Dysphagia
Introduction
Dysphagia is difficulty in swallowing liquids, solids, or both, resulting from disruption to the swallowing mechanism anywhere between the mouth and the oesophagus.[1] It is broadly classified as oropharyngeal dysphagia (affecting the oral and pharyngeal phases of swallowing) or oesophageal dysphagia (affecting the oesophageal phase). Oesophageal dysphagia typically requires referral to a gastroenterologist and is not the focus of this page.
If left unmanaged, dysphagia can lead to serious complications [2][3]:
- Aspiration pneumonia
- Dehydration
- Malnutrition
- Choking, and in severe cases, death
Epidemiology
Dysphagia is common yet frequently under‑reported.[4] In the United States, around one million people are diagnosed each year, although only about half seek medical attention.[5][6] Prevalence is particularly high after stroke, where dysphagia affects many patients in the acute phase and contributes to pulmonary complications.[5] [7] Older adults are also disproportionately affected, both through the underlying conditions associated with dysphagia (e.g. stroke, dementia, Parkinson's disease) and through presbyphagia - age-related changes to swallowing function that occur even in the absence of overt disease.[8]
Physiology of Swallowing
A sound knowledge of anatomy and physiology of swallowing and eating helps in the diagnosis and treatment of dysphagia.[9] There are four stages involved in the physiology of swallowing[9]:
- Oral preparatory stage - prepares the bolus for the next stage, i.e. propelling food to the pharynx, and prevents liquid and solid food from entering the pharynx until the bolus is ready to be swallowed.
- Oral propulsive stage - once the solid or liquid food is ready to swallow, the bolus is transferred into the oropharynx with the help of the tongue.
- Pharyngeal stage - its main feature is preventing food from entering the respiratory tract and preventing aspiration.
- Oesophageal stage - begins after the bolus enters the upper oesophageal sphincter (UES). During this phase, peristaltic movement and gravity move the bolus into the stomach.
Physiologically, swallowing takes priority over respiration, due to closure of the airway by elevation of the soft palate and tilting of the epiglottis, and neural suppression of respiration in the brainstem. The duration of the respiratory pause differs between swallowing a liquid and a solid bolus.[9]
Aetiology
Dysphagia can arise from a wide range of underlying conditions, including stroke, traumatic brain injury, Parkinson's disease, motor neuron disease, dementia, head and neck cancers, and prolonged intubation or tracheostomy. Older adults may also experience age related swallowing changes, known as presbyphagia. Causes are broadly categorised as:[7][10]
Structural abnormalities
It refers to congenital or acquired anatomical deviations that alter the normal architecture of the swallowing pathway and interfere with bolus flow at any stage of swallowing. These abnormalities can obstruct, narrow, or distort the oral cavity, pharynx, or oesophagus, leading to impaired bolus propulsion, residue, or aspiration risk.[10] For example:
- Cleft palate - A congenital defect that disrupts separation between the oral and nasal cavities, compromising effective bolus containment and increasing nasal regurgitation risk.[11]
- Cervical osteophytes - Bony outgrowths from the cervical spine that may mechanically compress the pharynx or oesophagus, impede bolus transit and contribute to globus sensation or aspiration.[12]
- Webs or strictures - Narrowing within the pharyngeal or oesophageal passage that restricts bolus flow, often presenting with food sticking, regurgitation, or compensatory swallowing behaviours.
These structural deviations can affect any stage of swallowing, from oral containment to pharyngeal clearance and oesophageal transit, ultimately altering normal swallowing physiology and increasing the likelihood of dysphagia. [9]
Functional abnormalities
It refers to impairments in the neuromuscular control of the swallowing mechanism, affecting any of the four stages of swallowing. These abnormalities do not arise from structural defects but from disrupted coordination, strength, timing, or sensory feedback within the swallowing musculature and neural pathways.[9] Dysfunction in any of the four stages of the swallowing process can affect swallowing physiology and cause dysphagia.
