What are the treatment options for a patient with functional dysphagia?

Treatment for Functional Dysphagia

Functional dysphagia requires behavioral swallowing therapy as the primary treatment, including compensatory strategies (postural maneuvers and dietary modifications) combined with rehabilitative exercises to restore swallowing function. 1

Initial Evaluation and Team-Based Approach

• All patients with suspected functional dysphagia require instrumental evaluation (videofluoroscopic swallow evaluation [VSE] or fiberoptic endoscopic evaluation of swallowing [FEES]) to identify the specific swallowing impairment and guide treatment selection. 1
• Multidisciplinary management involving speech-language pathologists (SLPs), physicians, dietitians, and nurses is essential. 1
• Early SLP evaluation within 24 hours significantly reduces aspiration pneumonia rates from 6.4% to 0% (p=0.03) and decreases mortality from 11% to 4.6%. 1

Compensatory Strategies: Dietary Modifications

Thickened liquids are the primary intervention for reducing aspiration risk in patients who aspirate thin liquids. 2, 1

• Aspiration occurs significantly more with thin liquids compared to nectar-thick liquids, and more with nectar-thick than honey-thick liquids (p<0.001). 1
• Modified consistency foods (soft, semisolid, or semiliquid) should be used to compensate for poor oral preparation and ease oral/pharyngeal transport. 1
• Water is particularly difficult to swallow because it flows quickly, requires precise coordination, and provides minimal sensory feedback, increasing aspiration risk. 3
• Unthickened water should be introduced at the end of rehabilitation when the patient demonstrates control over other consistencies. 3

Compensatory Strategies: Postural Maneuvers

Postural maneuvers eliminate aspiration in 77% of dysphagic patients when applied during instrumental evaluation. 1

• Chin-down (chin-tuck) posture is the most universally applicable maneuver, offering airway protection by opening the valleculae and preventing laryngeal penetration. 1
• Postural changes should be tested during instrumental assessment to verify effectiveness for each individual patient. 3

Rehabilitative Exercises

The Shaker exercise (head lifts in supine position, three times daily for 6 weeks) significantly improves upper esophageal sphincter opening and anterior laryngeal excursion (p<0.01), with 93% of patients returning to regular or soft mechanical diet. 1

• Expiratory muscle strength training (EMST) for 4 weeks improves penetration/aspiration scores and hyolaryngeal complex function (excursion time and displacement). 2, 1
• Oral motor exercise programs supervised by SLPs, involving training with different amounts and consistencies of food for 5 weeks, increase strength and range of motion of the mouth, larynx, and pharynx. 2
• Structured swallowing programs improve neuromuscular control of the oral phase and tongue function during oral and pharyngeal phases. 2

Treatment Algorithm

1. Perform instrumental assessment (FEES or VSE) to identify specific swallowing impairments. 1
2. Implement immediate compensatory strategies: Start with honey-thick liquids and chin-down posture during swallowing. 1
3. Initiate rehabilitative exercises: Begin Shaker exercises three times daily and consider EMST if available. 2, 1
4. Progress consistency gradually: Advance from honey-thick to nectar-thick to thin liquids based on instrumental reassessment. 3
5. Monitor for silent aspiration: Silent aspiration (aspiration without cough) is common with thin liquids and increases respiratory complication risk. 1, 3

Critical Safety Considerations

• Silent aspiration is particularly dangerous because it occurs without cough reflex, especially with thin liquids, increasing respiratory complication risk. 1, 3
• Cup drinking causes more aspiration than spoon feeding (p<0.001), and straw drinking reduces airway protection in elderly patients. 1
• Patients with reduced level of consciousness should not receive oral liquids until their condition improves. 3

Enteral Nutrition Considerations

• Enteral nutrition via PEG tube is recommended for dysphagic patients unable to cover nutritional needs orally, particularly in chronic conditions. 2, 1
• This decision should be made after attempting behavioral interventions and considering goals of care. 4

Common Pitfalls to Avoid

• Do not rely on clinical assessment alone: Silent aspiration cannot be detected by bedside examination and requires instrumental evaluation. 1, 3
• Do not use thickened liquids indefinitely without reassessment: Exclusive use can lead to dehydration and decreased quality of life. 3
• Do not assume dysphagia location based on patient perception: Obstructive symptoms that seem to originate in the throat may actually be caused by distal esophageal lesions. 4