Review

Authors: John M Wilkinson, Don Chamil Codipilly, Robert P Wilfahrt...

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.

Topics: Deglutition; Deglutition Disorders; Esophagus; Family Practice; Female; Humans; Male; Pharynx; Physical Examination

PubMed: 33448766
DOI: No ID Found

Review

Authors: Colleen Christmas, Nicole Rogus-Pulia

Swallowing problems, or dysphagia, are common as people age, and are associated with significant negative outcomes, including weight loss, pneumonia, dehydration, shortened life expectancy, reduced quality of life, and increased caregiver burden. In this article, we will discuss the complex process of swallowing in normal circumstances and with healthy aging, then review etiologies that contribute to dysphagia. We will discuss approaches to evaluating and treating dysphagia, providing relevant data where they are available. We highlight the desperate need for high-quality research to guide best practices in treating dysphagia in older adults. J Am Geriatr Soc 67:2643-2649, 2019.

Topics: Aged; Aging; Deglutition; Deglutition Disorders; Dehydration; Humans; Quality of Life; Weight Loss

PubMed: 31430395
DOI: 10.1111/jgs.16137

Authors: Koichiro Matsuo, Jeffrey B Palmer

Eating and swallowing are complex behaviors involving volitional and reflexive activities of more than 30 nerves and muscles. They have two crucial biologic features: food passage from the oral cavity to stomach and airway protection. The swallowing process is commonly divided into oral, pharyngeal, and esophageal stages, according to the location of the bolus. The movement of the food in the oral cavity and to the oropharynx differs depending on the type of food (eating solid food versus drinking liquid). Dysphagia can result from a wide variety of functional or structural deficits of the oral cavity, pharynx, larynx, or esophagus. The goal of dysphagia rehabilitation is to identify and treat abnormalities of feeding and swallowing while maintaining safe and efficient alimentation and hydration.

Topics: Deglutition; Deglutition Disorders; Eating; Humans; Upper Gastrointestinal Tract

PubMed: 18940636
DOI: 10.1016/j.pmr.2008.06.001

Review

Authors: Renée Speyer, Reinie Cordier, Daniele Farneti...

This White Paper by the European Society for Swallowing Disorders (ESSD) reports on the current state of screening and non-instrumental assessment for dysphagia in adults. An overview is provided on the measures that are available, and how to select screening tools and assessments. Emphasis is placed on different types of screening, patient-reported measures, assessment of anatomy and physiology of the swallowing act, and clinical swallowing evaluation. Many screening and non-instrumental assessments are available for evaluating dysphagia in adults; however, their use may not be warranted due to poor diagnostic performance or lacking robust psychometric properties. This white paper provides recommendations on how to select best evidence-based screening tools and non-instrumental assessments for use in clinical practice targeting different constructs, target populations and respondents, based on criteria for diagnostic performance, psychometric properties (reliability, validity, and responsiveness), and feasibility. In addition, gaps in research that need to be addressed in future studies are discussed. The following recommendations are made: (1) discontinue the use of non-validated dysphagia screening tools and assessments; (2) implement screening using tools that have optimal diagnostic performance in selected populations that are at risk of dysphagia, such as stroke patients, frail older persons, patients with progressive neurological diseases, persons with cerebral palsy, and patients with head and neck cancer; (3) implement measures that demonstrate robust psychometric properties; and (4) provide quality training in dysphagia screening and assessment to all clinicians involved in the care and management of persons with dysphagia.

Topics: Aged; Aged, 80 and over; Deglutition; Deglutition Disorders; Humans; Mass Screening; Psychometrics; Reproducibility of Results

PubMed: 33787994
DOI: 10.1007/s00455-021-10283-7

Meta-Analysis Review

Authors: Weisong Zhang, Huijuan Pan, Ya Zong...

OBJECTIVE

To investigate whether respiratory muscle training is capable of reducing the occurrence of respiratory complications and improving dysphagia (swallowing or cough function) after stroke.

DATA SOURCES

Cochrane Library, Excerpta Medical Database (EMBASE), PUBMED, and Web of Science were searched for studies published in English; the China Biology Medicine (CBM), China Science and Technology Journal Database (VIP), China National Knowledge Infrastructure (CNKI), and Wanfang Database were searched for studies published in Chinese up to August 10, 2021.

STUDY SELECTION

Eleven randomized control trials (RCTs) (N=523) met the inclusion criteria were included in this systematic review.

DATA EXTRACTION

Data and information were extracted by two reviewers independently and disagreements was resolved by consensus with a third coauthor. Primary outcome was the occurrence of respiratory complications, secondary outcomes would be represented by swallowing and cough function. The quality of each included RCT were assessed by Cochrane risk-of-bias criteria and the GRADE evidence profile was provided to present information about the body of evidence and judgments about the certainty of underlying evidence for each outcome.

DATA SYNTHESIS

Respiratory muscle training reduced the risk of respiratory complications (relative risk, 0.51; 95% confidence interval [CI], 0.28-0.93; I=0%; P=.03; absolute risk difference, 0.068; number need to treat, 14.71) compared with no or sham respiratory intervention. It also decreased the liquid-type Penetration-Aspiration Scale scores by 0.81 (95% CI, -1.19 to -0.43; I=39%; P<.0001). There was no significant association between respiratory muscle training and Functional Oral Intake Scale (FOIS) scores, cough function: increased FOIS scores by 0.47 (95% CI, -0.45 to 1.39; I=55%; P=.32), decreased peak expiratory cough flow of voluntary cough by 18.70 L per minute (95% CI, -59.74 to 22.33; I=19%; P=.37) and increased peak expiratory cough flow of reflex cough by 0.05 L per minute (95% CI, -40.78 to 40.87; I=0%; P>.99).

