What are the management options for dysphasia (difficulty swallowing)?

Management Options for Dysphagia

The management of dysphagia should focus on identifying the underlying cause, implementing targeted therapeutic interventions, and preventing complications such as malnutrition, dehydration, and aspiration pneumonia. 1, 2

Diagnostic Assessment

Before implementing management strategies, proper assessment is crucial:

• Bedside examination by a speech-language pathologist (SLP) to evaluate:

  • Oral motor function
  • Swallowing ability
  • Presence of cough/choking during trials
  • Vocal quality after swallowing 3

• Instrumental assessment when indicated:

  • Videofluoroscopic swallowing study (VFSS)
  • Fiberoptic endoscopic evaluation of swallowing (FEES)
  • Esophagogastroduodenoscopy for esophageal dysphagia 2

Management Approaches for Different Types of Dysphagia

Functional Dysphagia

For functional dysphagia (without structural or neurological cause):

1. Education and explanation about the diagnosis and normal swallowing physiology
2. Address psychological factors that may contribute to symptoms
3. Cognitive behavioral therapy to reduce anxiety around swallowing
4. Symptomatic treatment to improve swallowing mechanics 1

Neurogenic Dysphagia (e.g., Post-stroke)

1. Chin tuck against resistance exercises - targets suprahyoid musculature to improve hyoid and laryngeal movement 1

2. Respiratory muscle strength training - uses devices that provide resistance during inhalation or exhalation to strengthen respiratory muscles and reduce aspiration risk 1

3. Direct swallowing treatment by SLP when treatable disorders in swallow anatomy or physiology are identified 1

4. Compensatory strategies:

   • Postural adjustments (head turn, chin tuck)
   • Double swallows
   • Effortful swallow technique
   • Mendelsohn maneuver (prolonged laryngeal elevation) 1, 3

Nutritional Support

• Diet modifications:

  • Texture modifications (pureed, minced, soft)
  • Thickened liquids (nectar, honey, pudding consistency)
  • Small, frequent meals 2, 4

• Enteral feeding for patients unable to maintain adequate oral nutrition:

  • Consider nasogastric tube for short-term needs
  • Consider percutaneous endoscopic gastrostomy (PEG) for longer-term needs 1

Special Considerations

Elderly Patients

• Higher risk of complications from dysphagia
• May have multiple contributing factors (neurological, medication-related)
• Requires discussion about goals of care before implementing invasive interventions 2

Functional Globus Pharyngeus

• Often presents as sensation of a lump in the throat
• Management includes:
  • Reassurance after excluding structural causes
  • Treatment of concurrent conditions (reflux, anxiety)
  • Speech therapy techniques to reduce pharyngolaryngeal tension 1

Multidisciplinary Approach

Effective dysphagia management requires collaboration between:

• Speech-language pathologists
• Physicians
• Dietitians
• Nurses
• Occupational therapists 3, 2

Monitoring and Follow-up

• Regular reassessment of swallowing function
• Monitoring for signs of aspiration pneumonia
• Evaluation of nutritional status and hydration
• Adjustment of strategies as the patient's condition changes 4

Common Pitfalls to Avoid

1. Failing to identify the type of dysphagia (oropharyngeal vs. esophageal) which requires different management approaches

2. Overlooking dysphagia in elderly patients with progressive neurological disease, leading to silent aspiration and pneumonia

3. Implementing overly restrictive diets that may lead to decreased oral intake and malnutrition

4. Delaying enteral feeding when clearly indicated, risking nutritional compromise

5. Not addressing psychological aspects of dysphagia, particularly in functional cases where anxiety about swallowing can exacerbate symptoms 1, 2, 4

By implementing a structured approach to dysphagia management that addresses the underlying cause while preventing complications, clinicians can significantly improve patients' quality of life, nutritional status, and reduce morbidity associated with this challenging condition.