1. Chapter 10: Dysphagia
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

2. Focus Questions What is dysphagia? How is dysphagia classified?
10.1
Focus Questions
What is dysphagia?
How is dysphagia classified?
What are the defining characteristics of dysphagia?
How is dysphagia identified?
How is dysphagia treated?
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

3. 10.2
Introduction
Dysphagia: impairment in the ability to swallow because of neurological or structural problems that alter the normal swallowing process
ASHA expanded the Scope of Practice for speech-language pathologists to include swallowing disorders in late 1980s
Dysphagia intervention now makes up about 50% of a SLP’s caseload in medical settings (e.g., hospital, nursing homes)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

4. Case Study #1: Sylvia Anderson
10.3
Case Study #1: Sylvia Anderson
78-year old with Alzheimer’s dementia living in a nursing home – needs minimal to moderate assistance while eating
Lately, hasn’t been finishing meals, has gurgly voice quality during mealtime, and has recently had severe coughing episodes while eating
SLP suspects a pharyngeal stage swallowing problem and wants a further instrumental assessment at local hospital
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

5. 10.4
Case Study #1 Questions
Transporting Sylvia to the local hospital for an instrumental examination is costly. How can the costs be justified?
How might reliance on others for assistance with feeding influence nutritional status and hydration?
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

6. 10.5
Case Study #2: Lee Chin
43-year old bilingual man who has persistent dysphagia following cancer of the right buccal space
To treat the cancer, Lee had radiation therapy and neck dissection
Currently exhibits pharyngeal dysphagia, aspiration, hoarse vocal quality, and right lower facial weakness
Currently receives nutrition through a g-tube
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

7. 10.6
Case Study #2 Questions
Is Lee a candidate for dysphagia therapy at this time? Why or why not?
What education should be provided to Lee regarding his situation?
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

8. Case Study #3: Martin Coleman
10.7
Case Study #3: Martin Coleman
45-year old man diagnosed with ALS 18 months ago
Unable to work, on a puree diet with thin liquids, has lost 15 pounds in past two months, just recovered from severe aspiration pneumonia
MBS shows severe oral and pharyngeal dysphagia with aspiration
Martin and his family now need to decide whether or not to resort to feeding tube, and want to consult their priest to make sure decision is in keeping with their religious beliefs
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

9. 10.8
Case Study #3 Questions
As the speech-language pathologist, what are your responsibilities to this client and his family in making their decision?
What support systems should be provided to this family during their decision-making process?
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

10. 10.9
I. What is Dysphagia?
Disorder of swallowing rendering person unable to safely and/or efficiently eat or drink
To understand disorder swallowing, must first understand the normal swallowing process
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

11. 10.10
The Normal Swallow
Innate ability which is present in the developing fetus
Necessary to maintain nutrition and hydration
Adults swallow approximately 580 times daily unconsciously
Swallowing is a four-phase process:
Oral preparatory phase
Oral phase
Pharyngeal phase
Esophageal phase
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

12. Oral Preparatory Phase
10.11
Oral Preparatory Phase
Begins as food or liquid enters the mouth
Containing, manipulating, and preparing the food or liquid into a bolus
Chewing (mastication) occurs to grind solid bolus into manageable texture
Requires coordination of lips, tongue, teeth, mandible, and cheeks
Duration: variable depending on substance
Respiration: normal through the nose (mouth closed)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

13. Oral Phase Bolus is propelled to the back of the mouth
10.12
Oral Phase
Bolus is propelled to the back of the mouth
“stripping action” by the tongue
Tension in the cheeks (buccal muscles)
Duration: seconds
Respiration: normal through the nose
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

14. 10.13
Pharyngeal Phase
Begins as the bolus reaches the tonsils (faucial pillars)
Pharygeal swallow reflex is triggered:
Pharyngeal wall and back of tongue move together and pharyngeal muscles squeeze to move bolus down through the pharynx
Upper esophageal sphincter opens to allow passage of bolus into esophagus
Time: 1 second
Respiration: briefly halted (apneic moment)
During bolus transit, risk of food or liquid entering the airway
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