CONCLUSION

This meta-analysis provided evidence that respiratory muscle training is effective in reducing the risk of respiratory complications and improving dysphagia by reducing penetration or aspiration during swallowing liquid bolus after stroke. However, there was no sufficient evidence to determine that respiratory muscle training improves cough function. Additional multicenter studies using larger patient cohorts are required to validate and support these findings. Furthermore, long-term follow-up studies should be performed to measure outcomes, while avoiding bias due to confounding factors such as heterogeneity of the etiologies of dysphagia.

Topics: Breathing Exercises; Cough; Deglutition; Deglutition Disorders; Humans; Respiration Disorders; Stroke

PubMed: 34780729
DOI: 10.1016/j.apmr.2021.10.020

Review

Authors: Teresa Pitts, Kimberly E Iceman

Despite centuries of investigation, questions and controversies remain regarding the fundamental genesis and motor pattern of swallow. Two significant topics include inspiratory muscle activity during swallow (Schluckatmung, i.e., "swallow-breath") and anatomical boundaries of the swallow pattern generator. We discuss the long history of reports regarding the presence or absence of Schluckatmung and the possible advantages of and neural basis for such activity, leading to current theories and novel experimental directions.

Topics: Humans; Deglutition; Respiratory System

PubMed: 35998250
DOI: 10.1152/physiol.00005.2021

Authors: C M Wiles

Topics: Deglutition; Deglutition Disorders; Humans; Nervous System Diseases

PubMed: 1783912
DOI: 10.1136/jnnp.54.12.1037

Review

Authors: Ishrat Rahim, Angela Napolitano, Chris Burd...

The pharynx plays a significant role in swallowing and speech, and this is reflected in both its complex anatomy and degree of physiological motility. Patients who present with pharynx-related symptoms such as sore throat, globus, dysphagia or dysphonia will usually undergo visual and nasal endoscopic examination in the first instance. Imaging is frequently required to supplement clinical assessment and this typically involves MRI and CT. However, fluoroscopy, ultrasound and radionuclide imaging are valuable in certain clinical situations. The aforementioned complexity of the pharynx and the myriad of pathologies which may arise within it often make radiological evaluation challenging. In this pictorial review, we aim to provide a brief overview of cross-sectional pharyngeal anatomy and present the radiological features of a variety of pharyngeal pathologies, both benign and malignant.

Topics: Humans; Pharynx; Cross-Sectional Studies; Deglutition Disorders; Deglutition; Fluoroscopy

PubMed: 37334795
DOI: 10.1259/bjr.20230046

Review

Authors: Bonnie Martin-Harris, Cagla Kantarcigil, Erin L Reedy...

Swallowing occurs preferentially in the expiratory phase of the quiet breathing cycle and at mid-to-low tidal volume. This coordinative pattern imparts important biomechanical advantages to swallowing and airway protection and facilitate laryngeal elevation, laryngeal vestibular and vocal fold closure, and cricopharyngeal sphincter opening. This preferred coordinative relationship between breathing and swallowing is impaired in a variety of patient populations, including head and neck cancer survivors with dysphagia. We developed a training protocol to re-establish more optimal phasing of swallowing with breathing in these patients with striking outcomes, including reduced swallowing physiological impairments and improved airway protection. This motivated us to continue to refine and expand this training protocol and develop new assistive technologies for swallowing monitoring outside of the lab. In this review, we highlight the origins of our optimal respiratory-swallowing coordination hypothesis, describe the biomechanical advantages it provides, carefully describe our training protocol and findings, and chart a course for the next phase of this work. Our overall goal is to harness technology combined with carefully constructed learning paradigms to improve the lives of patients with impaired respiratory-swallowing coordination consequent to a variety of pathologies including head and neck cancer and degenerative neurological conditions such as Parkinson's disease.

Topics: Humans; Deglutition; Respiration; Deglutition Disorders; Larynx; Head and Neck Neoplasms

PubMed: 36378345
DOI: 10.1007/s00455-022-10538-x

Review

Authors: Zohar Argov, Marianne de Visser

Dysphagia (impaired swallowing) is not a rare problem in various neuromuscular disorders, both in the pediatric and the adult patient population. On many occasions such patients are first presented to other medical specialists or health professionals. Disorders of deglutition are probably underrecognized in patients with a neuromuscular disease as a result of patient's and doctor's delay. This review will focus on dysphagia in adults suffering from a myopathy. Dysphagia in myopathies usually affects the oropharyngeal phases which rely mostly on voluntary muscle activity of the mouth, pharynx and upper esophageal sphincter. Dysphagia is known to contribute to a reduction of quality of life and may also lead to increased morbidity and mortality. The review includes an overview on symptomatology and tools of assessments, and elaborates on dysphagia in specific hereditary and acquired myopathies.

Topics: Deglutition; Deglutition Disorders; Esophagus; Humans; Mouth; Muscular Diseases; Pharynx; Quality of Life

PubMed: 33334661
DOI: 10.1016/j.nmd.2020.11.001