Dysphagia

Question 1

What is dysphagia?

Answer 1

• Swallowing difficulties.
• Some people with dysphagia have problems swallowing certain foods or liquids, while others can’t swallow at all.

Question 2

Signs/symptoms of Dysphagia

Answer 2

• coughing or choking when eating or drinking
• bringing food back up, sometimes through the nose
• a sensation that food is stuck in your throat or chest
• persistent drooling of saliva
• being unable to chew food properly
• a gurgly, wet-sounding voice when eating or drinking
• Over time, dysphagia can also cause symptoms such as weight loss and repeated chest infections.

Question 3

What will GP want to know about someone experiencing these symptoms?

Answer 3

• how long you’ve had signs of dysphagia
• whether your symptoms come and go or are getting worse
• whether dysphagia has affected your ability to swallow solids, liquids or both
• whether you’ve lost weight

Question 4

What are the two types of dysphagia?

Answer 4

• your mouth or throat (oropharyngeal dysphagia)
• your oesophagus (known as oesophageal dysphagia)

Question 5

Someone suspected of dysphagia will be referred for further testing to who?

Answer 5

• a speech and language therapist (SLT)
• a neurologist – a specialist in conditions that affect the brain, nerves and spinal cord
• a gastroenterologist – a specialist in treating conditions of the gullet, stomach and intestines

Question 6

What is the swallow test?

Answer 6

A swallow test is usually carried out by a speech and language therapist (SLT) and can give a good initial assessment of your swallowing abilities.

The SLT will ask you to swallow some water.

The time it takes you to drink the water and the number of swallows required will be recorded.

You will also be asked to chew and swallow a soft piece of pudding or fruit so the SLT can look at how well your lips, tongue and the muscles in your throat work.

Question 7

What is videofluoroscopy?

Answer 7

A videofluoroscopy assesses your swallowing ability. It takes place in the X-ray department and provides a moving image of your swallowing in real time.

The patient will be asked to swallow different types of food and drink of different consistencies, mixed with a non-toxic liquid called barium that shows up on X-rays.

The results are recorded, allowing your swallowing problems to be studied in detail.

A videofluoroscopy usually takes about 30 minutes. There are usually few side effects, though the barium may cause constipation.

Question 8

What is nasoendoscopy?

Answer 8

A nasendoscopy, sometimes known as fibreoptic endoscopic evaluation of swallowing (FEES), is a procedure used to examine the nose and upper airways.

An endoscope (a thin, flexible tube with a light and a camera at one end) is inserted into your nose so that the specialist can look down into your throat and upper airways and identify any blockages or problem areas.

FEES can also be used to test for oropharyngeal dysphagia after you swallow a small amount of test liquid (usually coloured water or milk).

You may be given a local anaesthetic spray into your nose, but because the camera doesn’t go as far as your throat, it doesn’t cause retching. The procedure is very safe and usually only takes a few minutes.

Question 9

What is Manometry and 24-hour pH study ?

Answer 9

• A specific test for oesophageal dysphagia
• assesses the function of oesophagus. A small tube with pressure sensors is passed through the nose into the oesophagus to measure the amount of acid that flows back from your stomach. This can help determine the cause of any swallowing difficulties.

Question 10

What is diagnostic gastroscopy?

Answer 10

Also known as diagnostic endoscopy of the stomach or OGD (oesophagogastroduodenoscopy), is an internal examination using an endoscope (a thin, flexible tube with a light and a camera at one end).

The endoscope is passed down your throat and into your oesophagus. It can often detect cancerous growths or scar tissue.

Question 11

Why do people with dysphagia get a nutritional assessment?

Answer 11

to check that the patient is not lacking in nutrients (malnourished).

Question 12

What are the specific tests for oesophageal dysphagia?

Answer 12

• Manometry and 24-hour pH study
• Diagnostic gastroscopy

Question 13

What are the tests for dysphagia?

Answer 13

• swallow test
• videofluoroscopy
• nasoendoscopy

Specific tests for oesophageal dysphagia
- Diagnostic gastroscopy
- manometry 24-hour pH study

Question 14

What is the treatment for a baby for with dysphagia due to cerebral palsy?

Answer 14

a speech and language therapist (SLT) will teach your child how to swallow, how to adjust the type of food they eat and how to use feeding tubes.

Question 15

What is the treatment for a baby for with dysphagia due to cleft lip and palate?

Answer 15

This is usually treated with surgery.

Question 16

What is the treatment for a baby for with dysphagia due to narrowing of the oesophagus?

Answer 16

May be treated with a type of surgery called dilatation to widen the oesophagus.

Question 17

What determines the treatment for dysphagia?

Answer 17

• Depends on whether the swallowing problem is in the mouth or throat (oropharyngeal dysphagia), or in the oesophagus (oesophageal dysphagia).
• Cause of dysphagia is also considered when deciding on treatment or management. E.g. in some cases, treating the underlying cause, such as mouth cancer or oesophageal cancer, can help relieve swallowing problems.

Question 18

Causes of dysphagia

Answer 18

• neurological causes
• Congenital and developmental conditions
• Obstruction of throat or narrowing or oesophagus
• musclular conditions
• Other causes e.g COPD or complication with head or neck surgery

Question 19

Examples of neurological causes of dysphagia

Answer 19

• stroke
• brain tumours
• mysasthenia gravies
• conditions that damage the brain and nervous system over time, including: Parkinson’s disease, multiple sclerosis, dementia, and motor neurone disease

Question 20

Example of congenital and developmental conditions that cause dysphagia

Answer 20

• learning disabilities – where learning, understanding, and communicating are difficult
• cerebral palsy – a group of neurological conditions that affect movement and co-ordination
• a cleft lip and palate – a common birth defect that results in a gap or split in the upper lip or roof of the mouth

Question 21

What are the two muscular conditions associated with dysphagia?