15. Pharyngeal Phase – Protective Mechanisms
10.14
Pharyngeal Phase – Protective Mechanisms
Soft palate elevates to stop bolus from flowing upward into nasal area
Larynx moves forward and higher in the neck to reduce risk of entrance into airway
Epiglottis forms a cover over the larynx
Vocal folds come together to close the entrance into the larynx
If material does enter the larynx, reflexive cough to expel it will occur
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

16. 10.15
Esophageal Phase
Bolus is propelled through the esophagus by an involuntary wave or contraction
Moves from the upper esophageal sphincter through the lower esophageal sphincter and into the stomach
Time: 8-20 seconds, can be influenced by age (often increase in duration in elderly population)
Respiration: normal through nose and mouth
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

17. Disordered Swallow: Dysphagia
10.16
Disordered Swallow: Dysphagia
Impairment can occur in one, some, or all of the four phases of swallowing
Some persons have impairments that result in aspiration (food or liquid moves below the level of vocal folds into the airway)
Some persons have to alter their diet to control the consistencies, but this can cause difficulty maintaining hydration and nutrition
Some persons require an enteral feeding tube for nutritional maintenance
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

18. Additional Considerations
10.17
Additional Considerations
Dysphagia should not be confused with a disruption in feeding, but it is one subgroup of feeding disorders
Dysphagia is not a disease but a symptom of several etiologies (e.g., neurological injuries, progressive brain diseases)
Social and psychological impacts of dysphagia: changes in eating routines and food choices, decreased personal independence, and challenge to participating in community activities
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

19. Prevalence and Incidence
10.18
Prevalence and Incidence
Statistics on who experiences dysphagia:
14% of acutely hospitalized patients
30-35% of patients in rehabilitation facilities
50% of residents in nursing home environments
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

20. II. How is Dysphagia Classified?
10.19
II. How is Dysphagia Classified?
No universally accepted system, but usually based on etiology, manifestation, and severity
Some available instruments:
Penetration-Aspiration Scale: 8-point scale to describe degree of airway protection during the swallow (1 = no material enters airway, = aspiration)
New Zealand Index for Multidisciplinary Evaluation of Swallowing: rates swallowing performance on a scale from 0 to 4 (0 = no significant impairment, 4 = profound impairment)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

21. III. Defining Characteristics of Dysphagia
10.20
III. Defining Characteristics of Dysphagia
Structural abnormalities or physiological deficits for each of the phases of swallowing:
Oral preparatory
Oral
Pharyngeal
Esophageal
SLP manages oral preparatory, oral, and pharyngeal dysphagias (i.e., oropharyngeal dysphagia); gastroenterologist manages esophageal dysphagia
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

22. Oral Preparatory Phase Dysphagia
10.21
Oral Preparatory Phase Dysphagia
Likely causes: head and neck cancers, stroke, Parkinson’s disease
Characteristics:
Decreased lip closure
Problems controlling ingested materials
Problems biting or chewing
Inefficient oral preparation (long duration)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

23. 10.22
Oral Phase Dysphagia
Likely causes: stroke, progressive neurological diseases
Characteristics:
Difficulty moving bolus to the back of mouth
Inability to control bolus flow
Delayed initiation of bolus movement
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

24. Pharyngeal Phase Dysphagia
10.23
Pharyngeal Phase Dysphagia
Likely causes: head and neck cancers, neurological disorders
Characteristics:
Incomplete palatal elevation (nasal reflux)
Delayed initiation of pharyngeal swallow reflex
Weak tongue and pharyngeal muscle forces
Reduced laryngeal elevation (more prone to aspiration)
Inadequate opening of the upper esophageal sphincter (bolus cannot move into the esophagus)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