- Problem in oral stage of swallowing may lead to drooling of food, dehydration, and a feeling of food trapped in oral cavity. and difficulty chewing and mastication.
- Dysfunction in the pharyngeal stage leads to impaired initiation of swallowing and a feeling of bolus retention in the pharynx. Impairment at this stage may result in nasal regurgitation and aspiration (due to insufficient UES opening).
- Oesophageal dysfunction is common and often asymptomatic. Oesophageal dysphagia can lead to a feeling of food retention in the oesophagus, which may in turn lead to aspiration of food. [9]
Diagnosis
There are many bedside and instrumental tools available for the diagnosis and treatment of dysphagia. Dysphagia evaluation tools can be grouped broadly as:
- Imaging - ultrasound, video-fluoroscopy, fibreoptic endoscopic evaluation of swallowing (FEES), and FEES with sensory testing
- Non-imaging - bedside assessment tools, and pharyngeal manometry.[3]
Management and Rehabilitation
Rehabilitative exercises change and improve the swallowing physiology in force, speed or timing, with the goal being to produce a long-term effect, as compared to compensatory interventions used for a short-term effect. Rehabilitative exercises also involve retraining the neuromuscular system to bring about neuroplasticity, since pushing any muscular system in an intense and persistent way will bring about changes in neural innervation and patterns of movement.[6] Rehabilitation exercises can be broadly divided into:
- Swallowing exercises
- Non-swallowing exercises
Swallowing Exercises
Swallowing exercises are often used to treat dysphagia with the goal of altering swallowing physiology and promoting long-term change. These exercises are expected to affect swallowing mechanics and bolus flow. [13] The effortful swallow, Mendelsohn manoeuvre, super-supraglottic swallow, and Masako manoeuvre are examples of swallowing exercises.[14] Swallowing exercises follow many of the neuroplasticity principles listed below:[6]
- Use it or lose it
- Use it and improve it
- Specificity
- Transference
- Intensity
Non-Swallowing Exercises
Non-swallowing exercises are those that do not involve the act of swallowing, for example, tongue strengthening exercises. They can be performed by patients who cannot eat orally (are tube-fed), or by those who are temporarily restricted from oral intake post-surgery. The Shaker head lift, tongue strengthening, Lee Silverman Voice Treatment, and expiratory muscle strength training are examples of non-swallowing exercises.[14] Non-swallowing exercises follow fewer neuroplasticity principles, namely:[6]
- Transference
- Intensity
Therapeutic Interventions
Therapeutic techniques can be divided into those used as:
- Compensatory strategies: Head Rotation (Head Turn), Chin Tuck (Head Flexion). Head Tilt and Bolus Viscosity, Texture, and Volume Modifications.
- Exercises: Tongue Hold and Shaker Exercise.
- Both compensatory strategies and/or exercises: Supraglottic Swallow, Super-Supraglottic Swallow, Effortful Swallow, Mendelsohn Manoeuvre
- Alternate methods: Neuromuscular Electrical Stimulation (NMES), Oral Stimulation and Other Interventions.
Head Rotation (Head Turn)
Head rotation is a compensatory strategy used for patients with unilateral pharyngeal and/or laryngeal weakness as well as reduced UES opening.[13]
Instructions: While swallowing food, turn your head to the weaker side as if you are looking over your shoulder.[13]
Physiological benefits:
- It redirects the bolus to the side of the pharynx opposite the rotation (the stronger side) [13]
- It increases the duration of UES opening.[13]
Chin Tuck (Head Flexion)
The chin tuck (head flexion) is used for patients who have decreased airway protection associated with delayed swallow initiation and/or reduced tongue base retraction.[13]
Instructions: While swallowing food, bring your chin to the chest and maintain this posture throughout the duration of the swallow.
Physiological benefits:
- Expansion of vallecular recesses
- Approximation of tongue base toward pharyngeal wall
- Reduction in distance between hyoid and larynx
- Increases duration of swallowing apnoea during the swallow[13]
Head Tilt
The head tilt is used for patients with unilateral oral weakness. [13]
Instructions: While swallowing, tilt your head as if you are trying to touch your ear to your shoulder. Swallow while maintaining this position.
