Swallowing Difficulties Treatment

  • Treatment

    If a person is having difficulty breathing, is choking, or has stopped breathing, call for emergency help immediately. Perform first aid for choking and cardiopulmonary resuscitation (CPR) if necessary. In some people with dysphagia, food “going down the wrong pipe” (aspiration of swallowed material) can lead to choking and even complete airway obstruction. If a person begins choking or has difficulty breathing, it is important to call for emergency medical help immediately. Emergency phone numbers should be posted clearly near all telephones.

    If a person is choking, perform first aid for choking; if a person stops breathing, perform cardiopulmonary resuscitation (CPR). Local hospitals and clinics often provide classes in these potentially life-saving skills, so that bystanders can be prepared for emergencies. This preparation is particularly important for family members, friends, and coworkers of people who have dysphagia.

    All cases of dysphagia warrant medical attention. The following measures can be undertaken only after dysphagia has been medically evaluated and its cause has been determined.

    Eliminate alcohol and dietary sources of caffeine. In some people, foods and beverages containing caffeine (coffee, tea, chocolate, and colas) and alcohol make swallowing difficulties worse. Eliminating these substances from the diet may relieve dysphagia.

    Adjust eating habits to accommodate swallowing limitations. Measures that can minimize dysphagia include changing postures, removing distractions, using special swallowing maneuvers, eating more slowly, taking smaller mouthfuls of food, and using special utensils and prosthetics. A doctor and a swallowing therapist can outline the best measures for each person's specific type of dysphagia.

    Adjust meal composition to accommodate swallowing limitations. Dysphagia may cause difficulty swallowing solids, liquids, or both solid and liquids. Choosing foods of specific consistencies may help alleviate different types of dysphagia. Solid foods can often be pureed in a blender or food processor. Adjusting the temperature, taste, and texture of foods may also help minimize dysphagia. Doctors, swallowing therapists, and dietitians can often provide helpful tips for meal preparation.

    Choose appetizing foods that are dense in calories. Moderate and severe dysphagia can lead to weight loss and malnutrition. Selecting appetizing foods and foods that contain many calories in small portions can improve a person's motivation for eating and help ensure that they consume sufficient calories and nutrients. A nutritionist can help you to calculate the required calories and suggest different menus.

    If dry mouth (xerostomia) is causing dysphagia, try chewing gum, sucking on lozenges, or using a homemade artificial saliva solution. In some cases of xerostomia (dry mouth), saliva secretion can be promoted by chewing gum or sucking on sour lozenges. If the salivary glands cannot secrete saliva, a homemade artificial saliva solution can be made by adding 1 teaspoon of baking soda and 1 teaspoon of salt to a quart of water.

    Your doctor is the best source of information on the drug treatment choices available to you.

    Esophageal tumors may be treated with a variety of different therapies. Treatment options for esophageal tumors depend on whether they are benign or malignant. Benign tumors can be removed either surgically or endoscopically. Treatment of malignant tumors depends on how advanced they are. If a tumor is malignant (esophageal cancer), treatment may include radiation therapy and chemotherapy. Tumors that block the esophagus may also be treated with electrocoagulation (the application of electric current to a tumor in an attempt to dissolve it) or laser therapy.

    Dilatation may alleviate esophageal dysphagia caused by strictures, lower esophageal rings (Schatzki's rings), and achalasia. Dilatation refers to gradual mechanical stretching of constricted areas of the esophagus. Dilatation is usually performed during several sessions spaced out over weeks or months. Cylindrical dilators (also called bougies and the process bougienage) made of plastic or filled with mercury are advanced into the esophagus, where they exert outward pressure on the constriction. This pressure stretches the tissue; over time, successively larger dilators can be used to further stretch the constriction. Dilatation is most commonly used to treat esophageal dysphagia caused by strictures, lower esophageal rings (Schatzki's rings), and achalasia. Dilatation carries a small risk of complications such as esophageal tears; a person considering dilatation should discuss these possible complications with a doctor before the procedure.

    Balloon dilatation can alleviate dysphagia caused by achalasia and lower esophageal rings (Schatzki's rings). Balloon dilatation (also called pneumatic dilatation) is done to widen the constricted region of the esophagus. This type of dilatation is usually completed in a single session. A doctor advances a deflated balloon type instrument to the narrowed region and then inflates it. This action mechanically ruptures the fibers of the constriction. Balloon dilatation is most often used to stretch the lower esophageal sphincter (LES) in people with achalasia, and to stretch lower esophageal rings (Schatzki's rings). Balloon dilatation carries a small risk of complications such as esophageal tears and bleeding; a person considering dilatation should discuss these possible complications with a doctor before the procedure. Furthermore, this type of dilatation can lead to reflux in a small percentage of people.

    Injection of botulinum toxin (Botox) is a new treatment for certain causes of esophageal dysphagia. Injections of botulinum toxin (Botox) can prevent certain nerve cells from triggering muscle contraction. The treatment allows muscles or sphincters to relax. Botulinum toxin injections are being used to alleviate dysphagia caused by esophageal conditions such as achalasia.

    Several measures can alleviate dysphagia that is caused by drugs. If a specific drug is causing dysphagia, the drug may be tapered to a lower dose or discontinued completely, or another drug with similar function may be substituted.

