Oropharyngeal dysphagia

Oropharyngeal dysphagia is the inability to empty

Oropharyngeal dysphagia
material from the oropharynx into the esophagus as a
result of malfunction near the esophagus.[5] Other names Transfer dysphagia
Oropharyngeal dysphagia manifests differently
depending on the underlying pathology and the nature
of the symptoms. Patients with dysphagia can
experience feelings of food sticking to their throats,
coughing and choking, weight loss, recurring chest
infections, or regurgitation.[2] Depending on the
underlying cause, age, and environment, dysphagia
prevalence varies. In research including the general
population, the estimated frequency of oropharyngeal
dysphagia has ranged from 2 to 16 percent.[3]

Signs and symptoms

Some signs and symptoms of swallowing difficulties
include difficulty controlling food in the mouth,
inability to control food or saliva in the mouth,
difficulty initiating a swallow, coughing, choking,
frequent pneumonia, unexplained weight loss, gurgly
or wet voice after swallowing, nasal regurgitation, and
dysphagia (patient complaint of swallowing
difficulty).[6] Other symptoms include drooling,
dysarthria, dysphonia, aspiration pneumonia,
depression, or nasopharyngeal regurgitation as
associated symptoms.[7][8] When asked where the food
is getting stuck patients will often point to the cervical The digestive tract, with the esophagus marked
(neck) region as the site of the obstruction.[3] in red
Specialty Gastroenterology, ENT
Complications surgery
Symptoms Hesitation or inability to
If left untreated, swallowing disorders can potentially initiate swallowing, food
cause aspiration pneumonia, malnutrition, or sticking in the throat, nasal
dehydration.[6] regurgitation, difficulty
swallowing solids, frequent
Diagnosis repetitive swallows. frequent
throat clearing, hoarse voice,
Oropharyngeal dysphagia is going to be suspected if cough, weight loss, and
the patient answers yes to one of the following recurrent pneumonia.[1]
questions: Do you cough or choke when trying to eat?
Complications Aspiration, chest infection,
After you swallow, does the food ever come back out
malnutrition, dehydration,
through your nose?[8]
and death.[2]
A patient will most likely receive a Modified Barium Causes Stroke, head trauma,
swallow (MBS). Different consistencies of liquid and neurodegenerative diseases,
food mixed with barium sulfate are fed to the patient by muscular or neuromuscular
spoon, cup or syringe, and x-rayed using disorders, and local or
videofluoroscopy. A patient's swallowing then can be
structural lesions.[1]
evaluated and described. Some clinicians might choose
to describe each phase of the swallow in detail, making Diagnostic Clinical swallow assessment,
mention of any delays or deviations from the norm. method videofluoroscopy, fibreoptic
Others might choose to use a rating scale such as the endoscopic evaluation of
Penetration Aspiration Scale. The scale was developed swallowing, High-resolution
to describe the disordered physiology of a person's manometry, Functional
swallow using the numbers 1–8.[9][8] Other scales also Lumen Imaging Probe, and
exist for this purpose.
accelerometry.[2]
A patient can also be assessed using videoendoscopy, Differential Esophageal dysphagia and
also known as flexible fiberoptic endoscopic diagnosis Globus sensation.[3]
examination of swallowing (FFEES). The instrument is
Treatment Dietary modification,
placed into the nose until the clinician can view the
manipulation of swallowing
pharynx and then he or she examines the pharynx and
posture, or swallowing
larynx before and after swallowing. During the actual
swallow, the camera is blocked from viewing the technique, thickening agents,
anatomical structures. A rigid scope, placed into the enteral tube feeding, surgical
oral cavity to view the structures of the pharynx and management, and botulinum
larynx, can also be used, though this prevents the toxin injection,[4]
patient from swallowing.[6] Frequency 6–50%[2]

Other less frequently used assessments of swallowing

are imaging studies, ultrasound and scintigraphy and nonimaging studies, electromyography (EMG),
electroglottography (EGG)(records vocal fold movement), cervical auscultation, and pharyngeal
manometry.[6]

Differential diagnosis
A stroke can cause pharyngeal dysfunction with a high occurrence of aspiration. The
function of normal swallowing may or may not return completely following an acute phase
lasting approximately 6 weeks.[10]
Parkinson's disease can cause "multiple prepharyngeal, pharyngeal, and esophageal
abnormalities". The severity of the disease most often correlates with the severity of the
swallowing disorder.[10]
Neurologic disorders such as stroke, Parkinson's disease, amyotrophic lateral sclerosis,
Bell's palsy, or myasthenia gravis can cause weakness of facial and lip muscles that are
involved in coordinated mastication as well as weakness of other important muscles of
mastication and swallowing.
Oculopharyngeal muscular dystrophy is a genetic disease with palpebral ptosis,
oropharyngeal dysphagia, and proximal limb weakness.
Decrease in salivary flow, which can lead to dry mouth or xerostomia, can be due to Sjögren
syndrome, anticholinergics, antihistamines, or certain antihypertensives and can lead to
incomplete processing of food bolus.
Xerostomia can reduce the volume and increase the viscosity of oral secretions making
bolus formation difficult as well as reducing the ability to initiate and swallow the bolus[10]
Dental problems can lead to inadequate chewing.
 Abnormality in oral mucosa such as from mucositis, aphthous ulcers, or herpetic lesions can
interfere with bolus processing.
Mechanical obstruction in the oropharynx may be due to malignancies, cervical rings or
webs, crico-phyringeus muscle dysfunction, or cervical osteophytes.
Increased upper esophageal sphincter tone can be due to Parkinson's disease which leads
to incomplete opening of the UES. This may lead to formation of a Zenker's diverticulum.
Pharyngeal pouches typically cause difficulty in swallowing after the first mouthful of food,
with regurgitation of the pouch contents. These pouches may be accompanied by
malodorous breath due to decomposing foods residing in the pouches. (See Zenker's
diverticulum)
Dysphagia is often a side effect of surgical procedures like anterior cervical spine surgery,
carotid endarterectomy, head and neck resection, oral surgeries like removal of the tongue,
and partial laryngectomies[10]
Radiotherapy, used to treat head and neck cancer, can cause tissue fibrosis in the irradiated
areas. Fibrosis of tongue and larynx lead to reduced tongue base retraction and laryngeal
elevation during swallowing[10]
Infection may cause pharyngitis which can prevent swallowing due to pain.
Medications can cause central nervous system effects that can result in swallowing
disorders and oropharyngeal dysphagia. Examples: sedatives, hypnotic agents,
anticonvulsants, antihistamines, neuroleptics, barbiturates, and antiseizure medication.
Medications can also cause peripheral nervous system effects resulting in an oropharyngeal
dysphagia. Examples: corticosteroids, L-tryptophan, and anticholinergics[10]

