Dysphagia Treatment & Management

The goals of dysphagia treatment are to maintain adequate nutritional intake for the patient and to maximize airway protection.

Disorders of oral and pharyngeal swallowing are usually amenable to rehabilitation, including dietary modification and training in swallowing techniques and maneuvers. ^[1] Surgery is rarely indicated for patients with swallowing disorders, although in patients with severe disorders, bypassing the oral cavity and pharynx in their entirety and providing enteral nutrition may be necessary. Options include percutaneous endoscopic gastrostomy and intermittent oroesophageal catheterization.

Various treatments have been suggested for the treatment of oropharyngeal dysphagia in adults. Direct and indirect strategies for treating dysphagia have been described. Direct strategy usually refers to treatment that involves food, whereas indirect strategy refers to an exercise regimen performed without a food bolus. Direct techniques include modifications of food consistency; indirect techniques include stimulation of the oropharyngeal structures and the adoption of behavioral techniques, such as those involving postural changes or the swallow maneuver. ^{[48, 49]}

The Dietetics in Physical Medicine and Rehabilitation dietetic practice group conceived the National Dysphagia Diet project in 1996. This group became known as the National Dysphagia Diet Task Force (NDDTF). Growing frustration regarding a lack of standardization for solid-food textures, liquid consistencies, and nomenclature led to the formation of a task force to study the issue and to formulate a new diet based on scientific food properties and clinical swallowing problems. In 2002, the American Dietetic Association established the National Dysphagia Diet (NDD) to provide national guidelines and standardized terminology for texture modification for dysphagia management. The NDD contains suggested viscosity ranges for different types of modified fluids. ^[50]

Medications used in the treatment of dysphagia include the following:

• Botulinum toxin type A (BoNT-A): Injected endoscopically into the gastroesophageal sphincter and upper esophagus to decrease tone; this can be very useful in cricopharyngeal spasms causing dysphagia ^[51]

• Diltiazem: Can aid in esophageal contractions and motility, especially in the disorder known as the nutcracker esophagus

• Cystine-depleting therapy with cysteamine: Treatment of choice for patients with dysphagia due to pretransplantation or posttransplantation cystinosis ^[52]

• Nitrates: Including isosorbide dinitrate, which can especially be recommended in achalasia

Dietary modification is the key component in the general treatment program of dysphagia. A diet of pureed foods is recommended for patients who have difficulties with the oral preparatory phase of swallowing, who pocket food in the buccal recesses, or who have significant pharyngeal retention of chewed solid foods.

As patients' swallowing function improves, their dysphagic diet may be advanced to the next level of soft and semisolid foods with regular consistencies. Recommend to patients that they alternate bites with sips, bite or sip size, and the number of swallows per size.

Viscosity and texture

Food viscosity is defined as frictional resistance to shear. Food texture is defined as the group of physical properties derived from the structure of the food that can be sensed by touch. Touch usually is performed by elements of the oral and pharyngeal cavities. Food and liquid textures play important roles in the care of patients with dysphagia.

If oral feedings are determined to be appropriate, the viscosity and texture of the food should be considered, because patients vary in their ability to swallow thin and thick liquids. Liquids can be thickened with various thickening agents. Many commercially available, starch-based food thickeners are used to increase the consistency of food, and prethickened water, juice, coffee, and other products are available.

A uniform and viscous bolus of food or beverage enables a patient with a delayed swallow reflex to control mastication and transport. It also allows the individual to swallow with less risk of aspirating residue material, because there is a reduced tendency for the material to fall over the base of the tongue before the swallow mechanism is triggered. Viscosity also influences the swallowing reflex and peristaltic activity.

Viscosity of the diet for dysphagia is frequently described in a nonobjective manner. For example, tomato juice, nectar, honey, and pudding have been referred to as fluids.

Viscosity can be objectively determined by using a device called a viscometer. Another objective method of determining viscosity is a line-spread test. ^{[53, 54]} In this, diluted mix is placed on a circle marked on a glass plate and is allowed to stream for 5 minutes. Lengths of the 4 stream directions are measured, and their mean is determined.

