Dysphagia, or difficulty swallowing, is a common medical condition amongtoday’s patients. It is estimated the approximately 15% of individualsolder than 60 years experience dysphagia. Approximately 40% of institu-tionalized patients (i.e., patients residing in nursing homes, group homes,or assistive care facilities) have swallowing difficulties (Zagaria, 2005).

The swallowing mechanism is quite complex, involving more than 50pairs of muscles. Impairment of any one or more of these muscles may re-sult in a serious health risk to the patient. The patient may be at risk of as-pirating food or saliva into the lungs, creating a potentially life-threaten-ing medical condition.

Anne Brady, MS, CCC-SLP

vol. 26 • no. 1 • January 2008 Home Healthcare Nurse 41

42 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins www.homehealthcarenurseonline.com

The 3 Stages of the SwallowThe swallow is divided into 3 phases: oral, pha-ryngeal, and esophageal. The first, or oral, phasebegins when the bolus enters the oral cavity andis mixed with saliva during mastication to allowformation of a cohesive bolus.

The second stage of the swallow, the pharyn-geal stage, is entered as the bolus is propelled to-ward the oropharynx, where the swallow reflex istriggered. Soft palate elevation during this stageprevents foods and liquids from entering the na-sopharynx. The hyoid bone and larynx arepulled upward and anteriorally and the vocalfolds midline. The epiglottis, a cartilage flap,closes, thereby protecting food from entering theairway. The posterior tongue base propels thefood through the pharynx with the assistance ofthe peristalic wave contraction of the posteriorpharyngeal wall (Nam-Jong Paik, 2006).

As the food is passed through the pharynx tothe esophagus, the upper esophageal sphincterrelaxes, allowing the food to pass through into theesophagus. Peristaltic wave contractions continueto propel the food toward the stomach. The loweresophageal sphincter, located at the juncture ofthe esophagus and stomach,opens to allow entry of thefood into the stomach. Thissphincter then closes, pre-venting reflux (Nam-JongPaik, 2006). Esophageal con-ditions affecting swallowingmay include gastroe-sophageal reflux, achalasia,and esophageal strictures,among many others.

A delay or impairment inany stage of the swallowmay result in dysphagia.The speech and languagepathologist (SLP) workswith the oral and pharyn-geal stages of the swallow.The SLP may evaluate theneed for an instrumental as-sessment of the swallow,identify the need for a refer-ral to another medical pro-fessional, make appropriaterecommendations regard-ing management of the pa-tient’s dysphagia, provide

swallowing treatment, and serve as an educa-tional source for the training of other profession-als in management of the patient’s dysphagia(American Speech and Language Hearing Associ-ation, 2002).

Symptoms in the oral stage, the first stage ofthe swallow, may include frequent drooling, poorrotary jaw movement, difficulty manipulating thebolus within the oral cavity, loss of food from themouth during eating, and residue after eating.The patient may pocket food in his or her cheekor have food remaining within the oral cavityalong the tongue or palate after eating.

Overt symptoms in the pharyngeal stage thatsuggest swallowing dysfunction include coughingor choking during eating. A wet-sounding vocalquality or frequent throat clearing may be heard.Patients may complain about the sensation offood “sticking” in their throat or may make multi-ple attempts to swallow a small bolus (Table 1).

Unfortunately, many patients also are at riskfor what is known as a silent aspiration event.Silent aspiration is defined as food or saliva aspi-rated with no obvious reaction, such as coughingor choking. This is the reason why it is very im-

Oral Stage Dysphagia Symptoms

Pharyngeal Stage DysphagiaSymptoms

1. Difficulty with bolus management

2. Inability to manage oral secretions (drooling)

3. Food residue along the tongue/palate orfood retained in cheeksafter swallowing

4. Difficulty chewing food5. Loss of food from mouth

while eating

1. Coughing/choking while eating

2. Wet vocal quality3. History of frequent upper res-

piratory tract infections orpneumonia

4. Complaints of food “sticking”in throat

5. Spiking high-grade tempera-ture or consistently running alow-grade temperature

6. Increased respirations withoral intake

7. Throat clearing during meals8. Pain during the swallow9. Leakage of liquids through

the nose while eating10. Repetitive swallows

Table 1. Oral Stage Dysphagia Symptoms vs.Pharyngeal Stage Dysphagia Symptoms

vol. 26 • no. 1 • January 2008 Home Healthcare Nurse 43

portant for the SLP to obtain extensive case his-tory information. Right lower lobe pneumoniasoften are viewed as a primary clinical indicator ofpossible aspiration, as are frequent low-gradetemperatures or a sudden spike in temperature.Patients exhibiting a wet vocal quality should al-ways be evaluated for dysphagia. This is a clini-cal indicator that the patient may be aspiratinghis or her own saliva. Bacterial organisms in thesaliva may potentially cause pneumonia.

