Understanding Dysphagia

Dysphagia, derived from the Greek words 'dys' (bad) and ' phaegin' (eat), refers to the medical condition characterised by difficulty swallowing. Dysphagia can be acute or chronic, intermittent or persistent and affects individuals across all age groups who experience brain injury, certain neurological disorders, head and neck cancers and functional neurological conditions. The implications of dysphagia extend beyond discomfort during eating; they can lead to significant health complications and adversely affect an individual's quality of life.

The windpipe, or trachea, and food pipe, or oesophagus, are positioned very closely together in the neck. The swallow mechanism is designed to close and protect the airway so that food/drink is directed into the oesophagus, but neurological conditions such as stroke, Parkinson's disease, and multiple sclerosis may impair the nerve signals responsible for coordinating swallowing. Both the anatomy and physiology of our muscles required for a safe swallow function can be disrupted or impaired due to these conditions.

Additionally, age-related changes in muscle function and the effects of specific medical treatments, such as radiation therapy for head and neck cancers, can contribute to the onset of dysphagia. Gastroesophageal reflux disease (GERD), where stomach acid repeatedly flows back up the food pipe, is a further condition that can lead to difficulties eating and drinking and exacerbate swallowing difficulties.

Introducing Amrita Mahal

Amrita is a highly experienced Speech and Language Therapist with expertise in managing swallowing, speech, language, and communication disorders across various age groups, from children to adults. She specialises in advanced dysphagia, having held lead roles in the assessment and management of complex swallowing disorders, utilising evidence-based practices and techniques such as Clinical Bedside Swallow Evaluations, FEES, and the McNeil Dysphagia Program.

Additionally, Amrita has a specialist interest in functional neurological disorder (FND), which involves how the brain processes or interprets signals, rather than structural brain damage, and how this impacts swallowing, voice, and communication. Amrita explains; “FND is often described as an issue with the brain’s 'software' rather than its 'hardware’, meaning the problem lies in how the brain functions rather than in its physical structure”.

She is practised in addressing voice disorders, having completed courses in the Lee Silverman Voice Treatment, manual therapy/laryngeal massage, and supporting individuals who want to align their voice and communication style with their gender identity.

Amrita holds a BSc (Hons) in Language and Communication Sciences and is a member of the Royal College of Speech and Language Therapists and the Health and Care Professions Council.

Presentation of dysphagia

Dysphagia can present in several forms, and the symptoms may vary depending on the underlying cause and the severity of the condition. Patients may experience dysphagia due to altered motor control, heightened anxiety, or specific triggers that exacerbate swallowing difficulties, with common presentations associated with dysphagia including:

Difficulty swallowing: Individuals may experience hesitation or inability to begin swallowing. This can be particularly pronounced in those with neurological disorders, where the brain’s signals to the swallowing muscles may be impaired.
Sensation of food sticking: Many individuals report a feeling of food being lodged in the throat or chest, which can lead to anxiety and fear of choking and further complicate the eating experience.
Coughing or choking: A hallmark sign of dysphagia is the occurrence of coughing or choking when attempting to swallow food or liquids. This can often indicate that the swallowing mechanism is not functioning as it should, potentially leading to aspiration.
Regurgitation: Individuals may experience the involuntary return of food or liquid from the stomach back into the mouth. This can be distressing and may contribute to a reduced appetite and weight loss.
Changes in voice quality: wet-sounding voice quality may suggest the presence of residual food or liquid in the throat.
Drooling: Difficulty in swallowing can lead to an inability to manage saliva effectively, resulting in drooling. This is particularly common in individuals with neurological conditions such as Parkinson’s disease.
Weight loss: As dysphagia progresses, a person may avoid certain foods due to fear of choking or reduce their overall intake due to a lack of enjoyment in eating because they are unable to taste food. This can lead to weight loss and nutritional deficiencies.
Food refusal or avoidance: In some cases, individuals may develop a reluctance to eat or drink altogether, stemming from the anxiety associated with swallowing difficulties. This behaviour can have severe implications for nutritional status and overall health.
Fatigue: The effort required to swallow may cause fatigue, particularly in older adults or those with underlying health issues, prolonging mealtimes and further impacting adequate nutrition.

The relationship between physical and psychological impacts can be a fundamental contributor to how dysphagia presents. Functional Neurological Disorder (FND) is a complex condition characterised by neurological symptoms that arise from dysfunction in the nervous system rather than structural abnormalities. Dysphagia is a common manifestation in individuals with FND, often resulting from the interplay of physiological and psychological factors.