Diet classifications

The dysphagia diet can be classified according to viscosity, as follows:

• level I: Pudding, crushed potato, and ground meat

• level II: Curd-type yogurt, orange juice (mixed with 3% thickener), cream soup, and thin soup with starch

• level III: Tomato juice, fluid-type yogurt, and thick, fluid rice

• level IV: Water and orange juice

Diets for patients with dysphagia include the following:

• Dysphagia diet 1: Thin liquids (eg, fruit juice, coffee, tea)

• Dysphagia diet 2: Nectar-thick liquids (eg, cream soup, tomato juice)

• Dysphagia diet 3: Honey-thick liquids (ie, liquids that are thickened to a honey consistency)

• Dysphagia diet 4: Pudding-thick liquids/foods (eg, mashed bananas, cooked cereals, purees)

• Dysphagia diet 5: Mechanical soft foods (eg, meat loaf, baked beans, casseroles)

• Dysphagia diet 6: Chewy foods (eg, pizza, cheese, bagels)

• Dysphagia diet 7: Foods that fall apart (eg, bread, rice, muffins)

• Dysphagia diet 8: Mixed textures

Nutritional evaluation and support

The effect of dysphagia on the patient's nutritional status is profound. As the patient's ability to swallow becomes impaired, adequate dietary intake becomes a challenge, and vice versa. Therefore, early detection and management of dysphagia are critical to halting malnutrition. ^[55]

Malnutrition is a risk factor for pneumonia because it renders patients susceptible to altered microbial colonization in the oropharynx and because it depresses the immune system, reducing resistance to infection. It may also lead to lethargy, weakness, and reduced alertness, all of which may increase the probability of aspiration.

Moreover, malnutrition may reduce the strength of cough and the mechanical clearance of the lungs. It also contributes to overall functional decline, muscle breakdown, osteoporosis, osteopenia, iron-deficiency anemia, skin breakdown, and poor wound healing.

Therefore, in addition to dysphagia screening, formal nutritional assessment is necessary in high-risk patients. Nutritional needs are determined by means of thorough body composition analysis, clinical examination, and biochemical assessment. Energy, protein, and fluid requirements must also be assessed.

In an investigation of the nutritional status of patients admitted to a rehabilitation service, 49% of all patients admitted for stroke were malnourished, ^[33] and 65% of persons admitted for stroke with dysphagia were malnourished. ^[28]

Many commercial products are available to provide nutritional support. A patient's protein and calorie intake can be enhanced not only with thickening agents but also with prethickened beverages, prepacked puree molds, oral liquid supplements, and modular components. When oral nutrition is inadequate, enteral nutrition is indicated.

Because fluid intake is restricted in most patients with dysphagia, these individuals are at risk of dehydration. Therefore, the patient's hydration status must be closely monitored. Dehydration may lead to lethargy, mental confusion, and increased aspiration. In addition, dehydration depresses the immune system, making the patient susceptible to infection, and it may also be a risk factor for pneumonia, because it decreases salivary flow (thus promoting altered microbial colonization of the oropharynx).

The hydration state of a patient can be assessed by using input and output records, laboratory values (eg, serum osmolality), and physical indicators (eg, dry mucous membranes, poor skin turgor, darkened urine).

Adequate fluid intake can be achieved through simple interventions, such as systematically offering patients preferred liquids or foods with high fluid content (eg, pureed fruits and vegetables, hot cereals, custards, puddings) and having an adequate number of supervised staff to help patients drink while properly positioned. Intravenous fluids or water boluses given via a feeding tube may be necessary if hydration cannot be maintained.

Oral hygiene and dental care are important. Changes in the oral milieu may occur secondary to decreased salivary production and abnormalities in swallowing. These abnormalities may result in the impaired clearance of organisms, allowing for pathogenic colonization. Dried secretions that accumulate on the tongue and palate reduce oral sensitivity and promote bacterial growth. Lemon glycerin swabs or a damp washcloth can be used to remove the secretions.

