What is the recommended management for younger individuals with chronic intermittent choking during eating or drinking?

Management of Chronic Intermittent Choking in Younger People

For younger individuals with chronic intermittent choking during eating and drinking, videofluoroscopic swallowing studies (VFSS) should be performed to evaluate for oropharyngeal dysphagia, followed by appropriate dietary modifications and swallowing therapy based on findings. 1

Diagnostic Evaluation

Initial Assessment

• Question patients and caregivers specifically about:
  • Timing of choking episodes (during or after meals)
  • Types of foods/liquids that trigger choking
  • Associated symptoms (coughing, throat clearing, wet/hoarse voice)
  • Fear of choking while eating or drinking 1

Risk Factors to Identify

• Neurological conditions (even mild or subclinical)
• Developmental disorders
• History of respiratory symptoms
• Medications that may affect swallowing
• Dental issues or orthodontic appliances 2, 3

Diagnostic Testing

1. Videofluoroscopic Swallowing Study (VFSS): Gold standard for evaluating pharyngeal phase swallowing dysfunction 1

   • Can identify silent aspiration (occurs in 71% of patients with aspiration) 1
   • Particularly important as subjective reports of coughing while eating/drinking have sensitivity of only 38-74% 1

2. Fiberoptic Endoscopic Evaluation of Swallowing (FEES): Alternative when radiation exposure is a concern 1

Management Approach

Dietary Modifications

• Thickened Liquids: Most effective intervention for liquid aspiration

  • Studies show >90% reduction in aspiration events when using thickened liquids versus thin liquids 1
  • Consider progression from thickened to thin liquids as swallowing function improves

• Food Texture Modifications:

  • Avoid high-risk foods: hard candy, nuts, seeds, whole grapes, raw carrots, apples, popcorn, chunks of peanut butter, marshmallows, chewing gum, sausages 1
  • Provide easily chewable foods with appropriate texture based on VFSS findings 1

Swallowing Techniques

• Pacing: Slow the rate of liquid/food intake 1
• Posture Modifications:
  • Maintain upright, stable position during meals
  • Avoid shortening of the neck during eating/drinking 1
  • Consider specific head positions based on VFSS findings

Multidisciplinary Management

• Speech-Language Pathologist: Regular reviews for swallowing therapy and technique training 1, 4
• Dietitian: Ensure nutritional adequacy with modified diet 4
• Gastroenterologist: Evaluate for potential reflux contributing to symptoms 5
• Neurologist: Assess for underlying neurological conditions 3, 4

Special Considerations

Silent Aspiration

• Be aware that absence of coughing during meals does not rule out aspiration
• 71% of patients with aspiration on VFSS have silent aspiration 1
• Objective measures of voluntary cough may help identify those at risk 6

Persistent Symptoms

• For persistent symptoms despite conservative management, consider:
  • Evaluation for gastroesophageal reflux disease (GERD) 5
  • Reassessment of swallowing function with repeat VFSS
  • More aggressive interventions if nutritional status is compromised 1

Feeding Tube Considerations

• Consider gastrostomy placement if:
  • Significant weight loss occurs
  • Aspiration pneumonia develops
  • Adequate nutrition cannot be maintained with oral feeding 1
  • Early rather than late placement may be beneficial in progressive disorders 1

Pitfalls to Avoid

• Relying solely on patient reports: Silent aspiration is common and may not present with obvious symptoms 1
• Delaying evaluation: Early identification and intervention improves outcomes 1
• Overlooking medication effects: Many drugs, especially those acting on the CNS, can impair swallowing 3
• Focusing only on the act of swallowing: Consider the entire mealtime experience, including positioning, environment, and feeding techniques 1

By following this structured approach to evaluation and management, the risk of aspiration and associated complications can be significantly reduced in younger individuals with chronic intermittent choking during eating and drinking.