How do I know that I or my loved one may need a swallowing evaluation?

by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

Does it hurt to swallow? Does food get stuck?

Signs of dysphagia (difficulty swallowing): 

• Swallowing is painful or uncomfortable
• Drooling
• Difficulty chewing
• Taking a long time to chew a single mouthful of food.
• Difficulty moving food around in the mouth. (The tongue gathers the food into a ball – also called a “bolus.” The tongue even holds or controls liquid bolus in the mouth with a cup-like shape. The tongue helps control food and liquid as it moves the ball/bolus upward and backward, towards the back of the mouth.)
• Food pocketing or getting stuck in your cheeks.
• Food falling out of your mouth or into the back of your throat before you are ready to swallow.
• Requiring many swallows to get food and/or liquid to go down and through your throat.
• Requiring liquids to wash food out of mouth or through your throat and/or food tube to the stomach (esophagus).
• Feeling food, liquid and/or pills get stuck in your mouth, throat, and/or food tube (esophagus).
• Sometimes people describe food and/or pills getting stuck up high in the throat where they can be coughed back up. Other times it feels like a ball or lump in the lower neck area that does not clear. See if you can point to where you feel it. Testing by a Speech-Language Pathologist (SLP) is so important to differentiate between a throat problem for an esophageal problem. Actual residue in the throat could put you at risk for choking, whereas food remaining in the esophagus can be uncomfortable and even painful, but it will not cause choking unless there is regurgitation or back flow out of the esophagus back to the lower throat. The SLP can give you a videofluoroscopic swallow study with different types of foods, liquids and even a barium pill and scan the throat and esophagus to see where the problem is and what to do about it. 
• Voice sounding wet and gurgly during or shortly after eating or drinking.
• Coughing on saliva or voice sounding wet throughout the day due to saliva pooling in the throat and voice box (larynx).
• Frequent throat clearing, coughing, and/or choking (airway blockage) during or shortly after eating, drinking, or taking medications.
• Feeling food or liquid poke into the top of your airway (penetration into the larynx/voice box) or fall through the vocal cords into the trachea and lungs (aspiration).

Aspiration is when material is inhaled, falls into the airway, or is misdirected into the airway due to inadequate airway protection. Once the material drops below the vocal folds (in your voice box/larynx, commonly referred to as the Adam’s apple), that is an aspiration. If it is not immediately detected and coughed out, it will fall into the lungs. Sometimes material can get into the airway and not be detected by the person, and this is referred to as “silent aspiration.”

• • • The SLP looks for overt or obvious signs of dysphagia and aspiration, such as throat clearing and coughing.
    • However, the SLP, the person, caregivers, and staff may not realize there are signs of dysphagia present.
    • The person and/or caregiver may not realize that the aspiration is occurring. There may be poor sensation and a reduced urge to cough.
    • Silent aspiration is quite common for people who have Dementia, Parkinson’s Disease, and Chronic Obstructive Pulmonary Disease/COPD, and Obstructive Sleep Apnea (OSA) to name a few diseases – due to poor sensation.
    • Sensation of residue and aspiration can also be poor if people have had surgeries to the neck, such as cervical spinal fusions, and radiation to the head and neck due to cancer.
    • The SLP can help evaluate for less obvious signs of dysphagia and aspiration.

Less obvious signs of dysphagia:

• Tiring easily before you are able to finish your meal.
• Feeling full quickly.
• Eating slower and eating less.
• Unexplained weight loss.
• Increased effort or work of breathing while sitting up to eat/drink. 
• Increased congestion or shortness of breath during or after eating or drinking. Worsening or exacerbation of your chronic respiratory conditions (such as Chronic Obstructive Pulmonary Disease / COPD).
• Repetitive respiratory infections (e.g., pneumonia).

Most of the time signs of dysphagia (aka, a swallowing disorder) are not so obvious. This is the universal sign for choking.

What should I do?

TALK WITH YOUR DOCTOR and describe the feelings and symptoms as best as you can. He/she can give you a doctor’s order (prescription) to see a swallowing specialist (a Speech-Language Pathologist who specializes in swallowing and swallowing disorders). Read more about how your swallowing can be tested.

If left untreated, a swallowing problem could lead to:

• Dehydration (by not taking in enough fluids),
• Weight loss and malnutrition (by not getting in enough calories and essential nutrients), and
• Aspiration pneumonia (a lung infection from bacteria getting into your lungs with the food, liquid, saliva, and/or regurgitated/refluxed material). Not all aspiration equals an aspiration pneumonia. However, if you are immune compromised, dependent on others for your care, have poor oral hygiene, and are bedridden, you risks of developing an aspiration pneumonia are much higher. Talk with your medical team about how to reduce your risks.

Seeing a Speech-Language Pathologist can help you and your doctor figure out what type of test(s) would be the best and most efficient way to fully evaluate your problem.