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My Professional Pet Peeve

Holy MOLY!  I cannot believe it is JULY already! I have been trying to finish this blog post since the first week of June!  Things have gotten busier here at Resurgence, which is GREAT for business, not so great for blogging!  Alas, June was National Dysphagia Month, so in the spirit of dysphagia education, here I go!

“What the heck is dysphagia,” you ask?

Great question!  The short answer is:  it’s trouble swallowing.  (The yellow line in the picture is the route our food/drinks should take.)

But this BLOG isn’t about the short answer, now is it?  🙂  

What does it mean to have “trouble swallowing,” anyway?  Buckle up, I’m about to tell you.

You would like to think it’s a simple answer, but it’s really not.  To understand the “trouble” part, you must first understand the “swallow” part. 

The “normal” swallow consists of 4 parts.  

  1.  The first part of swallowing is hearing, seeing, smelling, or physically touching the food as it’s cooking.  That part tends to get left out of the picture, but it’s a very important piece of the physical part of the swallow.  
  2. The second part is the part that happens in your mouth:  if you’re drinking, it’s feeling the liquid on your lips, tongue, and inside of your mouth.  If you’re eating it’s feeling the food come into your mouth and chewing it.  
  3. The third part is when it gets into your throat.
  4. The last part is when your food enters your esophagus to go to your stomach.

Let me take you on a swallow journey… The phases seem straightforward, but it’s the mechanics that make it really wild!  

  1. You chew the food or drink the drink, it goes onto the back of your tongue, the tongue pushes it back down your throat, and that’s where the magic happens.  
  2. All within a second (usually), the food comes in, 
  3. your larynx rises, 
  4. your hyoid bone rocks forward, 
  5. pulling your epiglottis down over your vocal cords, 
  6. which are closing at the same time, 
  7. as your esophagus opens, 
  8. your throat squeezes together, 
  9. pushing the food down your upper esophageal sphincter 
  10. and into your esophagus.
  11. Then your esophagus begins to push the food down to your belly with contractions called peristalsis. 

BOOM.  Normal swallow.  Now, there are some variations of normal, just like any other biological process.  Generally, this is how it works.

This, what we call “normal” swallow is a finely tuned & coordinated, complex event that happens from the time you can visualize the food or drink, until the time it reaches your belly.  Now think about all the body parts involved, and try to imagine how many muscles are involved; 26 to be exact!  So MANY things could disrupt the normal “flow” of things, but typically it works out just fine.  But when it doesn’t go the way it should, it can make people very sick.  

Here are some common signs of dysphagia.

I am a member of several disease specific on-line forums and I see members ask other members how to handle their “trouble swallowing” all the time.  Nothing makes me yell, “NOOOOOOOOOOOOOOO” at my computer louder than that.  They give the advice with the very best of intentions; that, I DO very much understand.  However, I cringe at the advice that gets given, because normal people (as in anyone that is NOT a speech language pathologist with expertise in swallowing) do not have any idea how much they could be hurting that person.  

Seeing people ask for medical advice over non-medical on-line forums has become my professional pet peeve. 

“Why?” Because the “trouble” part during swallowing is unique to each individual.  Like the system I explained above, the “fix” is not as simple as some may think!  Just because a strategy worked for one person does NOT mean it will work for another.  It depends on so many factors… stage in disease process, breath support, anatomical variations, strength, timing, location & amount of residue left in the throat, how fast your esophagus can push the food/drink down… It is different for every person.  And those factors listed can only be confirmed by visualizing in the throat!  (this point I will get to later.)  

You see, changing a head position, may actually make someone’s swallow LESS safe; nobody can see a cervical osteophyte altering the shape of the posterior pharyngeal wall without imaging.  One level of thickening could send someone to the hospital; if a person has pharyngeal weakness, they might not be able to push thicker liquids down, the residue will stay in their pharynx, dry up, grow bacteria and get inhaled increasing the risk of pneumonia.  You can’t see that without imaging either.  One exercise could work the wrong muscle, which may not help the person swallow at all…  

Giving advice on swallowing is not like giving harmless dating or cleaning advice.  When a person gets food down into their lungs, they have a very high chance of getting aspiration pneumonia.  

