Management of neurogenic dysphagia: use of fluid and food thickeners (two case studies)

Dysphagia refers to pathologies of the esophagus and larynx. With this condition, swallowing liquids and food is difficult or impossible. The causes may include both disturbances in the functioning of various organs and diseases of a neuralgic nature. To make a diagnosis, a thorough examination is necessary, and therapeutic measures are selected individually for each patient.

Pathology cannot be left without attention, since it is impossible to do without the help of doctors. Doctors at the 24-hour Yusupov Hospital specialize in this pathology and successfully cope with dysphagia of any severity.

Esophageal dysphagia: symptoms

Esophageal dysphagia is most often caused by esophageal diseases, diseases of the gastrointestinal tract, and pathology of the mediastinal organs.

Acute esophageal dysphagia occurs as a result of:

• allergic edema (Quincke's edema);
• obstruction by a foreign body.

Causes of esophageal dysphagia:

• Narrowing of the lumen of the esophagus causes esophageal cancer (stomach cancer localized in the cardia) and GERD also occur. Cicatricial narrowings occur after chemical burns and radiation therapy for thoracic oncology.
• When the esophagus is compressed by tumors of the chest organs (lung cancer, bronchi), enlarged lymph nodes of the mediastinum, paraesophageal hiatal hernia, cardiac pathology with severe myocardial hypertrophy.
• Violation of coordinated contraction of the esophageal muscles can be a sign of achalasia, total spasm of the esophagus, diabetes mellitus, and scleroderma.
• Infectious diseases (tuberculosis) and uncontrolled use of certain drugs (calcium antagonists, nitrates) can lead to disruption of esophageal peristalsis.

Symptoms of esophageal dysphagia:

• in the initial stage of the disease, patients complain of difficulty swallowing dry, solid food;
• retrosternal pain, drooling, often heartburn, dry cough, hoarseness appear;
• As the symptoms progress, the symptoms increase, and difficulties appear when swallowing soft foods and then liquids.

When to see a doctor

A person needs to consult a therapist if he regularly has problems swallowing food or liquids. In this case, there is vomiting or regurgitation. Emergency medical care is necessary for the patient if breathing is impaired.

The doctor will prescribe a comprehensive examination to make an accurate diagnosis and select effective treatment, taking into account the results obtained. You should not engage in self-therapy, since esophageal dysphagia can lead to serious consequences.

Types of dysphagia

All diseases occurring with dysphagia syndrome, depending on the anatomical level of swallowing disorders, are divided into:

1. Oropharyngeal (oropharyngeal) dysphagia is a violation of the formation of a food coma and its movement into the pharynx, in this case the initial swallowing movements are disrupted.

The causes may be neurological pathology, thyromegaly, lymphadenopathy, oncological diseases of the head and neck, and degenerative processes of the spine. Main symptoms:

• cough;
• nasal regurgitation;
• attacks of suffocation.

Treatment depends on the causes of this syndrome.

1. Esophageal (esophageal) dysphagia is a violation of the movement of food from the pharynx to the stomach. The causes of the disease are narrowing or compression of the esophageal tube, as well as impaired motility.

In addition, all dysphagia is divided into:

• spicy;
• chronic

According to the nature of the flow:

• intermittent;
• permanent;
• progressive, with increasing clinical symptoms.

Why does it occur in children?

A feature of dysphagia in childhood is its connection with a disorder of underdeveloped nervous regulation of swallowing. The disease can be congenital or acquired. Often accompanies cerebral palsy and developmental anomalies.

Constant spitting up should cause concern for parents

Parents can suspect the first signs in infants by slow eating, refusal of nipples with a large hole, choking and coughing when eating quickly, better condition with slow feeding, adjustment of the baby's head before sucking, milk flowing into the nose. Less commonly, the pathology is detected against the background of frequent bronchitis and pneumonia, bronchial asthma.

Dysphagia - what is it?

Dysphagia (Greek dys - denial, phagein - is) is the general name for a swallowing disorder.

Dysphagia is a syndrome (complex of symptoms) manifested by a violation of the act of swallowing.