Answer 21

• scleroderma – where the immune systemattacks healthy tissue, leading to a stiffening of the throat and oesophagus muscles
• achalasia – where muscles in the oesophagus lose their ability to relax and open to allow food or liquid to enter the stomach

Question 22

What are some causes of narrowing and obstruction that can lead to dysphagia

Answer 22

• mouth cancer or throat cancer, such as laryngeal cancer or oesophageal cancer – once these cancers are treated, the obstruction may no longer be an issue
• pharyngeal (throat) pouches – a large sack develops in the upper part of the oesophagus, which reduces the ability to swallow both liquids and solids; it’s a rare condition that mainly affects older people
• eosinophilic oesophagitis – a type of white blood cell (eosinophil) builds up in the lining of the oesophagus due to a reaction to foods, allergens or acid reflux; the build-up damages the lining of the oesophagus and causes swallowing difficulties
• radiotherapy treatment – can cause scar tissue, which narrows the passageway in your throat and oesophagus
  gastro-oesophageal reflux disease (GORD) – stomach acid can cause scar tissue to develop, narrowing your oesophagus
• infections, such as tuberculosis or thrush – can lead to inflammation of the oesophagus (oesophagitis)

Question 23

What does treatment depend on?

Answer 23

On whether problem is from mouth or throat (oropharyngeal dysphagia), or in the oesophagus (oesophageal dysphagia).

As well as underlying cause of dysphagia e.g. treating mouth cancer or oesophageal cancer, can help relieve swallowing problems.

Question 24

What are the 3 main treatments for oropharyngeal dysphagia?

Answer 24

Aim is to make eating and drinking as safe as possible

• swallowing therapy
• dietary changes
• feeding tubes

Oropharyngeal dysphagia can be difficult to treat if it’s caused by a condition that affects the nervous system. This is because these problems can’t usually be corrected using medication or surgery

Question 25

What is swallowing therapy?

Answer 25

You may be referred to a speech and language therapist (SLT) for swallowing therapy. An SLT is trained to work with people with eating or swallowing difficulties.

SLTs use a range of techniques that can be tailored for your specific problem, such as teaching you swallowing exercises.

Question 26

Examples of Dietary changes for oropharyngeal dysphagia

Answer 26

• Softer foods and thickened fluids that may be easier to swallow
• Also try to ensure you’re getting the support you need at meal times.

Question 27

Feeding tube treatment

Answer 27

A feeding tube can make it easier to take medication needed for other conditions.

There are 2 types of feeding tubes:

• a nasogastric tube – a tube passed through the nose and down into the stomach
• a percutaneous endoscopic gastrostomy (PEG) tube – a tube is implanted directly into the stomach

Nasogastric tubes are designed for short-term use. The tube will need to be replaced and swapped to the other nostril after about a month.

PEG tubes are designed for long-term use and last several months before they need replacing.

Most people with dysphagia prefer to use a PEG tube because it can be hidden under clothing. However, they carry a greater risk of minor complications, such as skin infection or blocked tube, compared to nasogastric tubes.

Two major complications of PEG tubes are infection and internal bleeding.

You can discuss the pros and cons of both types of feeding tubes with your treatment team.

Question 28

What are the 5 main treatments for oesophageal dysphagia

Answer 28

• medication
• Botox
• surgery
• endoscopic dilatation
• inserting a stent

Question 29

Endoscopic dilatation for treatment of oesophageal dysphagia

Answer 29

Endoscopic dilatation is widely used to treat dysphagia caused by obstruction. It can also be used to stretch your oesophagus if it’s scarred.

Endoscopic dilatation will be carried out during an internal examination of your oesophagus using an endoscopy.

An endoscope (a thin tube with a light and a camera at one end) is passed down the throat and into the oesophagus, and images of the inside of the body are transmitted to a television screen.

Using the image as guidance, a small balloon or a bougie (a thin, flexible medical instrument) is passed through the narrowed part of the oesophagus to widen it.

If a balloon is used, it will gradually be inflated to widen your oesophagus before being deflated and removed.

Patients may be given a mild sedative before the procedure to relax them. There’s a small risk that the procedure could cause a tear or perforation to your oesophagus.

Question 30

Why might a stent be used instead of endoscopic dilatation for individuals with oesophageal cancer?

Answer 30

This is because, if you have cancer, there’s a higher risk of perforating your oesophagus if it’s stretched.

If you have oesophageal cancer the stent can not be removed

Question 31

What does inserting a stent for oesophageal dysphagia entail?

Answer 31

A stent (usually a metal mesh tube) is inserted into the oesophagus during an endoscopy or under X-ray guidance.

The stent then gradually expands to create a passage wide enough to allow food to pass through. To keep the stent open without blockages, patients will need to follow a particular diet.

Question 32

Botox can be used to treat oesophageal dysphagia but what specific type and what is the mechanism?

Answer 32

Sometimes be used to treat achalasia: where the muscles in the oesophagus become too stiff to allow food and liquid to enter the stomach.

Botox can be used to paralyse the tightened muscles that prevent food from reaching the stomach. However, the effects only last for around 6 months.

Question 33

When might medication be used to treat dysphagia (oesophageal)

Answer 33

Depending on the cause. For example, proton pump inhibitors (PPIs) used to treat indigestion may improve symptoms caused by narrowing or scarring of the oesophagus.