Let’s talk about that for a minute–  Aspiration is when the food/drink gets into your trachea; the tube to your lungs.  The trachea is protected by your vocal folds & your epiglottis when they all come together in that 1 second event explained above.

So, when you feel food or drinks “go the wrong way,” and you cough your head off until you can barely breathe and your eyes are watering, you have likely aspirated.  It happens to all of us occasionally.  It’s when it happens regularly that creates the need for some help. OR it’s when a person is more susceptible to pneumonia, like a person undergoing chemo/radiation therapy for cancer.  And, by the way, a person can aspirate without coughing; it’s called “silent aspiration.”  The only way to know if it’s happening is to look inside the throat during swallowing tasks.

We all aspirate.  But, most of us are in good health.  Our immune systems are good. We are active; we have good respiratory support.  Our bodies can usually fight it off.  But the elderly, or someone who is really really sick, are at higher risk for aspiration pneumonia.

AND THAT’S WHY I DON’T LIKE IT WHEN PEOPLE WHO DON’T KNOW ABOUT SWALLOWING GIVE ADVICE ON SWALLOWING!  You can kill someone if you don’t know what you’re talking about.  That fact should not be taken lightly.  Ever.  

And you can probably tell I’m very passionate about this topic!

A “chin tuck” does not fix everything.  Thicker is not always better.  And, not everyone who has dysphagia has pharyngeal weakness.

I try to make sure I answer solicitations for advice in on-line forums with: “Please ask your doctor for an order to see a speech language pathologist that specializes in your specific disease.  If you are unable to find one, I will be glad to help you.”  And it’s true.  I’m happy to help ANYONE find a speech language pathologist, in their area, with specialization in their specific disease/disorder.  

*And now I step down from my soapbox…

So what did we learn with those last 5 paragraphs?  I hope you just said, “Swallowing is different for everyone.” ORRRRR you said, “Nobody other than an SLP, specializing in swallowing, should be giving advice to people with dysphagia!”  

Right!  And thank you for reading! And I hope you muttered to yourself, “Wow, I never thought of it THAT way before,” at least once, because it is my goal when providing education.

Now, the only way for us to really know what IS happening in the throat when a person swallows is to actually LOOK there during the swallow.  So, who has x-ray vision?  Anyone?  

What?  I don’t see any hands raised! *stepping back up onto my soapbox.

So, that means anyone recommending a diet consistency (not a nutritional diet, like keto; that’s a registered dietician’s area of specialty) or a liquid consistency without looking in your throat has a high likelihood of being wrong. 

Dr. Steven Leder, a leading dysphagia researcher, found in a research study, written in 2002, that SLP’s over diagnose 70% of the time without an instrumental evaluation.  This means that the diets are unnecessarily restrictive… think about eating pureed foods and drinking honey thick liquids all the time. (which, is not only unappetizing, but COSTS additional MONEY, and leads to additional healthcare costs secondary to malnutrition & dehydration because people don’t want to consume it!)  To read more about why those consistencies are recommended, click on the hyperlinks; these take you to Karen Sheffler’s website.  She is a speech language pathologist and board certified swallowing specialist; in other words a swallowing guru!

The accurate assessment of the what’s happening inside your throat can only be known for sure with the use of instrumental evaluations such as:  

  1.  A modified barium swallow study, which is an x-ray of your swallow.  You will be given different consistencies of barium and asked to swallow it.  The radiologist will record snippets of you swallowing each consistency to see where it goes. 

ORRRRRRRRRRRRR

  1. A Fiberoptic (or Flexible) Endoscopic Evaluation of Swallowing (FEES), where an endoscope is used to visualize and record you eating/drinking food; no barium, just food coloring.  

