History
Disorders leading to dysphagia may affect the oral, pharyngeal, or esophageal phases of swallowing. Thorough history taking and careful physical examination are important in the diagnosis and treatment of dysphagia. The bedside physical examination should include examination of the neck, mouth, oropharynx, and larynx. A neurologic examination also should be performed.
Specific questions about the onset, duration, and severity of dysphagia and about a variety of associated symptoms may help to narrow the differential diagnosis. Review the patient's general health information, including long-term illnesses and current prescription medications.
Patients who have dysphagia may present with a variety of signs and symptoms. They usually report coughing or choking or the abnormal sensation of food sticking in the back of the throat or upper chest when they are trying to swallow; however, some of these presentations can be quite subtle or even absent (eg, in patients with silent aspiration). [35, 36, 37]
Signs and symptoms of oral or pharyngeal dysphagia include the following:
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Coughing or choking with swallowing
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Difficulty initiating swallowing
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Food sticking in the throat
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Sialorrhea
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Unexplained weight loss
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Change in dietary habits
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Recurrent pneumonia
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Change in voice or speech (wet voice)
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Nasal regurgitation
Signs and symptoms of esophageal dysphagia include the following:
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Sensation of food sticking in the chest or throat
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Change in dietary habits
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Recurrent pneumonia [1]
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Symptoms of gastroesophageal reflux disease (GERD), including heartburn, belching, sour regurgitation, and water brash
Other associated factors/symptoms of dysphagia include the following:
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General weakness
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Mental status changes
Morbidities
Relevant patient history also includes occurrence of the following:
Physical Examination
The bedside physical examination should include examination of the neck, mouth, oropharynx, and larynx. A neurologic examination also should be performed.
Look for oral-motor and laryngeal mechanisms; testing of cranial nerves V and VII-XII is essential for determining whether physical evidence of oropharyngeal dysphagia exists. Direct observation of the following is necessary:
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Lip closure
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Jaw closure
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Chewing and mastication
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Tongue mobility and strength
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Palatal and laryngeal elevation
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Salivation
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Oral sensitivity
Check the patient's level of alertness and cognitive status, because they can impact the safety of swallowing and the ability to learn compensatory measures. Dysphonia and dysarthria are signs of motor dysfunction of the structures involved in oral and pharyngeal swallowing. (The neurologic exam should also include an examination of muscle strength, reflexes, coordination, gait, and functional status.)
Inspect the oral cavity and pharynx for mucosal integrity and dentition, and examine the soft palate for position and symmetry during phonation and at rest.
Evaluate pharyngeal elevation by placing 2 fingers on the larynx and assessing movement during a volitional swallow; this technique helps to identify the presence or absence of key laryngeal protective mechanisms.
The gag reflex is elicited by stroking the pharyngeal mucosa with a tongue depressor. Testing for the gag reflex is helpful, but absence of the reflex does not necessarily indicate that a patient is unable to swallow safely; many people with no gag reflex have normal swallowing abilities, and some patients with dysphagia have a normal gag reflex. Pulling of the palate to one side during testing of the gag reflex indicates weakness of the muscles of the contralateral palate and suggests unilateral bulbar pathology.
Cervical auscultation becomes part of the clinical evaluation of dysphagic patients; assess sound strength and clarity, the timing of apneic episodes, and the speed of swallowing. Also assess respiratory function; if the respiratory force of a cough or clearing of the throat is inadequate, the risk of aspiration is increased. In addition, lungs should be checked for rales/crepitations, wheezes, rhonchi, air entry, and other abnormalities.
The final step in the physical examination is direct observation of the act of swallowing; at a minimum, watch the patient while he/she drinks a few ounces of water. If possible, assess the patient's eating of various food textures. Sialorrhea, delayed swallow initiation, coughing, or a wet or hoarse voice quality may indicate a problem.
After the swallow, observe the patient for 1 minute or more to see if a delayed cough response is present. DePippo and colleagues suggested that a swallow test be conducted with 3 oz of water. In their investigation, the test helped them to identify 80% of patients with stroke who, during a subsequent videofluoroscopic study, were found to be aspirating. [40]
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Lateral projection of the videoprint of a videographic swallowing study shows the epiglottis (E), pyriform sinuses (P), tongue (Tg), trachea (Tr), and vallecula (V).
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Lateral projection of the videoprint of a videographic swallowing study shows residues on the vallecula (Vr) and pyriform sinuses (Pr) and a small amount of aspirated liquid barium in the trachea (As).
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Anterior projection of the videoprint of a videographic swallowing study shows residues on the vallecula (Vr) and pyriform sinuses (Pr).
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Lateral projection of the videoprint of a videographic swallowing study shows supraglottic penetration.
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Lateral projection of the videoprint of a videographic swallowing study shows subglottic aspiration.
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Delayed posteroanterior chest image shows aspiration of liquid barium into the distal bronchus.
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Oroesophageal tube feeding can be used by patients who decline to be enterally fed through a nasogastric or gastrostomy tube.
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Oral preparatory phase of normal swallowing.
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Oral propulsive phase of normal swallowing.
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Pharyngeal phase of normal swallowing.
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Esophageal phase of normal swallowing.
Tables
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Pharmacologic Treatment
- Dietary Modification
- Hydration
- Oral Hygiene and Dental Care
- Exercise
- Facilitation Techniques
- Compensatory Techniques
- Enteral Feeding
- Cricopharyngeal Myotomy
- Other Maneuvers and Techniques
- Surgery for Chronic Aspiration
- Treatment of Tracheostomy-Associated Dysphagia
- Evaluating Recovery From Dysphagia
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- Guidelines
- Medication
- Questions & Answers
- Media Gallery
- References
