So much of our society is centered around food and drink. But swallowing issues can prevent some people from participating and enjoying this important life activity.
In The Eye & Ear Foundation’s December 1 webinar, “The Why and the How Behind Treating Swallowing Disorders,” Tamara Wasserman-Wincko, MS, CCC-SLP, discussed the causes of dysphagia, or difficulty swallowing, along with the evaluation process, impact, and treatment.
Dr. Jonas Johnson, Chair of the Otolaryngology Department at the University of Pittsburgh School of Medicine, introduced Wasserman-Wincko as an expert on swallowing. As Director, Speech-Language Pathology Division, she specializes in the evaluation and treatment of swallowing disorders.
The Swallowing Process
To start, Wasserman-Wincko outlined the swallowing process, which has three phases:
- Oral – Food is placed in the mouth, moistened with saliva, chewed and manipulated by the tongue
- Pharyngeal – The palate elevates to seal the nasal cavity and prevent food/liquid from coming out of the nose. The base of the tongue is the driving force behind the swallow. When the swallow is triggered, the voice box elevates and moves out of the way, so food/liquid does not enter the airway. During this time, the vocal folds close, the epiglottis inverts, and at the height of the swallow, a valve relaxes to allow food to pass to the esophagus.
- Esophageal – Peristalsis (constriction and relaxation of muscles) moves the food through the esophagus to the stomach.
When dysphagia occurs, it can lead to dehydration, malnutrition, or aspiration pneumonia. In a worse case scenario, it can lead to death. Difficulty swallowing can be a problem, impairing quality of life.
The Speech-Language Pathologist’s Role
A speech-language pathologist (SLP) sees a patient with dysphagia with four goals in mind:
- Identify the cause of dysphagia
- Improve efficiency of swallowing with strategies and exercise
- Ensure the patient achieves optimal quality of life
- Help the patient avoid aspiration pneumonia
Causes of Dysphagia
Often, dysphagia is a consequence of illness, including:
- Neurological disorders (ALS, PD, MS, MG)
- Head and neck cancer
- Esophageal disease
Dysphagia does have other causes, such as:
- Deconditioning/prolonged illness
- Trauma to the face/neck
- Post-operative edema (head and neck cancer, C-spine surgery)
- Prolonged endotracheal intubation (having a breathing tube for greater than 48 hours)
Dysphagia is also prevalent with advanced age. Loss of muscle mass plus malnutrition and comorbidities lead to frailty and less functional reserve.
The Evaluation Process
The evaluation process begins observing the patient drinking a glass of water. The SLP looks for coughing, throat clearing, multiple swallows (effort), fatigue, and vitals.
Predictors of dysphagia include:
- Dysphonia (difficulty speaking)
- Dysarthria (slurred or slow speech)
- Abnormal volitional cough
- Cough after swallow
- Voice change after swallow
Two or more of these clinical features mean the patient is a high risk for aspiration.
A more formal swallow study is then conducted to look at the safety and efficiency of swallowing. Are food and liquid going in the airway? How well is the patient transferring food?
The first type of test used is a Modified Barium Swallow (MBS), done in the radiology suite. Different liquid consistencies are administered, and a video is taken of the swallow function.
Another test is the Fiberoptic Endoscopic Evaluation of Swallowing (FEES), which employs an endoscope with a small camera chip at the end placed through the patient’s nose. A video is taken of the swallow function here too. This test is portable and can be done in the clinic or hospital.
Sometimes if the evaluation begins with one test, another may be needed to complement.
During these tests, the healthcare provider looks at the transfer of food/liquid, movement of structures, and aspiration.
Strategies to Reduce or Eliminate Aspiration/Dysphagia
The following strategies are used to help patients with their dysphagia:
- Head rotation/posture change
- Breath hold technique
- Effortful swallow
- Liquid wash to rinse
- Diet modification
Dysphagia in Head and Neck Cancer
Since dysphagia is common in head and neck cancer, it’s not surprising that it is also the number one patient complaint (70 percent) in the Survivorship Clinic. Severity is associated with three main things:
- Tumor – site, size
- Patient – age, comorbidities, prior treatment, function
- Treatment – surgery, radiotherapy, chemoradiotherapy
When patients undergo radiation treatment or chemo radiation, there are three phases: Pre-treatment, treatment, and post-treatment. Different things happen in each phase, but Wasserman-Wincko emphasized that everyone’s journey is different.