The elderly have an increased incidence of oropharyngeal colonization with respiratory pathogens, a well-known risk factor for pneumonia, making oral care extremely important in pneumonia prevention.

Exercises are used to increase muscle tone and augment pharyngeal swallow. Two types of exercise can be recommended to patients with dysphagia: indirect (eg, exercises to strengthen swallowing muscles) and direct (eg, exercises to be performed while swallowing).

Exercise techniques are geared especially toward range of motion (ROM), coordination, and the strengthening of muscles of the jaw, lips, cheek, tongue, soft palate, and vocal cords. Exercises designed to facilitate oral motor strength, ROM, and coordination usually are performed 5-10 times per day.

Biofeedback techniques are used to reeducate muscles affected in facial palsy and disorders of articulation. Such techniques include electromyographic feedback, with surface electrodes placed over the anterior neck. Visual feedback is obtained through a videofluoroscopic swallowing study (VFSS) while experimentation with head positions and swallowing maneuvers is conducted.

Lips

Lip exercises can facilitate the patient's ability to prevent food or liquid from leaking out of the oral cavity. Tongue exercises are used to facilitate manipulation of the bolus and its propulsion through the oral cavity or to facilitate retraction of the tongue base. Passive ROM and active-assistive ROM exercise concepts also can be applied in this technique. Tongue-holding maneuvers facilitate compensatory anterior movement of the posterior pharyngeal wall.

Head lift

Head-lift exercises increase anterior movement of the hyolaryngeal complex and opening of the upper esophageal sphincter. Patients lie flat and are instructed to keep their shoulders on the floor as they raise their head high enough to see their toes, maintaining this position for 1 minute. They repeat this activity 3 times, followed by 30 consecutive repetitions of the same action. Patients should perform this exercise 3 times per day for several weeks.

A study by Choi et al indicated that combining head-lift exercises with conventional dysphagia therapy is more effective than conventional dysphagia therapy alone in the treatment of poststroke dysphagia. Greater improvement in degree of aspiration (evaluated using the Penetration-Aspiration Scale) and oral diet level (assessed via the Functional Oral Intake Scale) was seen in the head-lift group than in the patients who received only conventional treatment. ^[56]

Other

Jaw exercises help to facilitate the rotatory movements of mastication. Respiratory exercises (eg, resistive straw sucking, coughing, incentive spirometer) are recommended to improve respiratory strength. Vocal cord adduction exercises can promote strengthening of weak vocal cords.

Electrical stimulation can be applied for dysphagia, being administered with a modified, handheld, battery-powered electric stimulator connected to a pair of electrodes positioned on the neck. This technique is comparable to neuromuscular stimulation or functional electrical stimulation applied to the limb.

Somatosensory input influences motor function, and oral sensory deficit is associated with increased tendency toward aspiration. Somatosensory stimulation in the form of an electrical current applied to the pharynx can change the excitability of the corticobulbar projection and induce cortical reorganization in patients with poststroke dysphagia. ^{[57, 58, 59]}

Deep pharyngeal neuromuscular stimulation (DPNS) is a therapeutic program that uses the afferent-efferent cycle (ie, sensory stimulation-motor response) to improve pharyngeal swallow. DPNS focuses on stimulating 3 reflex sites with frozen lemon-glycerin swabs. The first site—the bitter taste buds and tongue base—is used to improve tongue-base retraction. The second site is the soft palate, which is stimulated to improve palatal elevation. The therapy is applied to the third site, the superior and medial pharyngeal constrictor, to improve pharyngeal peristalsis and cricopharyngeal opening.

A pilot randomized, controlled study by Sproson et al reported that better poststroke swallowing rehabilitation results were obtained with the use of a combination of transcutaneous neuromuscular electrical stimulation and swallow-strengthening exercises than with usual dysphagia care. The study noted improvement in 75% of patients in the electrical stimulation group, compared with 57% of those receiving usual care. ^[60]

Tactile-thermal stimulation (TTS) can be used to increase the speed of swallow. TTS involves the application of cold by rubbing the bilateral anterior facial arch with a laryngeal mirror that has been placed in ice. The purpose is to sensitize the area of the oral cavity where the swallow is triggered.

