Dysphagia medical therapy

The main objective of treating dysphagia is to avoid aspiration of the food and bolus impaction, reduce the morbidity associated with ongoing symptoms. Effective medical management begins with early identification of the underlying cause with a detailed history, physical examination and, judicious use of investigations. Several postural techniques and swallowing maneuvers are used to help the patient swallow the food bolus. Other management options are dietary modification, environmental modification, feeding tubes and oral prosthetic devices. Medications that can worsen dysphagia should be avoided. Botulinum toxin injection can be used in the treatment of hypercontractile disorders of esophagus.

The medical treatment of dysphagia is as follows:^[1][2][3]

• Supportive care
• Treat the underlying disorder.
• Postural techniques
• Swallowing maneuvers that facilitate strengthening of the swallowing muscles.
• Dietary modification
• Medications known to cause or worsen dysphagia (potassium tablets, doxycycline,NSAIDs, bisphosphonates) should be avoided.
• After assessment, a Speech Language Pathologist will determine the safety of the patient’s swallow and recommend treatment accordingly.
• Boltulinum toxin injection is employed for the use of hypercontractile disorders of the esophagus such as achalasia.

Each specific postural technique has a particular effect on the flow food and coordination of oropharyngeal structures. They provide compensation for the specific defects in oropharyngeal swallow. The following postural techniques and other postural combinations are used to prevent the complications of dysphagia:^[4][5][6]

• Chin down (flexion): This technique is used in patients who have difficulty initiating the swallow.
  • It allows the oropharyngeal passage to become wider and narrows the airway to prevent aspiration.

• Head turned (extension):
  • This posture employs the use of gravity to help move the food from the front of the mouth to the back.
• Head tilted (turning head to look over shoulder):
  • In this technique the head is turned to the damaged or weaker side with chin down.
• Lying down on one side:
  • This technique is used when there is weakness of the pharyngeal muscles and causes the residue to be aspirated.

The following video demonstrate the postural techniques:{{#ev:youtube|H4S1Afq4fps}}

The following maneuvers are used to manage dysphagia:

• Supraglottic swallow:
  • This maneuver is used when there is late vocal fold closure.
  • The patient is asked to take a deep breath and then hold their breath.
  • They swallow while holding their breath and cough after swallowing.
• Super-supraglottic swallow:
  • This maneuver is used when there is reduction in closure of the airway.
  • The patient is asked to take a breath, hold their breath tightly while bearing down, swallow while still holding the breath hold, and then coughing immediately after the swallow.
• Mendelsohn maneuver:
  • The maneuver is used when there is discoordination in swallowing.
  • The patient is taught to hold their adam’s apple up during the swallow.

The following video helps demonstrate the mendelsohn maneuver used in the management of dysphagia. {{#ev:youtube|XbKVZN7yJSI}}

• Dietary modification, such as thickened liquid diet are commonly used for the prevention of aspiration in oropharyngeal dysphagia.^[7][8][9]

• Environmental modification can be suggested to assist and reduce risk factors for aspiration.

For example:

• Using a straw while drinking liquids.
• Putting a pillow behind the patient’s head during feeding.

Feeding tubes can be used to provide nutrition to the patient while they are recovering their ability to swallow. Following feeding tube can be used:

• Nasogastric tube
• Percutaneous endoscopic gastrostomy tube

Complications:

• Infection
• Internal bleeding

• Palatal lift or obturator
• Maxillary denture

Elderly patients benefit from swallowing rehabilitation programs regardless of the fact that underlying cause is treatable or not.^[10][11]

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