Oropharyngeal dysphagia

Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly, in patients who have had strokes, and in patients who are admitted to acute care hospitals or chronic care facilities. Other causes of dysphagia include head and neck cancer and progressive neurologic diseases like Parkinson's disease, Dementia, Multiple sclerosis, Multiple system atrophy, or Amyotrophic lateral sclerosis. Dysphagia is a symptom of many different causes, which can usually be elicited by a careful history by the treating physician. A formal oropharyngeal dysphagia evaluation is performed by a speech-language pathologist.

Dysphagia is classified into two major types: oropharyngeal dysphagia and esophageal dysphagia. In some patients, no organic cause for dysphagia can be found, and these patients are defined as having functional dysphagia.

Oropharyngeal dysphagia arises from abnormalities of muscles, nerves or structures of the oral cavity, pharynx, and upper esophageal sphincter.

Signs and symptoms
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). 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.

Complications
If left untreated, swallowing disorders can potentially cause aspiration pneumonia, malnutrition, or dehydration.

Etiology and differential diagnosis

 * 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.
 * 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.
 * 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
 * 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 parital laryngectomies
 * 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
 * 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

Assessment of adults
A Speech Language Pathologist or other trained medical professional may be called upon to evaluate a patient who complains of dysphagia. During this initial examination a medical history is obtained, the mini-mental state examination is sometimes administered, and oral and facial sensorimotor function, speech, and swallowing are evaluated non-instrumentally.

A patient needing further investigation will most likely receive a Modified Barium swallow (MBS). Different consistencies of liquid and food mixed with barium sulfate are fed to the patient by spoon, cup or syringe, and x-rayed using videofluoroscopy. A patient's swallowing then can be evaluated and described. Some clinicians might choose to describe each phase of the swallow in detail, making mention of any delays or deviations from the norm. Others might choose to use a rating scale such as the Penetration Aspiration Scale. The scale was developed to describe the disordered physiology of a person's swallow using the numbers 1-8. Other scales also exist for this purpose.

A patient can also be assessed using videoendoscopy, also known as flexible fiberoptic endoscopic examination of swallowing (FFEES). The instrument is placed into the nose until the clinician can view the pharynx and then he or she examines the pharynx and larynx before and after swallowing. During the actual swallow, the camera is blocked from viewing the anatomical structures. A rigid scope, placed into the oral cavity to view the structures of the pharynx and larynx, can also be used, though this prevents the patient from swallowing.

Other less frequently used assessments of swallowing are imaging studies, ultrasound and scintigraphy and nonimaging studies, electromyography (EMG), electroglottography (EGG)(records vocal fold movement), cervical auscultation, and pharyngeal manometry.

Treatment
After assessment, a Speech Language Pathologist will determine the safety of the patient's swallow and recommend treatment accordingly. The Speech Language Pathologist will also advise staff/caregivers and give information about what signs to look for to know if the client is aspirating (e.g. coughing, choking, voice quality becoming 'wet' or 'gurgly', chest colds, recurrent pneumonia) and feeding instructions if required, including posture while eating, consistency of food, and size of mouthfuls.


 * Postural techniques.
 * 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.
 * 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.

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.
 * Diet modifications

Environmental modification can be suggested to assist and reduce risk factors for aspiration. For example: having the patient use a straw while drinking liquids, putting a pillow behind the patient's head during feeding, removing distractors like too many people in the room or turning off the TV during feeding, etc.
 * Environmental modifications

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.
 * Oral sensory awareness techniques
 * 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 (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.
 * Electrical stimulation


 * Prosthetics
 * Palatal lift or Palatal obturator
 * Maxillary denture

These are usually only recommended as a last resort.
 * Surgical treatments
 * Tracheotomy
 * Tracheostomy
 * Vocal fold augmentation/injection
 * Thryoplasty medialization
 * Arytenoid adduction
 * Partial or total laryngectomy
 * Laryngotracheal separation
 * Supralaryngectomy
 * Palatoplasty
 * Cricopharyngeal Myotomy
 * Zenker's Diverticulectomy
 * Percutaneous endoscopic gastrostomy
 * Feeding tube