The bite reflex can be inhibited by applying sustained pressure to the tongue with a rubber seizure stick, in the chin-tuck position. A hypoactive gag reflex can be facilitated by applying a tongue depressor or a quick tap to the arch of the soft palate. A hyperactive gag can be desensitized by using firm pressure with a tongue depressor, which is advanced farther back in the mouth.

Maintaining oral feeding often requires compensatory techniques to reduce aspiration or improve pharyngeal clearance.

Chin-tuck position

In this, the patient holds his/her chin down, increasing the epiglottic angles, and pushes the anterior laryngeal wall backward, thereby decreasing the airway diameter.

The chin-tuck position decreases the space between the base of the tongue and the posterior pharyngeal wall, creating increased pharyngeal pressure to move the bolus through the pharyngeal region. Use of this position often is helpful for patients with delayed swallow reflex, because, by narrowing the airway entrance and increasing the vallecular space, it increases the probability that the bolus will remain in the vallecular before the pharyngeal swallow is triggered. In this way, the risk of aspiration is decreased.

Rotation of the head to the affected side

This technique closes the pyriform sinus on the affected side, directing food down the opposite, stronger side. This posture also adds external pressure on the damaged vocal cord and moves it toward the midline, improving airway closure.

Tilting of the head to the strong side

By tilting the head to the strong side, the bolus tends to be directed down the stronger side in the oral cavity and in the pharynx. The head tilt is also effective for patients who have unilateral tongue dysfunction or a unilateral pharyngeal disorder.

Lying on one's side or back during swallowing

Using this posture often helps patients who, because of residue in the pharynx, aspirate after swallowing. Such aspiration occurs because gravity drops the residual food into the airway when they inhale after the swallow.

Supraglottic swallow

The supraglottic swallow, a technique that most patients can master, involves simultaneous swallowing and breath-holding, closing the vocal cords and protecting the trachea from aspiration. The patient thereafter can cough to expel any residue in the laryngeal vestibule. This technique can be useful for patients who have reduced laryngeal closure. Advise the patient to practice the following steps ^[61] :

• Take a deep breath and hold your breath

• Keep holding your breath and lightly cover your tracheostomy tube, if applicable

• Keep holding your breath while you swallow

• Cough immediately after the swallow

The extended supraglottic swallow is helpful for patients with severe reductions in tongue mobility or severely reduced tongue bulk due to surgical procedures for oral cancer, because these persons essentially have little or no oral transit. Advise these patients to learn the following technique:

• Hold your breath firmly

• Put the entire 5-10 mL of liquid in your mouth

• Continue to hold your breath and toss your head back, thus dumping the liquid into the pharynx as a whole

• Swallow 2-3 times or as many times as needed to clear the majority of the liquid while continuing to hold your breath

• Cough to clear any residue from the pharynx

The supersupraglottic swallow incorporates the supraglottic swallow with a Valsalva effect. This technique is designed to close the airway entrance voluntarily by tilting the arytenoid cartilage anteriorly to the base of the epiglottis before and during the swallow. This strategy is used in patients with reduced closure of the airway entrance, particularly those who have undergone supraglottic laryngectomy.

Bolus-clearing maneuvers

The effortful swallow is designed to improve posterior tongue-base movement, in that way improving clearance of the bolus from the valleculae. Patients are instructed to swallow hard.

Mendelsohn maneuver

This maneuver is a form of supraglottic swallow in which the patient mimics the upward movement of the larynx by voluntarily holding the larynx at its maximum height to increase the duration of the cricopharyngeal opening. Patients are instructed to swallow, to hold the swallow for 2-3 seconds, and then to complete the swallow and relax when the pharynx is in the uppermost stage. Repeatedly swallowing and washing food through the pharynx may be helpful to patients who have excessive residue in the pharynx after the swallow.