Oropharyngeal dysphagia

Oropharyngeal dysphagia is also called “upper”; with this form of dysfunction, the oral and oropharyngeal phases of swallowing are disrupted.

Oropharyngeal dysphagia syndrome includes the following symptoms:

• difficulty at the very beginning of swallowing;
• return of food through the nasal passages;
• cough;
• attack of suffocation;
• neurological diseases leading to oropharyngeal dysphagia often occur with dysarthria (impaired articulation and pronunciation) and diplopia (impaired function of the visual muscles);

Causes of oropharyngeal dysphagia:

1. Obstruction of the esophageal tract.

• various infectious processes (sore throats, pharyngitis, abscesses);
• enlargement of the thyroid gland (thyromegaly);
• various lymphadenitis;
• Zenker's diverticulum;
• various types of myositis and fibrosis;
• cervical osteochondrosis;
• oropharyngeal malignancy;

1. Disturbance in the conduction of nerve impulses to muscle fibers:

• diseases of the central nervous system (brain tumors, stroke, Parkinson's disease);
• disorder of nerve impulse transmission to smooth muscles (ACD dysfunction).

1. Psychosomatic disorders (neuroses, various functional disorders).

Treatment of oropharyngeal dysphagia depends on the etiology of the disease.

Dysphagia in stroke

Swallowing is a complex reflex reaction.

Peripheral innervation of the muscles involved in the act of swallowing is carried out by pairs of cranial nerves, their afferent and efferent fibers (trigeminal nerve, facial nerve, glossopharyngeal nerve, recurrent, hypoglossal nerve).

The central nuclei of regulation of the act of swallowing are located in the reticular formation of the brain stem. The cortical swallowing centers are located in the posterior parts of the frontal lobes.

With cortical strokes, a clinical picture of pseudobulbar syndrome appears:

• as a result of central paresis of the masticatory muscles, chewing food becomes impossible, the lower jaw droops;
• due to central paresis of the muscles of the tongue and cheeks, the movement of food to the root of the tongue is disrupted.

With brainstem strokes, a clinical picture of bulbar syndrome develops, caused by central paralysis of the cranial nerve:

• choking when swallowing liquid food as a result of it entering the respiratory tract;
• difficulty and inability to swallow solid food as a result of paresis of the pharyngeal muscles;
• nasal tone of voice;
• aphonia due to paresis of the vocal cords;
• dysarthria due to paralysis of articulatory muscles;
• cardiac pathology (arrhythmias).

In the treatment of dysphagia after a stroke, in addition to the neurologist, a speech therapist plays an active role. He primarily assesses the severity of dysphagia, dysarthria and dysphonia, since the same muscle groups are affected. For this purpose, the L.I. scale is used. Wasserman, a dysphagia rating scale, a three-sip test, a protocol that records in detail the condition of the facial muscles, articulatory apparatus, and the condition of the soft palate.

The speech therapist gives the patient’s relatives a reminder:

• how to properly care for a neurological patient, how to feed the patient;
• what products can be used and in what form, how to properly use a food thickener;
• how to do facial gymnastics yourself.

During the rehabilitation period, a patient suffering from dysphagia after a stroke learns to swallow again.

If the swallowing function is completely disabled and the patient is unable to swallow anything, a nasogastric tube is placed.

Paradoxical dysphagia

Paradoxical dysphagia is a special type of change in the act of swallowing, when the patient is able to swallow solid food, but liquid food is retained.

Paradoxical dysphagia (Lichtenstein syndrome), characteristic of:

• achalasia cardia;
• esophageal diverticulum;
• burns of the esophagus;
• HH;
• esophagitis;
• esophageal tumors.

In the mechanism of occurrence of the syndrome, the main role is played by hypermotor dyskinesia of the esophagus.

Sideropenic dysphagia

Sideropenic dysphagia (Plummer-Vinson syndrome) occurs with a lack of iron in the body and hypovitaminosis B₂ and B₉. The disease occurs more often in women.