If a patient comes to the Survivorship Clinic with pre-treatment dysphagia (due to an advanced tumor, for example), a patient survey called the Eat-10 is administered. This is an eating assessment tool with 10 questions. The higher the score, the worse the outcome. Tumor-associated dysphagia may mean pain with swallowing and food may stick. Strategies to address this include liquid wash, head rotation, and diet modification (smoother foods, more liquified).
In general, patients who receive pre-treatment education are advised of the following:
- Changes with swallowing that might occur during treatment (why, when, what to expect)
- Modification of oral diet
- EAT & Exercise program
- Expectations of swallowing therapy
“It is important that patients understand so they want to participate and do the best that they can through their treatment,” said Wasserman-Wincko.
Starting early with swallowing exercises can help patients. It has been found to help with better quality of life scores, mouth opening, better diet level outcomes, and less hospitalizations after chemo radiation.
The treatment phase can result in early side effects. Sometimes modifying the diet is all that is needed. But if there is pain, that can lead to malnutrition/dehydration, muscle atrophy, and possibly a feeding tube. A feeding tube is not necessarily permanent, however. The goal is for it to help the patient get through treatment and then have it removed afterwards.
Acute side effects of treatment can include ulcerations, dry mouth, pain/mucositis, and altered taste.
To get through the treatment process, the following is recommended:
- Eating routine
- Keep a food diary
- Be prepared when going to chemo – pack food
- Avoid empty calories (jello) and spicy and acidic food/drink
- Focus on foods that are most easy to swallow
- Collaborate with a dietician to get high calories (Ensure Plus has 100+ calories)
The post-treatment phase can result in radiation associated dysphagia (RAD). The epiglottis can sometimes be thicker and stiffer after radiation. The space around the tongue region can get narrower and lead to some problems. Because this is known in advance, early exercise is extremely important.
A late radiation effect can result in lymphedema, swelling caused by tissue damage. Three months after treatment, 75 percent of patients experience this, one study found. It affects swallowing, and there can be irritation and fullness on the inside as well.
Another late radiation effect is fibrosis, which means a lot of stiffness. It can cause problems with swallowing, but the neck’s range of motion becomes impaired. Physical therapy is typically needed.
Trismus, decreased mouth opening (less than 35 mm), can occur. This causes difficulty with eating. Dental work can be challenging, and intubation may be difficult as well. A three-finger test can be used to gauge the mouth opening if no tool is available to measure.
Swallowing rehabilitation for head and neck cancer involves maximizing function by utilizing swallowing strategies and exercise. Maintaining function is also important. Rehab techniques and strategies are employed like using a gavage for bolus placement, therabite for oral opening stretches, IOPI tongue strengthening, and expiratory muscle strength training.
Q & A
Wasserman-Wincko addressed a question about swallowing issues during dementia. Sometimes it is very difficult to provide therapy for patients with dementia because they do not/may not be able to follow instructions during therapy sessions. It is important to start with a swallowing evaluation to determine what the best diet would be. Diet modification is one approach if the patient cannot participate in strategies. Talking to the family about how to help support their loved one is also key here.
Since swallowing issues can be prevalent in a variety of diseases, someone asked if a PCP should recommend a swallowing exam. Dr. Johnson said anyone can recommend a swallowing test; a referral is not needed for evaluation. An x-ray test of swallowing, however, does require a doctor’s order. He encouraged anyone struggling with swallowing to ask what is going on and how they can be helped.
As for how long it typically takes to train someone how to swallow, it varies because it is all patient dependent. When patients are referred for therapy, they usually start with an eight-week program.
“People don’t just get better just by coming to therapy once a week,” said Wasserman-Wincko. “They have to participate and be engaged.”
At the end of the eight weeks, a check is done to determine progress and if retesting needs to be done. Goals are varied because everyone has different objectives of what they want to do.
“We always say you’re the driver,” Wasserman-Wincko said. “We’re here to help support that.”
If swallowing issues stem from conditions, they can be resolved with rehab. But if they stem from something like a stroke, the patient may have to deal with some deficits forever. Dr. Johnson did clarify that people who have strokes do improve and can get better with exercise and proper instruction.
“We are always optimistic that there is opportunity to help people,” Dr. Johnson said.
Cancer is not the number one cause of swallowing issues. Throat cancer only makes up four percent of cancer cases, which is a small number.
The last question was about whether carbonated beverages give people trouble or discomfort with swallowing. Turns out some studies show they can simulate swallowing a little more. Dr. Johnson said the bubbly part of carbonation gives people an enhanced awareness that seems to help.
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