1. Coughing at meals.

2. Struggling to eat.

3. Taking longer to eat.

4. Chronic excessive secretions including tracheal secretions, chronic bronchitis, and asthma.

5. Weight loss of unexplained origin.

6. Pneumonia, especially recurrent.

7. Gurgly voice quality, especially during or after meals.

8. Recurrent fevers or increased secretions within 1 to 1 1/2 hours after meals.

9. Elimination of some consistencies of foods from the diet.

10. Difficulty managing own saliva.

11. Patient complaint of difficulty swallowing.

1. Aspiration pneumonia. A significant positive correlation has been found between the aspiration observed during a modified barium swallow (MBS) test and the development of pneumonia within the next 6 months.

4. Increased costs of health care including hospitalization for aspiration pneumonia and other costly medical complications, nonoral feeding, nursing care, if dysphagia is not managed properly.

In patients with neurologic damage or disease, dysphagia cannot be prevented, but the expensive medical complications that result from swallowing disorders can be prevented as a result of appropriate assessment and treatment.

1. Prevent expensive medical complications. Aspiration pneumonia alone is a significant cost to the health care system.

2. Facilitate the patient’s return to safe and efficient oral intake. Nonoral feeding requires greater nursing care and often specially prepared feedings, both of which are more costly than oral feeding.

1. Oral preparatory stage (variable duration) includes chewing and other oral manipulations, which reduce food to a consistency appropriate for swallowing and provide taste and pleasure of eating. It does not depend on good dentition. Lip closure, circular and rotary action of the tongue, normal facial tone, and rotary jaw action are included in this stage of swallow. Oral tongue action and fine motor control of the tongue are most important because tongue action controls food in the mouth.

2. Oral stage (lasts approximately 1 second). The oral tongue is responsible for propelling food through the oral cavity and for providing sensory input contributing to triggering the pharyngeal stage of swallow.

3. Pharyngeal triggering (takes half a second or less) involves sensory input from the oral cavity to the cortex and brainstem, which is recognized as a swallow stimulus in the nucleus tractus solitarius in the brainstem. This sensory information is passed to the nucleus ambiguous, which triggers the pharyngeal motor response.

4. Pharyngeal stage (lasts less than 1 second) involves closure of the airway to prevent the entry of food into the airway (aspiration), opening of the upper esophageal sphincter (UES) to allow food to pass into the esophagus, and pressure applied to the bolus by the tongue and pharyngeal walls to clear food efficiently into the esophagus.

5. Esophageal stage (lasts 8-20 seconds) involves sequential contraction of the esophageal muscle fibers from top to bottom, propelling the bolus ahead of the contractile wave into the stomach. This phase also involves relaxation of the lower esophageal sphincter to allow the bolus to pass into the stomach.

1. Lip closure is maintained from the time food is placed in the mouth until the pharyngeal swallow is completed. If lip closure cannot be maintained, the nasal airway may not be patent.

2. Lingual control. Oral tongue action is required in oral preparation because the tongue controls the food in the mouth during chewing. The tongue also forms the food into a ball or bolus in preparation for the swallow, subdividing the food in the mouth if necessary, to ensure the appropriate size bolus for swallowing. The oral portion of the tongue then propels the food through the oral cavity and into the pharynx.

3. Rotary, lateral jaw motion. Jaw action crushes the food, which is placed on the biting surfaces of the teeth by the tongue.

4. Velar or soft palate elevation and closure of the velopharyngeal port prevent food from entering the nasal cavity.

5. Tongue base posterior motion. Tongue base motion generates pharyngeal pressure on the bolus, as does sequential contraction down the pharyngeal wall.

6. Airway closure prevents aspiration. Airway closure begins at the true vocal folds, proceeds to the level of the airway entrance, that is, the false vocal folds, arytenoids, and base of epiglottis, and ends as the epiglottis is folded over the airway. The most critical level of airway closure is at the entrance, that is, the arytenoid cartilage and the base of epiglottis and false vocal folds. This level of closure prevents food from entering the airway.

7. Opening of the UES involves a complex set of actions including (1) relaxation of the cricopharyngeal muscular portion of the valve, which does not open the sphincter; (2) laryngeal upward and forward motion, which opens the sphincter by carrying the anterior wall of the sphincter, the cricoid cartilage, away from the pharyngeal wall; and (3) arrival of the bolus under pressure, which increases the width of the opening of the upper sphincter.

8. Esophageal peristalsis begins when the tail of the bolus enters the esophagus and follows the bolus through the esophagus.

Not all swallows are alike. Normal
oropharyngeal swallow physiology changes systematically as the volume and viscosity of the food being swallowed increases. A great deal of voluntary control can also be exerted over the oropharyngeal swallow. These systematic changes help to explain why patients have more difficulty with one type of food than another. The swallows are, in fact, different for different foods.

1. As bolus volume increases, the duration of the oral and pharyngeal stages of the swallow increases. The duration of airway closure and cricopharyngeal opening increases systematically.

2. Increasing viscosity of food increases the width of cricopharyngeal opening.

3. Volitional control also changes the characteristics of the oropharyngeal swallow.

1. Oral transit time slows 0.5 to 1.0 seconds with increasing age, probably because older adults most often hold the bolus on the anterior floor of the mouth and must pick it up with their tongue to begin the swallow.

2. Slightly slower shift from the oral to pharyngeal stage in individuals over age 60, probably because of slower neural processing.

3. After age 80, range of motion of pharyngeal structures is reduced, that is, there is less muscle reserve and less flexibility in the swallow. This is particularly true in men.

4. Over age 60, esophageal peristalsis becomes less efficient.

5. Healthy elderly individuals do not aspirate more often than young people. Elderly patients (over age 80) who become generally weak and sick will demonstrate a weak swallow because of their reduced muscular reserve. This can cause aspiration.

1. Normal swallows are efficient, moving food quickly through the mouth and pharynx and into the esophagus (under 2 seconds).