This systemic disease is characterized by the following symptoms:

• dysphagia, which can be constant and accompanied by unpleasant sensations along the esophagus;
• hypochromic anemia;
• atrophy of the mucous membranes (atrophic glossitis, pharyngitis, esophagitis, gastritis);
• trophic changes in nails, hair, skin;
• disturbance of taste, smell, vision.

Neurogenic dysphagia

Various neurological diseases are often complicated by dysphagia. The act of swallowing is a complex reflex reaction that requires the coordinated work of many muscles, which is ensured by the work of all levels of the central nervous system and peripheral nerves.

The condition can occur with organic diseases of the brain, subcortical formations, brain stem, and cerebellum. Often there is psychogenic dysphagia, which is purely functional in nature, developing against the background of various neuroses.

The cause of peripheral neurogenic dysphagia is damage to the glossopharyngeal (IX pair of cranial nerves), sublingual (XII pair of cranial nerves) and recurrent (X pair) nerves.

The most common cause of neurogenic dysphagia is stroke.

Together with organic pathology of the nervous system, dysfunction of the swallowing muscles is a common manifestation of psychogenic, functional disorders. Against the background of prolonged mental stress, overwork, and emotional exhaustion, various types of neuroses appear, accompanied by a feeling of fear, unconscious aggression, and a tendency to hysteria.

Symptoms:

• complaints of difficulty swallowing;
• itching;
• sore throat;
• hoarseness of voice.

Treatment of neurogenic dysphagia is carried out by a neurologist, and if necessary, the patient is consulted by a psychiatrist.

Dysphagia in the elderly

Dysphagia is a common human pathology, but older people are more likely to suffer. This is due to the fact that with age, muscles lose elasticity and firmness, age-related muscle weakening occurs, and, as a result, dysphagia occurs.

In addition, they contribute to the development of dysphagia in older people:

• degenerative diseases of the central nervous system;
• past illnesses (stroke, head injury, gastrointestinal diseases);
• oncological diseases;
• the presence of severe chronic diseases (diabetes mellitus, ischemic heart disease, hypertension).

Dysphagia in children

Dysphagia in children has some features. First of all, this is due to the diseases that cause this syndrome.

The causes are the following pathologies:

1. Cerebral palsy is the general name for a large group of diseases, common to which is damage to the brain structures responsible for voluntary movements.
2. Athetosis (hyperkinesis) – involuntary movements in individual muscle groups, occurs when subcortical structures are damaged. It appears immediately after birth, is the result of birth injuries, kernicterus.
3. Various congenital pathologies of the oral cavity and nasopharynx.
4. Infectious lesions of the pharynx, larynx, esophagus.
5. Consequences of surgery.
6. Oncological pathology.

The efforts of doctors are aimed at treating the disease that caused dysphagia and eliminating or reducing the severity of this syndrome.

Particular attention is paid to neurological pathology, since these diseases have not only medical, but also social significance. An entire rehabilitation program for patients with cerebral palsy has been developed. Rehabilitation measures begin almost from the first days of life (drug therapy, massage, exercise therapy, physiotherapeutic procedures are carried out). From the age of three, a speech therapist is involved in treatment.

Dysphagia after fundoplication

In severe forms of GERD, a fundoplication operation is performed - this is an anti-reflux operation, which consists in forming a special cuff from the bottom of the stomach around the esophagus, preventing the reflux of reflux into the esophagus (Nissen fundoplication). The operation has proven itself and gives good results. However, after fundoplication in the early stages after surgery, dysphagia and moderate epigastric pain are often observed. This is due to the fact that a “new” esophageal valve is being formed and the body is adapting to it. These unpleasant sensations go away without any treatment.

Functional dysphagia

Functional dysphagia is a manifestation of various neuroses. This form of pathology can manifest at any age. People suffering from cadiospasm have a special psychological characteristic - they:

• suspicious;
• anxious;
• are susceptible to various types of phobias.

In children, functional dysphagia of the esophagus and pharynx may be present from a very early age. It is often accompanied by the following symptoms:

• poor appetite;
• frequent regurgitation, vomiting
• bad night's sleep.