    Swallowing therapy (swallowing rehabilitation) can maximize swallowing function and develop compensatory skills. Swallowing therapy helps a person retrain the muscles involved in swallowing and learn strategies for working around any residual dysphagia. During swallowing therapy, a person may be taught any of the following measures:

    • Oral exercises
    • Swallowing maneuvers
    • Postural adjustments
    • Breathing and coughing strategies
    • Pacing strategies
    • Guidelines for selecting and preparing foods
    • Guidelines for using assistive feeding devices

    Swallowing strategies for neurologic causes of dysphagia often include eating smaller and more frequent meals, drinking through a straw; avoiding distractions, taking smaller bites of food, eating more slowly, tucking the head during swallowing and swallowing twice, and choosing softer foods that have a high caloric content and foods that have appealing tastes, smells, and textures.

    Functional dysphagia may be treated with psychiatric therapies. If tests fail to detect any anatomic or physiologic cause for dysphagia, the dysphagia may be classified as functional (psychogenic) dysphagia. A doctor may recommend psychotherapy and psychoactive drugs for the treatment of functional dysphagia.

    If dysphagia causes saliva to pool, an aspirator can be used to periodically suction saliva from the mouth.

    Customized oral devices can reduce dysphagia caused by structural conditions. Speech-language pathologists, swallowing therapists, and rehabilitation specialists can design and construct oral devices to counter specific structural problem. These devices include prosthodontic appliances, obturators, and palatal lifts.

    Special feeding implements and devices can alleviate dysphagia.

    Dysphagia caused by overactive sphincters can be treated with myotomy. Myotomy refers to direct cutting of the muscle fibers of a sphincter. Achalasia can be treated by myotomy of the lower esophageal sphincter (LES); similarly, overactivity of the cricopharyngeus muscle (the upper esophageal sphincter [UES]) can also be treated by myotomy. Although this surgical procedure once required an open incision of the chest or abdominal wall, myotomy can now be performed laparoscopically, through tiny incisions made in the skin. Tiny instruments, cameras, and lights allow the surgeons to operate on the area without opening up the abdominal cavity. The camera projects the images onto a video monitor, and the instruments, located on the ends of very long, skinny tubes, are controlled at the top of the handle.

    Diverticula (the outward pouching of a wall of an organ or structure) that cause symptoms can be surgically corrected.

    Surgery may be used to completely remove or to decrease the size of esophageal tumors.

    Antireflux surgery can halt esophageal injury in people with severe gastroesophageal reflux disease (GERD). If gastroesophageal reflux disease (GERD) does not respond to medical treatment, antireflux surgery (also called fundoplication) may be used to halt acid reflux.

    Several surgical procedures can help minimize and prevent aspiration (entry of food or liquid into the airway). These procedures include tracheotomy (creation of an opening in the airway), vocal cord medialization (surgery to improve the closing action of the vocal cords), and separation of the larynx and trachea; these three procedure result in loss of voice, but they can be reversed at a later time if dysphagia resolves. Surgical removal of the larynx (laryngectomy) can also stop aspiration, but this procedure results in permanent loss of voice.

    Several surgical procedures can provide alternate routes for nutrition. If dysphagia is markedly interfering with calorie and nutrient intake, and if it poses a serious risk for choking, surgical procedures can be used to permit feeding by placing food directly into the stomach or intestine using a feeding tube (enteral feeding), or intravenous feeding (parenteral feeding).

    • Enteral feeding. Direct opening through the abdominal skin into the stomach (percutaneous endoscopic gastrostomy [PEG]), or into the region of the intestine called the jejunum (percutaneous endoscopic jejunostomy [PEJ]) can be performed by using endoscopy. If edoscopic approach is not possible, alternatively radiologic or surgical approach may be used. Liquefied food can be placed directly in the PEG and PEJ, bypassing the mouth, pharynx, and esophagus.
    • Parenteral feeding. Surgery can be used to place a port into a large vein in the chest. Nutritive solutions can then be infused directly into the vascular system. This type of feeding is also called total parenteral nutrition (TPN). Unfortunately, TPN is not practical for long-term treatment because of its high cost, inability to meet a person's total nutritional needs, and associated complications. When parenteral feeding is required only for short term, peripheral veins may be used for this purpose.

    The ducts of salivary glands can be surgically relocated if a person is having trouble controlling secretions.

    Any sudden deterioration of stable dysphagia needs immediate medical attention.

    If the patient is unable to swallow saliva immediate medical attention is warranted.

    The prognosis of dysphagia depends on the underlying cause. The underlying cause of dysphagia usually determines if dysphagia will improve, remain stable, or worsen. A doctor can outline the typical prognosis for a specific type of dysphagia. However, even for specific causes of dysphagia, many individual factors can affect the course of the condition.

    For dysphagia caused by neurologic conditions, dysphagia that occurs suddenly is likely to improve over time, whereas dysphagia that develops gradually often worsens over time. Dysphagia caused by stroke usually improves. In contrast, dysphagia caused by neuromuscular disorders often worsens.

    Conditions that require dilatation or botulinum toxin injection may require additional treatments. Although dilatation and botulinum toxin injections promptly relieve some types of dysphagia, the effect of treatment may decrease over time, and additional treatment sessions may be needed.

    Regular medical exams are necessary to monitor the degree of dysphagia and to assess the effects of treatment. During regular medical exams, a doctor can determine if dysphagia is improving, remaining stable, or progressing. Exams are also useful for assessing the effects (and any side effects) of treatment, for checking weight and nutritional status, and for planning additional treatment measures.

    Certain conditions that cause esophageal dysphagia require follow-up, because these conditions increase the risk of esophageal cancer. Some conditions, such as achalasia and gastroesophageal reflux disease (GERD), are associated with an increased risk of esophageal cancer. These conditions may warrant regular medical exams and specific screening tests.

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