Adult Dysphagia

Treatment

The primary goals of dysphagia intervention are to

 safely support adequate nutrition and hydration and return to safe and efficient oral
intake (including incorporating the patient's dietary preferences and consulting with
family members/caregivers to ensure that the patient's daily living activities are being
considered);
 determine the optimum feeding methods/technique to maximize swallowing safety
and feeding efficiency;
 minimize the risk of pulmonary complications;
 reduce patient and caregiver burden while maximizing the patient's quality of life;
and
 develop treatment plans to improve safety and efficiency of the swallow.

Management of individuals with dysphagia should be based on results of the

comprehensive assessment. Decision making must take into account many factors about
the individual's overall status and prognosis. This might include information concerning the
individual's health and diagnosis, cognition, social situation, cultural values, economic
status, motivation, and personal choice. Of primary concern is how the individual's health
status can be maintained or maximized. The SLP should consider and integrate the
patient's wishes and advocate on behalf of the patient to the health care team, the family,
and other relevant individuals.

Treatment Approaches and Principles

Consideration for the underlying neurophysiological impairment is necessary for
understanding swallow function and deficits. Different management approaches may be
necessary for individuals with dysphagia that has resulted from an acute event,
chronic/stable condition, or progressive neurological disorder. Treatment targeting a specific
function or structure may also affect function in other structures.
Treatment of dysphagia may include restoration of normal swallow function (rehabilitative),
modifications to diet consistency and patient behavior (compensatory), or some
combination of these two approaches.

Compensatory techniques alter the swallow when used but do not creating lasting functional
change. An example of a compensatory technique includes a head rotation, which is used
during the swallow to direct the bolus toward one of the lateral channels of the pharyngeal
cavity. Although this technique may increase swallow safety during the swallow, there is no
lasting benefit or improvement in physiology when the technique is not used. The purpose
of the technique is to compensate for deficits that cannot be or are not yet rehabilitated
sufficiently.

Rehabilitative techniques, such as exercises, are designed to create lasting change in an

individual's swallowing over time by improving underlying physiological function. The intent
of many exercises is to improve function in the future rather than compensate for a deficit in
the moment.

In some circumstances, certain techniques may be used for both compensation and
rehabilitative purposes. For example, the super-supraglottic swallow is a rehabilitative
technique that increases closure at the entrance to the airway. If used during a meal, it can
serve as a compensation to protect the airway.

Treatment Options and Techniques

Upon completion of the clinical and/or instrumental evaluation, the clinician should be able
to use the acquired data to identify which treatment options would be most beneficial.
Treatment options for patients with dysphagia should be selected on the basis of evidence-
based practice, which includes a combination of the best available evidence from published
literature, the patient's and family's wishes, and the clinician's experience. Options for
dysphagia intervention include medical, surgical, and behavioral treatment.

Biofeedback
Biofeedback incorporates the patient's ability to sense changes and aids in the treatment
of feeding or swallowing disorders. For example, patients with sufficient cognitive skills can
be taught to interpret the visual information provided by these assessments (e.g., surface
electromyography, ultrasound, FEES) and to make physiological changes during the
swallowing process.

Diet Modifications
Modifications to the texture of the food may be implemented to allow for safe oral intake.
This may include changing the viscosity of liquids and/or softening, chopping, or pureeing
solid foods. Modifications of the taste or temperature may also be employed to change the
sensory input of the bolus. Clinicians consult with the patients and caregivers to identify
patient preference and values for food when discussing modifications to oral intake.
Consulting with the team, including a dietician, is also a relevant consideration when
altering a diet to ensure that the patient's nutritional needs continue to be met.

Electrical Stimulation
The body of literature about electrical stimulation for swallowing is growing, and additional
studies are underway to further the knowledge about this technique and its implications for
dysphagia treatment. Electrical stimulation is promoted as a treatment technique for speech
and/or swallowing disorders that uses an electrical current to stimulate the nerves either
superficially via the skin or directly into the muscle in order to stimulate the peripheral nerve.
Electrical stimulation for swallowing is intended to strengthen the muscles that move the
larynx up and forward during swallow function.

Equipment/Utensils
Patients may benefit from the use of specific equipment/utensils to facilitate swallow
function. A patient can use utensils to bypass specific phases of the swallow, to control for
bolus size, or to facilitate oral control of the bolus. SLPs collaborate with other team
members in identifying and implementing use of adaptive equipment.

