Problems with swallowing can interfere with nutrition, enjoyment of food and even breathing. In severe cases, people may also develop pneumonia. If you or a loved one experience difficulty swallowing, our experienced physicians and occupational therapist are here to help.

Dysphagia (swallowing difficulty associated with foods, fluids and saliva) is common after acute stroke with an incidence between 40 and 78%. There is a link between dysphagia and poor outcomes including a higher risk of longer hospital stay, chest infection, disability and death (Martino et al, 2005).

Evidence from national audit shows that delays in the screening and assessment of dysphagia are associated with an increased risk of stroke-associated pneumonia (Bray et al, 2016).

Differential diagnosis

(Edmiaston J et al, 2010, Noh EJ et al, 2010, Martin RJ, 2004)

All causes of dysphagia are considered as differential diagnoses. Some common ones are:

• Esophageal atresia
• Paterson-Kelly syndrome
• Zenker’s diverticulum
• Esophageal varices
• Benign strictures
• Achalasia
• Esophagial diverticula
• Scleroderma
• Diffuse esophageal spasm
• Polymyositis
• Webs and rings

• Esophageal cancer
• Eosinophilic esophagitis
• Hiatus hernia, especially paraesophageal type
• Dysphagia lusoria
• Stroke
• Fahr’s disease
• Wernicke encephalopathy
• Charcot–Marie–Tooth disease
• Parkinson’s disease
• Multiple sclerosis
• Amyotrophic lateral sclerosis

Swallow Analysis

 Before recommending treatment, our specialists will locate and study the swallowing problem to get clues about its origin. They have a variety of tests at their disposal to help diagnose swallowing problems:

• Physical swallowing tests (Dennis MS et al, 2005, Kuo Yw et al, 2015, Rofes L et al, 2013)

• Physical Status
• Feeding Type
• Observation
• Oral Control
• Oral Stage
• Pharyngeal Control

Electrodiagnostic studies such as electromyography — the study of the muscles involved in swallowing

Dysphagia Treatment Procedures

(Logemann et al, 1998)

 Compensatory Treatment Procedures are designed to change the flow of the food/liquids and eliminate symptoms, but do not directly change the physiology of the swallow.

• Postural Techniques
• Food Consistency (Diet) Changes
• Modifying Volume and Speed of Food Presentation
• Technique to Improve Oral Sensory Awareness
• Intraoral Prosthetics

Therapeutic Treatment Procedures are designed to change and/or improve the physiology of the swallow. (Logemann et al, 1998, Perry, 2016)

• Oral and Pharyngeal Range-of-Motion Exercises
• Resistance Exercises
• Bolus Control Exercises
• Swallowing Maneuvers
• Supraglottic swallow
• Super-supraglottic swallow
• Effortful swallow
• Mendelsohn maneuver

Education

• Swallowing exercise
• Facial strengthening exercise
• Tongue strengthening exercise

Plan

Long term plan

• To prevent aspiration and airway protection
• Educated posture to precent opening airway, Safe swallow guidelines
• To improve overall swallowing function to progress dysphagia diet after VFSS result

Short term plan

• To improve the base of tongue motion/retraction, the patient will complete Masako maneuver and Effortful swallow.
• To improve laryngeal excursion and coordination of UES opening, the patient will complete Shaker maneuver (Alternative strategy) and Mendelsohn maneuver given verbal and visual cueing.
• To improve hyolaryngeal elevation and UES opening, the patient will complete Mendelshohn maneuver and Falsetto voice

Plan of Care

Safely support adequate nutrition and hydration and return to safe and efficient oral intake (including incorporating the patient’s dietary preferences and consulting with family members/caregivers to ensure that the patient’s daily living activities are being considered)

References

1. Martino et al, 2005; Carnaby et al, 2006; Royal College of Speech and Language Therapists, 2007, 2008; Terre and Mearin, 2012.
2. Bray BD, Smith CJ, Cloud GC, Enderby P, et al, 2016. The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. Journal of Neurology, Neurosurgery & Psychiatry.
3. Edmiaston J, Connor LT, Loehr L, Nassief A (July 2010). “Validation of a dysphagia screening tool in acute stroke patients”. American Journal of Critical Care.
4. Noh EJ, Park MI, Park SJ, Moon W, Jung HJ (July 2010). “A case of amyotrophic lateral sclerosis presented as oropharyngeal Dysphagia”. Journal of Neurogastroenterology and Motility.
5. Martin RJ (September 2004). “Central pontine and extrapontine myelinolysis: the osmotic demyelination syndromes”. Journal of Neurology, Neurosurgery, and Psychiatry. 75 Suppl 3: iii22–28.
6. Dennis MS, Lewis SC, Warlow C & Collaboration FT, 2005. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet, 365, 764-72.
7. Kuo YW, Yen M, Fetzer S, Chiang LC, et al, 2015. A home-based training programme improves family caregivers’ oral care practices with stroke survivors: a randomized controlled trial. International Journal of Dental Hygiene, 14, 82-91.
8. Rofes L, Arreola V, Lopez I, Martin A, et al, 2013. Effect of surface sensory and motor electrical stimulation on chronic poststroke oropharyngeal dysfunction. Neurogastroenterology & Motility, 25, 888-e701.
9. Logemann, Jeri A. (1998). Evaluation and treatment of swallowing disorders. Austin, Tex: Pro-Ed.
10. Perry, Alison; Lee, Siew Hwa; Cotton, Susan; Kennedy, Catriona (2016-08-26). Cochrane ENT Group (ed.). “Therapeutic exercises for affecting post-treatment swallowing in people treated for advanced-stage head and neck cancers”. Cochrane Database of Systematic Reviews.