Physiological benefits:
- It directs the bolus to the stronger side of the oral cavity[13]
Bolus Viscosity, Texture, and Volume Modifications
Bolus modifications involve adjusting viscosity, texture, or volume to improve oral control and airway protection during swallowing.
- Increasing the volume and/or viscosity for liquids is another technique used for patients who have poor oral control of thin liquids and/or demonstrate reduced airway protection.
- Some patients may benefit from texture-modified foods.[13]
Supraglottic Swallow
The supraglottic swallow is used for patients who demonstrate reduced airway protection during the swallow and delayed swallow initiation.
Instructions: Before swallowing, first, inhale deep then hold your breath, continue to hold your breath and swallow immediately after you swallow before you inhale, cough then immediately swallow again.
Physiologic benefits: [13]
- Increases airway closure
- Increases UES opening during the swallow.
Super-Supraglottic Swallow
Super-supraglottic swallow differs from supraglottic swallow only when implementing an effortful breath hold
Instructions: Before swallowing, take a breath and hold it tightly while bearing down; continue to hold your breath and bear down as you swallow; immediately after your swallow (before you inhale), cough, then immediately swallow hard again.
Physiological benefits: [13]
- Patient has earlier tongue base movement
- Higher hyoid position at swallow onset
- Increased hyoid movement as well as longer bolus transit time
Note: Both the supraglottic swallow and the supra-supraglottic swallow manoeuvres may result in Valsalva and can result in arrhythmia in stroke patients during treatment sessions. Hence, clinicians should be mindful of using these manoeuvres in stroke patients, especially in those with coexisting heart disease.[13]
Effortful Swallow
The effortful swallow is used for patients who present with clinically significant residue in the valleculae and/or pyriform sinuses as well as for patients who may have decreased airway closure.
Instructions: while swallowing, squeeze your throat muscles as hard as you can.
Physiological benefits:
- It increases hyolaryngeal excursion, duration of hyoid elevation
- Increases UES opening
- Increases laryngeal closure
- Increases lingual pressures
- Increases peristaltic amplitudes in the distal oesophagus
- Increases pressure and duration of tongue base retraction[13]
Mendelsohn Manoeuvre
This technique is used for patients with decreased hyolaryngeal excursion and/or decreased duration of UES opening.
Before giving the command, ask the patient to first feel laryngeal elevation by palpation while swallowing saliva.
Instructions: After palpating the thyroid cartilage, feel the cartilage elevation while swallowing, now hold it up for several seconds and swallow the food while holding it up.
Physiologic benefits:
- It increases time and duration of hyolaryngeal excursion
- Increased time of UES opening, pharyngeal peak contractions
- Increased bolus transit time and duration, and pressure of tongue base contact[13]
Tongue Hold
The tongue hold is used for reduced tongue base, and pharyngeal wall contact.
Instructions: While swallowing the food, hold the anterior tongue (slightly posterior to the tongue tip) between the teeth.
Physiological benefits:
- It increases anterior bulging of the posterior pharyngeal wall.[13]
Shaker Exercise
The Shaker Exercise is used for patients who have decreased UES opening and weakness of the suprahyoid muscles.
Instructions: Patient position is supine and patient is asked to complete 3 head lifts sustained for 1 min each; 1 min rest period between each head lift; then complete 30 consecutive head lifts holding for 2 s each. The suggested frequency is three times each day for 6 consecutive weeks.
