Over 15 million Americans currently exhibit difficulty swallowing. This disorder is referred to as Dysphagia. Symptoms of dysphagia include coughing and choking on food, liquid and even one’s own saliva. Unfortunately, Dysphagia can have devastating consequences. The Agency for Health Care Policy and Research (AHCPR) reported that over 60,000 Americans die from complications associated with swallowing difficulties, most commonly aspiration pneumonia – caused by food or saliva going down the windpipe and into the lungs. Aspiration pneumonia is rapidly becoming one of the leading causes of hospitalization in the elderly. Pneumonia of all types, is the fifth leading cause of death of Americans over the age of 65, and the third leading cause of death in those over 85.
Typically, patients develop dysphagia as a result of other acute medical conditions. Examples include Stroke, Head and Neck Cancer, Progressive Neurological Disease (ALS, Parkinson’s Disease), and Respiratory Disease. Onset can be either sudden, or worsen over longer periods of time. Severity of dysphagia can vary significantly from mild to severe. Some patients may exhibit subtle symptoms which require limited intervention, while other patients may be completely to eat safely by mouth. The best way to prevent serious complications from dysphagia is to notify your physician and request a referral to a dedicated Voice and Swallowing Center. These centers offer specialized services delivered by a team of experts including a Laryngologist (Voice and swallowing certified otolaryngologist) and a speech-language pathologist (SLP). SLP’s are able to perform diagnostic studies that can objectively quantify the nature and severity of the disorder as well as identify treatment strategies that may help alleviate the problem. Frequently, SLP’s will generate recommendations relating to the type (texture/viscocity) of food that may be most safely eaten. It is crucial that patients adhere to these recommendations in order to avoid serious complications from the disorder. Therapists may also administer a comprehensive exercise regimen that targets specific muscle groups. New and innovative modalities are now available which can boost the overall success of the program and help patients regain the pleasure of eating.
Aspiration during FEES (Fiberoptic Endoscopic Evaluation of Swallowing)
Below is an exam demonstrating aspiration, which means material passed below the level of the vocal cords and into the lungs. The white line to the right is a feeding tube that the individual has placed in the left side of their nose and goes into their esophagus. This is because they acutely developed a swallowing problem after a stroke. The rounded half-circle at the bottom of the image is the epiglottis, which sits behind the tongue and should close to protect the lungs while swallowing. Above the epiglottis you will notice a white “V”. These are the vocal cords; they are the final defense mechanism to prevent aspiration. We give this individual a sip of liquid tinted blue and you will notice it splashes right down into the “V” and presumably into the lungs. They receive nutrition and hydration through the feeding tube so they won’t develop pneumonia from all the material that goes into their lungs when they attempt to swallow. If their problem persists beyond 1-2 weeks, they will likely have a feeding tube placed directly in their stomach while they undergo swallowing therapy with a speech-language pathologist.
Aspiration during MBSE (Modified Barium Swallow Exam)
This is an alternative way of assessing if food or liquids are passing into the lungs and posing risk of aspiration pneumonia. A MBSE is performed in radiology with a radiologist, speech-language pathologist and radiology technician. A variety of textures are mixed with barium to assess whether they pass into the esophagus or airway. Performing a MBSE allows for viewing of the esophagus and even stomach. If your doctor or speech-language pathologist suspect the cause of swallowing difficulty is related to tight esophageal sphincters, poor esophageal transport/motility or reflux, they may elect to perform this test. In the example below, notice how the dark liquid drips into the structure on the far left just under the chin. This is the trachea, which leads into the lungs.