Without treatment, by the age of 7, children experience dystrophy, increased fatigue, and poor tolerance of physical and mental stress.

Physiology of swallowing

Swallowing while eating is carried out by a person reflexively. This means that we do not think or specifically strain any part of the body to ensure the function of passing food from the mouth to the stomach. Although we can force ourselves by a strong-willed decision to swallow, for example, saliva, a bitter medicine.

In the act of swallowing, physiologists distinguish 3 successive phases:

• oral - initial, controlled, initiated by the centers of the brain, activating the swallowing apparatus with their impulses, while the contents of the mouth extend beyond the palatine arches;
• pharyngeal - ensured by involuntary movements, responsible for the entry of the food bolus into the upper part of the esophageal tube and reflex movement downwards;
• esophageal - occurs inside the esophagus due to peristaltic movements of the muscles, guarantees the transport of contents through the cardiac sphincter into the stomach.

The study of changes during swallowing showed that esophageal dysphagia as a pathological condition is a disorder of either a functional or organic nature at any stage of the process. The disease can be treated correctly only by understanding the type of lesion.

Diagnosis of dysphagia

Dysphagia syndrome itself usually does not cause diagnostic difficulties. All efforts of doctors are aimed at identifying the disease that causes dysphagia. In terms of diagnosis, the following examinations are carried out:

1. Pharyngoscopy is a method that allows you to identify the causes of oropharyngeal dysphagia: glossitis, tonsillitis, neoplasms, foreign bodies. Pharyngoscopy is complemented by indirect laryngoscopy; the method allows identifying pathology of the epiglottis.
2. Fluoroscopy with contrast of the esophagus can detect esophageal motility disorders and diverticula.
3. EFGS reveals foci of inflammation and areas suspicious for cancer pathology. If necessary, a tissue biopsy is performed for morphological examination.
4. Long-term measurement of the pH of the environment inside the esophagus is the most reliable method for identifying GERD; esophageal manometry is performed (to determine disturbances in the functioning of the esophageal esophagus).
5. Laboratory research methods are nonspecific:

• in peripheral blood, slight leukocytosis, anemia, and increased ESR may be detected;
• in venous blood, a decrease in total protein, dysproteinemia, is most often observed;
• testing stool for occult blood.

In order to identify neurological pathology, an in-depth neurological examination is performed. If clinical diagnosis is in doubt, instrumental diagnostics are performed:

• CT scan of the brain;
• MRI;
• EEG.

If cardiac or pulmonary pathology is suspected, the following is carried out:

• chest x-ray;
• ECG;
• echocardiography.

Treatment of dysphagia is carried out after the final diagnosis.

Prevention

Esophageal dysphagia (symptoms and treatment require careful examination) at an early stage is accompanied by invisible symptoms that few people pay attention to. As pathological processes progress, the person’s condition worsens.

The syndrome can be prevented if you remember simple rules:

1. It is necessary to get rid of bad habits.
2. It is important to visit a doctor for preventive purposes, especially if there are relatives in the family with a similar disease, in order to promptly identify pathological changes.
3. You need to eat right.
4. It is recommended to adhere to a healthy lifestyle.
5. It is important to harden the body.
6. Avoid stressful situations and overexertion.

If a diagnosis of chronic esophageal dysphagia is made, the patient is advised to undergo timely treatment to prevent exacerbation of the pathological condition.

Treatment

The doctor’s tactics in the treatment of dysphagia are determined by the cause of the disease and the severity of the syndrome. The efforts of doctors are aimed at quickly restoring the act of swallowing and preventing aspiration complications.

Acute cases of dysphagia require urgent care:

• the foreign body is urgently removed.
• desensitizing therapy is urgently carried out.

