Oropharyngeal dysphagia arises from abnormalities of muscles, nerves or structures of the oral cavity, pharynx, and upper esophageal sphincter.

Signs and symptoms

Some signs and symptoms of swallowing difficulties include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent

pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severit ...

, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and dysphagia (patient complaint of swallowing difficulty). Other symptoms include drooling, dysarthria, dysphonia, aspiration pneumonia, depression, or nasopharyngeal regurgitation as associated symptoms. When asked where the food is getting stuck patients will often point to the cervical (neck) region as the site of the obstruction.

Complications

If left untreated, swallowing disorders can potentially cause

aspiration pneumonia Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may inclu ...

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues ...

, or

dehydration In physiology, dehydration is a lack of total body water, with an accompanying disruption of metabolic processes. It occurs when free water loss exceeds free water intake, usually due to exercise, disease, or high environmental temperature. Mil ...

Diagnosis

Oropharyngeal dysphagia is going to be suspected if the patient answers yes to one of the following questions: Do you cough or choke when trying to eat? After you swallow, does the food ever come back out through your nose? A patient will most likely receive a Modified Barium swallow (MBS). Different consistencies of liquid and food mixed with

barium Barium is a chemical element with the symbol Ba and atomic number 56. It is the fifth element in group 2 and is a soft, silvery alkaline earth metal. Because of its high chemical reactivity, barium is never found in nature as a free element. The ...

sulfate are fed to the patient by spoon, cup or syringe, and x-rayed using videofluoroscopy. A patient's swallowing then can be evaluated and described. Some clinicians might choose to describe each phase of the swallow in detail, making mention of any delays or deviations from the norm. Others might choose to use a rating scale such as the Penetration Aspiration Scale. The scale was developed to describe the disordered physiology of a person's swallow using the numbers 1–8. Other scales also exist for this purpose. A patient can also be assessed using videoendoscopy, also known as flexible fiberoptic endoscopic examination of swallowing (FFEES). The instrument is placed into the nose until the clinician can view the

pharynx The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its struct ...

and then he or she examines the pharynx and

larynx The larynx (), commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about ...

before and after swallowing. During the actual swallow, the camera is blocked from viewing the anatomical structures. A rigid scope, placed into the oral cavity to view the structures of the pharynx and larynx, can also be used, though this prevents the patient from swallowing. Other less frequently used assessments of swallowing are imaging studies,

ultrasound Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...

and

scintigraphy Scintigraphy (from Latin ''scintilla'', "spark"), also known as a gamma scan, is a diagnostic test in nuclear medicine, where radioisotopes attached to drugs that travel to a specific organ or tissue (radiopharmaceuticals) are taken internally and ...

and nonimaging studies,

electromyography Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles. EMG is performed using an instrument called an electromyograph to produce a record called an electromyogram. An electromyog ...

(EMG), electroglottography (EGG)(records vocal fold movement), cervical

auscultation Auscultation (based on the Latin verb ''auscultare'' "to listen") is listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory and respiratory systems (hear ...

, and pharyngeal manometry.

Differential diagnosis

* A

stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop funct ...

can cause pharyngeal dysfunction with a high occurrence of aspiration. The function of normal

swallowing Swallowing, sometimes called deglutition in scientific contexts, is the process in the human or animal body that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. Swallowing is ...

may or may not return completely following an acute phase lasting approximately 6 weeks.Murray, J. (1999). ''Manual of Dysphagia Assessment in Adults''. San Diego: Singular Publishing. *

Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms usually emerge slowly, and as the disease worsens, non-motor symptoms beco ...

can cause "multiple prepharyngeal, pharyngeal, and esophageal abnormalities". The severity of the disease most often correlates with the severity of the swallowing disorder. * Neurologic disorders such as

amyotrophic lateral sclerosis Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or Lou Gehrig's disease, is a neurodegenerative disease that results in the progressive loss of motor neurons that control voluntary muscles. ALS is the most comm ...