In some patients, enteral feeding may be necessary in order to bypass the oral cavity and pharynx. In general, enteral feeding is indicated in any patient who is unable to achieve adequate alimentation and hydration by mouth. Patients with an impaired level of consciousness, massive aspiration, silent aspiration, esophageal obstruction, or recurrent respiratory infections fall into this category.

There has been some controversy regarding the most appropriate mode and method of administering enteral feeding (eg, continuous or intermittent, intestinal or gastric). Esophagostomy is needed in patients in whom other placements may not be possible and can help in the control of pharyngeal secretions.

Nasogastric tube feeding

Nasogastric tube (NGT) feeding is a commonly used method of enteral feeding. In patients with a short-term life expectancy, nasogastric feeding is a more appropriate route for enteral nutrition. Insertion of an NGT is an easy, quick, relatively noninvasive procedure; it requires little training and is associated with negligible mortality. However, many patients find the NGT uncomfortable and repeatedly pull the tube out, which results in interrupted feeding and potential malnutrition.

Its prolonged use can lead to complications, such as lesions to the nasal wing, chronic sinusitis, gastroesophageal reflux, and aspiration pneumonia, although H2 blockers or proton-pump inhibitors given as prophylaxis can prevent some complications. ^[62]

Oroesophageal tube feeding

Campbell-Taylor and colleagues introduced oroesophageal tube feeding in 1988 (see the image below). ^[63] Patients who refuse nasogastric or gastrostomy tubes can use this method. The patient is taught to insert the 14F urethral tube into the mouth and past the side of the tongue, pushing slowly until the catheter end reaches the lips. Food supplements and liquid are administered by means of a 500-mL syringe at a rate of approximately 50 mL/min.

The absence of a gag reflex indicates the possible need for oroesophageal tube feeding. The patient must be cooperative and alert but need not be completely cognitively intact. This method is relatively contraindicated in patients with a hyperexaggerated gag reflex, esophagitis, Zenker diverticulum, or anteriorly directed cervical osteophytes.

This method has several advantages. First, oroesophageal tube feeding may prevent the harmful effects of continuous NGT feeding. Second, the speed of pouring liquids can be faster than with NGT feedings. Third, oroesophageal tube feeding provides training for facilitating the swallowing reflex.

However, a couple of disadvantages should also be noted. First, performance of this procedure requires skillful technique. Second, the need for frequent manipulation (6 times per day) may be troublesome for the assistant.

Percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG), in which endoscopy is used to percutaneously place a tube into the stomach, has several advantages over surgical gastrostomy (which requires a laparotomy under general or local anesthesia). These include reduced procedure time, cost, and recovery time, as well as the fact that PEG requires no general anesthesia. However, PEG does require the invasive insertion of the feeding tube through the anterior abdominal wall, which can result in complications, including the following ^[64] :

• Bleeding

• Peritonitis or perforation of other abdominal organs

• Chest infections

• Local infection around the insertion site

• The tubes being pulled out

Relative contraindications for PEG are aspiration pneumonia due to gastroesophageal reflux, significant ascites, and morbid obesity. Prospective, randomized trials have shown increased compliance, convenience, and continuity of feeding with PEG tubes compared with nasogastric intubation.

Reflux prevention involves feeding the patient in a vertical position, using H2 blockers to decrease gastric pH, chlorpromazine or Maxolon to facilitate gastric emptying, and proton-pump inhibitors to decrease gastroesophageal reflux.

In one meta-analysis comparing effectiveness and safety between NGT feeding and PEG, PEG was found to be safer and more effective than NGT use. Intervention failure occurred in 19 of 156 patients in the PEG group, compared with 63 of 158 patients in the NGT group. However, complications, mortality rates, and pneumonia rates were comparable between NGT feeding and PEG. ^[65]

Cricopharyngeal myotomy (CPM) is a procedure designed to decrease pressure on the pharyngoesophageal sphincter (PES) by incising the main muscular component of the PES. However, no means of precisely determining the underlying PES dysfunction exists. For this reason, no rational guidelines have been compiled for recommending CPM.