Physiological benefits:
- It increases anterior hyolaryngeal excursion
- It increases UES opening
- It strengthens suprahyoid muscles
- It enhances thyrohyoid shortening.[13]
Masako Manoeuvre
In this manoeuvre, the patient is asked to protrude the tongue and hold it between the teeth while swallowing. [6]
Neuromuscular Electrical Stimulation (NMES)
Neuromuscular electrical stimulation (NMES) is a treatment where electrodes are placed on the anterior neck and an electrical current evokes a muscle contraction. NMES treatment is typically used as an adjunct modality concurrently while the patient swallows and/or performs a traditional exercise. [13]
Oral Stimulation and Other Interventions
Oral stimulation techniques and some other interventions used in dysphagia management are listed below:[13]
- Tactile-thermal stimulation
- lingual, and labial strengthening
- Ice massage to the throat, base of tongue, and the posterior pharyngeal wall for 10 s with rubbing and light compression (for patients with supranuclear lesion)
- Lip muscle training
- lingual exercise following I-PRO (isometric progressive resistance oropharyngeal)
- Trans-cranial magnetic stimulation (TMS)
- Transcranial direct current stimulation (tDCS)
Summary
Dysphagia is a common and potentially serious condition arising from structural or functional disruption anywhere along the swallowing pathway, with consequences ranging from reduced quality of life to life-threatening aspiration pneumonia. Accurate diagnosis relies on a sound understanding of swallowing physiology combined with appropriate bedside and instrumental assessment. Management typically combines compensatory strategies for immediate safety with rehabilitative exercises aimed at longer-term physiological change and should always be delivered within the clinician's scope of practice and as part of a multidisciplinary team.
References
- ↑ Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, et al. The International Dysphagia Diet Standardisation Initiative (IDDSI): development, testing, and global implementation. Dysphagia. 2017;32(2):293‑314.
- ↑ Balamurali K, Sekar D, Thangaraj M, Kumar MA. Dysphagia in Patients with Stroke: A Prospective Study. International Journal of Contemporary Medicine Surgery and Radiology.2018;3(2):B11-B120
- ↑ 3.0 3.1 González-Fernández M, Ottenstein L, Atanelov L, Christian AB. Dysphagia after stroke: an overview. Current physical medicine and rehabilitation reports. 2013 Sep 1;1(3):187-96.
- ↑ Bhattacharyya N. The prevalence of dysphagia among adults in the United States. Otolaryngol Head Neck Surg. 2014 Nov;151(5):765‑9.
- ↑ 5.0 5.1 Suntrup‑Krueger S, Ringmaier C, Muhle P, Schuster C, Rademacher C, Warnecke T, et al. Dysphagia in the acute phase of stroke: incidence, severity, and prognostic implications. Stroke. 2018;49(6):1522‑8.
- ↑ 6.0 6.1 6.2 6.3 6.4 Langmore SE, Pisegna JM. Efficacy of exercises to rehabilitate dysphagia: a critique of the literature. International Journal of Speech-Language Pathology. 2015;17(3):222-229.
- ↑ 7.0 7.1 Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005 Dec;36(12):2756‑63.
- ↑ Namasivayam‑MacDonald AM, Riquelme LF. Presbyphagia: dysphagia in the elderly. Phys Med Rehabil Clin N Am. 2018 Feb;29(1):59‑69.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing: normal and abnormal. Physical medicine and rehabilitation clinics of North America. 2008;19(4):691-707.
- ↑ 10.0 10.1 Cook IJ, Kahrilas PJ. Aetiology and pathophysiology of dysphagia. Nat Rev Gastroenterol Hepatol. 2008 Mar;5(3):138‑48.
- ↑ Kummer AW. Cleft palate and craniofacial anomalies: effects on speech and resonance. Semin Speech Lang. 2011;32(2):130‑9.
- ↑ Uchino A, Kato A, Takase Y, Kudo S. Anterior cervical osteophytes causing dysphagia: imaging features and clinical correlation. Clin Imaging. 2012;36(5):495‑8.
- ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 13.12 13.13 13.14 13.15 13.16 13.17 13.18 Vose A, Nonnenmacher J, Singer ML, González-Fernández M. Dysphagia management in acute and sub-acute stroke. Current physical medicine and rehabilitation reports. 2014;2(4):197-206.
- ↑ 14.0 14.1 McCabe D, Madill C, Martin A, Steele CM. Biomechanical effects of rehabilitative swallowing exercises: a systematic review. Dysphagia. 2020;35(5):745‑62.