Symptomatology 403

Management of dysphagia Dysphagia, or swallowing difficulties, is a prevalent disorder associated with certain neurological, obstructive and muscular conditions; stroke is the most recognised neurological cause. Swallowing difficulties are known to adversely affect all aspects of quality of life. Early identification and management is essential. Prognosis is variable and is improved with multidisciplinary management.3 Dr Natalie Walker* Speciality registrar, Department of Elderly Health, Trafford Healthcare NHS Trust, Manchester, UK Dr Denise Stevens Speciality doctor, Trafford Healthcare NHS Trust, Manchester, UK Dr Simon Musgrave Consultant stroke physician, Trafford Healthcare NHS Trust, Manchester, UK *email [email protected]

Dysphagia occurs commonly in commonly tuberculosis. Muscular/ chewing or swallowing, dry primary and secondary care but neuromuscular causes include mouth (xerostomia), soft epidemiological studies of it are autoimmune aetiologies, commonly voice, unexplained weight loss, rare.1 A recent study reported the scleroderma and polymyositis and regurgitation of food and recurrent lifetime prevalence of swallowing more rarely myasthenia gravis. chest infections.6 disorders as 38%. Most participants Achalasia, scleroderma and diffuse The acuteness or otherwise described a sudden onset with oesophageal spasm are the most of the symptoms can help make a chronic problems persisting more common causes of neuromuscular differential diagnosis. For example, than four weeks.2 Dysphagia motility disorders.5 We present neuromuscular dysphagia gradually adversely affects all aspects of a a case of motor neurone disease progresses whereas mechanical person’s quality of life. We need (Box 1) and myasthenia gravis obstruction progresses rapidly. to promote a multidisciplinary (Box 2) to highlight presentation It is important to review approach to its management. characteristics secondary to a medication to minimise adverse neurological and neuromuscular effects; for example, nonsteroidal aetiology, respectively. anti-inflammatory drugs may be Classification contributing to the problem as they can cause direct mucosal injury There are three broad categories of Presentation to the oesophagus. Alcohol and swallowing difficulties: neurological, smoking consumption should also obstructive and muscular. Presenting symptoms vary but be noted as important risk factors Neurological causes include stroke, patients usually report coughing, for malignancy and obstructive cerebral palsy, Parkinson’s disease, choking or the abnormal sensation lesions. multiple sclerosis and motor of food sticking in the back of the neurone disease. Stroke is the most throat or upper chest when they common cause,4 but we need to initiate a swallow. Neurological Investigations consider differential diagnoses. causes of dysphagia are more Obstructive causes include likely to present with the former The focus of physical examination cancer of the mouth and symptoms and obstructive may be based on the patient’s oesophagus, cleft lip and palate, dysphagia with the latter. history. Neurological examination radiotherapy, gastro-oesophageal Other symptoms associated may reveal signs suggestive of a reflux disease and infections such with all three types of dysphagia new stroke, specific cranial nerve as herpes simplex virus and less include difficulty or painful palsies and fatiguability associated

www.gerimed.co.uk August 2010 | Midlife and Beyond | GM 404 Symptomatology

with myasthenia gravis, or mixed upper and lower motor neurone Box 1: A case of dysphagia of neurological aetiology signs with prominent fasciculations for motor neurone disease. A An 89-year-old Asian woman was referred to a secondary care medical cachexic state may also be noted; clinic with a five-month history of difficult and painful swallowing and this is a worrying sign as it can significant weight loss. Her past medical history included tuberculosis, reflect either obstructive dysphagia asthma and gastritis. She was taking ranitidine and using a salbutamol inhaler. She lived with her extended family, had never smoked and secondary to malignancy or a did not drink alcohol. Clinically she was emaciated, frail and had chronic presentation of neurological hepatomegaly. Tumour markers, chest and abdominal imaging, barium dysphagia. Organomegaly, swallow and the opinion of ear, nose and throat specialists were all particularly hepatomegaly, may negative for malignancy and tuberculosis. One month later she had indicate liver metastases and in developed choking and breathlessness. She failed a bedside swallow the context of dysphagia may well test, had both upper limb and tongue fasciculation and brisk reflexes. originate from a gastrointestinal Motor neurone disease was therefore suspected. An electromyogram source. A bedside swallow showed reduced muscle action potentials, reduced nerve conduction assessment is crucial as part of the velocities and spontaneous muscle fasciculation, while sensory nerve conduction was normal. These features were consistent with anterior initial investigation. This requires horn cell disease. The patient was referred to a local tertiary motor a patient to drink a small volume neurone disease service. Unfortunately, she rapidly developed type 2 of water whilst sitting upright, respiratory failure, markedly deteriorated and died. following which checks are made for delayed swallow, the presence of drooling, coughing and dysphonia. and reduced nerve conduction modifications and language skills. Simple blood tests, possibly velocity in the presence of In our hospital, we have a nutrition from bleeding ulcers or tumours, spontaneous muscle fasciculation team with specialist nurses who can help identify anaemia and can is consistent with anterior horn cell daily assess patients with suspected also detect autoimmune cases. disease. Video-fluoroscopy has a poor swallow and initiate naso– However, specific dysphagia role in assessing neurological cases gastric (NG) feeding, or, if the studies are usually required. of dysphagia and specialist input swallow is unlikely to return, liaise Direct laryngoscopy is useful from a consultant neurologist may with the gastroenterology team in evaluating oropharyngeal further elucidate the cause. regarding more permanent feeding dysphagias. Barium studies are such as percutaneous endoscopic usually the first-line investigation gastrostomy (PEG). Many senior for identifying obstructive lesions; Management nurses are being trained to screen however, endoscopy provides for swallowing difficulties.7 the optimum assessment of the The management of neurological oesophagus in suspected obstructive dysphagia requires a Unsafe swallow cases. Manometry, useful in multidisciplinary approach. Here, An unsafe swallow may or may reflux disease, uses electronic we focus on stroke. Much of this not improve. The SALT may give pressure probes to measure relates to, and overlaps with, the guidance to enable patients to motor function and responses to management of other neurological/ “relearn” how to swallow. Dietary swallowing, and pH monitoring, muscular dysphagia cases. changes may be necessary and via a nasogastric tube, records include softer foods and thickening pH levels within the oesophagus. Stroke of fluids, or feeding via an NG or EMG (electromyography) assesses The speech and language therapist PEG tube. NG tubes last 10–28 days. muscular responses to electrical (SALT) is a key member of the PEG tubes are designed to last for stimulation. stroke multidisciplinary team. In six months. A decremental response accordance with national stroke There are complications indicating muscle fatiguability is guidelines, the SALT will assess associated with PEG placement. characteristic of myasthenia gravis. a swallow within 24 hours of These include tube displacement, Reduced muscle action potential admission, and advise on food skin infection, tube blockages

