The swallowing process involves chewing of food in the mouth before its delivery to the throat for a complex and highly coordinated process of gradual emptying into the esophagus and then the stomach.
Dysphagia occurs when any of the above processes goes wrong. Up to 50 percent of the elderly in Hong Kong may have a degree of dysphagia.
Many medical conditions could lead to dysphagia. These include brain disorders such as strokes, brain tumors, Parkinson’s disease, dementia and muscle disorders. While these brain disorders generally occur in the older population, younger people could also develop such disorders from cerebral palsy, acquired at birth from brain injury. Diseases affecting the head and neck regions could also lead to dysphagia. These include nasopharyngeal cancer and cancers of the tongue and throat etc. Surgical and radiotherapy treatment for these cancers, as well as lung diseases, such as lung cancer, severe emphysema and others could also cause dysphagia.
Patients with dysphagia often eat very slowly, and have noticeable food debris left in the mouth afterwards. While eating, or shortly afterwards, they often develop hoarseness, coughing, breathing difficulty and more sputum, due to inhalation of the food or fluid into the windpipe. They often develop malnutrition and weight loss, with poor general health subsequently. The above usually become worse when dealing with thin fluids such as water, as the flow into the throat is much faster than thick paste (such as congee or puree). Blocking of the windpipe could occur, resulting in pneumonia or in severe cases, instant death due to suffocation.
Pneumonia is a common (up to 10 cases per 1,000 population) and potentially fatal illness particularly affecting the young and elderly. Pneumonia secondary to dysphagia, known as aspiration pneumonia, could account for up to 15 percent of all pneumonia cases. These patients could have a severe cough, breathing difficulties, fever, extreme fatigue, and lots of sputum mixed with blood. It is, therefore, extremely important to prevent the occurrence of aspiration pneumonia by early identification of patients with dysphagia.
The older version of swallowing test, “video-fluorescopic swallowing study”, entails detection of the swallowing process by X-ray mediated filming of the movement of food stuff mixed with barium to provide a contrast. Barium is un-tasty and often itself causes a degree of swallowing problem. Instead of the traditional test, many professionals would now prefer to proceed to test the patient with “fibreoptic endoscopic evaluation of swallowing (FEES)” as the patient could be observed to swallow food stuff without the need of barium, and often in the company of their carers. Additionally, should any aspiration of food occur, the physician could remove such from the airways immediately. The precise defect for swallowing, such as voice box abnormalities and poor muscle coordination could be identified at FEES to allow planning of further treatment.
It is important to diagnose early to rectify the swallowing defect with choice of correct food texture. For instance, some patients with dysphagia could overcome the aspiration risks by simply adding “thickeners” into their drinks. More severely affected patients would need feeding with mincing or blending of food and be fed in small volumes. Very severely affected patients, who would aspirate most food stuff readily, would need a nasogastric tube, passed via the nose into the stomach. Some such long term patients would benefit from direct passage of a tube via the abdominal wall into the stomach, known as percutaneous gastrostomy. Treatment is tailored for each individual patient.
Dysphagia is a common problem, often ignored even by health care professionals. Assessment of swallowing should be part of general health care delivery to benefit these sufferers.
This article was written by Kenneth Tsang, MD (Hons) FRCP (Edin, Glas, London) FHKAM (Med), Specialist in Respiratory Medicine and Consultant Physician, Hong Kong Adventist Hospital – Stubbs Road; Pance Kung BSc (Hons) MSc, Speech Therapist, Hong Kong Adventist Hospital – Stubbs Road
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