Bell's palsy Bell's palsy is a type of facial paralysis that results in a temporary inability to control the facial muscles on the affected side of the face. In most cases, the weakness is temporary and significantly improves over weeks. Symptoms can vary f ...

, or

myasthenia gravis Myasthenia gravis (MG) is a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness. The most commonly affected muscles are those of the eyes, face, and swallowing. It can result in double vision, droo ...

can cause weakness of facial and lip muscles that are involved in coordinated mastication as well as weakness of other important

muscles of mastication There are four classical muscles of mastication. During mastication, three muscles of mastication (''musculi masticatorii'') are responsible for adduction of the jaw, and one (the lateral pterygoid) helps to abduct it. All four move the jaw late ...

and swallowing. *

Oculopharyngeal muscular dystrophy Oculopharyngeal muscular dystrophy (OPMD) is a rare form of muscular dystrophy with symptoms generally starting when an individual is 40 to 50 years old. It can be autosomal dominant neuromuscular disease or autosomal recessive. The most common i ...

is a genetic disease with palpebral ptosis, oropharyngeal dysphagia, and proximal limb weakness. * Decrease in salivary flow, which can lead to dry mouth or

xerostomia Xerostomia, also known as dry mouth, is dryness in the mouth, which may be associated with a change in the composition of saliva, or reduced salivary flow, or have no identifiable cause. This symptom is very common and is often seen as a side eff ...

, can be due to

Sjögren syndrome Sjögren syndrome or Sjögren's syndrome (SjS, SS) is a long-term autoimmune disease that affects the body's moisture-producing (lacrimal and salivary) glands, and often seriously affects other organ systems, such as the lungs, kidneys, and nerv ...

anticholinergics Anticholinergics (anticholinergic agents) are substances that block the action of the neurotransmitter called acetylcholine (ACh) at synapses in the central and peripheral nervous system. These agents inhibit the parasympathetic nervous system ...

antihistamines Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provides re ...

, or certain

antihypertensives Antihypertensives are a class of drugs that are used to treat hypertension (high blood pressure). Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke and myocardial infarction. Evidence suggests that r ...

and can lead to incomplete processing of food bolus. *

Xerostomia Xerostomia, also known as dry mouth, is dryness in the mouth, which may be associated with a change in the composition of saliva, or reduced salivary flow, or have no identifiable cause. This symptom is very common and is often seen as a side eff ...

can reduce the volume and increase the

viscosity The viscosity of a fluid is a measure of its resistance to deformation at a given rate. For liquids, it corresponds to the informal concept of "thickness": for example, syrup has a higher viscosity than water. Viscosity quantifies the inter ...

of oral secretions making bolus formation difficult as well as reducing the ability to initiate and swallow the bolus * Dental problems can lead to inadequate chewing. * Abnormality in oral mucosa such as from

mucositis Mucositis is the painful inflammation and ulceration of the mucous membranes lining the digestive tract, usually as an adverse effect of chemotherapy and radiotherapy treatment for cancer. Mucositis can occur anywhere along the gastrointestinal (G ...

, aphthous

ulcers An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing o ...

, or herpetic lesions can interfere with bolus processing. * Mechanical obstruction in the oropharynx may be due to malignancies, cervical rings or webs, crico-phyringeus muscle dysfunction, or cervical

osteophytes Osteophytes are exostoses (bony projections) that form along joint margins. They should not be confused with enthesophytes, which are bony projections that form at the attachment of a tendon or ligament. Osteophytes are not always distinguished ...

. * Increased upper esophageal sphincter tone can be due to

which leads to incomplete opening of the UES. This may lead to formation of a

Zenker's diverticulum A Zenker's diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the human pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a pseudo diverticulum (not involving all layers o ...