Both studies are wonderful.  If utilized appropriately, either can provide a plethora of information about a person’s swallow.  Either assessment will show the presence or absence of aspiration (food into the trachea) or penetration (headed to trachea, but above the vocal folds), when it occurred (before, during, or after the swallow) which is HUGELY important, and then, it can show us signs that point to…. THE CAUSE of the dysphagia, so it can be targeted during therapy!!!!!  And, if you have an excellent SLP leading either exam, they will test different strategies to determine which are most effective for you to use.  Because, the only way to really know what truly works, is to SEE it.

I’ll be honest, I tend to prefer FEES, which is why I have it at my office.  That doesn’t mean I don’t like modified barium swallow studies.  A modified barium swallow study is GREAT for visualizing aspiration during the swallow, as well as esophageal dysphagia.  Some people will argue that a FEES will not show aspiration during a swallow – and they are correct!  However, you can see aspiration before and after the swallow, so if there’s food or liquid particles in the trachea, without the visualization of the aspiration event, you can deduce that it happened during the swallow. And, yes, I can see food/liquid particles in the trachea with a FEES exam.

I’m going to tell you why I like FEES:

  1.  No barium.  It tastes bad.  It isn’t a true consistency; it’s a little thicker & stickier, which doesn’t really show how a person swallows non-barium food.
  2. I get to record the WHOLE TEST.  Maybe it’s a control thing, but I’ve been involved in too many modified barium swallow studies, where the radiologist has stopped the fluero and missed aspiration of residue after the swallow.  I have also seen it turned off not capturing back-flow, or reflux events, at the esophagus.  OR s/he has decided with 1 instance of aspiration that the study is over, and refuses to allow trials of compensatory strategies.
  3. I can watch frame by frame as many times as I need to without taking up a much needed computer in the radiology department.  This way I can get all the information I need to create a patient centered & targeted therapy plan.
  4. The assessment can last as long as needed because there is no radiation exposure.
  5. We can trial specific foods during this assessment.  So, if you have trouble with scrambled eggs or rice, or bread, or milk… bring them!! I’ll watch you eat them, and see exactly why you’re having trouble with them.
  6. I can assess the mucosa to determine presence of reflux or acid exposure.  Although I cannot diagnose reflux, I have assessment tools at my disposal to assess the tissue inside a person’s throat, which can be sent to the doctor, and used to aid in a diagnosis, if there isn’t one already.
  7. It’s in my office, so I don’t have to wait for a report from any other health care professional, which means ability to begin treatment on the day of evaluation.

Now that you know what dysphagia is and how it is evaluated, I want you to know about a really cool resource available to you.  It’s the Swallow Support Group of the Carolinas, co-hosted by yours truly and my amazing colleague in the Durham area, Nancy Smith.  This support group is sponsored by the National Foundation of Swallowing Disorders (NFOSD) and meets the last Tuesday of each month, at 7 pm, over Zoom.  It is designed to provide a safe place for people who have been directly or indirectly affected by swallowing disorders; both kids and adults!  If you’re looking for education, resources, or just a place to talk about the challenges of swallowing disorders please join us!

Now, I have to get back to writing evaluations and treatment notes!

Until next time…

Cheers!  

Michelle Hill MS CCC-SLP is a speech language pathologist and Owner/Founder/CEO of Resurgence Neuro Rehab.
She has been performing adult speech therapy for 10 years, specializing in cognition, language, speech, swallowing, and voice. To learn more about Michelle, visit https://resurgenceneurorehab.com/?staff=tom-stafford

References:  

Daniels, S. K., & Huckabee, M. L. (2008). Dysphagia following stroke. San Diego: Plural Pub. Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J

Leder, S.B., Espinosa, M.S. Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002; 17:214-218

Ylinne T. Lynch, Brendan J. Clark, Madison Macht, S. David White, Heather Taylor, Tim Wimbish, Marc Moss.  The accuracy of the bedside swallowing evaluation for detecting aspiration in survivors of acute respiratory failure.  Journal of Critical Care.  Volume 39.2017.  Pages 143-148, ISSN 0883-9441.  https://doi.org/10.1016/j.jcrc.2017.02.013.

(https://www.sciencedirect.com/science/article/pii/S0883944116305366)