Cognitive dysfunction also may affect theswallowing process. Patients, often those withdegenerative neurologic disorders (i.e.,Alzheimer’s, dementia), may begin to experiencedifficulty knowing what to do when food is placedin the mouth. They may exhibit a tonic bite (i.e.,holding the mouth closed when food is intro-duced) or may hold food in their mouths forlengthy periods, unaware of the need to begin theswallowing process (swallowing apraxia).

Sensory techniques such as gentle pressureon the tongue may help the patient remember toswallow. Cueing and encouraging a patient tofeed him- or herself may help the patient elicit amore natural swallow. Eating is an automatic be-havior, and by allowing a patient to feed him- orherself, the medical professional is not only en-couraging independence, but also allowing thenatural process of swallowing to occur.

Causes of DysphagiaDysphagia often is thought of as resulting from astroke or other neurologic injury such as a trau-matic brain injury. However, dysphagia may re-sult from a host of medical problems (Table 2).

Any neurologic injury may cause dysphagia, par-ticularly if brain stem impairment is involved.Dysphagia also may result from general debilita-tion in patients with heart failure, cancer, orother medical condition. Patients with chronicobstructive pulmonary disease (COPD) alsoshould be closely monitored for signs or symp-toms of dysphagia. This population often is atrisk for a silent aspiration event. Even traceamounts of aspiration are a potential health riskfor COPD patients because their lung status is al-ready compromised.

Medications also may affect swallow function.Xerostomia, or dry mouth, is a common com-plaint among patients taking heart medications,

diabetic patients, and somepatients with cancer. Psy-chotropic and anticholiner-gic medications or medica-tions for controllingseizures also may result indysphagia (Al-Shehri, 2003).In addition, nitrates may in-crease reflux (Swigert,2000).

How Can a Speechand LanguagePathologist Help?The goal of dysphagia eval-uation and treatment is todetermine how the patient

Table 2. Disorders Commonly Diagnosed With Dysphagia

1. Patients with neurologi-cal conditions, such ascerebrovascular accidents, traumaticbrain injuries, Parkin-son’s, and so forth

2. Generally medically debilitated patients

3. Chronic obstructive pulmonary disease

4. Head and neck cancers

5. Esophageal disorders

6. Patients with tracheostomies

7. Failure to thrive

8. Cleft palate

9. Vocal fold paralysis

10. Gastroesophageal reflux disease

11. Dementias (ie, Alzheimer’s)

Patients with dysphagia should

avoid mixing consistencies.

Mixed consistencies typically

have both a solid and a thin

liquid consistency.

44 Home Healthcare Nurse www.homehealthcarenurseonline.com

may most safely be fed by mouth. After complet-ing an initial assessment, the SLP determineswhether a patient can eat by mouth and the levelof supervision required. The SLP also assesseswhether a modified barium swallow study is war-ranted and works with the physician to deter-mine and recommend the most appropriate ob-jective assessment (Figure 1). A modified bariumswallow study allows the SLP to create a video or

“movie” of the swallow evaluating each stage ofthe swallow. A radiologist also is typically pres-ent during the study to determine medicalpathology, such as tumor or other anomaly (Has-selkus& Kander, 2004). Thin liquids, thickenedliquids, pureed and solid consistencies are pre-sented by the SLP while examining the swallowthrough videofluroscopy. This allows the SLP toview the food from the time it enters the oral cav-

Figure 1. Dysphagia flow chart.

vol. 26 • no. 1 • January 2008 Home Healthcare Nurse 45

ity until it passes through the pharynx into theesophagus. The purpose is not only to determinewhether aspiration is present, but also to deter-mine what compensatory treatment strategiesmay assist in reducing aspiration risk and thesafest consistencies for dietary intake. Compen-satory strategies may include modifying bolussize (encouraging small bites/sips), chin tuck, po-sitioning strategies, alternating liquids andsolids, and the like.

The SLP may recommend the use of a thicken-ing agent to decrease the risk of aspiration.Thickeners increase the viscosity, or thickness,of the bolus, slowing its movement through themouth and pharynx, thereby promoting a saferswallow for some patients. Patients may beplaced on nectar-thick, honey-thick, or pureedthick liquids. Not particularly pleasant, compli-ance is a significant issue with these patients,and their pulmonary status should continue tobe closely monitored. Gel thickeners, such asSimplyThick (SimplyThick, LLC, St. Louis, Mis-souri), are becoming more palatable, and somepatients are more compliant with this type ofthickener than with the powdered forms.