. * Pharyngeal pouches typically cause difficulty in swallowing after the first mouthful of food, with regurgitation of the pouch contents. These pouches may be accompanied by malodorous breath due to decomposing foods residing in the pouches. (See

) * Dysphagia is often a side effect of surgical procedures like anterior

cervical spine In tetrapods, cervical vertebrae (singular: vertebra) are the vertebrae of the neck, immediately below the skull. Truncal vertebrae (divided into thoracic and lumbar vertebrae in mammals) lie caudal (toward the tail) of cervical vertebrae. In sau ...

surgery,

carotid endarterectomy Carotid endarterectomy is a surgical procedure used to reduce the risk of stroke from carotid artery stenosis (narrowing the internal carotid artery). In endarterectomy, the surgeon opens the artery and removes the plaque. The plaque forms and t ...

, head and neck resection, oral surgeries like removal of the tongue, and partial laryngectomies *

Radiotherapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radi ...

, used to treat head and neck cancer, can cause tissue

fibrosis Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of perma ...

in the irradiated areas. Fibrosis of

tongue The tongue is a muscular organ in the mouth of a typical tetrapod. It manipulates food for mastication and swallowing as part of the digestive process, and is the primary organ of taste. The tongue's upper surface (dorsum) is covered by taste b ...

and

lead to reduced tongue base retraction and laryngeal elevation during swallowing * Infection may cause

pharyngitis Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice ...

which can prevent swallowing due to

pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...

. * Medications can cause

central nervous system The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain and spinal cord. The CNS is so named because the brain integrates the received information and coordinates and influences the activity of all par ...

effects that can result in swallowing disorders and oropharyngeal dysphagia. Examples:

sedatives A sedative or tranquilliser is a substance that induces sedation by reducing irritability or excitement. They are CNS depressants and interact with brain activity causing its deceleration. Various kinds of sedatives can be distinguished, but th ...

, hypnotic agents,

anticonvulsants Anticonvulsants (also known as antiepileptic drugs or recently as antiseizure drugs) are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of b ...

neuroleptics Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of oth ...

barbiturates Barbiturates are a class of depressant drugs that are chemically derived from barbituric acid. They are effective when used medically as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological addiction potential as we ...

, and antiseizure medication. Medications can also cause peripheral nervous system effects resulting in an oropharyngeal dysphagia. Examples:

corticosteroids Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...

, L-tryptophan, and

Treatment

;

Thickening agent A thickening agent or thickener is a substance which can increase the viscosity of a liquid without substantially changing its other properties. Edible thickeners are commonly used to thicken sauces, soups, and puddings without altering their ta ...

s Food thickeners can be used to improve swallowing in pediatric populations. ;Postural techniques. * Head back (extension) – used when movement of the bolus from the front of the mouth to the back is inefficient; this allows gravity to help move the food. * Chin down (flexion) – used when there is a delay in initiating the swallow; this allows the valleculae to widen, the airway to narrow, and the epiglottis to be pushed towards the back of the throat to better protect the airway from food. * Chin down (flexion) – used when the back of the tongue is too weak to push the food towards the pharynx; this causes the back of the tongue to be closer to the pharyngeal wall. * Head rotation (turning head to look over shoulder) to damaged or weaker side with chin down – used when the airway is not protected adequately causing food to be aspirated; this causes the epiglottis to be put in a more protective position, it narrows the entrance of the airway, and it increases

vocal fold The human voice consists of sound made by a human being using the vocal tract, including talking, singing, laughing, crying, screaming, shouting, humming or yelling. The human voice frequency is specifically a part of human sound producti ...

closure. * Lying down on one side – used when there is reduced contraction of the pharynx causing excess residue in the pharynx; this eliminates the pull of gravity that may cause the residue to be aspirated when the patient resumes breathing. * Head rotation to damaged or weaker side – used when there is paralysis or

paresis In medicine, paresis () is a condition typified by a weakness of voluntary movement, or by partial loss of voluntary movement or by impaired movement. When used without qualifiers, it usually refers to the limbs, but it can also be used to desc ...

