Opinion

Dysphagia: A Swallowing Difficulty

Tis the season! The chill from the harmattan at dawn, the jingles of Christmas carols, the aroma from sumptuous spicy foods, laughter of grateful people, the cheers of children and traders at their best commercial skills co-ordinate wonderfully to create a celestial atmosphere for the celebration of a special season.

In a few days, family, friends and invited guests would gather in homes, restaurants, chop bars, churches, and other places to celebrate Christmas. Different foods and an assortment of drinks, alcoholic and non-alcoholic, would be served. For many people, the celebration of Christmas brings joy to the world. For others, this is just another occasion to sigh and endure a painful and sometimes embarrassing situation because of difficulty in swallowing their food.

Medically, difficulty in swallowing food is termed as Dysphagia. This word is derived from the Greek root dys meaning “difficulty” or “disordered”, and phagia meaning “to eat”. Dysphagia is a sensation people feel when they experience difficulty in transporting food from their mouth to stomach. Swallowing is a very complex activity that requires a high degree of coordination of the mouth and throat muscles. To a lot of people, the ability to swallow seems so natural; the process is taken for granted until it is compromised.

Swallowing Stages

Typically, when we swallow, different muscles are activated in a very orderly sequence for food or liquid to be transported from the mouth to the pharynx and then esophagus, through which it enters the stomach. There are 3 sequential phases of swallowing: (1) Oral, (2) Pharyngeal, and (3) Esophageal. Each phase or stage facilitates a specific function. When we swallow food, it is transported in a smooth, coordinated and efficient process with complex series of voluntary and involuntary neuromuscular contractions through these 3 stages. But when there is any pathologic condition or disease which affects the stages in the swallow process, swallowing becomes difficult.

Causes of Dysphagia

Difficulty in swallowing or dysphagia, as a symptom of underlying disease, has many causes. These are usually divided into two broad groups. The first is any anatomical abnormalities from the mouth to the esophagus, which tend to physically obstruct the passage of food. The second is any functional abnormality in the organs (mouth to esophagus), the nerves of the brain, throat and esophagus, and the muscles of the throat and esophagus, whose normal function is necessary to coordinate swallowing.

There are many different diseases that can impact the efficiency of our swallow pattern. Diseases of the brain can affect the neurological control of the nerves and reflexes involved in swallowing. These include neurological disorders like Stroke, Parkinson’s disease, and Cerebral Palsy. Generally, a significant percentage of patients with stroke have dysphagia, which is the most significant risk factor for the development of pneumonia.

Diseases and conditions that affect muscle function or connective tissue throughout the body such as Muscular Dystrophy, Myasthenia Gravis, and Scleroderma can also cause dysphagia. Moreover, scar tissue such as inflammation of the esophagus and certain head and neck cancers can obstruct the upper digestive tract and esophagus. Acid reflux which is food backing up from the stomach backward toward the mouth can sometimes enter into the airway and compromise it.

This is regularly felt as heartburns. Persistent acid reflux can cause inflammation and scarring of our throat and narrow the width of the esophagus. This can also affect our swallowing process. Throat inflammation can also be caused by radiation, medications, or chemical toxins. Additionally, compression of the esophagus from structures outside of the digestive tract, such as tumors of the chest, and congenital anatomical abnormalities (birth defects) can affect our swallowing pattern. Trauma to the head and chest regions from accidents (including motor accidents) can be another significant cause of swallowing difficulty.

What people experience when they have dysphagia

The signs and symptoms of dysphagia will generally indicate the cause (e.g., neurologic or non-neurology). While some people have trouble with only solid foods, others have trouble with both liquid and solid foods. Other may also have to chew and re-chew for a considerable period of time with difficulty swallowing it. Some people will present with a consistent or intermittent feeling of food stuck in the throat. This feeling of food getting stuck in the throat may or may not interfere with their breathing. Others may feel severe chest pain which they will locate specifically to their breast bone or starting from their breast bone and spreading to the sides of their ribs.

Yet still, others may complain of having to bring portions of food back into their mouth (immediately or some hours later) after they have swallowed in order to re-swallow it. Some people with swallowing difficulty also complain of persistent coughing when they drink liquids of particular consistency. Others will have food/liquid enter into their lungs without even showing any outward symptoms/signs. These dysphagia symptoms, while intriguing to others, have severe impact on the health and quality of life of people with swallowing problems. The incidence of aspiration pneumonia, due to foreign materials (e.g., food and liquid) getting into the lungs, is a frequent possibility to people with swallowing difficulty. When aspiration pneumonia becomes a clear and present danger to some patients, a feeding tube may be recommended.

Impact of Dysphagia

When people have difficulty swallowing, it affects the type of food they take, the quantity ingested and sometimes the nutritional components of the food they eat. They tend to lose weight which makes them a fertile ground for other opportunistic diseases. It delays the recovery process for any underlying disease. Addition cost from dysphagia is the psycho-social impact to the quality of life of the person and the family. This can also lead to severe depression due to the interruption of patients’ normal ways of life. Dysphagia can ultimately have devastating consequences including death.

Evaluation

A team of professionals in swallow evaluation will generally include an Otolaryngologist (ENT), Gastroenterologist, Dentist, Speech Pathologist, Nutritionist, and Radiologist. Other healthcare specialists are consulted when needed. The evaluation involves a complete medical history and physical examination.

The evaluation includes questions about the duration, onset, and severity of swallowing symptoms as well as the presence of associated symptoms or chronic medical conditions. Specific diagnostic tests are frequently performed to evaluate the anatomy and physiology from the mouth to the stomach in relation to swallowing. The aim is always to mimic a typical swallowing process in order to diagnose the cause and plan treatment.

Swallowing Therapy

When the stage(s) of impairment is/are located, treatment protocols are initiated. Swallowing therapy may consist of medical or non-medical methods. The method of treatment is based on the results of the patient’s evaluation. The Otolaryngologist/Gastroenterologist usually provides medical treatments (surgery, prescriptions, etc.). Non-medical therapies such as swallowing strategies are provided by the Speech Pathologist. In some cases, a combination of both treatments is required.

Typically, swallowing therapy is available on a daily or weekly basis. Swallow strategies and modification of food consistency with a hierarchical progress in food consistency are planned as part of the therapeutic process. Clinical experience has demonstrated that daily treatment sessions lead to faster progress. In many cases improved swallowing has been noticed within two to four weeks. Many patients recover sufficient swallowing ability to eliminate their reliance on feeding tubes.

Hope for people with dysphagia

So during this Christmas season, while salivating in the presence of the meals served, and gently rubbing palms together in anticipation of consuming our sumptuous meal, we can also acknowledge that a section of our people have some difficulty swallowing. What we tend to take for granted is a daily struggle for some members of our families, some friends, and some of our invited guests (who may sometimes have preferred not to honor our invitation). If we experience difficulty swallowing our solid or liquid food, our healthcare practitioners are always available for a comprehensive evaluation and treatment. So, while we prepare our hearts to make room for heaven and nature to sing in a coordinated manner, we could make room for others with impairment in their swallow process. For it is in doing thus that we can also share the wonders of His love.

Levi Ofoe is a Graduate Student at University of Florida, Speech, Language and Hearing Sciences Department. His clinical interests include Speech Fluency, Voice and Swallowing Disorders.Email:Lcofoe@ufl.edu

Tags: