So What is “Dysphagia” anyway?

My patients often tell me that they had no idea that someone could have trouble swallowing, until they did. Dysphagia, simply put, means trouble swallowing, and its very common. Many times when I see a patient for dysphagia, they know or feel their difficulty. They feel when they “aspirate”, which is the word for food or liquids going down the wrong pipe. Sometimes, however, my patients are somewhat disbelieving. “I swallow fine!” they insist. If you can’t feel dysphagia because sensation is affected, you can aspirate without feeling it. Its called “silent aspiration.”

So how, exactly, do we know that a person has dysphagia, even when they don’t know themselves? Dysphagia can be caused by many things. The most common causes of dysphagia in adults are strokes and head/neck cancer with or without radiation. In children, dysphagia is often caused by prematurity, birth injury/Cerebral Palsy or developmental/congenital disorders such as Down Syndrome or cleft palate.

When a person has a risk factor, like those above, or is having difficulty such as coughing or choking with meals, a Speech-Language Pathologist may be called in to assess the patient. When I see a patient, I first take a detailed history. I may ask questions that seem unrelated, like “have you ever had pneumonia?” During this initial assessment, often called a “clinical swallow evaluation,” or a “bedside swallow evaluation,” I am determining two things: 1) does this patient have risk factors for dysphagia that need further assessment? and 2) is this person appropriate for imaging of the swallow. The CSE/BSE does not determine if the patient is in fact aspirating. I always tell my patients that I didn’t bring my x-ray vision! Even a seasoned SLP cannot tell for sure that a person is aspirating simply by looking and listening with the naked eye.

If I answer “yes” to both questions above, I refer the patient for imaging of the swallow. In my area, we only do Modified Barium Swallow Studies (MBS), but in other areas a patient may have this or another imaging study. These tests allow the SLP to actually see what is happening inside the person’s swallow, evaluate, and make recommendations. Imaging is the only and best way to determine the safest texture and circumstances for a patient to eat and drink. I will talk more about imaging studies in another post!

BUT WHY DOES THIS MATTER?

When a person has dysphagia they are at risk for aspiration. Aspiration means food or liquid goes into the air tube below the vocal folds. This is sometimes understood as choking, or going down the wrong pipe. The vocal folds, often called vocal chords, sit at the top of the airway and close when we swallow. This keeps things from going into the lungs. When food or liquids go into the lungs, this can cause pneumonia, often referred to as “aspiration pneumonia.” Look for a future post describing the way the swallow works in plain English! I totally nerd out talking about this topic because it is just so cool how it all happens, like a well-oiled machine! Dysphagia can be caused by weakness of the muscles, difficulty feeling or processing what is happening, problems with timing, or problems with pressure.

While aspiration is one problem, it can be one of many! Dysphagia can affect one or all of the phases of the swallow, oral, pharyngeal, and esophageal. These phases happen quickly, especially in babies! Oral dysphagia affects sucking, biting, chewing, and using the tongue to move the food or liquid around and to the back of the mouth to get ready to swallow. Pharyngeal dysphagia is often thought of as the main event and is talked about most. This is the phase where the food or liquid goes “over the cliff,” moving down the base of the tongue and into the throat, eventually (hopefully!) past the airway and into the food tube, the esophagus. Once it moves to the top of the esophagus and through that sphincter, that is the esophageal phase, which is usually not treated by an SLP. Dysphagia in the pharyngeal phase can cause aspiration, penetration (material goes into the airway but not below the vocal folds), and residue. Residue is concerning because material hiding in spaces in the throat can fall into the airway. Difficulty in any phase of the swallow can affect the other phases, so its all important!

Dysphagia in any phase is concerning and can be dangerous, but many SLPs are experts in swallowing disorders and will know what to do to help. If you or your family member are having difficulty swallowing, or have dysphagia, go see your doctor! She will refer you to a certified Speech-Language Pathologist who is experienced evaluating and treating dysphagia. If you are having difficulty finding an SLP in your area, email me at Brightideas.speechtherapy@gmail.com and I will refer you to local organizations that can hook you up with SLPs in your geographic area.