Oropharyngeal Dysphagia

See Also

Causes
Neuromuscular Disorders

Amyotrophic Lateral Sclerosis
Myasthenia Gravis
Bulbar Paralysis
Cerebrovascular Accident
1. See Dysphagia after Cerebrovascular Accident
Parkinson Disease
Multiple Sclerosis
Polymyositis or Dermatomyositis
Geriatric Degenerative Conditions
1. Dementia (e.g. Alzheimer Disease)
2. Frailty (Sarcopenia)

Causes
Extra-Oral Compression From Structural Disorders

Head and Neck Mass (see Neck Masses in Adults)
Head and Neck Surgery or Radiation Therapy
Zenker Diverticulum
Acute Calcific Tendonitis of the Longus Colli (ACTLC)
Cervical Spine Osteoarthritis with osteophyte related posterior pharynx compression
Lymphadenopathy
Thyroid Goiter
Cricopharyngeal bar

Causes
Medications and Toxins

Extrapyramidal Side Effect (e.g. Tardive Dyskinesia with ChoreiformTongue movements)
1. Antipsychotic Medications (e.g. Haloperidol, Risperdal)
2. Other agents (e.g. Levodopa, Metoclopramide, Phenytoin, Antidepressants)
Local Medication Effects
1. See Pharyngitis Causes
2. See Medication Causes of Dry Mouth
3. Stomatitis (e.g. Chemotherapy or Radiation Therapy induced)
Toxins and Metabolic Conditions

Causes
Oral Conditions

Extensive dental disease, poor Dentition or ill-fitting dentures
Xerostomia or Dry Mouth (e.g. Sjogren's Syndrome)

History

See Dysphagia
Difficulty initiating Swallowing?
Swallowing leads to coughing or Choking?
Swallowing with reflux into the nose or throat?
Acute Oropharyngeal Dysphagia?
1. Consider Cerebrovascular Accident
2. Consider Pharyngitis
3. Consider new medications with Xerostomia
Progressive Oropharyngeal Dysphagia?
1. Progressive neuromuscular disorder
2. Head and Neck Mass
Intermittent?
1. Consider new medications
2. Consider ill fitting dentures
Is there difficulty with chewing?
1. Chewing limited by jaw pain?
2. Chewing limited by Tooth Pain or malocclusion?
  1. Dental disease
  2. Ill-fitting dentures
3. Chewing limited by weakness?
Is there liquid Dysphagia only?
1. Solid Dysphagia or liquid and solid Dysphagia are more suggestive of Esophageal Dysphagia
Are the new medications?
1. Medication Causes of Dry Mouth
2. Pill Esophagitis provocative medications
Is there Unintentional Weight Loss?
1. Consider head and neck malignancy

Exam

See Dysphagia
General
1. Cachexia or Muscle wasting (consider active malignancy)
2. Frailty (Sarcopenia)
Oropharynx
1. Xerostomia
2. Dentition or Dentures
3. Tongue motor abnormalities (tongue Fasciculations, Tongue deviation)
Neck
1. Cervical Lymphadenopathy
2. Thyromegaly or Thyroid Goiter
3. Neck Mass
Skin Exam
1. Dermatomyositis findings (e.g. Gottron's Papules)
2. Scleroderma findings (e.g. Sausage Digits)
Neurologic Exam
1. Altered Mental Status
  1. Transient, acute risk for Aspiration Pneumonitis
2. Speech
  1. Weak, breathy or dysarthric in various neurologic and neuromuscular disorders
3. Swallowing
  1. Coughing or Choking when Swallowing (Oropharyngeal Dysphagia)
4. Focal Motor Weakness
  1. Cerebrovascular Accident
5. Generalized Motor Weakness
  1. Myasthenia Gravis (Ptosis, Diplopia, Dysarthria)
6. Cranial Nerves
  1. Eyelid Ptosis
  2. Gag Reflex loss (CN 9 and CN 10)
  3. Facial or Tongue neurologic deficits (CN 5, CN 7, CN 12)

Evaluation
Screening Tools

Eating Assessment Tool or EAT-10 (Nestle)
1. https://www.nestlehealthscience.com/health-management/gastro-intestinal/dysphagia/eat-10
2. Belafsky (2008) Ann Otol Rhinol Laryngol 117(12):919-24 +PMID:19140539 [PubMed]
What About Swallowing?
1. See Dysphagia
2. Standard Dysphagia history is as effective as EAT-10 questionnaire
3. Heijnen (2016) Dysphagia 31(2):214-22 +PMID:26753926 [PubMed]
Swallowing Quality of Life Questionnaire (SWAL-QOL)
1. Requires purchase of Questionnaire
Sidney Swallow Questionnaire
1. https://stgeorgeswallowcentre.org/sydney-swallow-questionnaire/
2. Dwiveldi (2010) Oral Oncol 46(4):e10-4 +PMID:20219415 [PubMed]

Evaluation
Diagnostics

See Swallowing Evaluation for Oropharyngeal Dysphagia
Undiagnosed Dysphagia and silent aspiration is common in the frail elderly
1. Consider in those with prior Cerebrovascular Accident, Dementia or Neuromuscular Disorder
Avoid over-aggressive treatment and dietary restrictions
1. Educate patient and their family on findings on options for management
2. Discuss risks and benefits of interventions
3. Tailor management to patient preferences

Management

Optimize meal schedule and eating environment to best suit the needs of the patient
Eat mindfully
1. Avoid foods that are more likely to cause Dysphagia
2. Cut food into small pieces
3. Eat slowly, with smaller bites and chew carefully
4. Frequently drink liquids to dilute food bolus consistency
5. Adding sauce to food may lubricate food bolus and allow easier Swallowing
Dietary changes
1. See Dysphagia Diet
2. Mechanical Soft Diet
  1. Indicated in chewing weakness or poor Dentition
3. Modified Consistency Diet (thickened foods and liquids that slow transit)
  1. Indicated in impaired Swallowing
4. Pureed Diet
  1. Indicated in chewing weakness, poor Dentition or Xerostomia
Swallowing Rehabilitation
1. Muscular reconditioning Exercises
  1. Exercises to stengthen jaw, lips and Tongue in clinically stable patients with learning potential
2. Compensatory safe Swallowing techniques (repositioning maneuvers)
  1. Eat while in upright position
  2. Chin-Tuck Maneuver
    1. Indicated in patients with aspiration risk due to stroke or neuromuscular disorder
    2. Directs food posteriorly, reducing the risk of aspiration
    3. Saconato (2016) Int Arch Otorhinolaryngol 20(1): 13-7 [PubMed]
  3. Head-Turn Maneuver
    1. Indicated in patients with Unilateral Weakness
    2. Turn head toward weak side
    3. Gravity directs food toward the stronger side
Enteral Feeding
1. Consider alternatives and follow patient wishes after education on choices
  1. Consider Palliative Care or hospice Consultation
  2. Careful hand feeding
    1. Non-invasive alternative to PEG Tubes with similar efficacy and safety
    2. DiBartolo (2006) J Gerontol Nurs 32(5):25-33 [PubMed]
2. Nasogastric Tube
  1. Allows for acute nutrition and medication administration in the first week after Cerebrovascular Accident
3. Percutaneous Endoscopic Gastrostomy (PEG)
  1. Allows for the longterm Oropharyngeal Dysphagia management in severe Dysphagia
  2. Does not reduce aspiration risk or decrease mortality
  3. Teno (2012) J Am Geriatr Soc 60(10): 1918-21 [PubMed]

Complications

References