Dysphagia, what is altering my swallowing?

Swallowing is a very complex process that we usually learn in childhood and forget about it until we have a problem when we are older, or when we have a pathology that causes it. It is really the process that takes the food from the table to the stomach. There are several phases, the first phase is that the food is introduced into the oral cavity and in the oral cavity is prepared by chewing, insalivation and transformation of a solid bolus into a bolus with texture, as if it were a puree, which then progresses through the tongue to the throat, to the pharynx. This process already has a series of imbrications with movements of the tongue, movements of the pharynx, movements of the lips, movement of the facial musculature and movement of the jaw, which will prepare the bolus.

During this phase, which is voluntary, it can be interrupted at will if any alteration occurs. After this, the sphincter that separates the soft palate from the pharynx opens and the bolus is propelled to the pharynx where it accumulates and is squeezed downwards reaching the esophagus to begin the esophageal process of swallowing. During this second pharyngeal phase of swallowing it is important to protect the airway, because there is a moment in which the airway and the digestive tract cross. The larynx, which is the entrance door to the lungs, has to be completely closed and protected to avoid the passage of this food into the lungs, which would cause important complications, safety complications and pneumonia and lung infections, which in many cases would lead to the death of the patient. That is why the swallowing process is very complex. Many pairs of muscles, many cranial nerves and much neurological and respiratory coordination are involved.

Dysphagia is really the process of alteration in this swallowing mechanism. There is subjective dysphagia, in which the patient thinks he/she cannot swallow, and there is objective dysphagia in which it is actually confirmed that the patient cannot swallow. It may happen that he cannot swallow because he is not able to ingest the food or it may happen that the disorder is that the food passes to the lungs. We would then speak of safety complications as opposed to efficacy complications which would only occur initially when the patient is not able to swallow enough food.

The mechanism by which dysphagia occurs is very complex and very varied. Dysphagia really is a symptom that affects patients with many diseases. Patients with neurological problems, the most frequent are cerebral infarcts or cerebrovascular pathology, complications of neurodegenerative diseases, Parkinson, multiple sclerosis, amyotrophic lateral sclerosis or neuromuscular diseases, such as myasthenia gravis or certain myopathies, or also occurs in case of diseases or direct pathology of the upper gastrointestinal tract. For example, as a consequence of tumors of the upper gastrointestinal tract or as a consequence of the treatment of these tumors, either by surgery or by chemo- or radiotherapy. Chemo- or radiotherapy produces many deduction disorders, just as surgery also tends to produce swallowing disorders in this type of patient. Each time we use less aggressive surgical techniques for the physiology and we achieve better functional results in case of these patients.

As for how to treat dysphagia, much depends on the cause. As I said before dysphagia is a symptom, a symptom that can be a consequence of many disorders. A disorder of the closing mechanism of the larynx, a disorder in the opening of the esophagus, can cause the patient to be unable to swallow. The treatment of each must be individualized. Dysphagia does not have a single treatment, it has different possible treatments that are combined according to the physiology and pathophysiology of each case and each patient.

How can dysphagia be prevented?

When we have a patient with dysphagia, first of all we have to find out and determine the cause of the dysphagia. The disease that produces it, if we can find out what it is. Sometimes it is directly the disease that brings the patient for consultation. We have to find out what is the mechanism that produces the dysphagia in that patient and with all these data we can propose how to treat it.

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The treatment can be of several forms and many times these forms are combined. One of them is rehabilitation. Rehabilitation carried out by speech therapists allows us to look for methods that can help the patient’s swallowing problem. Maneuvers that strengthen certain muscles, exercises that strengthen certain muscles, maneuvers that produce better security and prevent food from going to certain positions. For example, patients with paralysis of the vocal cord, with a turning movement of the head towards the paralyzed cord, are able to swallow better, by diverting the food bolus to the healthy side. On other occasions it is not only rehabilitation but also changing the type of diet. The texture of food is very important. More liquid foods in neurological patients tend to cause more safety disorders and more risk of pneumonia. In these cases, thickening agents or gelled water are used, which will enhance the patient’s defense mechanism with greater textures. Sometimes in patients with more organic dysphagia and who have more problems with solids, we would try to make a more liquid food that allows the bolus to be swallowed better.

In summary, it is to look for what type of food, with the exploratory maneuvers that we can perform, is going to allow swallowing and work in a more efficient and safer way. Rarely, but sometimes, there may be certain surgical procedures that could help alleviate swallowing disorders.

Why am I having trouble swallowing?

If the patient wonders why swallowing is difficult, it is really because any of the swallowing mechanisms have been altered. Either the oral phase, and the patient is not able to prepare the bolus in the oral cavity, or propel it from the mouth to the pharynx. Either the pharyngeal phase, and the patient is not able to propel the bolus from the pharynx to the esophagus, which is the mechanism by which it will pass directly from the esophagus to the stomach. Or because that bolus can be passed to the larynx and cause a safety disorder with risk of pneumonia. Any alteration in the physiological swallowing mechanisms can cause the patient to be unable to swallow. What we have to do in these cases, by means of instrumental explorations with videoendoscopy of swallowing or videofluoroscopy, is to determine where the cause or causes are that make the patient unable to swallow.