What is the treatment for dysphagia (swallowing disorder)?

Treatment for Dysphagia (Swallowing Disorder)

All patients with dysphagia should undergo instrumental swallow evaluation (videofluoroscopic swallow examination or fiberoptic endoscopic evaluation of swallowing) before initiating treatment, followed by multidisciplinary team management combining dietary modifications, behavioral swallowing therapy, and close monitoring for complications. 1

Diagnostic Evaluation

Instrumental assessment is mandatory because over 70% of patients with aspiration have silent aspiration that cannot be detected at bedside 1. Patients should undergo either:

• Videofluoroscopic swallow examination (VSE): Motion picture radiograph visualizing bone, cartilage, and soft tissue structures as barium-mixed food passes through all swallow stages 2
• Fiberoptic endoscopic evaluation of swallowing (FEES): Transnasal flexible nasopharyngoscopy providing direct observation of pharynx and larynx before and after swallowing 2

These studies serve dual purposes: diagnosis and determining which therapeutic techniques eliminate aspiration during oral intake 2.

Multidisciplinary Team Management

Organized multidisciplinary teams should manage all dysphagia patients, including physician, speech-language pathologist (SLP), nurse, dietitian, and physical/occupational therapists 2, 1. Implementation of such programs with SLP assessment within 24 hours of admission has demonstrated:

• Reduction in aspiration pneumonia from 6.4% to 0% 2
• Decreased overall costs 2
• Trend toward decreased mortality from 11% to 4.6% 2

Early SLP involvement is critical for thorough assessment and follow-up, especially in patients requiring proactive intervention for neural recovery (stroke) or maintaining function during disease progression (dementia) 2.

Dietary Modifications

Texture-modified diets and thickened liquids are cornerstone compensatory treatments, but only after instrumental assessment confirms their effectiveness 1. Testing should use foods and liquids simulating the patient's normal diet during VSE or FEES 2.

Liquid Consistency Modifications

• Honey-thick liquids are most effective for preventing aspiration if thin liquid aspiration is documented, followed by nectar-thick 3
• Aspiration is more common with cup versus spoon delivery (p < 0.001) 2
• Thin liquids show highest aspiration rates, followed by nectar-thick, then ultra-honey-thick (p < 0.001) 2

Important Caveats

Thickened liquids carry significant risks 2:

• Increased dehydration risk 2, 1
• Decreased quality of life 2
• Low adherence rates overall 2
• In one study, honey-thick liquids were associated with higher pneumonia rates compared to chin tuck with thin liquids, though the study was underpowered for this outcome 2

The evidence for dietary modifications on clinical outcomes (pneumonia, mortality) remains limited and insufficient 2.

Compensatory Maneuvers

Postural techniques can eliminate aspiration in many patients when cognitive status permits training 2:

• Chin-down posture: Opens valleculae and reduces aspiration risk, though fails in >50% of cases and should not be sole intervention 3
• Chin-up posture 2
• Head rotation 2
• Head tilt 2
• Lying down position 2

These maneuvers should be tested during instrumental evaluation to determine which technique eliminates aspiration for each individual patient 2.

Rehabilitative Interventions

Systematic, individualized swallowing therapy using specific exercises produces long-term physiological improvements and should be initiated early, even in tube-fed patients 1.

Specific Exercise Programs

Swallowing maneuvers with proven benefit 2:

• Effortful swallow: Increases pharyngeal pressure 2
• Mendelsohn maneuver: Patient voluntarily holds larynx in uppermost position for 2-3 seconds before completing swallow 2
• Shaker head lift exercise: Strongest evidence for improving suprahyoid muscle strength and upper esophageal sphincter opening 1. Patients perform sustained and repetitive head lifts three times daily while supine 2. In one study, 93% of patients (25/27) returned to regular or soft mechanical diet after 6 weeks 2

Progressive lingual strengthening with biofeedback devices produces measurable improvements in tongue strength with carryover to swallowing function in older adults and post-stroke patients 2, 3.

McNeill Dysphagia Therapy Program (MDTP): Progressive strengthening incorporating hard swallow across hierarchy of progressively challenging feeding tasks, shown to improve dysphagia severity in several patient groups 2.

Expiratory muscle strength training positively impacts swallowing components 2.

Evidence Quality

A Cochrane review found low and very low-quality evidence that swallowing interventions may reduce dysphagia and chest infections and may improve swallowing ability 2. Moderate quality evidence suggested reduced hospital length of stay, but no reduction in case fatality or death/disability 2.

Adjunctive Treatments

Neuromuscular electrical stimulation combined with behavioral swallowing treatment is superior to behavioral treatment alone, particularly in post-stroke dysphagia 1.

Pharmacological treatments (TRPV1 agonists like capsaicinoids, dopaminergic agents) may be used as adjunct therapy in patients with delayed swallow reflex, but require careful risk-benefit analysis 1, 4.

Feeding Tubes: Critical Considerations

Feeding tubes do NOT reduce aspiration pneumonia risk and may increase it 2:

• Placement does nothing to improve swallowing ability 2
• Does not reduce misdirection of contaminated oral secretions (most common contributor to aspiration pneumonia) 2
• Animal studies show increased gastric reflux due to reduced lower esophageal sphincter pressure with gastrostomy tubes 2
• Feeding tubes pose one of the highest risk factors for aspiration pneumonia 2
• Associated with cellulitis, fasciitis, and bacteremia 2

Specific Populations

For dementia patients: The American Geriatrics Society position statement suggests feeding tube placement should be seriously reconsidered, endorsing careful hand feeding as the preferred approach 2. Evidence shows feeding tubes provide no meaningful clinical benefit and may be associated with poorer outcomes 2.

For acute dysphagic stroke: Gastrostomy tube placement may be safely delayed one week; longer delays have unknown benefit or harm 2.

For progressive motor neuron diseases and esophageal cancer: Precious little evidence exists to guide treatment decisions 2.

If enteral feeding is necessary despite interventions, early PEG feeding is preferred over nasogastric tube 1.

Critical Safety Considerations

Patients with reduced level of consciousness should remain NPO (nothing by mouth) until consciousness improves due to extremely high aspiration risk 1.

Monitor closely for:

• Recurrent pneumonia 1
• Progressive weight loss 1
• Worsening respiratory symptoms 1

Collaborative Decision-Making

Involvement of a geriatrician in feeding tube discussions resulted in 50% reduction in feeding tube placement 2. Cultural values and emotional aspects around feeding should be carefully explored with families, trusted advisors, religious figures, and long-term physicians 2. The healthcare team must facilitate a collaborative and humble approach, acknowledging shared goals and limitations in the evidence base 2.