With a long course of the disease, complicated by dysphagia, a full course of etiopathogenetic treatment is carried out. The following medications are used:

1. Means for improving the neuroregulation of the act of swallowing. For degenerative diseases, dopamine agonists and precursors, central H-anticholinergic blockers are prescribed. For strokes, membrane stabilizers, neuroreparants, and neuroprotectors are widely used.
2. Calcium antagonists. The medicine reduces the concentration of intracellular calcium, thereby eliminating spasm of muscle fibers (diffuse esophageal spasm, achalasia), thereby improving the passage of food.
3. Antisecretory drugs. These drugs are used for GERD and eosinophilic esophagitis with dysphagia. Antacids, PPIs, and IGRs are used.
4. For infectious etiology of the disease (sore throat, abscesses, pharyngitis), antibacterial therapy is indicated.
5. Traditional medicine is widely used in the treatment of functional swallowing disorders.

In some cases, elimination of dysphagia is only possible through surgery. For neoplasias that cover the lumen of the esophagus or compress it, resection or removal of the pathologically altered organ (removal of the stomach, lung) is performed, followed by radiation and chemotherapy.

Also, patients with Zenker's diverticulum can only be treated in surgery; timely cricopharyngeal myotomy practically cures dysphagia.

For cicatricial narrowings of the esophagus that prevent the progression of the food coma, the following is used:

• bougienage;
• endoscopic dissection of strictures;
• stenting.

If dysphagia cannot be eliminated, the patient is given a nasogastric tube or a gastrostomy tube.

The main clinical recommendations concern the correction of the diet, the replacement of solid foods with soft foods.

Hypersecretory disorders require diet and a special lifestyle.

For neurological pathologies, a number of techniques have been developed to improve oral swallowing. The speech therapist selects individual methods for each individual patient during the rehabilitation period.

Possible complications

A person can expect a positive prognosis if they contact a specialist in a timely manner. In the absence of comprehensive diagnostics and specially selected therapy, the likelihood of serious consequences increases.

A complication of esophageal dysphagia is also dehydration and sudden weight loss. Persistent disruption of the respiratory process can result in its complete stop. There is always a risk of degeneration of the affected tissues, against which a tumor forms in the esophagus or stomach.

Esophageal dysphagia is a serious sign of the development of a certain disease, which must be identified at an early stage and treated promptly.

As pathological processes progress, the symptoms of the syndrome will intensify and cause discomfort to the person. At an early stage, problems can be managed by taking prescribed medications. If the condition worsens, it is impossible to do without surgical treatment.

Speech therapy massage

Therapeutic massage is widely used in medicine, both in adults and children. In neurology, it is used for pathologies of the central and peripheral nervous system.

Speech therapy massage is one of the types of therapeutic massage. It is carried out using a special probe with various attachments. Special techniques have been developed for this type of massage. The efforts of the logopath are aimed at:

• to normalize muscle tone, relieve spasms of facial and chewing muscles;
• improvement of blood circulation, metabolic processes, nerve conduction.

Nutrition

Compliance with a chemically, mechanically and thermally gentle diet is an important part of the treatment of dysphagia. The nutrition of a patient suffering from dysphagia should follow the following principles:

• It should be fractional: that is, the patient should eat little by little, but often (at least five times a day).
• The food consumed should be pureed, warm and lightly salted. When preparing it, you must use olive oil or butter. The use of pork fat is strictly contraindicated.
• The patient is prohibited from eating dry food or hastily. Any food should be chewed very thoroughly.
• To avoid regurgitation (esophageal vomiting), the patient must refrain from any (especially forward) body bending for two hours after eating.
• The last meal should take place at least a couple of hours before departure for the night's rest.

The diet of a person suffering from dysphagia should be as follows:

• The best way to cook food is boiling, baking and steaming.
• Smoked, fatty, fried, salted, spicy and canned foods are completely excluded from the daily diet. The consumption of fast food, any carbonated and alcoholic drinks, foods containing large amounts of coarse plant fiber, as well as strong coffee and tea are also strictly prohibited.
• The diet should be predominantly egg-milk-vegetable, containing cereals (semolina, oatmeal, buckwheat, rice) and mucous soups.
• The patient benefits from eating dairy and fermented milk products, meat (preferably white) and lean fish, boiled or steamed vegetables.