GM | Midlife and Beyond | August 2010 www.gerimed.co.uk Symptomatology 405

and leakages, and less common complications, such as serious Box 2: A case of dysphagia of neuromuscular aetiology internal infection and bleeding. An 80-year-old woman presented to the acute medical ward with a Medication management three-day history of difficulty swallowing and inability to tolerate It is important to think carefully food or fluid, which she felt was sticking in her throat. She was also about medication management. experiencing problems being understood and felt her speech was softer. She described increased sputum, and frequent coughing and Pharmacists may help with choking fits over the past year. Her past medical history included consideration of liquid, or hypertension and chronic renal impairment. She took diltiazem, alternative routes of administration. irbesartan and omeprazole. She was widowed, had never smoked and An occupational therapist may did not drink alcohol. She regularly played golf up to a few days prior advise on feeding implements and to admission. Clinically she had expressive dysarthria and an unsafe adapted cutlery, and a dietician bedside swallow with pooling of secretions. She had no long tract signs. may advise on nutritional intake. The differential diagnosis underlying her dysphagia was stroke, or Nursing staff have an important another structural or neuromuscular cause. ENT investigation showed role in the physical action of taking weakness of the left palate and secretions of the pyriform fossa. The impression was of a stroke affecting the 9th and 10th cranial nerves. in food. The National Institute for However, her head CT scan showed no acute infarction, haemorrhage Health and Clinical Excellence or space-occupying lesion. She clinically deteriorated and developed (NICE) policy on nutrition support progressive bulbar and facial weakness with incomprehensible speech. in adults is particularly useful.8 An electromyogram was performed. Repetitive nerve stimulation showed significant decremental responses supportive of a diagnosis Other neurological causes of myasthenia gravis. She was commenced on pyridostigmine and In management of non-stroke prednisolone, and transferred to the local tertiary neurology centre. She neurological causes, specific was later admitted to the intensive care unit, underwent a tracheostomy and received a course of immunoglobulins. She later stabilised and was medications may help. Botulinum transferred back to ward-level care. toxin can treat muscular dysfunction, such as achalasia. For obstructive causes, surgical and we need to promote healthy al. Dysphagia following stroke. Eur procedures, or dilatation and lifestyles to reduce risk factors for Neurol 2004; 51: 162–67 stenting may help. cerebrovascular disease. 5. Spieker MR. Evaluating dysphagia. Am Fam Physician 2000; 15: 3639–48 6. Wright D, Chapman N, Foundling- I have no conflict of interest Miah M et al. Consensus guideline Prognosis on the medication management of References adults with swallowing difficulties. The prognosis for recovery from (http://tiny.cc/xxtz4) dysphagia varies from excellent 1. Wilkins T, Gillies R, Thomas AM et 7. Davies S. An interdisciplinary to poor depending on its severity, al. The prevalence of dysphagia in approach to the management of primary care patients: a hamesnet dysphagia. Prof Nurse 2002; 18: 22–5 aetiology and compliance with research network study. J Am Board 8. Nutrition support in adults. National treatment. Fam Med 2007; 20: 144–50 Institute for Health and Clinical Dysphagia affects up to 80% of 2. Roy N, Stemple J, Merrill RM, Excellence. 2006. CG32. (www.nice. stroke patients.9 However, previous Thomas L. Dysphagia in the elderly: org.uk/CG32) research has suggested that 37% preliminary evidence of prevalence, 9. Martino R, Foley N, Bhogal S suffer for less than eight days, and risk factors and socioeconomic et al. Dysphagia after stroke: up to 86% may be able to swallow effects. Ann Otol Rhinol Laryngol incidence, diagnosis, and pulmonary normally within 14 days.10 2007; 116: 858–65 complications. Stroke 2005; 36: 3. Ekberg O, Hamdy S, Woisard V et 2756–63 Primary prevention is where we al. Social and Psychological burden 10. Wilkinson TJ, Thomas K, MacGregor as clinicians must focus our efforts. of dysphagia: its impact on diagnosis S et al. Tolerance of early diet We need to educate our patients and treatment. Dysphagia 2002; 17: textures as indicators of recovery regarding risk factors for cancers, 139–46 from dysphagia after stroke. such as smoking and excess alcohol, 4. Paciaroni M, Mazzotti G, Corea F et Dysphagia 2002; 17: 227–32

www.gerimed.co.uk August 2010 | Midlife and Beyond | GM