way to assure an accurate diagnosis. A diagnosis is crucial in structuring an individually tailored treatment plan for each person. The interdisciplinary team may include primary care physician, dietitian, speech-language pathologist or occupational therapist, nurse, and behavioral therapist. Team disciplines will vary depending on the person’s medical history, stage of evaluation or management, their type living environment, and the specialists and resources available in the person’s area. Good communication and collaboration between disciplines is important in helping a person to safely eat.

Mealtime observation in a person’s usual environment is an important part of the assessment process and should include observing staff preparing food and assisting person with diet. The dietitian should observe for signs of dysphagia such as coughing, choking, wet vocal sounds or changes in respiratory patterns. A person who displays any signs of dysphagia should be referred to a swallowing therapist for further evaluation and intervention. The SLP may determine that a modified barium swallow (MBS) study or a video fluoroscopy is needed to further assess the problem and determine the best treatment. The MBS study shows the location of the problem, the physiology of the pharynx, and if and why aspiration is occurring. In contrast, the clinical evaluation of aspiration is unreliable, since as many as 40% of persons who aspirate will not have clinical signs or symptoms that suggest aspiration. During the MBS study the effects of posture, food consistency, and selected therapy techniques can be assessed in terms of their ability to eliminate aspiration and/or improve the efficiency of the swallow.

RDs have varying roles in the management of dysphagia depending on their settings and accessible resources. In rural and remote areas RDs can be the first health care professionals who are consulted when there are signs of swallowing issues, whereas other dietitians are in environments that enable them to work closely with SLPs who often are the clinicians who direct and oversee the management of swallowing problems. Whatever the setting, pursuing more training in the area of dysphagia management can assist RDs in becoming more proficient in this topic and contribute significantly to an individual’s care and quality of life.