Dysphagia

Stroke is the leading cause of dysphagia, which is paralysis of the throat muscles. This condition can disrupt the swallowing process and make eating, drinking, taking medicine and breathing difficult. More than 70 percent of stroke survivors experience dysphagia at some point after a stroke.

Swallowing is one of the most complicated processes of the central nervous system. It involves multiple areas of the brain and a series of voluntary and involuntary muscular contractions. If one of these areas is damaged by the stroke, the complications can be serious and slow down recovery.

Identifying swallowing issues early reduces hospital stays, healthcare costs and complications including pneumonia, dehydration and malnutrition. Dysphagia is most common immediately after a stroke, but usually declines over time.

Brain stem strokes often cause nerve damage that impairs swallowing, but dysphagia is more common among the aging population because muscles weaken over time. Dysphagia can also be caused by smoking, certain medications, excessive alcohol use and dentures.

Symptoms

There are two types of dysphagia:

Oropharyngeal (most common among stroke survivors)
Esophageal (most common among the aging population)

Dysphagia symptoms can range from mild to severe but the most common symptoms are coughing, choking or feeling like food is sticking in the back of the throat or upper chest when swallowing.

Oropharyngeal dysphagia occurs when it is difficult to move food or liquid from the mouth to the upper part of the esophagus.

Symptoms of oropharyngeal dysphagia

Difficulty initiating the swallow
Choking when food gets stuck
Coughing or gagging while swallowing
Nasal regurgitation (liquid coming out of the nose)
Food getting caught in the lungs
Inability to ingest enough food or liquid, causing weight loss
Weak voice
Drooling
Poor tongue control
Loss of gag reflex

Esophageal dysphagia occurs when moving food from the esophagus to the stomach is difficult.

Symptoms of esophageal dysphagia

Feeling like food is sticking in the throat or chest
Pain with swallowing
Chest pressure
Sore throat
Burping
Chronic heartburn

Dysphagia should not be confused with:

Odynophagia: painful swallowing
Globus: the constant feeling of a lump in the throat

Treatment

Treatment can lead to improvement, but up to 30 percent of stroke survivors will face issues with this condition. The goal of dysphagia treatment is to increase or restore the ability to independently chew and swallow and prevent pneumonia and aspiration.

To determine the most appropriate treatment, healthcare professionals often conduct a neurological exam and inspect the neck, mouth, throat/esophagus, chest and stomach with an endoscopy or an X-ray.

The most common treatment for dysphagia is swallow therapy, which includes compensatory exercises. Because of the many complications that can result when dysphagia is untreated or inappropriately treated, most dysphagia therapy is done with the help of a speech language, occupational or physical therapist. The major complications of dysphagia are pneumonia and aspiration (when food or fluid is inhaled into the lungs).

Swallow Therapy

Electrical stimulation to the faucial arches (muscles at the back of the mouth that help move food into the throat) can sometimes help improve swallowing.

Compensatory Exercises

Exercising the tongue, lips, throat and mouth can help relax and strengthen the muscles as well as increase their flexibility (examples include tucking the chin or rotating the head).

A speech language therapist can teach special exercises to stimulate the nerves involved in swallowing. Compensatory techniques can include adapting posture and sitting position, reducing distractions at mealtime, eating slower with smaller amounts of food and changing food consistency.

Medication

Some medications, such as muscle relaxers, can help open the throat. Note that some sedatives, immunosuppressants and antibiotics can make swallowing difficulties worse. Talk to a healthcare professional about potential medication side effects and alternative ways to ingest medicine if swallowing is a problem.

Surgery

Rarely, a healthcare professional will recommend surgery to address oropharyngeal dysphagia.

Management

A variety of strategies can be used to help promote recovery and improve the effects of treatment.

Dietary Modification

Dietary changes should be customized for each individual. For example, modify food texture by chopping, mincing or puréeing food. Maintaining adequate nutrition is a primary concern and it may be necessary to consult with a nutritionist or dietician to do this.

Dehydration is always a risk. Thin fluids such as water are harder to swallow; altering fluid viscosity (thickness) with liquid thickeners can be helpful.

Food should always be prepared and consumed correctly to avoid aspiration (food or liquid inhaled into the lungs).

Talk to a healthcare professional about how to manage dietary modifications.

Food
Consistency	Description
“Puréed”	Thick, homogeneous textures, e.g., pudding
“Ground or minced”	Easy-to-chew foods, no coarse textures, raw fruit or vegetables, e.g., mashed bananas
“Soft or easy to chew”	Soft foods prepared without the use of a blender, no tough skins, nuts or raw, crispy or stringy foods, e.g., meats should be minced or cut into cubes 1 cm or less
“Modified general”	Soft textures prepared without grinding or chopping; no nuts or crisp foods
Fluids
Consistency	Description
“Thin”	Regular fluids with no changes
“Nectar-like”	Fluids thin enough to be sipped through a straw or cup but thick enough to fall off a tipped spoon, e.g., eggnog or buttermilk
“Honey-like”	Thick fluids eaten with a spoon, unable to hold their shape and too thick for a straw, e.g., tomato sauce, honey, thick yogurt
“Spoon-thick”	Pudding-like fluids that must be eaten with a spoon and hold their shape on a spoon, e.g., thickened applesauce, thick milk pudding

Managing Emotional Responses to Dysphagia

Swallowing difficulties can cause anxiety. It is important for caregivers to know feeding techniques to assist and ensure safety.

If a stroke survivor has cognitive difficulties, he or she may not be able to follow modified swallowing instructions or even be aware of the swallowing problem.