MedifocusHealth

Signs of dysphagia include:

• Drooling
• Poor control of the tongue, tongue thrust, unintentionally spitting food from the mouth
• Pocketing food in the cheek or under the tongue
• Coughing or choking while eating
• Complaints by patients that food is stuck in their throats
• Excessive chewing time
• Facial weakness
• Slurred speech

Following evaluation by a speech-language pathologist, a videofluorographic swallowing study of liquids, purees, and solids may be undertaken to identify the swallowing disorder and organize a treatment plan. Fiberoptic laryngoscopy may be a useful means to rule out tracheal aspiration if tracheal aspiration and pharyngeal pooling are not observed during laryngoscopy and the gag reflex is normal. Other diagnostic procedures may include ultrasound of the oral musculature, scintigraphy to assess gastroesophageal reflux, and manometry of the pharynx and esophagus.

Suspicion of dysphagia should be high in stroke survivors since only 40% of patients who aspirate food or fluid may be identified during a bedside evaluation. Presence of aspiration or other types of swallowing disorders are not associated with the stroke lesion site. However, patients with combined bilateral hemispheric and brainstem lesions are more likely to aspirate than patients with cortical or brainstem lesions alone. Symptoms associated with aspiration include dysphonia (altered voice) and an impaired gag reflex associated with impaired cough. Rehabilitation programs which include identification and treatment of dysphagia also report reductions in rates of pneumonia.

Consequences of dysphagia include:

• Malnutrition - This is estimated to occur in up to 64% of patients immediately following stroke onset, 35% of stroke patients 2 weeks after the stroke, and in up to 50% of stroke patients with severe stroke or prolonged hospitalizations. At two to four months poststroke, the incidence is thought to drop to approximately 20%. Malnutrition in stroke survivors is correlated with:
  • impaired function
  • longer stay in rehabilitation/nursing facility
  • frequency of infection
  • decubiti (bed sores)
  • death
• Weight loss
• Dehydration
• Aspiration of food - Some studies have identified aspiration in 30-50% of stroke patients. It is a common cause of pneumonia.
• Pneumonia - Up to 11% of stroke survivors develop pneumonia in the first three months after stroke and it is the most common cause of death in stroke survivors in the second and third month following stroke.

Other complications of stroke that could result in dysphagia include depression, factors preventing patients from feeding themselves such as paralysis or visual-spatial deficits, cognitive changes affecting concentration during eating, sensory deficits, or agnosia (denial of existence of a deficit).

Treatment of dysphagia includes modification in diet, head positioning, or other compensatory strategies to prevent aspiration. Many stroke survivors will regain normal swallowing function within 2 to 3 weeks. Most patients tolerate a full oral diet by the conclusion of rehabilitation, although some cannot drink thin liquids safely. When enteral feedings are necessary, the use of gastrostomies (a hole, or stoma, in the abdomen where a feeding tube is inserted) significantly lowers mortality when compared to that of nasogastric tubes. Even when stroke survivors are fed exclusively by gastrostomy, every attempt should be made to begin some oral feeding. The ability to take even small amounts of food by mouth allows the stroke survivor to practice swallowing and also provides some social element when friends and family gather together for a meal. In addition, patients who undergo therapy for dysphagia have lower rates of pneumonia than those who do not.

Depression