Even less certain is the advisability of performing a CPM in patients with neurogenic dysphagia, such as patients with stroke. The fact that neurogenic causes of dysphagia usually involve a lack of coordination of the swallow rather than any intrinsic or extrinsic muscle dysfunction probably explains this consideration. The injection of botulinum toxin injection into the PES has been introduced as a replacement for CPM.

The Shaker exercise is a head lift designed to increase anterior movement of the hyolaryngeal complex and opening of the upper esophageal sphincter.

The Heimlich maneuver is used to dislodge food that the patient cannot cough out of the airway. The maneuver consists of wrapping one's arms around the upper abdomen of the victim from behind and squeezing mightily and quickly in a brief, fervent hug.

Biofeedback can be useful for oral motor and facial exercises. The patient also receives feedback on the actual swallow.

Adaptive equipment for patients who have difficulty with the motor or perceptual components of feeding compensates for decreased upper extremity functions, accommodating limited grasp, incoordination, decreased ROM, and hemiparesis. Examples include the following:

• Rocker knives

• Swivel utensils

• Built-up handles on utensils

• Scoop dishes

• Nonskid mats

• Large-handled cups

Surgery for chronic aspiration may involve the following:

• Medialization: This helps to restore glottic closure and subglottic pressure during the swallow

• Laryngeal suspension: The larynx is in a relatively protected position under the tongue base

• Laryngeal closure: This may be performed to close the glottis off, in this way protecting the airway at the expense of phonation

• Laryngotracheal separation-diversion: This procedure may be done to separate the airway from the alimentary tract

In the acute setting, when the need to decrease the aspiration of secretions is urgent, a tracheostomy is a simple and effective choice. However, in a chronic situation in which the patient has no likelihood of recovering a safe swallow and voice, laryngectomy is the most effective choice. In patients for whom recovery of voice and swallowing function is uncertain but aspiration of secretions is life threatening, temporary laryngeal closure by a diversion procedure can be used.

A tracheostomy tube worsens dysphagia by tethering the trachea to the skin and decreasing laryngeal elevation over time. To restore glottic closure, subglottic pressures, and transglottic airflow in patients with a tracheostomy, 1-way speaking valves are used. The value of the occlusion of the tracheostomy tube may be related to the provision of a closed aerodigestive tract, which enables the patient to effectively react to aspiration.

Other important benefits include improved communication, improved olfaction, and assistance with decannulation. Restoration of glottic function can also be accomplished by downsizing the standard cuffed tracheostomy tube toward stepwise decannulation.

Patients receiving mechanical ventilation often cannot control the duration of inspiratory and expiratory airflow. Therefore, ventilator settings, such as tidal volume and flow rate, may need to be adjusted during meals. (Tidal volume may need to be increased, and flow rate may need to be reduced.) The patient may have to relearn the inspiratory and expiratory phases of the breathing cycle for optimal coordination with swallowing.

Recovery from dysphagia is associated with increased pharyngeal representation in the brain, suggesting brain reorganization in recovery.

Several scales have been suggested to determine patients' functional outcomes. ^{[66, 67, 68]} One of them is the Swallowing Rating Scale (recommended by the American Speech-Language-Hearing Association [ASHA]), the categories of which are as follows:

• level 0: The patient cannot be tested

• level 1: Swallowing is not functional

• level 2: Inconsistent and/or delayed swallowing, which hinders eating and therefore prevents the patient from meeting nutritional needs; however, some swallowing is possible

• level 3: The swallowing disorder prevents eating for a portion of nutritional needs, and supervision is required for eating

• level 4: The swallowing disorder does not prevent eating to meet nutritional needs, although general supervision is required to ensure the use of compensatory techniques

• level 5: Swallowing is functional enough to meet nutritional needs, although self-monitoring and compensatory techniques are used; the patient may need occasional cueing, feeding with special techniques, and modifications

• level 6: Swallowing is functional for most eating activity, although mild difficulty may periodically occur; additional time may be necessary for eating

• level 7: Swallowing is normal in all situations