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Signs and Symptoms of Abnormal Swallow: Aspiration (Coughing, Choking)

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Anda Doroftei

The document discusses signs and symptoms of abnormal swallowing, including aspiration and inefficient swallowing. Aspiration can occur before, during, or after swallowing due to issues like reduced tongue control, delayed swallow response, or residue left in the pharynx after swallowing. Determining the cause of aspiration is important for treatment. Inefficient swallowing can cause malnutrition or dehydration. Screening and evaluation of swallowing is important for patients who have difficulty swallowing. Radiologic tests like modified barium swallow and manometry can be used to evaluate swallowing function. Abnormal findings may indicate disorders of the brainstem, cranial nerves, myoneural junction, or pharyngeal musculature.

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Signs and Symptoms of Abnormal Swallow: Aspiration (Coughing, Choking)

Uploaded by

Anda Doroftei
51 views2 pages
The document discusses signs and symptoms of abnormal swallowing, including aspiration and inefficient swallowing. Aspiration can occur before, during, or after swallowing due to issues like reduced tongue control, delayed swallow response, or residue left in the pharynx after swallowing. Determining the cause of aspiration is important for treatment. Inefficient swallowing can cause malnutrition or dehydration. Screening and evaluation of swallowing is important for patients who have difficulty swallowing. Radiologic tests like modified barium swallow and manometry can be used to evaluate swallowing function. Abnormal findings may indicate disorders of the brainstem, cranial nerves, myoneural junction, or pharyngeal musculature.

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The document discusses signs and symptoms of abnormal swallowing, including aspiration and inefficient swallowing. Aspiration can occur before, during, or after swallowing due to issues like reduced tongue control, delayed swallow response, or residue left in the pharynx after swallowing. Determining the cause of aspiration is important for treatment. Inefficient swallowing can cause malnutrition or dehydration. Screening and evaluation of swallowing is important for patients who have difficulty swallowing. Radiologic tests like modified barium swallow and manometry can be used to evaluate swallowing function. Abnormal findings may indicate disorders of the brainstem, cranial nerves, myoneural junction, or pharyngeal musculature.

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© All Rights Reserved
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Download as docx, pdf, or txt
51 views2 pages

Signs and Symptoms of Abnormal Swallow: Aspiration (Coughing, Choking)

Uploaded by

Anda Doroftei
The document discusses signs and symptoms of abnormal swallowing, including aspiration and inefficient swallowing. Aspiration can occur before, during, or after swallowing due to issues like reduced tongue control, delayed swallow response, or residue left in the pharynx after swallowing. Determining the cause of aspiration is important for treatment. Inefficient swallowing can cause malnutrition or dehydration. Screening and evaluation of swallowing is important for patients who have difficulty swallowing. Radiologic tests like modified barium swallow and manometry can be used to evaluate swallowing function. Abnormal findings may indicate disorders of the brainstem, cranial nerves, myoneural junction, or pharyngeal musculature.

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SIGNS AND SYMPTOMS OF ABNORMAL SWALLOW

ASPIRATION (COUGHING, CHOKING)


Aspiration is the entry of material into the airway below the true vocal folds. The effect of chronic aspiration in adults is not well understood, but
long-term chronic aspiration may result in pneumonia or pulmonary changes. Patients who are observed to aspirate on a radiographic study of
swallowing are at significantly greater risk of pneumonia developing than patients who do not show aspiration on such a study. Many patients with
head and neck cancer who have chronic aspiration do not survive long enough to experience the long-term effects of their aspira tion. Aspiration may
occur before, during, or after the pharyngeal swallow.4 Aspiration that occurs before the pharyngeal swallow may result from one of two disorders:
reduced tongue control or a delayed or absent pharyngeal swallow. When tongue control is reduced during the oral preparatory or oral stages of the
swallow, bits and pieces of food may fall into the pharynx and the open airway as the patient chews. Importantly, the airway is normally open during
the oral preparatory and oral stages of the swallow. The airway is closed only for a fraction of a second during the pharyngeal swallow. Aspiration
before the swallow can also occur because of a delayed or absent pharyngeal swallow. In these patients, the food is pro pelled out of the oral cavity by
the tongue and falls into the pharynx, wherein it may come to rest in the valleculae, the piriform sinus, or the airway before the pharyngeal swallow is
triggered. The entry of food into the airway does not always trigger a cough, particularly in neurologically impaired patients and in some patients with
head and neck cancer in whom sensory input is damaged.41,42
Aspiration during the swallow takes place when airway closure is inadequate to prevent material from entering the airway
during the pharyngeal swallow. Aspiration after the swallow occurs for a number of reasons that include reduced laryngeal
elevation, reduced tongue-base retraction, reduced pharyngeal contraction, unilateral pharyngeal damage, and
cricopharyngeal dysfunction. In all of these instances, residue remains in the pharynx after the swallow. When the patient
opens the larynx to inhale as is normal after a swallow, some of this residue is sucked into or falls into the airway.
Determination of the cause of aspiration is critical for efficient treatment because aspiration is only a symptom of a disorder.
Evaluation of swallow is designed to identify the anatomic or physiologic cause of the aspiration; treatment is designed to
eliminate the reason for the aspiration. Each of the disorders noted previously as potential causes of aspiration is treated
differently.