on one side of the pharyngeal wall; this causes the bolus to go down the stronger side. * Head tilt (ear to shoulder) to stronger side – used when there is weakness on one side of the oral cavity and pharyngeal wall; this causes the bolus to go down the stronger side. ;Swallowing maneuvers. * Supraglottic swallow - The patient is asked to take a deep breath and hold their breath. While still holding their breath they are to swallow and then immediately cough after swallowing. This technique can be used when there is reduced or late vocal fold closure or there is a delayed pharyngeal swallow. * Super-supraglottic swallow - The patient is asked to take a breath, hold their breath tightly while bearing down, swallow while still holding the breath hold, and then coughing immediately after the swallow. This technique can be used when there is reduced closure of the airway. * Effortful swallow - The patient is instructed to squeeze their muscles tightly while swallowing. This may be used when there is reduced posterior movement of the tongue base. * Mendelsohn maneuver - The patient is taught how to hold their

adam's apple The Adam's apple or laryngeal prominence is the protrusion in the human neck formed by the angle of the thyroid cartilage surrounding the larynx, typically visible in men, less frequently in women. Structure The topographic structure which is e ...

up during a swallow. This technique may be used when there is reduced laryngeal movement or a discoordinated swallow. ;Medical device In order to strengthen muscles in the mouth and throat areas, researchers at the

University of Wisconsin–Madison A university () is an institution of higher (or tertiary) education and research which awards academic degrees in several academic disciplines. Universities typically offer both undergraduate and postgraduate programs. In the United States, the ...

, led by Dr. JoAnne Robbins, developed a device in which patients perform

isometric exercise An isometric exercise is a form of exercise involving the static contraction of a muscle without any visible movement in the angle of the joint. The term "isometric" combines the Greek words ''isos'' (equal) and ''-metria'' (measuring), meaning ...

s with the tongue. ;Diet modifications Diet modification may be warranted. Some patients require a

soft diet A mechanical soft diet or edentulous diet or soft food(s) diet is a diet that involves only foods that are physically soft, with the goal of reducing or eliminating the need to chew the food. It is recommended for people who have difficulty che ...

that is easily chewed, and some require liquids of a thinned or thickened consistency. The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life. There has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures. However, the International Dysphagia Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a continuum of 8 levels (0-7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. ;Environmental modifications Environmental modification can be suggested to assist and reduce risk factors for aspiration. For example, removing distractions like too many people in the room or turning off the TV during feeding, etc. ;Oral sensory awareness techniques Oral sensory awareness techniques can be used with patients who have a swallow apraxia, tactile

agnosia Agnosia is the inability to process sensory information. Often there is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss. It is usually ...

for food, delayed onset of the oral swallow, reduced oral sensation, or delayed onset of the pharyngeal swallow. * pressure of a spoon against tongue * using a sour bolus * using a cold bolus * using a bolus that requires chewing * using a bolus larger than 3mL * thermal-tactile stimulation (controversial) ;Prosthetics * Palatal lift or

Palatal obturator {{no footnotes, date=February 2017 The Latham Device Post Latham Nasal Alveolar Molding Device Post Insertion A palatal obturator is a prosthesis that totally occludes an opening such as an oronasal fistula (in the roof of the mouth). They are ...

* Maxillary denture

Surgery

These are usually only recommended as a last resort. *

Tracheotomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The re ...

Tracheostomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The re ...

* Vocal fold augmentation/injection * Thryoplasty medialization * Arytenoid adduction * Partial or total

laryngectomy Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and ...

* Laryngotracheal separation * Supralaryngectomy * Palatoplasty * Cricopharyngeal myotomy * Zenker's diverticulectomy *

Percutaneous endoscopic gastrostomy Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (fo ...

Feeding tube Eating (also known as consuming) is the ingestion of food, typically to provide a heterotrophic organism with energy and to allow for growth. Animals and other heterotrophs must eat in order to survive — carnivores eat other animals, herbi ...

References

External links

Swallowing and Feeding
{{Digestive system and abdomen symptoms and signs Symptoms and signs: Digestive system and abdomen