Managing swallowing disorders after injury
Swallowing disorders, or dysphagia, can arise after damage to the nervous system from causes and conditions including stroke, brain and spinal cord injury, Parkinson’s disease, multiple sclerosis, muscular dystrophy, cerebral palsy, and Alzheimer’s disease.
Understanding swallowing stages
- Oral phase: Sucking, chewing, and moving food or liquid to the throat
- Pharyngeal phase: Beginning of the swallow reflex, squeezing food down the throat and closing the airway to prevent food and liquid from entering the airway (aspiration) or prevent choking
- Esophageal phase: Relaxing and tightening the muscles of the esophagus by squeezing food through the esophagus into the stomach
Symptoms
Dysphagia may result in poor nutrition or dehydration, aspiration, pneumonia, less enjoyment of eating and drinking, and embarrassment or isolation in social situations centered around eating. Aspiration, either with or without symptoms, occurs when food or liquid enter the airway below the level of the vocal cords. Common symptoms include:
- Coughing or throat-clearing during or right after eating or drinking
- Gurgling sounds during or after eating and drinking
- Watery eyes or runny nose during eating and drinking
- Multiple swallows seen for every bite or sip
- Shortness of breath when eating or drinking
- Food or liquid escaping from the mouth or becoming stuck in the mouth
- Recurring pneumonia or chest congestion
- Weight loss or dehydration from not being able to eat enough
Diagnosis and evaluation
Difficulties can occur when food or liquid are in the mouth, throat, or esophagus during the swallowing process. A speech-language pathologist (SLP) can help diagnose the issue.
- Bedside swallow evaluation: A process used by the SLP to examine the patient’s swallow and evaluate the overt signs and symptoms of aspiration.
- Modified barium swallow study: The individual eats and drinks food or liquid with barium in it for the SLP to view the swallow process under X-ray.
- Endoscopic assessment: A lighted scope is put in the nose to the level of the throat and the swallow process is then viewed on a screen.
Communicate with your SLP about ongoing changes and strategies related to swallow safety. As treatment progresses, diet consistencies will change. Ask questions.
Treatment
Treatment recommendations are based on the results of each person’s evaluation, with the shared goal of safe eating and drinking as independently as possible.
Modified food textures
Level 1: Dysphagia pureed
- Texture: Homogenous, very cohesive, pudding-like, requiring very little chewing ability
- Examples: Cream of wheat, thinned grits, pureed or scrambled eggs, applesauce, smooth yogurt, pudding, Jell-O, strained soups, mashed potatoes, pureed vegetables, pureed fruits, pureed meats with gravy, ice cream, sherbet, and baby foods
Level 2: Dysphagia mechanical altered
- Texture: Cohesive, moist, semi-solid foods, requiring some chewing
- Examples: Thinned oatmeal, grits, cereal without nuts or dried fruits, scrambled or poached eggs, all yogurt, cottage cheese, soups without chunks, soft or fork-mashed vegetables, fork-mashed fruits, pasta, baked and mashed potatoes, baked fish, ground meats with gravy, cream pies, egg salad, fish salad, and all pureed foods
Level 3: Dysphagia advanced
- Texture: Soft foods that require more chewing ability
- Examples: All eggs, pancakes with syrup, french toast with syrup, canned fruits, soft cooked vegetables, salads, meat salads, chopped meats with gravy, rice with gravy, pasta, french fries, breads, pies, soft cookies, biscuits, rolls, and all foods on pureed and mechanical diets.
- Exclusions: Hard raw vegetables, crisp fruits, fried meats or vegetables, nuts, seeds, and dried fruits
Regular diet
- Texture: All food consistencies as per nutritional recommendations
Modified liquid textures
- Thin: Regular liquids such as water, juice, soft drinks, Jell-O, juice, milk, tea, Ensure, ice cream, and soup broths
- Nectar-thick: Liquids with a thicker consistency, such as V8 juice, buttermilk, and shakes
- Honey-thick: Liquids thickened to the consistency of honey or thin pudding
Swallow precautions to reduce the risk of choking
- Sit in an upright position (90 degrees) when eating and drinking.
- Eat slowly.
- Reduce distractions.
- Make sure the mouth is clear completely between bites.
- Take small bites and sips.
- Remain in an upright, seated position for about 30 minutes after eating and drinking.