Home therapy

It should only be carried out under the supervision of a doctor. The action of the medications is aimed at eliminating inflammation, muscle spasms, and calming the nervous system:

1. "Atropine" - helps relax the muscles of the esophagus, eliminates spasm and pain.
2. Buscopan is a rectal suppository used to relieve spasms of smooth muscles and reduce the secretion of digestive enzymes.
3. "Gastrocepin". The drug temporarily blocks the vagus nerve and eliminates excess secretion of hydrochloric acid.
4. "Motilium". The drug stimulates gastric motility, which accelerates the passage of food through the gastrointestinal tract.
5. "Platifillin." It calms the nervous system and eliminates vascular hypertonicity.
6. "Nikoshpan." Has a relaxing effect on cerebral vessels, improves blood circulation in the brain.

The drugs have contraindications and side effects. Therefore, they should be treated only after consultation with a doctor.

Concept

Dysphagia is difficulty or complete exclusion of food passing through the esophagus. Impaired swallowing leads to discomfort and pain in the throat. In this case, the coordination of the muscles of the food tract changes, and the food bolus is not able to move freely through the throat.

A violation of the swallowing reflex occurs when swallowing a very large piece of food. This also occurs when peristalsis is disrupted. This leads to complications in respiratory function, weight loss, and exhaustion of the body, so urgent consultation with a doctor is necessary.

Causes and risk factors

Although swallowing seems like a normal task to most people, it is actually quite a complex process. For normal swallowing, the brain must reflexively coordinate the activity of numerous small muscles of the throat and esophagus. These muscles must contract strongly in the proper sequence in order to push the food in the mouth to the back of the throat and then into the esophagus. The lower part of the esophagus must then relax to allow food to enter the stomach. Thus, difficulty swallowing can result from the following:

• Brain or nervous system disorders;
• Muscle diseases in general;
• Esophageal disorders (physical blockage or movement disorder [impaired motor function]).

Degrees of illness

According to severity, swallowing disorder is divided into 4 degrees:

1. The patient has difficulty swallowing. This function is not available with some solid foods.
2. It is difficult to swallow any solid food, but semi-liquid and soft foods pass easily.
3. A person can only eat liquid food.
4. Swallowing is impossible completely; no food, even liquid, can pass through the pharynx.

Folk remedies

Treatment with folk remedies is allowed only for mild pathology, which is caused by nervous tension, inflammation of the throat or esophagus, hyperacid gastritis.

To relax muscles and calm nerves, a collection of sweet clover, oregano, nettle, kelp, hops, and mint is used. Dry herbs take 1 tsp. and mix. The mixture (1 tablespoon) is brewed with boiling water (300 ml) in a thermos. After 30 minutes, filtering is performed, the product is taken 100 ml of warm broth 3 times a day.

A collection based on rose hips, calendula and chamomile flowers, mint, licorice, sage, and rue has a general strengthening and anti-inflammatory effect. Plant components must be mixed in equal quantities. The collection (2 tablespoons) is brewed with boiling water (1 liter) in a thermos and left for an hour. You should take ½ cup of the decoction 40 minutes after meals.

To reduce blood pressure and normalize the functioning of the stomach, a collection of motherwort herbs, hawthorn flowers, mint leaves, and calamus root is used. 1 tsp. each dry raw material is mixed in a glass jar. You will need 1 tbsp. l. mixture, which is brewed with boiling water (500 ml). In the morning, 20 minutes before breakfast, drink 150 ml of decoction, and then repeat before lunch and dinner.

Treatment of peptic ulcer disease is carried out using in complex therapy a medicinal collection from identical parts of fennel fruits, chamomile flowers, licorice and marshmallow roots, wheatgrass rhizomes, and yarrow herb. The mixture (1 tbsp) is poured with boiling water (200 ml). Infusion is carried out for half an hour, and then you need to take ½ glass 3 times a day.

Treatment with herbal remedies should be carried out for 10 days, and then a break of 2 weeks is required. If desired, herbal medicine can be resumed by changing the composition of the medicinal collection. If nausea, headache, skin rashes, stool disorders and other symptoms appear during treatment, then therapy is canceled.