Maneuvers
Maneuvers are specific strategies that clinicians use to change the timing or strength of
particular movements of swallowing. Some maneuvers require following multistep directions
and may not be appropriate for patients with cognitive impairments. Examples of
maneuvers include the following:

 Effortful swallow —increases posterior tongue base movement to facilitate bolus

clearance. The patient is instructed to swallow and push hard with the tongue
against the hard palate (Huckabee & Steele, 2006).
 Mendelsohn maneuver —designed to elevate the larynx and open the esophagus
during the swallow to prevent food/liquid from falling into the airway. The patient
holds the larynx in an elevated position at the peak of hyolaryngeal elevation.
 Supraglottic swallow —designed to close the vocal folds by voluntarily holding
one's breath before and during swallow in order to protect the airway. The patient is
instructed to hold his or her breath just before swallowing to close the vocal folds.
The swallow is followed immediately by a volitional cough.
 Super-supraglottic swallow —designed to voluntarily move the arytenoids
anteriorly, closing the entrance to the laryngeal vestibule before and during the
swallow. The super-supraglottic swallow is similar to the supraglottic swallow;
however, it involves increased effort during the breath hold before the swallow,
which facilitates glottal closure (Donzelli & Brady, 2004).
Oral-Motor Therapy/Exercises
Oral-motor treatments include stimulation to or actions of the lips, jaw, tongue, soft palate,
pharynx, larynx, and respiratory muscles that are intended to influence the physiologic
underpinnings of the oropharyngeal mechanism in order to improve its functions. Some of
these interventions can also incorporate sensory stimulation. Oral-motor treatments range
from passive to the more active (e.g., range-of-motion activities, resistance exercises, or
chewing and swallowing exercises). Examples of exercises include the following:

 Laryngeal elevation —similar to the Mendelsohn maneuver (discussed in

"Maneuvers" section above), the patient uses laryngeal elevation exercises to lift and
maintain the larynx in an elevated position. The patient is asked to slide up a pitch
scale and hold a high note for several seconds. This maintains the larynx in an
elevated position.
 Masako or tongue hold —the patient holds the tongue forward between the teeth
while swallowing; this is performed without food or liquid in the mouth, to prevent
coughing or choking. Although sometimes referred to as the Masako
"maneuver,"the Masako (tongue hold) is considered an exercise (not a maneuver),
and its intent is to improve movement and strength of the posterior pharyngeal wall
during the swallow.
 Shaker exercise, head-lifting exercises —the patient rests in a supine position
and lifts his or her head to look at the toes to facilitate an increased opening of the
upper esophageal sphincter through increased hyoid and laryngeal anterior and
superior excursion.
 Lingual isometric exercises —the patient is provided lingual resistance across
exercises to increase strength.

Pacing and Feeding Strategies

Specific volumes of food per swallow may result in faster pharyngeal swallow responses.
Clinicians modify the bolus size (i.e., bigger/smaller bolus amounts), particularly for patients
that require a greater volume to adequately stimulate a swallow response or for patients
that require multiple swallows per bolus. Patients may also require cuing and assistance to
maintain an appropriate rate during meals. Impulsivity and/or decreased initiation are
examples of cognitive deficits evident across a number of disorders that may affect a
patient's pace during meals.

Postural/Position Techniques
Postural techniques redirect the movement of the bolus in the oral cavity and pharynx and
modify pharyngeal dimensions in a systematic way. Postural techniques may be appropriate
to use with patients with neurological impairments, head and neck cancer resections, and
other structure damage. Postural techniques may be used in patients of all ages. Examples
of postural techniques include the following:

 Chin-down posture —the chin is tucked down toward the neck during the swallow,
which may bring the tongue base closer to the posterior pharyngeal wall, narrow the
opening to the airway, and widen the vallecular space.
 Chin-up posture —the chin is tilted up, which may facilitate movement of the bolus
from the oral cavity.
 Head rotation (turn to the side) —the head is turned to either the left or the right
side, typically toward the damaged or weak side (although the opposite side may be
attempted if there is limited success with the first side) to direct the bolus to the
stronger of the lateral channels of the pharynx.
 Head tilt —the head is tilted toward the strong side to keep the food on the chewing
surface.

Postures and maneuvers may be combined in an appropriate manner, taking care to

minimize patient effort/burden, where possible.

Prosthetics/Appliances
Prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize
pressures and movements in the intraoral cavity by providing compensation or physical
support for patients with structural deficits/damage to the oropharyngeal mechanism. With
this support, swallowing efficiency and function may be improved. Intraoral
appliances(e.g., palatal plates) are removable devices with small knobs that provide tactile
stimulation inside the mouth to encourage lip closure and appropriate lip and tongue
position for improved swallow function. This treatment option is most often used with
patients following treatment for head and neck cancer; however, it may be implemented
with other patients suffering from similar challenges.

Note: Future Practice Portal pages on head and neck cancer and on craniofacial anomalies
will further discuss prosthetics and appliances. Check back regularly with thePractice
Portal website for updates.

Sensory Stimulation
Sensory stimulation techniques vary and may include thermal-tactile stimulation (e.g., using
iced lemon glycerin swab, cold laryngeal mirror) or tactile stimulation applied to the tongue,
around the mouth, and/or in the oropharynx. Patients who are tactically defensive may need
approaches that reduce the level of sensory input initially, with incremental increases as
tolerance improves. The opportunity for sensory stimulation may be needed for those with
reduced responses, overactive responses, or limited opportunities for sensory experiences.
Sensory stimulation may prime the swallow system for the subsequently presented bolus to
lower the threshold needed to initiate a swallow response and improve the timeliness of the
swallow.

