Dysphagia

Overview
Dysphagia, or difficulty in swallowing, can be a medical and feeding issue at any age; however, it is
particularly prevalent in older individuals (Akhtar 2002, Castellanos 2003, Germain 2006, Taylor
2006). Identification of dysphagia is done using medical history, clinical observation, and physical
examination (Logemann 1999). Some treatments for dysphagia include H-2 blockers, Proton Pump
Inhibitor, and GI stimulants (International Scleroderma Network):

Dysphagia is not a disease, but a disruption of a normal swallowing process. Without effective
treatment it can lead to (Robbins 2007, Walker 2005):

 Malnutrition
 Aspiration pneumonia
 Dehydration
 Unintended weight loss
 Depression
 Mortality
 Pneumonia (pulmonary complications)
 Decreased rehabilitation potential
 Decreased quality of life
 Increased length of hospital stay
 Increased costs

Swallowing is a complex process involving some 50 pairs of muscles and dozens of nerves to move
food and fluid from the mouth to the stomach. (NIDCD 2007)

Swallowing may be defined as the moving of food, liquid, secretions, or medications from the mouth
to the stomach, usually in a series of musle contractions causing pressure changes in the aero-
digestive tract (Robbins 2007).

Muscle weakness or incoordination, impaired gag or swallowing reflexes, and impaired cough
contribute to dysphagia (Moore 2005b). Dysphagia is an impairment in one or all stages of swallowing,
resulting in the reduced ability to obtain adequate nutrition by mouth and/or reduced safety during
oral feeding (Niedert 2004). Dysphagia may result from neurological disorders, degenerative diseases,
cancers, or postintubation trauma (Bales 2004). Thorough history taking and careful physical
examination are important in the diagnosis and treatment of dysphagia. Assessment and treatment of
dysphagia should be completed by a team comprised of the physician, registered dietitian, speech
language pathologist (SLP), and occupational therapist (OT).

Background Information
Eating is necessary to sustain life and is considered one of life's greatest pleasures. When an individual
is unable to eat, the impact on quality of life can be substantial and potentially can contribute to
nutritional depletion.

Swallowing is a complex act that involves the coordinated activity of the mouth, pharynx, larynx, and
esophagus (Palmer, 2000). Any alteration to these structures or swallowing phases, such as a mass or
a neurological insult, can result in dysphagia. In patients with cancer, there are multiple etiologies that
can contribute to the development of dysphagia. In patients with cancers of the head and neck,
dysphagia can be caused by the following:

 Obstruction of swallowing caused by the presence of the tumor

  Surgical resection of structures involved in the swallowing process
 Effects of radiation therapy (Cooper, 1995)

As an example, patients with a partial glossectomy will experience significant interference with
movement of a food bolus if the resection has been a transverse rather than a vertical resection or if
more than 50% of the tongue is resected. Radiation therapy can cause long-term xerostomia, making
it difficult to manipulate and propel a bolus or initiate the swallowing reflex, leading to dysphagia
(Logemann, 2001). Chemotherapy can also contribute to the development of dysphagia if it causes
nutrition impact symptoms such as xerostomia and mucositis (Dimeo, 1999).

Patients with cancers of the central nervous system can experience dysphagia caused by metastasis or
a primary tumor affecting one of the cranial nerves, causing neurologic disruption of the swallowing
reflex. Dysphagia can also result from an extrinsic or intrinsic compression of the esophagus
(McDonnell, 1999). Extrinsic compression of the esophagus can result from adenopathy in the
mediastinum with lung cancer. Even deconditioning and disease states that can be present as a
comorbid condition in patients with cancer may increase the likelihood of dysphagia (Lofton, 1999).

Disease Process
Swallowing disorders are commonly seen in patients with the following conditions:

 Neurodegenerative disorders such as:

o Parkinson’s disease
o Multiple sclerosis
o Guillain-Barre
o Huntington's disease
o Poliomyelitis
o Post-polio syndrome
o Amytrophic lateral sclerosis (ALS, AKA Lou Gehrig's Disease)
o Multiple dystrophies
o Alzheimer's disease
o Bulbar palsy
 Neuromuscular disorders such as:
o Spastic motor disorders
 Diffuse esophageal spasm
 Hypertensive lower esophageal sphincter
 Nutcracker esophagus
o Achalasia (incomplete relaxation of the lower esophageal sphincter [LES] after
swallowing)
o Scleroderma
o Myasthenia gravis
o Chagas disease
o Amyloidosis
o Eaton-Lambert Syndrome
o Botulism
 Esophageal cancer
 Diabetes, type 1 (long-term)
 Head and neck cancer, including brain stem tumors
 Goiter
 Pharyngeal pouch
 Presbyphagia (swallowing difficulty of old age)
 Cerebrovascular accident (CVA, AKA stroke)
 Gastroesophageal reflux (GERD) (Leslie 2003)
 Esophageal varisces
 Inflammatory masses
  Head injury

Dysphagia is also seen in patients with:

 Gastroparesis
 Intrinsic and extrinsic structural lesions (Spieker 2000)
 HIV infection (Zalar 2003)
 Acute cervical spinal cord injury (Wolf 2003)
 After intubation for cardiac surgery (Partik 2003)
 Post-intubation trauma
 Lung inflammation, including COPD, with excessive secretions
 Anoxia (Escott-Stump 2008)

Dysphagia in children has been associated with neurological conditions and anatomical anomalies
(Escott-Stump 2008, Field 2003, Perlman 1999). It has been noted in children with:

 Choroids plexus papilloma (Cornwell 2003)

 Stroke-induced trismus after botulinum toxin A treatment (Spillane, 2003)
 After traumatic brain injury (Morgan 2003)
 Cerebral palsy (Moore 2005a)
 Convulsive (seizure) disorders
 Esophageal atresia
 Cleft lip or palate

In late-stage Alzheimer's disease and other dementias, dysphagia and aspiration are the two most
serious medical conditions (Kalia 2003).

Aging also increases the potential for dysphagia (Akhtar 2002, Germain 2006, Mahan 2008, Taylor
2006).