Amrita highlights the impact dysphagia can have and how it can adversely affect other conditions:

The first phase of the swallow function begins when we see or smell food, or when we hold a cup or spoon. If you are unable to feed yourself, or need assistance with meals, the process is interrupted. Being fed by someone else can lead to a disruption in timing and coordination of a functional swallow”.

Associated health impacts

Primary concerns associated with dysphagia include malnutrition, dehydration, and aspiration pneumonia. Individuals with dysphagia may struggle to consume adequate nutrition and fluids, resulting in weight loss and nutritional deficiencies. This can weaken the immune system, making the individual more susceptible to infections and other health issues.

The use of feeding tubes to deliver food and liquids directly into the stomach can also lead to a restricted diet that may lack balanced nutrition and be less enjoyable.

Aspiration pneumonia is a serious complication that arises when food, liquid, or saliva is inhaled into the lungs instead of being swallowed into the stomach and can result in severe respiratory issues. The risk of aspiration is heightened in individuals with neurological conditions where the coordination of swallowing is compromised. The fear of choking or aspirating can create a significant psychological burden, causing individuals to limit their food choices to safer options and thereby compromising satisfaction in eating.

Dysphagia can also lead to social isolation and psychological distress; meals are often a focal point of social interaction and should be an experience shared with others. Difficulties in swallowing can create anxiety and embarrassment and result in individuals with dysphagia avoiding social situations, leading to feelings of loneliness and depression. The emotional toll of managing a chronic condition like dysphagia can have long-lasting negative impacts on mental health and further diminish overall well-being.

Assessment from speech and language therapists

Clinical Evaluation: The initial step involves a detailed medical history and a physical examination. Clinicians will inquire about the onset, duration, and severity of symptoms and any associated conditions, such as neurological disorders or structural abnormalities.
Screening Tools: Various screening tools can help identify the presence and severity of dysphagia, including simple questionnaires and bedside swallowing assessments. The use of standardised screening instruments helps stratify patients based on their risk levels.
Diagnostic Investigations: If dysphagia is suspected, further diagnostic evaluations may be needed, which can include:
- Videofluoroscopic Swallowing Study (VFSS): This procedure allows for real-time imaging of the swallowing process, enabling the clinician to observe the swallow function while a client eats and drinks, and identify any aspiration or penetration.
- Flexible Endoscopic Evaluation of Swallowing (FEES): Using an endoscope to capture the pharyngeal of swallowing provides insights into the safety and efficiency of the swallow.
Nutritional Assessment: Given the potential for malnutrition associated with dysphagia, a referral to a dietician and nutritionist would be made for assessment to evaluate, especially if food and fluid texture modifications are required

In highlighting the approach to therapy and the role of speech and language therapists in assessing dysphagia, Amrita adds:

Our mouth serves as the gateway to our body, and the ability to swallow safely is important for maintaining both physical and emotional well-being. Difficulties in swallowing can lead to significant stress and disrupt the gut-brain connection, so it’s important to maintain a balanced connection.

Once a diagnosis is established, a tailored therapy programme can be initiated which may include:

Exercises: Specific exercises aimed at strengthening the muscles involved in swallowing.
Postural techniques: Educating patients on various postures that can facilitate safer swallowing.
Mindful approach: Altering the speed of eating, and the amount of food and drink or concentrating on chewing properly can enhance safety.
Dietary modifications: Depending on the severity of dysphagia, texture modifications may be (e.g., pureed or soft diets) the clinician may also need to recommend a thickening agent, to ensure adequate fluid management, to reduce aspiration risk whilst maintaining oral intake
Pharmacological intervention: Underlying medical conditions contributing to dysphagia may require medications to manage reflux or inflammation, as well as treatments for neurological conditions that affect swallowing.
Multidisciplinary approach: Effective management of dysphagia requires the balancing of various needs and often necessitates a collaborative approach involving a multidisciplinary team, including speech and language therapists, dietitians, physicians, physiotherapists, and occupational therapists. This ensures a holistic strategy tailored to the individual needs of the individual.

Expert witness reports from Bush & Co.

Bush & Co. provides comprehensive speech and language expert witness reports prepared by qualified speech and language therapists with extensive experience assessing complex communication and swallowing disorders. Reports give a detailed prognosis, with assessment using evidence-based techniques to consider the nature and severity of the speech and language difficulties and highlighting the potential for improvement through therapeutic interventions.

Speech and language expert witness reports deliver valuable insights that contribute to medicolegal proceedings and play a crucial role in ensuring clients receive the support they need to enhance their communication skills and overall well-being.

For more information on dysphagia, visit the Bush & Co. website or call 01327 876210 to speak to a team member about our specialist Expert Witness services.