25. Esophageal Phase Dysphagia
10.24
Esophageal Phase Dysphagia
Likely causes: reflux, certain cancers
Characteristics:
Structural abnormalities in esophagus
Decreased esophageal motility or contraction
Inadequate opening of lower esophageal sphincter (bolus cannot move into stomach)
Excessive opening of the lower esophageal sphincter, allowing backward flow of contents from stomach to esophagus (reflux)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

26. Dysphagia Causes: Neurological Disease
10.25
Dysphagia Causes: Neurological Disease
Stroke
Interruption in blood supply to brain, resulting in brain damage
Frequency of dysphagia is about 50%
Increases risk for malnutrition, aspiration, and pneumonia
Traumatic brain injury
Dysphagia is common complication of neurological damage (from 26 – 71%)
Delay in pharyngeal swallow reflex, decreased pharyngeal constriction, and oral motor problems
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

27. Dysphagia Causes: Progressive Neurological Disease
10.26
Dysphagia Causes: Progressive Neurological Disease
Parkinson’s disease:
Incidence of dysphagia from 50% to 92%
Drooling, problems in bolus preparation and transport, delayed swallowing reflex, aspiration, residual materials in pharynx
Amyotrophic lateral sclerosis:
Also known as Lou Gehrig’s disease, patients will experience oropharyngeal dysphagia at some point in their disease process
Dementia:
Dysphagia is common feature in moderate and severe impairment levels
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

28. Dysphagia Causes: Head and Neck Cancers
10.27
Dysphagia Causes: Head and Neck Cancers
Many patients with cancers of the mouth, pharynx, and larynx experience dysphagia prior to medical management of the cancer, but treatments can cause dysphagia or make the already existing case more severe
The extent of the medical intervention to combat the cancer influences the swallowing profile
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

29. Dysphagia Causes: Medical Interventions
10.28
Dysphagia Causes: Medical Interventions
Surgical management: full or partial removal of components of swallowing
Radiation therapy: reduced saliva production, edema, tooth decay, and pain
Chemotherapy treatment: nausea, vomiting, and fatigue
Tracheotomy: tube alters normal air exchange, interfering with swallowing performance
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

30. IV. How is Dysphagia Identified?
10.29
IV. How is Dysphagia Identified?
SLP is responsible for these tasks:
Determine presence or absence of dysphagia
Determine underlying causes
Assess severity
Make recommendations
Design and implement rehabilitation plan
Share information with other professionals
Need to achieve a balance between concern for safety issues and quality of life
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

31. Consultation with the SLP
10.30
Consultation with the SLP
Referral from physician or nurse who suspects swallowing impairment
Interdisciplinary approach to screening at hospitals, rehabilitation centers, and clinics:
Health care staff members should be trained to recognize possible signs of dysphagia, and then make referral to SLP for further evaluation
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

32. Clinical Swallowing Examination
10.31
Clinical Swallowing Examination
Also called Bedside Swallow Examination:
Review of medical records
Comprehensive interview with client
Oral mechanism examination
Trial feedings observation
Feeding recommendations
Referrals for either:
Further instrumental assessment (need physician’s prescription to be covered by insurance)
Specialized testing by other professionals
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

33. Instrumental Dysphagia Exam
10.32
Instrumental Dysphagia Exam
More objective, quantifiable measure of swallowing function
Commonly used approaches:
Fiberoptic Endoscopic Examination of Swallowing: visualization of swallowing through flexible tube with recordable camera
Ultrasonography: uses sound waves to recreate a picture of structures (most beneficial in oral phase evaluation
Videofluorscopy: same as a modified barium swallow (most commonly used; “gold standard”)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

34. V. How is Dysphagia Treated?
10.33
V. How is Dysphagia Treated?
SLP works to remediate oropharyngeal dysphagia
Compensatory approaches
Restorative approaches
To maintain nutrition, dietary modifications and/or alternative nutrition via a feeding tube
Nasogastric, gastrostomy, jejunostomy
Include ongoing assessment of client’s response to intervention, and adjust goals and approaches to fit evolving needs
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.