Management of Dysphagia: A Speech-Language Pathologist Perspective

How to Cite This Chapter: Gandhi P, Steele CM. Management of Dysphagia: A Speech-Language Pathologist Perspective. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.I.1.99.1. Accessed July 01, 2022.
Last Updated: June 19, 2019
Last Reviewed: June 3, 2020
Chapter Information

Also see Dysphagia: General Considerations.

When a patient is diagnosed with dysphagia, an individualized management plan needs to be developed. The goals of dysphagia treatment and management are to:

1) Maximize the safety, efficiency, and effectiveness of swallowing function.

2) Ensure safety for oral intake by collaborating with medical, nursing, and allied health-care professionals to assess the patient’s need for nonoral nutrition and hydration.

3) Determine the most appropriate liquid and food consistency if oral intake is indicated.

4) Maximize the aspects of quality of life associated with drinking, eating, or feeding while considering the patient’s social and cultural needs.

5) Reduce risks associated with dysphagia (eg, need for patient supervision, assistance, or positioning).

6) Determine whether rehabilitation and/or compensation (liquid or food modification) will optimize swallowing outcomes.

TreatmentTop

Approaches and Principles

It is important to consider the underlying neurophysiologic impairment to understand swallowing function and deficits. Treatment in individuals with dysphagia that has resulted from a progressive neurologic disorder, acute event, or chronic condition requires different management approaches. Similarly, treatment targeted at improving a specific structure or function may impact the function of other structures. A speech-language pathologist may provide important contribution to the overall treatment plan.

Treatment options available to patients and clinicians can be broadly categorized as being compensatory or rehabilitative in nature:

1) Compensatory strategies are aimed at altering bolus flow in a way that compensates for compromised oropharyngeal function without altering the underlying physiology. A summary of compensatory techniques: Table 1.9-1.

2) Rehabilitative strategies aim to promote safe and efficient swallowing function by achieving improvements in the underlying anatomy and physiology (eg, improvements in speed, strength, rate, and coordination of the muscles required for safe and efficient swallowing). A summary of rehabilitation techniques: Table 1.9-2.

TablesTop

Table 1.9-1. Compensatory techniques used in patients with dysphagia

Compensatory technique

Examples

Texture modification of food or liquid

– Food: Regular, soft and bite-sized, minced and moist, pureed, liquidized

– Liquid: Extremely thick, moderately thick, mildly think, slightly thick, thin

Regular foods and fluids require exceptional muscle control and accurate coordination between swallowing-respiratory systems. Thickened fluids slow the act of swallowing, thus enhancing safe swallowing. Modified diets use alterations to food texture to reduce the need to orally prepare food

Food/liquid sensory adjustments (eg, temperature, flavor, tactile)

– Cold bolus; sour bolus; carbonated bolus

Sensory stimulation may prime the swallow system for subsequently presented bolus to lower threshold needed to initiate swallow response and improve timeliness of the swallow

Bolus volume modification

Altering cup size or supervised ingestion

Method of bolus delivery

Open cup, spoon, straw, spouted cup, sports bottle

Body posture

Supported upright with or without pillows

Head or facial posture

 

 

Head rotation/tilt

Head is tilted toward the strong side to keep food on chewing surface

 

Head turn

Head is typically turned toward the damaged or weak side to direct bolus to the stronger of lateral channels of the pharynx

 

Chin tuck

Chin is tucked down toward the neck during the swallow, bringing tongue base closer to posterior pharyngeal wall, narrowing opening to the airway, and widening vallecular space

 

Effortful swallow

Increases posterior tongue base movement to facilitate bolus clearance. Patient is instructed to swallow and push hard with tongue against hard palate

 

Mendelsohn maneuver

Designed to elevate the larynx and open esophagus during the swallow to prevent food/liquid from entering the airway. Patient holds the larynx in elevated position at peak of hyolaryngeal elevation

 

Supraglottic swallow

Designed to voluntarily close vocal folds by holding one’s breath before and during swallow to protect the airway. Patient is instructed to hold their breath just before swallowing (closing the vocal folds) and cough immediately after the swallow

 

Super-supraglottic swallow

Designed to voluntarily move the arytenoids anteriorly, closing off the entrance to laryngeal vestibule before and during the swallow. It is similar to supraglottic swallow but involves increased effort during the breath hold before the swallow, which assists with glottal closure

 

Pacing of food or liquid rate of ingestion

Recommendations of patient-specific rate of liquid or food ingestion to assist caregivers

 

Environmental adjustments

Limiting distractions; recommendations for frequency, timing, and volume of meals/feeds

Table 1.9-2. Rehabilitation techniques used in patients with dysphagia

Rehabilitation technique

Description

Masako maneuver

Patient holds the tongue forward between teeth while swallowing; this is performed without food/liquid in the mouth to prevent coughing or choking. Although sometimes referred to as the Masako “maneuver,” Masako (tongue hold) is considered an exercise, not a maneuver, and its intent is to improve movement and strength of posterior pharyngeal wall during the swallow

Head lift (shaker) maneuver

Patient rests in supine position and lifts their head to look at the toes to facilitate increased opening of the upper esophageal sphincter through increased hyoid and laryngeal anterior and superior excursions

Effortful swallow

Increases posterior tongue base movement to facilitate bolus clearance. Patient is instructed to swallow and push hard with tongue against hard palate

Biofeedback

Used to visually display swallowing physiology, it incorporates patient’s ability to sense changes and aids in treatment of feeding or swallowing disorders; eg, those with sufficient cognitive skills can be taught to interpret visual information provided by these assessments (surface electromyography, ultrasonography, FEES) and make physiologic changes during swallowing

Electrical stimulation

Used to contract muscle fibers by applying low-voltage electrical currents to muscle tissue

Strengthening exercises for cheek, jaw, lips, tongue

Patient is provided lingual resistance across exercises to increase strength (eg, tongue lateralization exercises support development of chewing skills)

FEES, fiberoptic endoscopic evaluation of swallowing.

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