Treatment
Thickening agents

Food thickeners can be used to improve swallowing in pediatric populations.[11]

Postural techniques.[6]

Head back (extension) – used when movement of the bolus from the front of the mouth to the
back is inefficient; this allows gravity to help move the food.
Chin down (flexion) – used when there is a delay in initiating the swallow; this allows the
valleculae to widen, the airway to narrow, and the epiglottis to be pushed towards the back
of the throat to better protect the airway from food.
Chin down (flexion) – used when the back of the tongue is too weak to push the food
towards the pharynx; this causes the back of the tongue to be closer to the pharyngeal wall.
Head rotation (turning head to look over shoulder) to damaged or weaker side with chin
down – used when the airway is not protected adequately causing food to be aspirated; this
causes the epiglottis to be put in a more protective position, it narrows the entrance of the
airway, and it increases vocal fold closure.
Lying down on one side – used when there is reduced contraction of the pharynx causing
excess residue in the pharynx; this eliminates the pull of gravity that may cause the residue
to be aspirated when the patient resumes breathing.
Head rotation to damaged or weaker side – used when there is paralysis or paresis on one
side of the pharyngeal wall; this causes the bolus to go down the stronger side.
Head tilt (ear to shoulder) to stronger side – used when there is weakness on one side of the
oral cavity and pharyngeal wall; this causes the bolus to go down the stronger side.

Swallowing maneuvers.[6]
 Supraglottic swallow — The patient is asked to take a deep breath and hold their breath.
While still holding their breath they are to swallow and then immediately cough after
swallowing. This technique can be used when there is reduced or late vocal fold closure or
there is a delayed pharyngeal swallow.
Super-supraglottic swallow — The patient is asked to take a breath, hold their breath tightly
while bearing down, swallow while still holding the breath hold, and then coughing
immediately after the swallow. This technique can be used when there is reduced closure of
the airway.
Effortful swallow — The patient is instructed to squeeze their muscles tightly while
swallowing. This may be used when there is reduced posterior movement of the tongue
base.
Mendelsohn maneuver — The patient is taught how to hold their adam's apple up during a
swallow. This technique may be used when there is reduced laryngeal movement or a
discoordinated swallow.[12]

Medical device

To strengthen muscles in the mouth and throat areas, researchers at the University of Wisconsin–Madison,
led by Dr. JoAnne Robbins, developed a device in which patients perform isometric exercises with the
tongue.[13]

Diet modifications

Diet modification may be warranted. Some patients require a soft diet that is easily chewed, and some
require liquids of a thinned or thickened consistency. The effectiveness of modifying food and fluid in
preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition,
hydration and quality of life.[14] There has been considerable variability in national approaches to
describing different degrees of thickened fluids and food textures. However, the International Dysphagia
Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a
continuum of 8 levels (0-7), where drinks are measured from Levels 0 – 4, while foods are measured from
Levels 3 – 7.[15]

Environmental modifications

Environmental modification can be suggested to assist and reduce risk factors for aspiration. For example,
removing distractions like too many people in the room or turning off the TV during feeding, etc.

Oral sensory awareness techniques

Oral sensory awareness techniques can be used with patients who have a swallow apraxia, tactile agnosia
for food, delayed onset of the oral swallow, reduced oral sensation, or delayed onset of the pharyngeal
swallow.[6]

pressure of a spoon against tongue

using a sour bolus
using a cold bolus
using a bolus that requires chewing
using a bolus larger than 3mL
thermal-tactile stimulation (controversial)

Prosthetics
 Palatal lift or Palatal obturator
Maxillary denture

Surgery

These are usually only recommended as a last resort.

Tracheotomy
Tracheostomy
Vocal fold augmentation/injection
Thryoplasty medialization
Arytenoid adduction
Partial or total laryngectomy
Laryngotracheal separation
Supralaryngectomy
Palatoplasty
Cricopharyngeal myotomy
Zenker's diverticulectomy
Percutaneous endoscopic gastrostomy
Feeding tube

References
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15. Cichero JA, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, Duivestein J, Kayashita J,
Lecko C, Murray J, Pillay M, Riquelme L, Stanschus S (April 2017). "Development of
International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids
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External links
Swallowing and Feeding (http://www.asha.org/public/speech/swallowing/)

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