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Speech Pathology and Dysphagia

Dysphagia (or difficulty swallowing) can be caused by a number of factors, including stroke, disability, traumatic brain injury or congenital defects. It can range in severity from mild to extremely severe, where a person might not be able to eat at all (this may require them to have a nasogastric tube, or perhaps a PEG into their stomach).

What is dysphagia?

Dysphagia refers to a difficulty with swallowing. This means that someone might find it hard to chew food, or keeping food/liquid in their mouth. If a person (including someone who has had a stroke) has significant trouble with chewing or swallowing, it can lead to coughing, choking or aspiration (where food or fluid enters the lungs). Aspiration can have deadly consequences. If a person’s dysphagia is not assessed and treated properly, aspiration pneumonia can occur, which can sometimes cause a person to die. There are a number of ways dysphagia can be assessed, including informal measures (such as palpating a person’s swallow) and more advanced methods, such as videofluoroscopic swallow studies (VFSS) or fibreoptic endoscopic evaluation of swallowing (FEES).

What is a videofluoroscopic swallow study (VFSS)?

A videofluoroscopic swallow study (VFSS) is an x-ray technique used to assess a person’s ability to swallow a range of textures. A speech pathologist is required to perform the VFSS, and give the person a sample of each texture. Common textures include: thin fluids (eg: water), crackers/biscuits, soft food (such as yogurt or fruit in juice), and a range of thickened fluids.

All types of food have barium added to them prior to the VFSS. This is so that they appear on the x-ray monitor. During the VFSS, the speech pathologist gives the person a sample of each texture, and then assesses how well it can be managed. From the x-ray, the speech pathologist can see exactly where the person’s issues with swallowing are.

Common issues can be:

  • Anterior spillage (ie: food/fluid coming out the front of the mouth)
  • Premature spillage (ie: food down the throat before the person has had a chance to finish swallowing)
  • Food becoming stuck in the pyriform sinuses and vallecula (common structures in the throat, just below the tongue)
  • Aspiration (food/fluid entering the lungs)

What is a fibreoptic endoscopic evaluation of swallowing (FEES)?

A FEES swallow study allows doctors and speech pathologists to assess the areas around the larynx (voicebox) and the opening of the oesophagus, through the use of an endoscope. The endoscope is passed up through the nose and down into the throat (the nose is anaesthetised first to minimise discomfort). Consequently, once the endoscope is in the right position, the person is given a variety of foods to eat. As a result, the specialist/doctor can observe and evaluate the swallowing process, and determine if there are any potential issues.

Both the VFSS and FEES examinations can be done with both children and adults. Children can often have difficulty with sitting still, so therefore the FEES may be more appropriate, however this needs to be determined on a case-by-case basis.

What happens if a person does have some form of dysphagia?

When a person has dysphagia, they may need to go on a modified diet. This can include changing the texture of both the food and fluid they consume. Modified textures (both food and fluid) can range from mild to extreme changes. The amount of texture changes required depends on the severity of the dysphagia, and the person’s risk of aspiration.

Fluid modification levels:

  • Mildly Thick Level 150: runs off a spoon, but leaves a slight coating, and is just a little thicker than normal fluid
  • Moderately Thick Level 400: similar in consistency to honey at room temperature, and can be consumed with a wide straw (though is best taken via a spoon)
  • Extremely Thick Level 900: jelly-like in consistency, and does not drip off a spoon
    • Extremely thick fluid would only be given to someone with severe dysphagia, or who has had episodes of aspiration/pneumonia previously, and is at significant risk of it again

Food modification levels:

  • Unmodified/regular foods: this is the type of diet that most of us eat everyday, and includes a variety of textures, such as crunchy, chewy/soft, and food that has small pieces (eg: peas)
  • Texture A (Soft): naturally soft foods (eg: ripe banana), or food that is cooked/cut to change its texture (eg: mashed potato); minimal cutting is needed for this, and sauce/gravy can be added
  • Texture B (minced/moist): food should be soft/moist, and easily mashed with a fork; the person uses their tongue to break apart the food rather than their teeth
  • Texture C (puree): should be smooth and free of any lumps, but should still be able to hold its shape on a spoon

If a person is showing signs of dysphagia (such as coughing/choking, difficulties with chewing, food/fluid coming out of the front of the mouth), it should be assessed by their GP, who may then refer them on for further investigation (eg: for a VFSS), and then perhaps to a speech pathologist for management. It is critical to deal with dysphagia in a timely and efficient manner, so as to avoid potentially fatal consequences.

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