INEFFICIENT SWALLOWING
Inefficient swallowing—that is, the inability to propel food or liquid into the stomach at each meal—can cause malnutrition,
dehydration, and/or weight loss. Many different anatomic or physiologic swallowing disorders may cause these complica-
tions. As with aspiration, treatment is directed at the anatomic or physiologic disorder that causes these complications.

SCREENING FOR SWALLOWING DISORDERS


Screening involves quickly reviewing patient characteristics to see whether they indicate the possible presence of a
swallowing disorder and the need for a more in-depth examination. To screen a patient, the clinician may do a chart review,
briefly talk with the patient, and/or observe him or her eating a meal.

EVALUATION OF SWALLOWING
Because inefficient swallowing or aspiration occurs in many patients without visible external symptoms such as coughing, a
careful evaluation of swallowing is imperative for patients who have been temporarily removed from oral feeding because of
surgery or a neurologic incident, such as a cerebrovascular accident or closed head trauma. The currently available proce-
dures to examine swallowing include fluoroscopy, manometry, ultrasonography, and endoscopy.

MOTILITY DISORDERS
PHARYNX
The modified barium swallow is the most appropriate radiologic test to evaluate swallowing dysfunction. 9 Although an esophagogram
provides some information about deglutition, the modified swallow uses barium of several different consistencies, which provides a more
detailed evaluation. Functional endoscopic evaluation of swallowing, with or without sensory testing, has been proposed as an alternative to
the modified swallow.38 However, the modified swallow provides a more physiologic environment because no endoscope is present to inter-
fere with motility. During a modified swallow, patients can use protective maneuvers such as a chin tuck and forced cough, which are not
available during endoscopy. Furthermore, the modified swallow evaluates the upper phases of swallowing in more detail. 39 Endoscopy and
modified swallow are considered complementary examinations at most institutions.
The modified barium swallow can evaluate all phases of the swallow reflex. 2,8,40,41 The tongue forms the oral bolus and then

transports it from the oral cavity to the oropharynx. The soft palate elevates and approximates the posterior pharynx to prevent
velopharyngeal reflux. The entire larynx elevates, followed by a peristaltic wave through the pharynx. The epiglottis inverts to
deflect the bolus into the piriform sinuses and protect the laryngeal vestibule. At the bottom of the hypopharynx, the
cricopharyngeus muscle relaxes to permit the passage of the food bolus.
Velopharyngeal occlusion can be observed directly. Elevation of the larynx is best visualized by observing the hyoid bone.
Epiglottic inversion is fast, and confirmation of this event may require review of the video images. Brief episodes of
contrast penetration may be seen in the laryngeal vestibule. If the contrast clears rapidly and without cough, this finding
does not indicate a risk of tracheal aspiration. A small amount of barium may pool in the valleculae or the piriform sinuses
in normal patients, but the peristaltic wave should strip the contrast from the remainder of the pharynx. The
cricopharyngeus muscle lies at the level of the C6 vertebral body, and it is not normally visualized.

Abnormal Deglutition
Aspiration can occur in any phase of deglutition and is classified as preprandial, prandial, or postprandial based on its relation ship to the
swallow reflex. During the oral phase (preprandial ), incomplete control of the oral bolus allows contrast to spill over the base of the tongue
into the vallecula. In severe cases, the vallecula will fill completely, and contrast will spill over the epiglottis into the larynx. During
peristalsis (prandial ), failure of epiglottic inversion allows contrast to enter the larynx. After the swallow (postprandial ), incomplete
clearance of contrast leads to aspiration when the patient resumes breathing.
Abnormal pharyngeal motility is caused by disorders of 1) the brainstem, 2) cranial nerves IX and X, 3) the myoneural
junction, or 4) the pharyngeal musculature. Myasthenia gravis is a disorder of the myoneural junction that produces
hesitancy in swallow initiation, nasopharyngeal reflux, enlargement of the pharynx, tracheal aspiration, and incomplete
clearance. The findings worsen over consecutive swallows and improve after neostigmine administration. 42 Diseases that
affect the cricopharyngeal impression between swallows. Cricopharyngeal chalasia is specific for myotonic dystrophy,
although most patients with myotonic dystrophy have cricopharyngeal achalasia instead.46
Delayed opening of the cricopharyngeus, seen in familial dysautonomia, results in aspiration and recurrent pulmonary
infections. This disorder is distinct from cricopharyngeal achalasia in that the muscle relaxes completely after a delay.

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