Medical Management Of Swallowing Disorders

Due to the interprofessional management of dysphagia, clinicians should be aware of
multiple options for dysphagia intervention, including medical, surgical, and behavioral
treatment. Such knowledge increases pertinent communication with other health care
providers and facilitates selection of the best treatment options for individual patients
(Groher & Crary, 2010).

Common Medical Options for Dysphagia Treatment

Pharmacologic Management

 Anti-reflux medications
 Prokinetic agents
 Salivary management

Common Surgical Options for Dysphagia Treatment

Improved Glottal Closure

 Medialization thyroplasty
 Injection of biomaterials

Protection of the Airway

 Stents
 Laryngotracheal separation
 Laryngectomy
 Tracheostomy tubes
 Feeding tubes

Improved Pharyngoesophageal Segment Opening

 Dilation
 Myotomy
 Botulinum toxin injection

Tube Feeding for Dysphagia Treatment

If the individual's swallowing safety and efficiency cannot reach a level of adequate function,
or if swallow function does not support nutrition and hydration adequately, the swallowing
and feeding team may recommend alternative avenues of intake (e.g., nasogastric [NG]
tube, gastrostomy). In these instances, team members consider whether the individual will
need the alternative source for a short or extended period of time. Education and
counseling may be provided concerning issues related to tube feeding, such as appropriate
positioning and duration of feeding times. Alternative feeding does not preclude the need for
rehabilitative techniques to facilitate sensory and motor capabilities necessary for oral
feeding. Percutaneous endoscopic gastrostomy (PEG) tubes may not be appropriate in all
populations and may not necessarily improve outcomes or quality of life (Plonk, 2005).

The decision to recommend use of a feeding tube is made in collaboration with the medical
team. The physician is ultimately responsible for selecting which type of tube is used, but a
brief description of several options is provided below, for the benefit of clinicians.

 Gastrostomy tube (PEG, G-tube)— inserted through the abdomen to provide non-
oral nutrition. A percutaneous endoscopic gastrostomy tube, or PEG tube, is a
common type of G-tube.
 Jejunostomy tube (PEJ, J-tube)— inserted through the abdomen and into the
jejunum, the second part of the small intestine, to provide non-oral nutrition.
 Nasogastric tube (NG-tube)— inserted through the patient's nose and passed
through the esophagus to the stomach to provide non-oral nutrition. NG-tubes are
often the preferred option for short-term use (over G-tubes or J-tubes). Tube size
may vary and may influence swallow function.

The patient, with his or her proxy, then chooses to accept or reject use of alternative
nutrition and hydration following a shared decision making, informed consent discussion.

Treatment Considerations Related to Progressive Disorders and End-

of-Life Issues
The role of the SLP in treating individuals with progressive neurological disorders is
designed to maximize current function, compensate for irreversible loss of function, assess
and reassess changes in status, and educate and counsel patients regarding the
progression of the disorder and potential options, including non-oral means of nutrition.

SLPs may encounter patients approaching the end of life. These patients may have
complex medical conditions related to feeding and swallowing. SLPs may work with these
patients and caregivers to develop compensatory strategies that will allow the patients to
eat an oral diet for as long as possible. As a member of the interprofessional team, the SLP
may contribute to decision making regarding the use of alternative nutrition and hydration.

Understanding emotional and psychological issues related to death are essential to treating
patients with swallowing problems at the end of life. When considering end-of-life issues, it
is important for clinicians to respect the patient's wishes, including social and cultural
considerations. Patients and caregivers may not agree with clinical recommendations and
may feel that these recommendations do not provide the best quality of life for their loved
one.

Ethical Concerns
One model for ethical decision making includes consideration of (Jonsen, Siegler, &
Winslade, 1992):

 Medical indications— Consider the patient's medical history, prognosis, and

available viable treatment options.
 Patient preferences— Consider the patient's cultural and personal background
influence, his or her preference to pursue or reject treatment, the patient's ability to
make and communicate these decisions, and the presence of an advance directive.
 Quality of life— Consider if the treatment creates a burden that outweighs the
potential benefit
 Contextual features— Consider the implications for caregiver burden if the patient
chooses to pursue or reject treatment and if there are relevant legal ramifications to
consider

Clinicians provide information regarding these considerations without factoring in their own
personal beliefs. Conflict may occur when medical recommendations do not match patient
preferences. After being educated about the risks and benefits of a particular
recommendation (e.g., oral vs. non-oral means of nutrition, diet level, rehabilitative
technique), if a patient (or his or her decision maker) chooses an alternate course of action,
then the SLP makes any appropriate recommendations and offers treatment as appropriate.
The SLP educates involved parties on the possible health consequences and documents all
communication with the patient and caretakers. If no treatment is warranted, then the SLP
may make recommendations about the safest course (and still document the risks of such
action) and may provide training to caregivers and family, as appropriate. The SLP may
then decide to discharge the patient but should avail him/herself to additional consultation or
communication with the parties involved, as appropriate. Many facilities have an ethics
consultation service that can help clinicians, patients, and families address challenges when
an ethical issue arises.
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