The patient’s diet may need to be softened ormodified to pureed consistency, thereby improv-ing oral control and reducing the risk of choking.Foods to be avoided often include raw fruits andvegetables, nuts, tougher meats, sticky breads,and foods that break apart easily in the mouth(e.g., cornbread, rice).

Patients with dysphagia also should avoidmixing consistencies. Mixed consistencies typi-cally have both a solid and a thin liquid consis-tency (e.g., canned fruit in its juice or cereal withmilk). Ice cream and jello should never be al-lowed unless thin liquids are tolerated. Oftenmisconstrued as a thickened liquid or pureedconsistency due to their solid state, ice creamand jello are considered thin liquids.

Treating DysphagiaDysphagia treatment is crucial to recovery. Di-rect dysphagia treatment may train the patient,family, or both to implement compensatorystrategies. It may involve exercises to improveoral control or to improve the overall strength,coordination, and initiation of the oropharyngealswallow.

Compensatory training may teach the patientto implement strategies for further reduction of

aspiration risk. These strategies may be the onlyoption for the patient to continue feedings bymouth. For example, a chin tuck strategy is com-monly recommended. This strategy places theepiglottis, a cartilage flap located immediatelyabove the larynx, in a more forward position, al-lowing for improved airway protection duringswallowing. A head turn may be beneficial for pa-tients with unilateral vocal fold paralysis to im-prove vocal fold closure during the swallow or tohelp patients with hemiparesis affecting move-ment of the bolus on one side of the throat. It isimportant to note that these strategies should bedetermined by the SLP before implementation isattempted.

VitalStim (Chatanooga Group, Hixson, Ten-nessee), an electrical stimulation treatment, is arelatively new method of dysphagia treatment(www.vitalstim.com). It allows the clinician tostimulate the muscles of the swallow directly toboth strengthen swallow musculature and retrainthe pathways of the brain (Wijting & Freed 2003).This treatment is provided in outpatient, hospi-tal, and long-term care facilities as well as inhome health settings.

Adaptive feeding equipment also may be anoption that could help to encourage implementa-tion of dysphagia management strategies such asmodifying bolus size or implementing a chin tuckstrategy. For example, a dysphagia cup may becontoured to prevent the patient from tilting hisor her head back while swallowing.

The patient’s diet may need to be softened

or modified to pureed consistency, thereby

improving oral control and reducing the risk

of choking. Foods to be avoided often

include raw fruits and vegetables, nuts,

tougher meats, sticky breads, and foods that

break apart easily in the mouth.

46 Home Healthcare Nurse www.homehealthcarenurseonline.com

Home Care Nurse ImplicationsRetaining the ability to eat by mouth is essentialto most people. This very basic function satisfiesnot only their nutritive needs, but also their so-cial needs. Through early identification and inter-vention, the interdisciplinary team can helpthese dysphagia patients swallow more safely.Learning to identify when a swallow evaluation iswarranted is crucial to the patient’s recovery.

Anne Brady, MS, CCC-SLP, Speech and LanguagePathologist, Visiting Nurse Association Health Ser-vices, Port Huron, Michigan.

Address for correspondence: Anne Brady, MS,CCC-SLP, Visiting Nurse Association Health Ser-vices, 1430 Military Street, Suite A, Port Huron, MI48060 (e-mail: abrady@vnabwh.com).

The author of this article has no significant ties,financial or otherwise, to any company that mighthave an interest in the publication of this educa-tional activity.

REFERENCESAl-Shehri, A. M. (2003). Dysphagia as a drug side effect.

The Internet Journal of Otorhinolaryngology 1(2).Available at: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijorl/vol1n2/dysphagia.xml.

American Speech-Language-Hearing Association.(2002). Roles of speech-language pathologists in swal-lowing and feeding disorders (position statement).Retrieved July 5, 2007 from www.asha.org/policy.

Hasselkus, A., & Kander, M. (2004). Must a radiologistbe present during a videofluroscopic evaluation?Perspectives on Swallowing Disorders, 13(3), 14-17.

Nam-Jong, P. (2006). Dysphagia. Retrieved June 28,2007 from http://www.emedicine.com/pmr/topic194.htm.

Swigert, N. (2000). The source for dysphagia. East Mo-line, Illinois: Linguisystems.

Wijting, Y., & Freed, M. (2003). VitalStim therapy trainingmanual (p. 8). Chesapeake, VA: Author.

Zagaria, M. A. (2005). Implications of dysphagia in theelderly: Concepts to consider. Retrieved July 5, 2007from http://www.uspharmacist.com/index.asp?show=article&page=8_1410.htm.

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